Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones

Variation in care between pediatric and adult patients presenting with nephrolithiasis to tertiary care pediatric emergency departments in the United States (2009-2020)

BACKGROUND

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.

OBJECTIVE

To assess variations in diagnostic and treatment interventions and hospital utilization between pediatric and adult patients presenting to the pediatric ED with nephrolithiasis.

STUDY DESIGN

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSIONS

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.

Variability in advanced imaging of pediatric neck infections in US emergency departments

OBJECTIVES

To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs).

METHODS

This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals.

RESULTS

There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan.

CONCLUSIONS

Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.

Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway

OBJECTIVE

To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care.

MATERIALS AND METHODS

The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge.

RESULTS

441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs. 23%, p<0.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs. 62%, p<0.001), and were less likely to return to the ED within 30 days (13% vs. 2%, p=0.01). These measures demonstrated special cause variation following Pathway release.

CONCLUSIONS

Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.

A clinical pathway to minimize computed tomography for suspected nephrolithiasis in children

INTRODUCTION

Ultrasound (US) imaging is preferred in the initial evaluation for children with suspected nephrolithiasis; however, computed tomography (CT) continues to be used in this setting with resultant unnecessary ionizing radiation exposure. The study institution implemented a standardized clinical pathway to reduce rates of CT utilization for children with nephrolithiasis.

OBJECTIVE

The aim of this study was to evaluate the impact of this pathway on initial imaging strategies for children with suspected nephrolithiasis.

STUDY DESIGN

A standardized pathway was designed and implemented using a systematic quality improvement process. A suspected cohort was created using 'reason for study' search terms consistent with a nephrolithiasis diagnosis. A confirmed cohort of children with a final diagnosis of nephrolithiasis was derived from this suspected cohort. The primary outcome was CT use as the initial imaging study in children with suspected or confirmed nephrolithiasis presenting to the emergency department (ED) between October 2013 and February 2018. Comparisons were made before and after pathway implementation (October 2015). Secondary outcomes included rates of CT scan within 30 days, while balancing measures included rates of admission, ED length of stay, and return visits.

RESULTS

A total of 534 children with suspected (220 prepathway; 314 postpathway) and 90 children with confirmed (37 prepathway; 53 postpathway) nephrolithiasis were included. For the suspected cohort, CT scans performed as the initial imaging evaluation (9.2% vs 2.5%, P = 0.001) and at any time during the index visit (15.7% vs 5.7%, P = 0.001) decreased after pathway implementation. Within the confirmed cohort, a non-significant decrease in initial CT rates was observed after implementation. No differences were observed in admission rates or ED length of stay after implementation. A trend toward lower return visits to the ED was seen after pathway implementation (5.5% vs 2.2%, P = 0.058).

DISCUSSION

Within a tertiary care pediatric ED associated with a strong institutional experience with clinical pathways, initial CT rates were decreased after pathway implementation for children with suspected nephrolithiasis. While retrospective assessment of suspected disease is limited, this is one of the first studies to address imaging patterns for nephrolithiasis beyond the final discharge diagnosis, thus capturing a broader cohort of children. Children with suspected nephrolithiasis can be safely managed with an US-first approach, and postvisit CT scans are rarely necessary for management.

CONCLUSIONS

A standardized clinical pathway for suspected nephrolithiasis can reduce rates of initial and overall CT utilization without adversely impacting downstream care.

Follow-up imaging after acute evaluations for pediatric nephrolithiasis: Trends from a National database

BACKGROUND

Overuse of computed tomography (CT) in the initial evaluation of children with upper urinary tract calculi (UUTC) has been well documented. Follow-up imaging patterns, however, remain undefined. Sequential imaging following an acute episode of UUTC represents additional opportunity for enacting good imaging stewardship, with the optimal goal to reduce unnecessary radiation exposure and cost while ensuring appropriate follow-up.

OBJECTIVE

We explored nationwide imaging patterns for children following emergency department (ED) evaluations for UUTC, hypothesizing that initial imaging choice and complicated visits for UUTC increase the risk of follow-up CT scans.

STUDY DESIGN

Claims from Marketscan (2007-2013), an employer-based dataset of privately insured patients, were used to assess children aged 1-18 years presenting to the ED an acute UUTC event. The primary outcome was any imaging within 90 days. Using logistic regression, odds for follow-up CT or plain film kidney-ureter-bladder/ultrasound (KUB/US) imaging were calculated adjusting for patient demographics, initial imaging modality, need for admission, and return ED visits.

RESULTS

A total of 821 children met the inclusion criteria, of whom 261 (31.8%) received no follow-up imaging. Overall follow-up imaging patterns, including the proportions of children receiving CT scans, KUB/US imaging, or no imaging are shown in the Summary Table. Of the children receiving follow-up imaging, KUB/US was obtained in 363 (65.0%) and CT obtained in 197 (35.0%) children. Risk factors for follow-up CT imaging include hospital admission and return ED visits. Children with ureteral calculi and index US evaluation were more likely to receive KUB/US imaging only at follow-up. For children with ureteral calculi, the median time to first follow-up imaging was 9 days (25th-75th percentiles, 2-26 days).

DISCUSSION

One-third of all children with follow-up imaging after an acute presentation for UUTC will receive a CT. Up to 28% of children with a ureteral calculus will not receive any follow-up imaging within 3 months of presentation. These findings suggest imaging strategies for children following acute evaluation for nephrolithiasis are suboptimal in two ways. First, children receive potentially unnecessary additional radiation burden, an alarming finding considering the high rates of CT scan in the index evaluation for these children. Second, many children with ureteral calculi fail to receive follow-up imaging to document stone passage.

