THERE IS NO QUESTION that emergency providers are seeing an increasing number of patients presenting with kidney stones. Researchers say the incidence of stone disease has nearly doubled in the past 15 years, most likely fueled by diet and lifestyle factors, according to Charles Scales, MD, MSHS, an assistant professor of surgery at Duke University Medical Center in Durham, NC. “What we found is that obesity, diabetes, and markers of the metabolic syndrome are certainly associated with stone disease, or whether someone has kidney stones or not,” he explains.
Of particular concern to emergency providers, though, are data showing that of the more than one million patients seeking care for kidney stones in the emergency setting each year, as many as one in nine patients will bounce back to the ED for a return visit, according to a new retrospective analysis completed by Scales and colleagues that looked at data collected from every ED in California over a two-year period.1
Scouring through administrative information culled from more than 128,000 ED visits for kidney stones, the researchers identified specific factors associated with the patients who made return ED visits. For instance, symptoms that prompted return visits included uncontrolled pain, severe vomiting that led to dehydration, or kidney stone-related infections that required emergency procedures.
One of the biggest factors associated with return ED visits had to do with the type of insurance a patient had, observes Scales. “In particular, patients who had Medicaid were at about a 50% higher risk of having a repeat visit than patients who had commercial insurance,” he says. “Since we know that sometimes Medicaid offers lower reimbursement and fewer physicians see Medicaid patients, that may be a barrier.”
The number of urologists practicing in a particular region also had a bearing on whether or not patients made return visits to the ED. “If they lived in an area where there were fewer urologists, they would be more likely to return to the ED as their source of care,” Scales says. “That is not necessarily surprising for a condition that is often treated by a urologist. If you just can’t find a urologist locally, then maybe the place you return is the ED.”
Follow the guidelines
While issues involving access were clearly associated with return ED visits, there was also evidence that the quality of care received in the ED was a contributing factor as well. “There are a few things that the guidelines either implicitly or explicitly suggest that patients receive: a CT scan or an alternative form of imaging under certain circumstances … and three different lab tests, [including] a urinalysis, an assessment of blood counts, and an assessment of kidney function,” Scales explains. “We looked at all four of these different tests … and we found that patients who had their blood count checked were 12% less likely to return to the ED than those who didn’t.”
This finding requires further investigation, but Scales suggests what may be happening is that some patients who come in for early treatment have kidney stones that are blocking a urinary infection. “That can cause severe illness or even death from sepsis or an infection that spreads throughout the bloodstream,” he explains. “[Patients] may not have a fever yet, their blood pressure may still be normal, and they may not appear to be infected … but one of the few manifestations of an impending systemic infection is a very high white blood count.”
Consequently, providers who check their patients’ blood counts are more likely to pick up such infections and provide treatment on the first ED visit, Scales suggests. “That would explain why we might see this relationship,” he says. “All of the other tests are related to outcomes for kidney stones, but are probably not things that would bring [a patient] back to the ED with a life-threatening condition.”
Consider quality at facility level
The study results highlight some opportunities for improvement in the emergency care of patients with kidney stones, Scales suggests. “The best thing to do is to use these findings as a signal that we need to examine our own practices and make sure that, in fact, we are delivering the best care possible,” he says.
Scales also observes that when the results were broken down by specific ED, there was considerable variation in the proportion of ED visits for kidney stones that resulted in bounce-back visits. “Two-thirds of the [facilities] we studied fell into the range of 6% to 16%, which means that depending on where you go, there is a pretty wide range in the probability of having a return visit,” he explains. “That would suggest that maybe there are some factors operating at the facility level that need to potentially be addressed.”
To conduct this kind of evaluation, emergency providers would need to examine the care that they deliver to kidney stone patients in coordination with primary care providers (PCP) and urologists “to make sure that these patients are taken care of in a coordinated way and delivered the right care at the right time,” Scales says. “Being able to coordinate care between the ED and the specialist, if that is required, or a PCP if a specialist is not required, would be a very important mechanism to address this and reduce those re-visits that are potentially avoidable.”
Current studies are delving further into the quality of care provided to kidney stone patients in the ED, particularly with respect to the finding that ties lack of a blood count test with repeat visits. “We are looking specifically at this population of patients who appear normal at their first ED visit and then return with a severe systemic infection,” Scales explains. “We are seeing if we can find predictors of that so that we can prevent people from going home who will turn out to be very severely ill within the next several days.”
Researchers are also specifically examining the role of PCPs in the care of patients with kidney stones. “Probably upwards of half the patients who show up in the ED with a kidney stone will pass it on their own. Those who get referred to urology are the ones that may not pass it or may have very severe or recurrent kidney stone disease, or they may need a procedure to remove the kidney stone,” he explains. “I think we are only seeing the tip of the iceberg when we look at urology care, so we are actually exploring what happens in the PCP office for kidney stones.”
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Scales CD Jr, et al. Emergency department revisits for patients with kidney stones in California. Acad Emerg Med 2015;4:468-474.
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Charles Scales, MD, Assistant Professor of Surgery, Duke Medical Center, Durham, NC. E-mail: [email protected].
