Emergent setting linked to lost follow-up for stents

Patients with ureteral stents are rarely lost to follow-up, but the risk is increased when patients are stented in an emergent setting rather than as part of an elective procedure, Yale University urologists reported at the 2018 World Congress of Endourology in Paris.

In order to minimize the incidence of these potentially impactful events, the authors underscored the importance of thoroughly counseling patients treated in an emergent setting about the need for follow-up care. They also advocated for the use of an electronic health record system to facilitate the identification and follow-up of patients with forgotten stents.

Using their EHR system (Epic), the authors identified 1,778 patients who had a ureteral stent placed from January 2015 to August 2017, of whom 16 (0.9%) had a stent in place for >90 days. A multivariate logistic regression analysis was performed to identify variables predicting the latter patients with a “forgotten” stent and found statistically significant associations with emergent surgery, which increased the risk by 3.5-fold, and African-American race, which predicted a 4-fold increased risk.

Demographic characteristics (sex and age) and type of insurance coverage were not independent predictors for having a long-retained stent.

“Lost ureteral stents are a low-probability event, but can affect a significant number of patients given that ureteral stent placement is a commonly performed procedure,” said first author Juan F. Javier-DesLoges, MD, a ­urology resident at Yale University, New Haven, CT.

“Our study supports the need to intensively counsel patients treated in an emergent setting so that they understand the need for stent removal and for providers to be proactive in scheduling a return visit. Considering that we routinely counsel patients treated in an emergent setting and that patient compliance is a variable beyond our control, there is also a need for a safety net system to identify patients lost to follow-up.”

“As a means to minimize and prevent the morbidity and mortality associated with retained stents, we encourage providers with access to the Epic EMR to use this resource to track all patients with ureteral stents,” said senior author Piruz Motamedinia, MD, assistant professor of urology at Yale.

With colleagues in the urology and IT departments at their center, Dr. Motamedinia and Patrick Kenney, MD, worked to create a workflow in their EMR to log insertion and removal of ureteral stents and to identify and report patients with stents retained >90 days. The latter individuals are then contacted for retrieval.

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“Using an EMR-linked protocol for tracking ureteral stent patients has several benefits,” Dr. Motamedinia said. “First, it is an automated system that does not rely on prospective inputting by a provider for the sole purpose of stent tracking. In addition, no third party is involved, it is HIPPA compliant, and it includes all providers in the health care system, which allows it to be a quality initiative.”

The authors noted that although African-American race was independently associated with increased risk for a retained stent, they believe the finding was confounded by unmeasured variables.

“Black race is probably a surrogate for one or more variables we cannot account for,” said Dr. Motamedinia.

They discounted the possibility that the association with race reflected access to health care.

“We believe insurance status correlates more closely with access to health care than race, and when we looked at an effect of insurance status by comparing patients who had Medicare or Medicaid coverage to those with commercial insurance, we did not find that insurance status was associated with having a forgotten stent,” Dr. Javier-DesLoges said.