CONCLUSIONS

Our findings identify follow-up imaging as another area for quality improvement within the care of children with UUTC. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging practices and initial evaluation, especially with for those children presenting with ureteral calculi.

Approaches to Eliminate Radiation Exposure in the Management of Pediatric Urolithiasis

PURPOSE OF REVIEW

Traditional management of pediatric urolithiasis has been associated with a significant amount of radiation exposure. The steady increase in pediatric urolithiasis in recent years has raised concerns of long-term consequences in this special population. This review seeks to highlight the newer insights towards eliminating radiation exposure in pediatric urolithiasis from contemporary literature.

RECENT FINDINGS

Establishing a clinical care pathway restricting usage of computed tomography in emergency rooms in suspected pediatric urolithiasis can eliminate unnecessary radiation exposure. Ultrasound can successfully replace fluoroscopy at ureteroscopy and percutaneous nephrolithotomy. Accredited technicians who use optimized settings combined with dose monitoring can significantly reduce fluoroscopic radiation. Radiation exposure in pediatric urolithiasis can be significantly reduced and potentially eliminated by employing standard protocols during workup, intervention, and follow-ups. Larger studies can support the feasibility of routinely performing ultrasound-guided surgeries instead of fluoroscopy. There is a need for development of consensus towards standardization of the management of pediatric urolithiasis.

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain

OBJECTIVES

To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014.

METHODS

We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength of the association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables.

RESULTS

Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [CI], 13.2%-16.0%) had CT imaging only, 10.9% (95% CI, 9.7%-12.1%) had ultrasound imaging only, and 1.9% (95% CI, 1.4%-2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period (P trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% CI, 0.17-0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% CI, 1.29-3.55).

CONCLUSIONS

CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children.

Use of Ultrasound in Pediatric Renal Stone Diagnosis and Surgery

Pediatric urolithiasis is on the rise globally and incidence rates have risen by 6-10% annually over the past couple of decades. Given the increasing incidence, high likelihood of recurrence, and long life expectancy of children, the use of ionizing radiation in the diagnosis, management, and follow up of pediatric urolithiasis has been scrutinized recently and many institutions and organizations have emphasized the use of non-ionizing imaging modality such as ultrasound. This review examines the use of ultrasound in the diagnosis and treatment of pediatric urolithiasis. Specifically, the role of ultrasound in shockwave lithotripsy, percutaneous nephrolithotomy, and, more recently, ureteroscopy will be examined.

Clinical effectiveness in the diagnosis and acute management of pediatric nephrolithiasis

The incidence of pediatric nephrolithiasis has risen over the past few decades leading to a growing public health burden. Children and adolescents represent a unique patient population secondary to their higher risks from radiation exposure as compared to adults, high risk of recurrence, and longer follow up time given their longer life expectancies. Ultrasound imaging is the first-line modality for diagnosing suspected nephrolithiasis in children. Although data is limited, the best evidence based medicine supports the use of alpha-blockers as first-line MET in children, especially when stones are small and in a more distal ureteral location. Surgical management of pediatric nephrolithiasis is similar to that in adults with ESWL and URS first-line for smaller stones and PCNL reserved for larger renal stone burden. Clinical effectiveness in minimizing risks in children and adolescents with nephrolithiasis centers around ED pathways that limit CT imaging, strict guidance to ALARA principles or use of US during surgical procedures, and education of both patients and families on the risks of repeat ionizing radiation exposures during follow up and acute colic events.

Is the Economic Impact and Utilization of Imaging Studies for Pediatric Urolithiasis Across the United States Increasing?

OBJECTIVE

To identify longitudinal trends of economic impact and resource utilization for management of pediatric urolithiasis using national databases.

METHODS

We analyzed the 2006-2012 Nationwide Emergency Department Sample and Nationwide Inpatient Sample. We used ICD-9 (International Classification of Diseases) codes to identify patients (≤18 years) diagnosed with urolithiasis. Diagnostic imaging and surgeries were identified using ICD-9 and Current Procedural Technology codes. We abstracted demographic, imaging, procedure, and charge data. Weighted descriptive statistics were calculated to describe the population's demographics and economic expenditures by clinical setting and year.

RESULTS

In total, 45,333 inpatient admissions (68% females) and 234,559 emergency department encounters (63% females) were identified. Most patients (84%) were teenagers and the southern region of the United States was the most common geographic region for all encounters (44%). There was no significant trend in number of urolithiasis encounters over the period studied. Utilization of all imaging techniques increased; in particular, computed tomography was used in 23% of encounters in 2006 and 40% in 2012 (P < .0001). The mean charge per emergency department visit increased by 60% from $3645 in 2006 to $5827 in 2012 (P < .0001). The mean charge increased for inpatient admissions by 102%, from $16,399 in 2006 to $33,205 in 2012 (P < .0001). Total charges increased 72% over the study period from $230 million in 2006 to $395 million in 2012 (P < .0001), outpacing medical inflation over the same period.

CONCLUSION

Charges for pediatric urolithiasis management increased by 65% from 2006 to 2012 despite stable frequency of patient encounters. The utilization of computerized tomography in pediatric urolithiasis increased as well.

Pediatric Kidney Stones - Avoidance and Treatment

Pediatric stone disease is increasing in incidence and healthcare costs. With more years at-risk for stone recurrence during their lifetimes, children with nephrolithiasis constitute a high-risk patient population that requires focused intervention through both medical and surgical means. Through high-quality future studies to compare methods of stone prevention and treatment, the burden of stone disease on the youngest members of society may be ameliorated.