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Variability of renal colic management and outcomes in two Canadian cities

  • Grant Innes (a1) (a2), Andrew McRae (a1), Eric Grafstein (a3), Michael Law (a4), Joel M. H. Teichman (a5), Bryce Weber (a6), Kevin Carlson (a6), Heidi Boyda (a1) and James Andruchow (a1) (a2)...

Abstract

Background

Some centres favour early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems.

Methods

We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modelling was performed to adjust for covariate imbalance.

Results

We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.9% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rates (52.1% v. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other.

Conclusions

An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.

Introduction

Dans certains centres hospitaliers, on préfère les interventions précoces dans le traitement des coliques néphrétiques tandis que, dans d’autres, on préfère les tentatives de passage spontané, mais les résultats relatifs aux deux types de traitement sont peu documentés. Les villes de Calgary et de Vancouver ont des populations comparables et, bien que les médecins aient les mêmes compétences, ils appliquent des approches différentes. Aussi avons-nous étudié les taux d’intervention et d’hospitalisation au bout de 60 jours, selon les deux approches, chez les patients ayant consulté, pour la première fois, un médecin au service des urgences (SU), pour des coliques néphrétiques.

Méthode

Nous avons utilisé des données administratives et procédé à un examen structuré des dossiers médicaux de tous les patients ayant consulté, pour la première fois, un médecin, dans les hôpitaux de Vancouver et de Calgary, pour des coliques néphrétiques, en 2014. Les données démographiques ainsi que les renseignements sur les caractéristiques à l’arrivée et les catégories de triage ont été tirés des systèmes d’information des SU, tandis que les renseignements sur les consultations au SU et les admissions ont été tirés des bases de données hospitalières, reliées entre elles au niveau régional. Les résultats des examens de laboratoire provenaient des dossiers médicaux électroniques, et les caractéristiques des calculs, des rapports d’imagerie diagnostique. Le principal critère d’évaluation consistait en l’hospitalisation ou en une intervention urologique rendues nécessaires entre le 1er et le 60e jour. Les critères d’évaluation secondaires comprenaient les reconsultations au SU, les réadmissions et les interventions de rattrapage. Nous avons réalisé une analyse du temps écoulé avant les événements cibles et appliqué le modèle de régression des hasards proportionnels de Cox afin de tenir compte des différences de covariables.

Résultats

Ont été examinés les dossiers de 3283 patients chez qui la présence de calculs a été confirmée par tomodensitométrie. Les caractéristiques relatives aux patients et aux calculs étaient comparables dans les deux villes. Il y a eu hospitalisation ou intervention chez 60,9 % des patients à Calgary contre 31,3 % des patients à Vancouver (p<0,001). Les patients à Calgary ont connu un taux plus élevé d’intervention au cours de la consultation de référence (52,1 % vs. 7,5 %) que ceux à Vancouver, et les premiers ont également reconsulté un médecin au SU ou ont été réadmis plus souvent que les seconds durant le suivi. D’après les données recueillies, les événements liés aux résultats étaient associés à un traitement excessif des petits calculs dans une ville et à un traitement insuffisant des gros calculs dans l’autre.

Conclusions

L’approche interventionnelle précoce était associée à des taux plus élevés de reconsultation au SU, d’hospitalisation et d’intervention. Si ces événements étaient des marqueurs d’incapacité, alors l’approche moins interventionnelle des petits calculs et l’application moins tardive du traitement indiqué des gros calculs pourraient réduire l’utilisation des ressources et améliorer les résultats cliniques chez les patients souffrant de coliques néphrétiques en phase aiguë.

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Copyright

Corresponding author

Correspondence to: Dr. Grant Innes; 781 East 8th Street, North Vancouver, BC, Canada V7L 2A1; Email: Grant.innes@ahs.ca

References

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Variability of renal colic management and outcomes in two Canadian cities

  • Grant Innes (a1) (a2), Andrew McRae (a1), Eric Grafstein (a3), Michael Law (a4), Joel M. H. Teichman (a5), Bryce Weber (a6), Kevin Carlson (a6), Heidi Boyda (a1) and James Andruchow (a1) (a2)...

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