Clinical, fiscal and environmental benefits of a specialist-led virtual ureteric colic clinic: a prospective study.

OBJECTIVES: To evaluate the clinical, fiscal and environmental impact of a specialist-led acute ureteric colic virtual clinic (VC) pathway. PATIENTS AND METHODS: All patients with uncomplicated acute ureteric colic, referred to a single tertiary centre, were prospectively entered into the study over a 4-year period (January 2015-December 2018). Inclusion criteria were: low-dose non-contrast computed tomography of kidneys, ureters and bladder; white blood cell count <16 × 109/L; pain controlled; normal renal function; and no clinical concern. Primary outcomes were: time (days) from referral to VC outcome; VC outcome (discharge, further VC, face-to-face [FTF] clinic, extracorporeal shockwave lithotripsy [ESWL], ureterorenoscopy [URS], percutaneous nephrolithotomy [PCNL]); and adverse events (sepsis or obstruction). Secondary outcomes were patient and stone demographics, cost and environmental analysis. The minimum follow-up was 3 months. RESULTS: A total of 1008 patients entered the study, of whom 91.5% (n = 922) were of working age. The median (interquartile range) time from presentation to VC outcome was 2 (4) days. VC outcomes were as follows: 16.3% of patients (n = 164) were discharged; 18.2% (n = 183) were discharged after further VC; 17.2% (n = 173) underwent an intervention; and 48.4% (n = 488) were referred to an FTF clinic. Interventions comprised: PCNL 0.5% (n = 5); ESWL 7.7% (n = 78); and URS 8.9% (n = 90). Stone demographics were as follows: 570 patients (56.5%) had lower, 157 (15.6%) had upper, 96 (9.5%) had mid-ureteric and 163 (16.2%) had renal calculi, and in 22 patients (2.2%) the stones had recently passed. The mean (sd) stone size was 3.5  (2.3) mm. Two adverse events (0.2%) were reported. Introducing a VC saved £145,152 for Clinical Commissioning Groups, the equivalent NHS tariff payment of performing 106 URS procedures or 211 ureteric stent insertions. Overall, 15,085 patient journey kilometres were avoided, equal to 0.70-2.93 metric tonnes of carbon dioxide equivalent production and the need to plant 14.7 trees to achieve carbon balance. CONCLUSION: A specialist-led acute ureteric colic VC reduced time to treatment decision to a median of 2 days. This creates additional clinic capacity and reduces the fiscal burden of traditional clinics and their associated carbon footprint.

Ureteral stent removal using an extraction string after uncomplicated ureteroscopy: a cost-benefit analysis.

PURPOSE: Some urologists used the extraction strings for removal of ureteral stent without cystoscopy. While some urologists may have concern about perceived risks, including accidental dislodgement, infection, renal?colic?and lower urinary tract symptoms. Therefore, we performed a retrospective study to help address this conflict. MATERIALS AND METHODS: Patients who had an indwelling ureteral stent with(n=58) or without(n=82) extraction strings inserted after ureteroscopy for unilateral ureteral stones were enrolled. For ureteral stent removal, the strings were pulled by physician, no string-stents were removed by cystoscopic. Postoperative morbidity was assessed. Patients' medical expense due to postoperative morbidity was collected. RESULTS: Patients with extraction string had shorter stent dwell time((5.3±1.8 versus 11.2±3.2 day, P= .001)  and  less cost (8.97±3.07 versus 455±0 CNY, P = .001)) for ureteral stent removal. However, six patients with extraction string had an accidental dislodgement, additional medical expenses were 345±137.9 CNY. There was no difference in the cost due to urinary tract infection, renal?colic?and LUTS between the two groups. The overall cost in patients without an extraction string was significantly more than in patients with an extraction string (86.7±167.7 versus 507.9±147.8 CNY, p =.008). CONCLUSION: Despite an increase in stent dislodgement related risks  to the extraction string, it results in significant cost savings for patients, and most of patients remove with extraction strings might benefit from it.  INTRODUCTION Nowadays, most of urologists place an indwelling ureteral stent following uncomplicated ureteroscopy(URS). However, ureteral stent may impact quality of life (QoL) of patients. And the additional suffering due to cystoscopic extraction is even more painful. Current ureteral stents are manufactured with a string attached to the distal end, allowing for removal without cystoscopy, which may lead to a reduction of the dwell time(usually less than one week)[1-8]. Although stent extraction strings have many advantages, more than two-thirds of urologists remove extraction strings prior to their insertion[9]. Surgeons who do not adopt?this?method?may have concern about perceived risks, including accidental dislodgement, infection, renal?colic?and lower urinary tract symptoms(LUTS). But how about incidence?rate of the risk aforementioned??does this increase the patient's financial burden compared with patients remove without extraction strings? Whether patients remove with extraction strings might benefit from it? Therefore, we performed a retrospective study to help address these questions by comparing patients those who underwent ureteric stent placement with and without extraction strings after URS for stone disease.

