Patients undergoing post-URS stent placement more likely to visit ED

The Michigan Urological Surgery Improvement Collaborative (MUSIC) sought to provide insight on stent use following ureteroscopy and its impact on unplanned health care use.

The recent analysis included ureteroscopic procedures for urinary stone disease from the MUSIC Reducing Operative Complications from Kidney Stones (ROCKS) clinical registry. It found that stent placement after ureteroscopy was common, varied substantially across urologists as well as practices, was associated with certain demographic and clinical characteristics, and increased the likelihood of a postoperative emergency department (ED) visit.

Spencer C. Hiller, MD, Endourology Fellow at the University of Michigan in Ann Arbor, presented the findings on behalf of his MUSIC colleagues. Hiller said, “It is common practice to place a ureteral stent after ureteroscopy for urinary stone disease.

“Several studies have demonstrated that stents are associated with patient discomfort, but the impact of stent placement on unplanned health care utilization is less clear,” added Hiller, working with Casey Dauw, MD, and colleagues.

The study, presented at the 2020 American Urological Association Virtual Experience1 included all patients who underwent primary ureteroscopy for urolithiasis from June 2016 to May 2019 in the MUSIC ROCKS clinical registry. After excluding urologists and practices with fewer than 10 ureteroscopies during the study period and patients having a second- look ureteroscopy, bilateral procedure, or with stones measuring greater than 2 cm, investigators identified 9662 procedures performed by 137 urologists representing 24 separate practices across the state of Michigan. Both academic and private practices, including group and solo practices, were represented.

Overall, a stent was placed following ureteroscopy in 73% of procedures, but the utilization rate ranged from 11% to 100% among providers and from 34% to 100% among practices. Investigators saw profound variation in stent use irrespective of case volume, even among urologists within individual group practices.

Bivariate and multivariate analyses were carried out to identify demographic and clinical characteristics associated with stent placement. Findings of the logistic regression analysis showed that the likelihood of stent placement decreased by 75% when a ureteral stent was present prior to ureteroscopy and by 31% in cases with a renal stone location. The likelihood of stent use increased by 5.43-fold in cases with ureteral access sheath use.

Increasing age was also a risk factor for stent placement. Relative to cases with a stone measuring 5 mm or less, stones larger than 5 mm to 10 mm were associated with a 1.89-fold increased risk of stent placement, and 4.68-fold in cases with stones larger than 10 mm.

In a bivariate analysis, the use of a stent after ureteroscopy was associated with a statistically significant increase in the rate of both ED visits and hospitalizations. The ED visit rate was 8.5% in cases where a stent was placed versus 7.1% where a stent was not used (P = .018), and the hospitalization rate was 3.8% for cases with a stent versus 2.9% for cases without a stent (P = .03).

In a multivariable logistic regression analysis, controlling for patient and stone factors along with surgeon and practice variation, stent placement was associated with a statistically significant, 25% increased likelihood of an ED visit. However, there was no longer a statistically significant association between stent placement risk of hospitalization.

Hiller concluded, “Because of our finding that patients with a stent are more likely to have an ED visit, we recommend that efforts should be made to identify patients suitable for stent omission in order to decrease these unplanned health encounters.”

Reference

1. Hiller S, Swarna K, Slayton J et al. Ureteral Stent Placement Following Ureteroscopy Increases Emergency Department Visits in a Statewide Quality Improvement Initiative. Presented at: 2020 AUA Virtual Experience. Abstract PD01-09.