Early Intervention during Acute Stone Admissions: Revealing “The Weekend Effect” in Urological Practice

Nephrolithiasis is rapidly increasing in the United States, with approximately 10% of the population experiencing a case of nephrolithiasis. Though it is not needed to treat acute stone diseases promptly, it is suggested that patients with obstructive stones in the setting of infection and/or sepsis should receive decompressive intervention urgently. Failure of timely operative intervention has been show to contribute to serious complications, including an increase in patient mortality. This study looks at analyzing patient factors that contribute to delayed intervention during acute stone admission.

The investigators retrospectively reviewed the HCUP SID (Health-care Cost and Utilization Project State Inpatient Database) for Florida and California from 2007 to 2011. A total of 10,301 patients were admitted for this study. The cutoff for early vs delayed intervention was 2 days (IQR 1-3); thus procedures performed within 48 hours were considered timely, and those performed after were considered delayed. Other demographic factors that were included were age at presentation, race, and primary insurance provider. Date of procedure was also taken down to compare weekend versus weekday admission. Univariate analysis was performed comparing patients undergoing intervention within 48 hours and after, and student’s independent t-test and Pearson’s chi-squared test were used for continuous and categorical variable, respectively.

The results of the study showed that early intervention was associated with a decrease in mortality when compared to delayed intervention (0.16% vs 0.47%, p=0.002). On multivariate analysis timely intervention significantly decreased the odds of inpatient morality (OR 0.43, p=0.044). Patients who went through delayed intervention were older, more likely to be non-Caucasian race, carry public insurance, to be admitted on a weekend, and to have higher rates of medical comorbidity. Patients who went through early intervention had improved outcomes, with decrease rates of new renal insufficiency (1% vs 1.8%, p=0.001) and inpatient mortality (0.16% vs 0.47%, p=0.002).

The findings of increased mortality with delayed decompressive intervention post similar results with Borofsky et al. The day of the week for patient’s admission to the hospital was the most significant factor to target for improvement in intervention. This phenomenon is known as the “the weekend effect.” The implication of this is that clinicians should strive to deliver same quality care throughout the whole week, including both weekdays and weekens. Further studies need to be done to determine why race and insurance type contribute to significant delays in care. The authors acknowledge some limitations of the study, including its data from administrative data, which did not include several other patient level variables that may impact care. In conclusion, clinicians should be aware of these discrepancies when performing decompressive interventions, in order to improve procedures related to acute stone admissions.

Authors: Robert H. Blackwell, Gregory J. Barton, Anai N. Kothari, Matthew A. C. Zapf, Robert C. Flanigan, Paul C. Kuo and Gopal N. Gupta

Affiliations: From the Departments of Urology (RHB, RCF, GNG) and Surgery (ANK, PCK, GNG), the Stritch School of Medicine (GJB, MACZ), and the 1:MAP Surgical Analytics Group (RHB, ANK, MACZ, RCF, PCK, GNG), Loyola University Medical Center, Maywood, Illinois

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Reference:

Scales CD Jr, Smith AC, Hanley JM et al: Prevalence of kidney stones in the United States. Eur Urol 2012; 62: 160.
Preminger GM, Tiselius HG, Assimos DG et al: 2007 guideline for the management of ureteral calculi. J Urol 2007; 178: 2418.
Borofsky MS, Walter D, Shah O et al: Surgical decompression is associated with decreased mortality in patients with sepsis and ureteral calculi. J Urol 2013; 189: 946.
Zapf MA, Kothari AN, Markossian T et al: The “weekend effect” in urgent general operative procedures. Surgery 2015; 158: 508.

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