The impact of unplanned postprocedure visits in the management of patients with urinary stones.
BACKGROUND
Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease.


METHODS
We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates.


RESULTS
We identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval [95% CI] 0.74-0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 [95% CI $30,453-33,859]) than after ureteroscopy ($23,436 [95% CI $22,281-24,590]).


CONCLUSIONS
Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.
Robert Wood Johnson Foundation Clinical Scholars Program and US Department of Veterans Affairs; Department of Urology, University of California, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address: chuck.scales@duke.edu.
Charles D
CD
Scales
Department of Urology, University of California, Los Angeles, CA.
Christopher S
CS
Saigal
RAND Corporation, Santa Monica, CA.
Janet M
JM
Hanley
RAND Corporation, Santa Monica, CA.
Andrew W
AW
Dick
RAND Corporation, Santa Monica, CA.
Claude M
CM
Setodji
Department of Urology, University of California, Los Angeles, CA; RAND Corporation, Santa Monica, CA; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, CA.
Mark S
MS
Litwin
D000293:Adolescent; D000328:Adult; D017281:Cost of Illness; D019468:Disease Management; D005260:Female; D006801:Humans; D015907:Hysteroscopy / Q000191:economics; D017602:Lithotripsy, Laser / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000191:economics; D017063:Outcome Assessment, Health Care; D011182:Postoperative Care / Q000191:economics*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D014545:Urinary Calculi / Q000191:economics / Q000628:therapy*; D055815:Young Adult