Original Contribution
Variation in the Intensity of Care for Patients with Uncomplicated Renal Colic Presenting to U.S. Emergency Departments

https://doi.org/10.1016/j.jemermed.2016.05.037Get rights and content

Abstract

Background

Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed.

Objective

We assessed patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones.

Methods

We identified ED visits from non-elderly adults (aged 19−79 years) with a primary diagnosis indicating renal stone or colic from the 2011 Nationwide Emergency Department Sample. Patients with additional diagnostic codes indicating infection, sepsis, and abdominal aortic aneurysm were excluded. We used sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics.

Results

Of the 1,061,462 ED visits for uncomplicated kidney stones in 2011, 8.0% of visits resulted in admission and 6.3% resulted in an inpatient urologic procedure. Uninsured patients compared to Medicaid insured patients were less likely to be admitted or have an inpatient urologic procedure (odds ratio [OR] = 0.72; 95% confidence interval [CI] 0.65−0.81 and OR = 0.80; 95% CI 0.72−0.87, respectively). Private- and Medicare-insured patients compared to Medicaid-insured patients were more likely to have an inpatient urologic procedure (OR = 1.20; 95% CI 1.11−1.30 and OR = 1.14; 95% CI 1.04−1.25, respectively).

Conclusions

For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.

Introduction

Renal colic is a relatively common, and typically low-morbidity, condition. Patients with renal colic are frequently diagnosed, treated, and discharged from the emergency department (ED) setting. The diagnosis and treatment of renal colic results in 1.3 million annual ED visits and > $5 billion U.S. dollars in health care charges annually 1, 2. Patients with renal colic typically present with nausea, vomiting, and sudden abdominal pain. ED management generally consists of confirming the diagnosis, providing supportive care (i.e., intravenous [IV] fluids, pain medications, and antiemetics), and discharging the patient home with outpatient follow-up. Patients, however, can require hospitalization and, at times, an inpatient urologic procedure when the case is complicated (infection, obstruction, intractable pain, etc.).

Unwarranted variation in care has been associated with unnecessary testing, increased rates of procedures, and medical errors 3, 4. Brown et al. reported variation in the diagnosis and treatment of renal colic in the ED and noted inconsistencies in the use of ancillary testing, such as x-ray studies, computed tomography scans, and ultrasound; and advocated for national guidelines as a strategy to reduce variation of practice (5). The American Urologic Association published guidelines on renal colic (2014), providing a clinical framework for the diagnosis, prevention, and follow-up for the medical management of renal colic (6). A 2007 guideline on the Management of Ureteral Calculi provided clinical guidance on when observation vs. surgical intervention is required (7). Despite the fact that a large proportion of patients will initially present to the ED with renal colic, neither report addressed ED management and disposition of acute renal colic. Guidelines fail to address criteria for both admission and when inpatient urologic procedures are warranted.

To our knowledge, our study adds to two gaps in the current literature. Ghani et al. performed a study with the same dataset, but the sample population was defined differently and the study did not provide an analysis of inpatient procedures (2). In essence, our sample population is unique in attempting to isolate uncomplicated cases and provide unique data on the utilization of inpatient procedures for these patients (2).

Our primary objective was to quantify ED variation in disposition and eventual utilization of inpatient procedures for patients with uncomplicated renal colic. We hypothesized that after controlling for patient comorbidities, nonclinical factors, in particular payer status, would play a role in patient admission or having an inpatient urologic procedure. Our secondary goal was to understand this variation in terms of cost or median charges of ED and inpatient visits.

Section snippets

Methods

We used the 2011 Nationwide Emergency Department Sample (NEDS). The NEDS is part of a set of hospital-based administrative databases that are part of the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (8). The NEDS contains between 25 and 50 million event-level records for > 950 hospitals, is weighted to provide national estimates, and is the largest all-payer ED database in the United States. NEDS provides financial data based on revenue codes. Professional

Results

Patients presenting to the ED with uncomplicated renal colic in 2011 accounted for approximately 1 million ED visits (Table 1). Patients with additional diagnostic codes indicating fever (780.6x,), urinary tract infection (599.0), sepsis (038.x), abdominal aortic aneurysm (441.3, 441.5), as well as ED disposition other than routine discharge or admission, were excluded (n = 104,072).

Uncomplicated renal colic patients were admitted and had an inpatient procedure at a rate of 8.0% and 6.3%,

Discussion

We assessed patient- and hospital-level variation for ED disposition and inpatient urologic procedures for patients with uncomplicated renal colic. We found that of approximately 1 million ED visits for uncomplicated renal colic, the majority resulted in discharges; however, 8.0% of patients were admitted and 6.3% had an inpatient procedure. Aside from female sex and older age, insurance status was associated with both admission and having an inpatient procedure. In general, private insurance

Conclusions

Uncomplicated patients with renal colic are typically discharged from the ED. For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. Nonclinical sources of variation of care have historically been associated with inefficiencies, increased cost, and worrisome disparities. The use of national guidelines that are endorsed by both emergency medicine and urology is a potential method to curb these inefficiencies of

References (15)

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The study was supported by award number K12HL109009 from the National Heart, Lung, and Blood Institute (to M. Kit Delgado). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.

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