Shepard Courtney L, Wan Julian
University of Michigan Department of Urology, Division of Pediatric Urology, Ann Arbor, MI, USA.
University of Michigan Department of Urology, Division of Pediatric Urology, Ann Arbor, MI, USA.
J Pediatr Urol. 2017 Aug;13(4):389.e1-389.e6. doi: 10.1016/j.jpurol.2017.04.024. Epub 2017 Jun 20.
More pediatric patients seem to present to the emergency department (ED) for non-urgent matters after urologic procedures than adult patients. Under new and expanding healthcare reform, pediatric urologists may be penalized for these visits. We compare our 30-day postoperative bounceback rates to the ED and the acuity of the concerns in these populations.
All urology consults at our institution are maintained on a prospectively tracked database. We identified all patients who presented to our adult or pediatric ED between July 2013 and June 2015 within 30 days of a urologic procedure. We investigated the patient demographics including age, race, insurance, distance from the home zip code to the ED, procedures performed, chief complaint in the ED, diagnosis, and treatment required.
In our pediatric group, there were 67 visits for 56 patients (19 female, 37 male, mean age 6.8 years), which represents an overall bounceback incidence of 2.7%. Of those, 19% required admission (0.60% overall readmission rate), 10% underwent a procedure (0.32% reoperative rate, 18% required catheter manipulation/placement, 13% were given a prescription (most commonly for constipation), 6% required local wound care, and 33% were reassured only). Most pediatric patients had private insurance (62.5%) and those with private insurance or who were uninsured tended to require only reassurance compared to those with Medicare/Medicaid (p = 0.053). In the adult population, there were 369 visits in 310 patients (111 female, 199 male, mean age 55.4 years) for an incidence of 4.4%. Of those, 42% were admitted (2.2% overall readmission rate), 14% underwent a procedure (0.74% reoperative rate), 11% required catheter manipulation/placement, 14% were given medication (most commonly antibiotics and narcotics), 4% were given local wound care, and 12% were reassured. Most adult patients had Medicare/Medicaid (48.7%), but insurance type was not related to treatment required (p = 0.382). On multivariable analysis, pediatric patients, closer proximity to the hospital, and earlier postoperative day at presentation to the ED were predictive of requiring only reassurance.
Compared to adults, pediatric patients are less likely to return to the ED postoperatively (p < 0.001), but they are significantly more likely to require only reassurance (p < 0.001) while adults are significantly more likely to require hospital admission (p < 0.001). In both groups, nearly one-third of patients required only catheter care or medication. This difference could have significant implications for new healthcare policy.
与成年患者相比，更多接受泌尿外科手术后的儿科患者因非紧急事项前往急诊科（ED）就诊。在新的且不断扩展的医疗改革背景下，儿科泌尿科医生可能会因这些就诊情况而受到处罚。我们比较了我们的术后30天重返急诊科的比率以及这些人群中所关注问题的严重程度。
我们机构的所有泌尿外科会诊都记录在一个前瞻性跟踪数据库中。我们确定了2013年7月至2015年6月期间在泌尿外科手术后30天内前往我们成人或儿科急诊科就诊的所有患者。我们调查了患者的人口统计学特征，包括年龄、种族、保险类型、从家庭邮政编码到急诊科的距离、所进行的手术、在急诊科的主要投诉、诊断以及所需的治疗。
在我们的儿科组中，56名患者有67次就诊（19名女性，37名男性，平均年龄6.8岁），总体反弹发生率为2.7%。其中，19%需要住院（总体再入院率为0.60%），10%接受了手术（再次手术率为0.32%），18%需要进行导管操作/放置，13%开具了处方（最常见的是用于便秘），6%需要局部伤口护理，33%仅得到了安抚。大多数儿科患者有私人保险（62.5%），与有医疗保险/医疗补助的患者相比，有私人保险或无保险的患者往往仅需要安抚（p = 0.053）。在成人组中，310名患者有369次就诊（111名女性，199名男性，平均年龄55.4岁），发生率为4.4%。其中，42%被收治入院（总体再入院率为2.2%），14%接受了手术（再次手术率为0.74%），11%需要进行导管操作/放置，14%接受了药物治疗（最常见的是抗生素和麻醉药），4%接受了局部伤口护理，12%得到了安抚。大多数成年患者有医疗保险/医疗补助（48.7%），但保险类型与所需治疗无关（p = 0.382）。多变量分析显示，儿科患者、距离医院较近以及在前往急诊科时术后天数较早预示着仅需要安抚。
与成年人相比，儿科患者术后返回急诊科的可能性较小（p < 0.001），但他们仅需要安抚的可能性显著更高（p < 0.001），而成年人需要住院的可能性显著更高（p < 0.001）。在两组中，近三分之一的患者仅需要导管护理或药物治疗。这种差异可能对新的医疗政策有重大影响。
