Assessment of Readmission Rates Following Surgical Management of Urolithiasis Using a New Nationally Representative Database
Brian J. Young, MD, Rohit Tejwani, MS, Ruiyang Jiang, MD, Hsin-Hsiao S. Wang, MD, MPH, Steven Wolf, MS, J. Todd Purves, MD, PhD, John S. Wiener, MD, Jonathan C. Routh, MD, MPH.
Duke University Medical Center, Durham, NC, USA.
Background: Diagnosis rates, treatment rates, and hospital-based costs of urolithiasis are all significantly increasing among children in the United States. With several possible surgical approaches to stone management, there is little data directly comparing the outcomes and need for readmission between procedures. Our objective was to use a new, nationally representative database to track readmission rates after pediatric inpatient, stone-related surgery. We hypothesized that readmission rates would differ depending on the initial procedure performed.
Methods: We analyzed the 2013 Nationwide Readmissions Database (NRD), one of a family of databases in the Healthcare Cost and Utilization Project. The NRD is designed to address a significant limitation of previous national databases: the ability to track hospital readmissions. The database is constructed using inpatient data from 21 states with reliable patient linkage to track readmissions. NRD represents 49% of the U.S. population. 2013 is the first and only year of data released to date. We used ICD-9 codes to identify children (<18 y) diagnosed with upper tract urolithiasis (592.0, 592.1) treated with ureteroscopy (URS), shock wave lithotripsy (SWL), or percutaneous nephrolithotomy (PCNL) during an inpatient admission. Patients with neurogenic bladder, ureterocele, megaureter, posterior urethral valves, bladder exstrophy, kidney transplant or prune belly syndrome were excluded. We also excluded encounters from January, to track patients stented prior to stone treatment, and encounters at the end of the calendar year to ensure a 90-day follow-up window. Weighted descriptive statistics were calculated to describe the population’s demographics. Our primary outcome was 30- and 90-day readmission rates. We performed a weighted multivariable regression adjusting for age, gender, insurance payer, Van Walraven comorbidity score, and hospital to estimate readmission risk.
Results: We identified 137 encounters (29 SWL, 46 URS, 62 PCNL) meeting inclusion criteria. There were no significant differences in age, gender, insurance provider, or Van Walraven score between the 3 groups. Groups differed in stone location; 45% of patients treated with SWL had renal stones compared to 84% of PCNL and 33% of URS patients. There was no significant difference in 30-day readmission rates between the groups, but 90-day readmission rates were significantly higher for PCNL (29%) than for URS (11%), or SWL (3%) (p=0.003). The number of 90 day readmissions also varied among groups; 15% of patients treated with PCNL were readmitted ≥2 times, while no patients were readmitted more than once after ESWL or URS (p=0.03). On multivariable analysis, patients treated with PCNL had an increased risk of readmission within 90 days compared to ESWL (OR=13.8, 95% CI 2-94, p=0.01).
Conclusions: There is significant variation in readmission rates following inpatient stone surgery, even after adjusting for patient comorbidity. The National Readmissions Database may serve as an important tool for future comparative effectiveness studies and optimization of surgical care.
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