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

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.

Unsuccessful Medical Expulsive Therapy: A Cost to Waiting?

OBJECTIVE: To compare clinical outcomes between patients with ureteral stones who underwent an unsuccessful trial of medical expulsive therapy (MET) and patients who did not attempt MET. METHODS: We reviewed the clinical records of all potential candidates for MET who were referred from the emergency department to a subspecialty stone clinic. RESULTS: Of 348 potential candidates, 133 patients (38%) went directly to surgery (NMET) and 215 patients (62%) initiated MET. In the latter group, MET was unsuccessful in 45 patients (21%) (UMET). Stone symptoms were the primary rationale for surgery in 20 (44%) UMET patients and 69 (52%) NMET patients. The UMET patients were more likely to be younger and have smaller, more distal stones than NMET patients. All stones were cleared by ureteroscopy. The average interval from stone clinic assessment to surgery was longer in the UMET patients (17 days) than in the NMET patients (1 day; P <.001). The UMET patients underwent more preoperative computed-tomography scans (2.1) than did the NMET patients (1; P <0.001). There were no differences between the 2 groups in the residual stone burden, pre- or postoperative repeat visits to the emergency department, or repeat surgery. CONCLUSION: In this population, we did not observe any detrimental impact of an unsuccessful trial of MET (beyond the additional time and imaging costs). If more confident and effective symptom control could be achieved, expansion of utilization and duration of MET may be a path to improved patient outcomes and cost control.

Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis.

PURPOSE: The use of medical expulsive therapy to hasten stone passage potentially decreases expenditures around episodes of renal colic. However, these efficiency gains may be mitigated if patients treated with medical expulsive therapy have frequent health care encounters due to pain while waiting for the stones to pass. MATERIALS AND METHODS: Using claims data (2002 to 2006) we identified adult men with acute renal colic. We compared 6-week payments as well as frequency of hospitalization and emergency department revisits associated with an initial course of medical expulsive therapy with those for early endoscopic stone removal. To account for unmeasured confounding we performed an instrumental variable analysis, exploiting variation in recommended treatments based on the day of the week that a patient's first emergency department visit occurred. RESULTS: Overall 1,835 and 4,397 men underwent medical expulsive therapy or early endoscopic stone removal, respectively. Although minimal differences existed between men with respect to the day of the week of emergency department presentation, weekend encounters were strongly associated with receiving medical expulsive therapy (p <0.001). Two-stage least squares regression revealed 6-week payments to be tenfold lower for men on medical expulsive therapy who were candidates for either treatment (p <0.001). While there was no difference in frequency of hospitalization, these men were more likely to have a repeat emergency department visit compared to those who underwent endoscopic stone removal (68.8% vs 39.6%, respectively, p = 0.025). CONCLUSIONS: Findings on medical expulsive therapy are mixed, with lower 6-week payments but more frequent repeat emergency department visits. These data inform patients who are candidates for medical expulsive therapy or endoscopic stone removal when making decisions about their care.