Quality of Acute Care for Patients With Urinary Stones in the United States.
OBJECTIVE
To describe guideline adherence for patients with suspected upper tract stones.


METHODS
We performed a cross-sectional analysis of visits recorded by the National Hospital Ambulatory Medical Care Survey (emergency department [ED] component) in 2007-2010 (most recent data). We assessed adherence to clinical guidelines for diagnostic laboratory testing, imaging, and pharmacologic therapy. Multivariable regression models controlled for important covariates.


RESULTS
An estimated 4,956,444 ED visits for patients with suspected kidney stones occurred during the study period. Guideline adherence was highest for diagnostic imaging, with 3,122,229 (63%) visits providing optimal imaging. Complete guideline-based laboratory testing occurred in only 2 of every 5 visits. Pharmacologic therapy to facilitate stone passage was prescribed during only 17% of eligible visits. In multivariable analysis of guideline adherence, we found little variation by patient, provider, or facility characteristics.


CONCLUSIONS
Guideline-recommended care was absent from a substantial proportion of acute care visits for patients with suspected kidney stones. These failures of care delivery likely increase costs and temporary disability. Targeted interventions to improve guideline adherence should be designed and evaluated to improve care for patients with symptomatic kidney stones.
Robert Wood Johnson Foundation Clinical Scholars Program, University of California, Los Angeles, CA; U.S. Department of Veterans Affairs, Greater Los Angeles Health Care System, Los Angeles, CA; Department of Urology, David Geffen School of Medicine, 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
Robert Wood Johnson Foundation Clinical Scholars Program, University of California, Los Angeles, CA; U.S. Department of Veterans Affairs, Greater Los Angeles Health Care System, Los Angeles, CA; Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.
Jonathan
J
Bergman
Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
Stacey
S
Carter
Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
Gregory
G
Jack
Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; RAND Corporation, Santa Monica, CA.
Christopher S
CS
Saigal
Department of Urology, David Geffen School of Medicine, 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
D000328:Adult; D000367:Age Factors; D000368:Aged; D003430:Cross-Sectional Studies; D003952:Diagnostic Imaging / Q000379:methods / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011787:Quality of Health Care; D018570:Risk Assessment; D012737:Sex Factors; D014481:United States; D014545:Urinary Calculi / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*