Variation in Care between Pediatric and Adult Patients Presenting with Urolithiasis to Pediatric Emergency Departments in the United States (2009 - 2020)
Ryan F. Walton, B.S.1, Chen Yen, MS2, Rachel Shannon, MPH1, Ilina Rosoklija, MPH1, James T. Rague, MD1, Emilie K. Johnson, MD, MPH1, Jonathan S. Ellison, MD3, Jonathan C. Routh, MD, MPH4, Gregory E. Tasian, MD, MSc, MSCE5, David I. Chu, MD, MSCE1.
1Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA, 2Northwestern University, Department of Preventative Medicine, Division of Biostatistics, Chicago, IL, USA, 3Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA, 4Duke University Medical Center, Durham, NC, USA, 5The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Background: Individuals with urolithiasis frequently present to the Emergency Department (ED). Pediatric EDs often enact quality and safety policies for children who present with urolithiasis, such as limiting radiation-based imaging and opioid analgesics. However, it is unknown whether pediatric EDs treat adult patients with urolithiasis differently, which may reflect gaps in these policies. This study aimed to compare diagnostic and treatment choices, resource utilization, and outcomes between pediatric and adult patients presenting to the pediatric ED with urolithiasis. Methods: A retrospective cross-sectional study examining encounters in 42 pediatric EDs from 2009-2020 was conducted using the Pediatric Health Information System (PHIS) database. Patients with an ICD-9 or ICD-10 principal diagnosis of urolithiasis with no urolithiasis-related visits within 6 months prior were included. Primary outcomes were ED-related imaging and medications, surgical interventions, admissions, 90-day ED revisits, and 90-day readmissions. Outcomes were compared by age: pediatric (<18-years-old) versus adult (≥18-years-old). Covariates included stone location determined by ICD code, race, ethnicity, insurance, urbanicity, census region, admission year, presence of complex chronic conditions (CCC), and pediatric medical complexity algorithm categories (complex chronic disease, non-complex chronic disease, no chronic disease). Associations were fit using generalized linear mixed models to estimate odds ratios (OR) and 95% confidence intervals (95%CI) with random hospital and patient effects to account for clustering and repeat encounters. Results: A total of 16,117 patients with 17,837 encounters were included. Most hospitals were academic (95.2%) and plurality were located in the South (38.1%). Most patients were <18-years-old (84.4%), female (57.9%), and White (76.3%), with 17.1% being Hispanic/Latino. Most had commercial insurance (52.9%) and resided within an urban setting (89.4%). Most had no CCC’s (89.2%) and no chronic disease (51.5%). Primary analysis adjusted models (Table) showed that adults compared to pediatric patients had higher odds of receiving any imaging compared to none (OR 1.16, 95%CI 1.06-2.27), computerized tomography scans compared to abdominal x-rays/kidney ultrasound (OR 1.43, 95%CI 1.29-1.59), and opioid analgesics compared to none (OR 1.45, 95%CI 1.33-1.58). Adults were not significantly different from pediatric patients in receiving alpha-blockers compared to none, urinary diversion (i.e., ureteral stent or nephrostomy tube) compared to no procedure, definitive stone surgery compared to no procedure, and definitive stone surgery compared to urinary diversion. Relative to pediatric patients, adults had lower odds of hospital admission (OR 0.78, 95%CI 0.70-0.86), 90-day ED revisit (OR 0.72, 95%CI 0.63-0.83), and 90-day readmission (OR 0.74, 95%CI 0.64-0.86). Conclusions: In this exploratory study, adults ≥18-years-old presenting to pediatric EDs with urolithiasis, compared to pediatric patients, had similar odds of undergoing stone-related procedures and receiving alpha-blockers, lower odds of admissions, 90-day ED revisits, and 90-day readmissions, but higher odds of receiving any imaging, CT scans, and opioid analgesics. Whether these variations in care reflect opportunities to improve care delivery for all patients with urolithiasis who present to pediatric EDs warrants further investigation. 
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