Ureteral Stent Placement during Kidney Stone Surgery Associated with Higher Emergency Department Visits within the PEDSnet Learning Health Network
Gregory Edward Tasian, MD, MSc, MSCE1, Mitchell Maltenfort, PhD1, Kyle Rove, MD2, Christina Ching, MD3, Ahmed Bani-Hani, MD4, Nicolas Fernandex, MD, PhD5, Douglas Coplen, MD6, Christopher Forrest, MD, PhD1, Jonathan Ellison, MD7.
1The Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2Children's Hospital Colorado, Denver, CO, USA, 3Nationwide Children's Hospital, Columbus, OH, USA, 4Nemours, Wilmington, DE, USA, 5Seattle Children's Hospital, Seattle, WA, USA, 6St. Louis Children's Hospital, St. Louis, MO, USA, 7Children's Hospital Wisconsin, Milwaukee, WI, USA.
BACKGROUND: Ureteral stents are often employed before and after kidney stone surgery. While stents are known to cause adverse symptoms and impair daily activities, there has been little investigation on how ureteral stents impact unplanned care episodes among children having surgery for kidney and ureteral stones. Using data from PEDSnet, we assessed the association of ureteral stent placement before or concurrent with ureteroscopy (URS) and shockwave lithotripsy (SWL) on subsequent emergency department visits at six large health systems in the United States.
METHODS: We conducted a retrospective cohort study of individuals < 24 years of age who underwent URS or SWL for nephrolithiasis at the six pediatric hospitals in PEDSnet from January 2009 to December 2019. PEDSnet is a multi-instuitional clinical research network that has harmonized the diverse EHR systems of participating institutions to assemble a longitudinal database for >7 million children by transforming source institutional EHR data into the OMOP common data model. The comparators were presence or absence of ureteral stent placement within 60 days before or concurrent with URS or SWL. The outcome was all-cause emergency department (ED) visits within 120 days of the index procedure. Final parsimonious Poisson regression models were adjusted for race, distance to hospital, non-genitourinary chronic conditions defined by the pediatric medical complexity algorithm, and PEDSnet health system.
RESULTS: A total of 1,365 unique patients (58.4% female) of a median age of 13.8 years (IQR 10.9, 17.1) and a median follow-up of 1.8 years (IQR 0.6, 3.6) had 1,548 surgical episodes of which 1,359 had URS as an index surgery and 189 had SWL. An initial stent was used in 1,132 (73.1%) of URS episodes and 19 (10.1%) of SWL episodes. Placement of ureteral stents were associated with a higher rate of ED visits among all patients who had surgery (IRR 1.36; 95% CI 1.06 - 1.76) and patients having URS (IRR 1.35, 95% CI 1.04 - 1.77), but not for patients who had SWL (IRR 1.58, 95% CI 0.61 - 3.72).
CONCLUSIONS: Ureteral stent placement before or at the time of URS was associated with excess ED visits across 6 pediatric health systems compared to URS alone. These data suggest the potential utility in limiting stent placement to decrease unplanned medical care and morbidity for the growing population of youth with kidney stone disease.
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