1 Loyola University Medical Center, Department of Urology, Maywood, Illinois.
2 Southern Illinois University School of Medicine, Division of Urology, Springfield, Illinois.
J Endourol. 2019 Feb;33(2):167-172. doi: 10.1089/end.2018.0760. Epub 2019 Jan 31.
Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality.
The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared.
We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients.
Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.
因急性非感染性尿路结石住院的患者适合接受药物排石治疗、输尿管支架置入或直接输尿管镜检查（URS）。我们旨在评估影响尿路结石治疗决策的社会经济因素，并根据治疗方式确定结果差异。
使用了 2007 年至 2011 年加利福尼亚州的医疗保健成本和利用项目州住院数据库、州门诊手术和服务数据库以及州急诊数据库，以及 2009 年至 2014 年佛罗里达州的州住院数据库、州门诊手术和服务数据库以及州急诊数据库。确定了以肾脏或输尿管结石为主要诊断而住院的患者。评估了最初使用的治疗方式，并分析了影响该决策的因素。使用多元逻辑回归模型确定与直接 URS 独立相关的因素。最后，比较了单独支架置入与 URS 治疗的非感染患者的结果。
我们确定了 146199 例患有尿路结石的住院患者。总体而言，45%的患者在评估时未进行干预。在接受手术干预的 55%患者中，42%接受单独支架置入，44%接受直接 URS，1%接受经皮肾造瘘管放置，8%接受体外冲击波碎石术，5%接受经皮肾镜取石术。多元逻辑回归模型显示，少数民族、年轻患者、无公共保险的患者、合并症更多的患者、周末入院的患者和入院于学术机构的患者接受直接 URS 的可能性显著降低。二次分析表明，在符合条件的患者中，直接 URS 与单独支架置入相比具有临床和节省成本的优势。
直接 URS 是一种被忽视的手术，具有临床和节省成本的意义。不幸的是，少数民族、有公共保险的患者和周末入院的患者接受直接 URS 的可能性较低，这是泌尿科医生应该解决的差异。
