Nearly 10% of URS patients visit emergency room

January 25, 2019

An analysis of nearly 2,000 patients undergoing ureteroscopy found that approximately 10% of the cohort had an emergency department visit after the procedure, a figure a statewide quality improvement initiative is looking to reduce via patient education regarding ureteral stents.

San Francisco-An analysis of nearly 2,000 patients undergoing ureteroscopy found that approximately 10% of the cohort had an emergency department visit after the procedure, a figure a statewide quality improvement initiative is looking to reduce via patient education regarding ureteral stents.

The Michigan Urological Surgery Improvement Collaborative (MUSIC) launched Reducing Operative Complications from Kidney Stones (ROCKS), its first quality improvement initiative beyond prostate cancer, in August 2016. At the 2018 annual meeting meeting in San Francisco, Khurshid R. Ghani, MD, MS, reported the group’s analysis of post-ureteroscopy ED visits.

The analysis included almost 2,000 patients treated with ureteroscopy at nine practices across the state. Focusing on unplanned encounters within the first 30 days after the procedure, the analysis found that approximately 10% of patients had an ED visit, of which 57% were considered potentially modifiable events, occurring for reasons of flank pain, hematuria, or urinary symptoms. Seventy percent of patients with an ED visit had a stent.

The ED visit rate among the nine practices included in the analysis ranged from 3% to 13%. Based on the observation that the practice with the lowest modifiable ED visit rate provided the most intensive patient education and because no practice had dedicated information related to stent symptoms, ROCKS addressed this gap by developing a ureteral stent patient education leaflet, which has been distributed to participating practices with the hope that trips to the ED can be minimized by setting proper patient expectations.

“Measuring to acquire data and sharing the information is not enough. We also have to develop action plans and disseminate interventions,” said Dr. Ghani, associate professor of urology, University of Michigan, Ann Arbor, and co-director of MUSIC.

“While we are starting small and focusing on stent-related issues for the moment, we know there are many things that we need to do to reduce ED visits after ureteroscopy.”

Next: Unplanned encounters encompass office visits, hospitalizationsUnplanned encounters encompass office visits, hospitalizations

Additional findings from the first analyses of data on URS patients showed that unplanned encounters within the first 30 days also included 55 office visits (2.8%) and 77 hospitalizations (3.9%). Overall, 72% of the total unplanned encounters occurred within 7 days of URS. Factors significantly associated with an ED visit were comorbidity, history of urinary tract infection, urinary diversion, ureteral dilation, and intraoperative complications. The stone clearance rate was 79% overall, 61% for renal stones, and 94% for ureteral stones.

The importance of developing a quality improvement initiative to reduce complications associated with kidney stone procedures is underscored by national data showing the high costs of these procedures associated with postprocedural ED visits and unplanned hospitalizations.

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Dr. Ghani said the idea of implementing the statewide quality improvement program germinated when he and his colleague, John Hollingsworth, MD, attended a meeting on kidney stones at the National Institutes of Health.

“During the meeting, Dr. Charles Scales commented on the MUSIC quality registry for patients with prostate cancer in Michigan, and how it would be great to have a similar registry for patients with kidney stones. Discussing this remark with other members of the MUSIC team, we thought about taking the opportunity to leverage the prospective registry that we have for prostate cancer in Michigan to begin to look at kidney stones,” Dr. Ghani said.

With support and funding from Blue Cross Blue Shield of Michigan, initial steps to set up ROCKS involved identifying what data elements would be captured prospectively, recognizing that the entries would be made by non-urologists who would require training, choosing a urologist at each practice to act as a clinical champion and lead the program locally, and recruiting patient advocates who are able to provide insight on what matters to patients.

So far, 34 community and academic practices have joined ROCKS, and data have been prospectively captured from more than 7,000 patients.