Quality of stone care: We can do better

In the current health care environment, increasing emphasis is placed on metrics that capture the quality of care. In the field of stone management, it is challenging both to track certain intuitively obvious quality markers, such as stone-free rates, and to define a method for the differentiation of other more subtle markers of quality such as a planned, staged treatment versus an unnecessary retreatment.

Therefore, quality metrics often focus on simpler-to-track measures such as the unplanned utilization of health care services in the postoperative period. Broadly, such services come in different forms; among the most frequently discussed are unplanned readmissions or emergency department utilization. However, the health care system can also be utilized in ways that are not hospital based, such as interactions with the medical office. Although the latter may not have a direct and easily determined cost associated with it, as an emergency department visit or hospital admission would, it is nonetheless an important quality metric.

In general, one would expect that patients undergoing stone treatment would have low rates of unplanned health care utilization. Du and associates from Washington University have very nicely investigated factors affecting readmission following ureteroscopic stone management (page 4). They found that unplanned encounters were actually fairly common following ureteroscopy. Over one-fourth of patients initiated phone contact with the physician’s office and almost 15% ultimately presented to the emergency department, with 5% being readmitted.

Ultimately, their analysis revealed that inadequate pain control, presence of a ureteral stent, and a first-time stone treatment were the most common reasons for unplanned utilization of health care services.

This study speaks to two important points: optimizing pain management following ureteroscopic procedures and managing patient expectations following their stone removal procedure. As all urologists know, stents are painful. At present, an optimal regimen of pain control has not been universally accepted; various medications, including narcotics, alpha-blockers, anticholinergics, antibiotics, and benzodiazepines are all utilized, but the evidence of their effectiveness is conflicting. Therefore, further study of this area is important.

However, this study also identified another important area to focus on: preparation of the patient for the symptoms of a ureteral stent following ureteroscopy, which urologists may not be doing as well as we should.