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

Ryan F. Walton, Chen Yeh, Rachel Shannon, Ilina Rosoklija, James T. Rague, Emilie K. Johnson, Elizabeth R. Alpern, Jonathan S. Ellison, Jonathan C. Routh, Gregory E. Tasian, David I. Chu*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

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.[Formula

Original languageEnglish (US)
Pages (from-to)742.e1-742.e11
JournalJournal of Pediatric Urology
Volume18
Issue number6
DOIs
StatePublished - Dec 2022

Funding

This work was supportedin part by research grants from the National Institute of Diabetes and Digestive and Kidney Diseases (K23 DK125670) to Dr. David I. Chu. The NIH and NIDDK had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the official view of the NIH or NIDDK. Thank you to the Children's Hospital Association PHIS team for assisting with building the cohort within the PHIS Business Objects and navigating the nuances of the PHIS database.

Keywords

  • Computerized tomography scans
  • Nephrolithiasis
  • Opioid analgesics
  • Pediatric emergency department
  • Quality improvement
  • Safety principles

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Urology

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