Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Northwestern University, Department of Preventive Medicine, Division of Biostatistics, Chicago, IL, USA.
J Pediatr Urol. 2022 Dec;18(6):742.e1-742.e11. doi: 10.1016/j.jpurol.2022.07.005. Epub 2022 Jul 15.
Individuals with nephrolithiasis frequently present to the Emergency Department (ED). Safety and quality principles are often applied in pediatric EDs to children presenting with nephrolithiasis, such as limiting ionizing radiation exposure and opioid analgesics. However, it is unknown whether pediatric EDs apply these same principles to adult patients who present with nephrolithiasis. We hypothesized that adult patients would be associated with higher use of radiation-based imaging and opioid analgesics.
To assess variations in diagnostic and treatment interventions and hospital utilization between pediatric and adult patients presenting to the pediatric ED with nephrolithiasis.
A retrospective cohort study was conducted, examining outcomes for pediatric (<18-years-old) versus adult (≥18-years-old) patients in 42 pediatric EDs from 2009 to 2020 using the Pediatric Health Information System (PHIS) database. Patients with an ICD-9/10 principal diagnosis code of nephrolithiasis with no nephrolithiasis-related visits within the prior 6 months were included. Primary outcomes were imaging, medications, and surgical interventions. Secondary outcomes were hospital admissions, 90-day ED revisits, and 90-day readmissions. Generalized linear mixed models with random effects were used to adjust for confounding and clustering.
In total, 16,117 patients with 17,837 encounters were included. Most hospitals were academic (95.2%), and a plurality were located in the South (38.1%). Most patients were <18-years-old (84.4%, median (interquartile range): 15 (12-17)-years-old), female (57.9%), and White (76.3%), and 17.1% were Hispanic/Latino. Most had no complex chronic conditions (89.2%) and no chronic disease per pediatric medical complexity algorithm (51.5%). For the primary outcome, adults, relative to pediatric patients, who presented to the pediatric ED with nephrolithiasis had higher adjusted odds of receiving computerized tomography (CT) scans (Odds Ratio [OR] 1.43 [95% Confidence Interval [CI] 1.29-1.59]) and opioid analgesics (OR 1.45 [95%CI 1.33-1.58]) (Summary Figure). Secondary outcomes showed that adults, relative to pediatric patients, had lower adjusted odds of hospital admissions, 90-day ED revisits, and 90-day readmissions.
Our results suggest that certain pediatric safety and quality principles, such as limiting ionizing radiation exposure and opioid analgesic prescriptions, are not being equally applied to pediatric and adult patients who present to pediatric EDs with nephrolithiasis. The mechanism of these findings remains to be elucidated.
Variations in care for individuals with nephrolithiasis reflect an opportunity for quality improvement in pediatric EDs and inform work exploring optimal care pathways for all patients presenting to the pediatric ED with nephrolithiasis.
肾结石患者经常到急诊科就诊。安全和质量原则通常适用于儿科急诊科就诊的肾结石患儿，例如限制电离辐射暴露和阿片类镇痛药的使用。然而，目前尚不清楚儿科急诊科是否将这些相同的原则应用于因肾结石就诊的成年患者。我们假设成年患者与肾结石就诊的儿科急诊科的放射成像和阿片类镇痛药的使用相关。
评估儿科急诊科就诊的儿童和成年肾结石患者在诊断和治疗干预措施以及医院利用方面的差异。
这是一项回顾性队列研究，使用儿童健康信息系统（PHIS）数据库，对 2009 年至 2020 年间 42 家儿科急诊科的儿科（<18 岁）和成年（≥18 岁）患者的结局进行了评估。纳入标准为 ICD-9/10 主要诊断代码为肾结石，且在过去 6 个月内无肾结石相关就诊的患者。主要结局是影像学检查、药物治疗和手术干预。次要结局为住院、90 天内急诊科再就诊和 90 天内再入院。使用具有随机效应的广义线性混合模型进行调整，以控制混杂因素和聚类。
共纳入 16117 例患者，共 17837 次就诊。大多数医院为学术型（95.2%），多数位于南部（38.1%）。大多数患者<18 岁（中位数（四分位距）：15（12-17）岁），女性（57.9%），白人（76.3%），17.1%为西班牙裔/拉丁裔。大多数患者无复杂的慢性疾病（89.2%）和根据儿科医疗复杂程度算法确定的无慢性疾病（51.5%）。对于主要结局，与儿科患者相比，到儿科急诊科就诊的成年肾结石患者接受计算机断层扫描（CT）的调整后比值比（OR）更高（1.43[95%置信区间[CI]1.29-1.59]）和阿片类镇痛药（OR 1.45[95%CI 1.33-1.58]）（汇总图）。次要结局显示，与儿科患者相比，成年患者的住院、90 天内急诊科再就诊和 90 天内再入院的调整后比值比更低。
我们的结果表明，在限制电离辐射暴露和阿片类镇痛药处方等儿科安全和质量原则方面，儿科急诊科对因肾结石就诊的儿科和成年患者的应用并不一致。这些发现的机制仍有待阐明。
肾结石患者的护理差异反映了儿科急诊科在质量改进方面的机会，并为探索所有因肾结石就诊于儿科急诊科的患者的最佳护理途径提供了信息。
