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Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease.

ABSTRACT: PURPOSE:We determined the association between urology consultation and emergency department revisits for children with urinary stones. MATERIALS AND METHODS:This retrospective cohort study included patients 18 years old or younger who presented to an emergency department in South Carolina with a urinary stone from 1997 to 2015. The primary exposure was urology consultation during the index emergency department visit. The primary outcome was a stone related emergency department revisit occurring within 180 days of discharge from an index emergency department visit. Secondary outcomes included computerized tomography use, inpatient admission and emergent surgery. RESULTS:Of 5,642 index emergency department visits for acute urinary stones 11% resulted in at least 1 stone related emergency department revisit within 180 days. Of revisits 59% occurred within 30 days of discharge and 39% were due to pain. The odds of emergency department revisit were highest within the first 48 hours of discharge home (OR 22.6, 95% CI 18.0 to 28.5) and rapidly decreased thereafter. Urology consultation was associated with a 37% lower adjusted odds of emergency department revisit (OR 0.63, 95% CI 0.44 to 0.90) and 68% lower odds of computerized tomography use across all emergency department visits (OR 0.32, 95% CI 0.15 to 0.69). Among patients who revisited the emergency department the frequency of pain complaints was 27% in those with a urological consultation at the index visit and 39% in those without. CONCLUSIONS:Urology consultation was associated with decreased emergency department revisits and computerized tomography use in pediatric patients with urinary stones. Future studies should identify patients who benefit most from urology consultation and ascertain processes of care that decrease emergency department revisits among high risk patients.

SUBMITTER: Kurtzman JT

PROVIDER: S-EPMC6002942 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease.

Kurtzman Jane T JT Song Lihai L Ross Michelle E ME Scales Charles D CD Chu David I DI Tasian Gregory E GE

The Journal of urology 20180221 1

<h4>Purpose</h4>We determined the association between urology consultation and emergency department revisits for children with urinary stones.<h4>Materials and methods</h4>This retrospective cohort study included patients 18 years old or younger who presented to an emergency department in South Carolina with a urinary stone from 1997 to 2015. The primary exposure was urology consultation during the index emergency department visit. The primary outcome was a stone related emergency department rev ...[more]

PMID: 29474848

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Project description:ObjectivesKidney stones affect nearly one in 11 persons in the United States, and among those experiencing symptoms, emergency care is common. In this population, little is known about the incidence of and factors associated with repeat emergency department (ED) visits. The objective was to identify associations between potentially mutable factors and the risk of an ED revisit for patients with kidney stones in a large, all-payer cohort.MethodsThis was a retrospective cohort study of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. A multivariable regression model was created to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of repeat ED visits. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.ResultsAmong 128,564 patients discharged from emergent care, 13,684 (11%) had at least one additional emergent visit for treatment of their kidney stone. In these patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit. On multivariable analysis, the risk of an ED revisit was associated with insurance status (e.g., Medicaid vs. private insurance; odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.43 to 1.61; p < 0.001). Greater access to urologic care was associated with lower odds of an ED revisit (highest quartile OR = 0.88, 95% CI = 0.80 to 0.97; p < 0.01 vs. lowest quartile). In exploratory models, performance of a complete blood count was associated with a decreased odds of revisit (OR = 0.86, 95% CI = 0.75 to 0.97; p = 0.02).ConclusionsRepeat high-acuity care affects one in nine patients discharged from initial emergent evaluations for kidney stones. Access to urologic care and processes of care are associated with lower risk of repeat emergent encounters. Efforts are indicated to identify preventable causes of ED revisits for kidney stone patients and design interventions to reduce the risk of high-cost, high-acuity, repeat care.

Project description:Studies in Europe have found that immigrants, compared to the local population, are more likely to seek out medical care in Emergency Departments (EDs). In addition, studies show that immigrants utilize medical services provided by EDs for less acute issues. Despite these observed differences, little is known about the characteristics of ED use by North African (NA) immigrants. The main objective of this study was to examine whether there were differences in ED discharge outcomes and psychiatric referrals between NA immigrants and Swiss nationals. A retrospective analysis was conducted using patient records from NA and Swiss adults who were admitted to the ED of the University Hospital in Bern (Switzerland) from 2013⁻2016. Measures included demographic information as well as data on types of admission. Outcome variables included discharge type and psychiatric referral. A total of 77,619 patients generated 116,859 consultations to the ED, of which 1.1 per cent (n = 1338) were consultations by NA patients. Compared to Swiss national patients, NA patients were younger, with a median age of 38.0 (IQR 28⁻51 years vs. 52.0 (IQR 32⁻52) for Swiss and predominantly male (74.4% vs. 55.6% in the Swiss). NA patient admission type was more likely to be "walk-in" or legal admission (7.5% vs 0.8 in Swiss,). Logistic regressions indicated that NA patients had 1.2 times higher odds (95% CI 1.07⁻1.40, p < 0.003) of receiving ambulatory care. An effect modification by age group and sex was observed for the primary outcome "seen by a psychiatrist", especially for men in the 16⁻25 years age group, whereby male NA patients had 3.45 times higher odds (95% CI: 2.22⁻5.38) of having being seen by a psychiatrist. In conclusion differences were observed between NA and Swiss national patients in ED consultations referrals and outcomes, in which NA had more ambulatory discharges and NA males, especially young, were more likely to have been seen by psychiatrist. Future studies would benefit from identifying those factors underlying these differences in ED utilization.

Project description:BackgroundTo develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.Methods and findingsA secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit ('index' visit), in 2012-2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7-2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65-0.74) and summary calibration slope of 0.83 (95% CI 0.67-0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87-5.01) and specificity 0.96 (95% CI 0.95-0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25-0.35), sensitivity 0.88 (95% CI 0.86-0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68-0.75) and summary calibration slope of 0.84 (95% CI 0.71-0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.ConclusionWe developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Project description:BackgroundThe proportion of Canadian youth seeking mental health support from an emergency department (ED) has risen in recent years. As EDs typically address urgent mental health crises, revisiting an ED may represent unmet mental health needs. Accurate ED revisit prediction could aid early intervention and ensure efficient healthcare resource allocation. We examine the potential increased accuracy and performance of graph neural network (GNN) machine learning models compared to recurrent neural network (RNN), and baseline conventional machine learning and regression models for predicting ED revisit in electronic health record (EHR) data.MethodsThis study used EHR data for children and youth aged 4-17 seeking services at McMaster Children's Hospital's Child and Youth Mental Health Program outpatient service to develop and evaluate GNN and RNN models to predict whether a child/youth with an ED visit had an ED revisit within 30 days. GNN and RNN models were developed and compared against conventional baseline models. Model performance for GNN, RNN, XGBoost, decision tree and logistic regression models was evaluated using F1 scores.ResultsThe GNN model outperformed the RNN model by an F1-score increase of 0.0511 and the best performing conventional machine learning model by an F1-score increase of 0.0470. Precision, recall, receiver operating characteristic (ROC) curves, and positive and negative predictive values showed that the GNN model performed the best, and the RNN model performed similarly to the XGBoost model. Performance increases were most noticeable for recall and negative predictive value than for precision and positive predictive value.ConclusionsThis study demonstrates the improved accuracy and potential utility of GNN models in predicting ED revisits among children and youth, although model performance may not be sufficient for clinical implementation. Given the improvements in recall and negative predictive value, GNN models should be further explored to develop algorithms that can inform clinical decision-making in ways that facilitate targeted interventions, optimize resource allocation, and improve outcomes for children and youth.

Dataset Information

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease.

Publications

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease.

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