Reviewer's Choice

Michel KF. et al., 2021: Emergency department and hospital revisits after ambulatory surgery for kidney stones: an analysis of the Healthcare Cost and Utilization Project

Wednesday, 23 June 2021

3380 Hits

Michel KF, Patel HD, Ziemba JB.
Division of Urology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3 West Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA, USA.
Department of Urology, Loyola University Medical Center, Maywood, IL, USA.
Division of Urology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3 West Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA, USA.

Abstract

Our objective was to identify the rate of revisit to either emergency department (ED) or inpatient (IP) following surgical stone removal in the ambulatory setting, and to identify factors predictive of such revisits. To this end, the AHRQ HCUP ambulatory, IP, and ED databases for NY and FL from 2010 to 2014 were linked. Cases were selected by primary CPT for shock-wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL) with accompanying ICD-9 for nephrolithiasis. Cystoscopy (CYS) was selected as a comparison group. The risk of revisit was explored using multivariate models. The overall unplanned revisit rate following stone removal was 6.4% (4.2% ED and 2.2% IP). The unadjusted revisit rates for SWL, URS, and PNL are 5.9%, 6.8%, and 9.0%, respectively. The adjusted odds of revisit following SWL, URS, and PNL are 1.93, 2.25, and 2.70 times higher, respectively, than cystoscopy. The majority of revisits occurred within the first two weeks of the index procedure, and the most common reasons for revisit were due to pain or infection. Younger age, female sex, lower income, Medicare or Medicaid insurance, a higher number of chronic medical conditions, and hospital-owned surgery centers were all associated with an increased odds of any revisit. The most important conclusions were that ambulatory stone removal has a low rate of post-operative revisits to either the ED or IP, there is a higher risk of revisit following stone removal as compared to urological procedures that involve only the lower urinary tract, and demographic factors appear to have a moderate influence on the odds of revisit.
Urolithiasis. 2021 Feb 17. doi: 10.1007/s00240-021-01252-8. Online ahead of print. PMID: 33598795

Comments 1

Peter Alken on Wednesday, 23 June 2021 10:30

The abbreviations some readers may not be familiar with are:
IP Inpatient hospitalization, HCUP Healthcare Cost and Utilization Project,
AHRQ Agency for Healthcare Research and Quality, FL Florida.
HCUP is a large all-payer database e.g. regardless of the patients’ insurance status.

An interesting paper offering a different from the usual view on the stone business. It provides answers to the question how safe is outpatient therapy, a continuously growing trend.
The authors comment on the earlier literature: “… revisit rates from the ambulatory setting are limited to single-institution, single-technique studies with highly variable rates ranging from 1 - 18% for PNL, 4 - 16% for URS, and 1–2% for SWL. These studies are significantly limited by their smaller sample size and, most importantly, inability to capture revisits that return to a different institution.”

The total number of urologic ambulatory procedures in the time period and in the two selected states was 2,882,517. Of these a small percentage was on stones (Table 1)
Table 1

Cystoscopy was chosen as a comparative procedure to serve as benchmark, as it is a non-therapeutic endourological procedure with an as low as possible risk of revisit.
The definition of ambulatory care depends on the health system. Table 2 shows that a procedure can be listed as an outpatient treatment despite a “hospitalization”.
Table 2

The authors list some limitations of their study:
• the data set from 2010 to 2014 is not very fresh but is the most recent available at study conception
• office-based visits are not included prohibiting to examine “the impact of ureteral stent removal on revisits, as the majority of these are expected to occur outside our dataset”.
At least 21% and 54 % of the ESWL and URS cases resp. had stents.
Data like these provide the basis for changes in health systems.

An interesting paper offering a different from the usual view on the stone business. It provides answers to the question how safe is outpatient therapy, a continuously growing trend.  
The authors comment on the earlier literature: “… revisit rates from the ambulatory setting are limited to single-institution, single-technique studies with highly variable rates ranging from 1 - 18% for PNL, 4 - 16% for URS, and 1–2% for SWL. These studies are significantly limited by their smaller sample size and, most importantly, inability to capture revisits that return to a different institution.”

The total number of urologic ambulatory procedures in the time period and in the two selected states was 2,882,517. Of these a small percentage was on stones (Table 1) 
Table 1
[img]https://www.storzmedical.com/images/blog/Michel_Table1.JPG[/img]

Cystoscopy was chosen as a comparative procedure to serve as benchmark, as it is a non-therapeutic endourological procedure with an as low as possible risk of revisit. 
The definition of ambulatory care depends on the health system. Table 2 shows that a procedure can be listed as an outpatient treatment despite a “hospitalization”. 
Table 2
[img]https://www.storzmedical.com/images/blog/Michel_Table2.JPG[/img]

The authors list some limitations of their study: 
•	the data set from 2010 to 2014 is not very fresh but is the most recent available at study conception
•	office-based visits are not included  prohibiting to  examine “the impact of ureteral stent removal on revisits, as the majority of these are expected to occur outside our dataset”.  
At least 21% and 54 % of the ESWL and URS cases resp. had stents. 
Data like these provide the basis for changes in health systems.

The abbreviations some readers may not be familiar with are: IP Inpatient hospitalization, HCUP Healthcare Cost and Utilization Project, AHRQ Agency for Healthcare Research and Quality, FL Florida. HCUP is a large all-payer database e.g. regardless of the patients’ insurance status. An interesting paper offering a different from the usual view on the stone business. It provides answers to the question how safe is outpatient therapy, a continuously growing trend. The authors comment on the earlier literature: “… revisit rates from the ambulatory setting are limited to single-institution, single-technique studies with highly variable rates ranging from 1 - 18% for PNL, 4 - 16% for URS, and 1–2% for SWL. These studies are significantly limited by their smaller sample size and, most importantly, inability to capture revisits that return to a different institution.” The total number of urologic ambulatory procedures in the time period and in the two selected states was 2,882,517. Of these a small percentage was on stones (Table 1) Table 1 [img]https://www.storzmedical.com/images/blog/Michel_Table1.JPG[/img] Cystoscopy was chosen as a comparative procedure to serve as benchmark, as it is a non-therapeutic endourological procedure with an as low as possible risk of revisit. The definition of ambulatory care depends on the health system. Table 2 shows that a procedure can be listed as an outpatient treatment despite a “hospitalization”. Table 2 [img]https://www.storzmedical.com/images/blog/Michel_Table2.JPG[/img] The authors list some limitations of their study: • the data set from 2010 to 2014 is not very fresh but is the most recent available at study conception • office-based visits are not included prohibiting to examine “the impact of ureteral stent removal on revisits, as the majority of these are expected to occur outside our dataset”. At least 21% and 54 % of the ESWL and URS cases resp. had stents. Data like these provide the basis for changes in health systems.

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