*Department of Emergency Medicine,University of Calgary,Calgary,AB.
‡Department of Emergency Medicine,University of British Columbia,Vancouver,BC.
CJEM. 2018 Sep;20(5):702-712. doi: 10.1017/cem.2018.31. Epub 2018 Apr 4.
Some centres favour early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems.
We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modelling was performed to adjust for covariate imbalance.
We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.9% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rates (52.1% v. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other.
An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.
一些中心主张对输尿管绞痛进行早期干预，而另一些中心则倾向于尝试自发性排石，但其相对结果描述不佳。卡尔加里和温哥华具有相似的人群和医生专业知识，但在处理输尿管绞痛方面采用了不同的方法。我们研究了在这两个不同系统中，首次因输尿管绞痛到急诊科就诊的患者在 60 天内的住院和干预率。
我们使用行政数据和结构化病历回顾研究了 2014 年在温哥华和卡尔加里因输尿管绞痛就诊的所有患者。患者的人口统计学特征、就诊特征和分诊类别均从急诊科信息系统中获取，而急诊科就诊和入院则从相关的区域医院数据库中获取。实验室结果从电子健康记录中获取，结石特征从诊断影像报告中提取。我们的主要结局是 0 至 60 天内的住院或泌尿科干预。次要结局包括急诊科复诊、再入院和抢救干预。采用时间事件分析，并进行 Cox 比例风险模型分析以调整协变量不平衡。
我们研究了 3283 例 CT 定义的结石患者。两个城市的患者和结石特征相似。60.9%的卡尔加里患者和 31.3%的温哥华患者需要住院或接受干预（p<0.001）。卡尔加里患者的初始干预率更高（52.1%比 7.5%），且在随访期间更频繁地出现急诊科复诊和住院再入院。数据表明，结局事件与一个城市中对小结石的过度治疗以及另一个城市中对大结石的治疗不足有关。
早期介入治疗方法与更高的急诊科复诊、住院和干预率相关。如果这些事件是患者残疾的标志物，那么对小结石采取较少介入的方法，并对大结石进行更早的确定性治疗，可能会减少系统利用并改善急性输尿管绞痛患者的结局。
