Justin B. Ziemba

Guideline of guidelines: kidney stones

Several professional organizations have developed evidence‐based guidelines for the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. The purpose of this article is to summarize these guidelines with reference to the strength of evidence. All guidelines endorse an initial evaluation to exclude concomitant infection, imaging with a non‐contrast computed tomography scan, and consideration of medical expulsive therapy or surgical intervention depending on stone size and location. Recommends for metabolic evaluation vary by guideline, but all endorse increasing fluid intake to reduce the risk of recurrence.

Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care. Choosing Wisely initiatives from numerous professional societies have identified repetitive laboratory testing in the face of clinical stability as low value care. Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes. To date, numerous interventions have been deployed across multiple institutions without a standardized approach. Health care professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing. This review presents an evidence-based implementation blueprint to guide teams aimed at improving appropriate routine laboratory testing among hospitalized patients.

Patient and Institutional Characteristics Associated with Initial Computerized Tomography in Children Presenting to the Emergency Department with Kidney Stones

PURPOSE Professional associations recommend ultrasound as the initial imaging study in children with suspected nephrolithiasis but computerized tomography remains frequently used. We identified patient and institutional characteristics associated with computerized tomography as the first imaging study in children with nephrolithiasis diagnosed in the emergency department. MATERIALS AND METHODS We performed a cross-sectional study of children 2 to 18 years old with nephrolithiasis who were referred to a freestanding pediatric hospital from 2003 to 2012. We identified the imaging modality first used to evaluate the child. Medical directors at the emergency department where children were first evaluated were sent a questionnaire to ascertain emergency department characteristics. Multivariate hierarchical logistic regression models were used to determine patient and institutional characteristics associated with initial computerized tomography. RESULTS Of 536 eligible children 323 (60.2%) were evaluated at emergency departments from which surveys were returned. Of the 323 children 238 (71%) underwent computerized tomography as initial imaging. Ultrasound was available at all emergency departments. Older patient age was associated with higher initial computerized tomography use (OR 1.09, 95% CI 1.04-1.16). A more recent year of diagnosis (OR 0.80, 95% CI 0.72-0.88) and a clinical care pathway that used ultrasound as initial imaging (OR 0.29, 95% CI 0.01-0.38) were associated with lower initial computerized tomography use. CONCLUSIONS A clinical care pathway in the emergency department was the only institutional characteristic associated with lower computerized tomography use. Future studies are needed to determine whether care pathways using ultrasound for initial imaging in children with suspected nephrolithiasis would decrease inappropriate computerized tomography and improve adherence to national guidelines.

Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial

Importance Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration. Objective To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. Design, Setting, and Participants The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions. Interventions Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. Main Outcomes and Measures Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. Results The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, −0.002 to 0.09; P = .06) or associated fees (

Consumer preferences and online comparison tools used to select a surgeon

0.24 per patient-day; 95% CI, −

Epidemiology and economics of nephrolithiasis

0.42 to

Flexible Ureteroscopy in Children with von Willebrand Disease

0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: −0.16; 95% CI, −0.31 to −0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: −0.01; 95% CI, −0.02 to −0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001). Conclusions and Relevance Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees. Trial Registration clinicaltrials.gov Identifier: NCT02355496

The clinical presentation and outcome of urothelial atypia on biopsy of the bladder.

Consumer Preferences and Online Comparison Tools Used to Select a Surgeon The public reporting of physician quality is mandated by the US federal government and made accessible through the website Physician Compare.1 However, Physician Compare is only 1 of several online resources that provide physician ratings to consumers.2 Despite the widespread availability of this information, little is known about how consumers use it to make decisions regarding health care, particularly when selecting a surgeon.

Unilateral Hypercalciuria: A Stealth Culprit in Recurrent Ipsilateral Urolithiasis in Children

Nephrolithiasis is a disease common in both the Western and non-Western world. Several population based studies have demonstrated a rising prevalence and incidence of the disease over the last several decades. Recurrence occurs frequently after an initial stone event. The influence of diet on the risk of nephrolithiasis is important, particularly dietary calcium and fluid intake. An increasing intake of dietary calcium and fluid are consistently associated with a reduced risk of incident nephrolithiasis in both men and women. Increasing evidence suggests that nephrolithiasis is associated with systemic diseases like obesity, diabetes, and cardiovascular disease. Nephrolithiasis places a significant burden on the health care system, which is likely to increase with time.

Trends in the Setting and Cost of Ambulatory Urological Surgery: An Analysis of Five States in the Healthcare Cost and Utilization Project

BACKGROUND AND PURPOSE Treatment options for urolithiasis include shockwave lithotripsy (SWL), percutaneous nephrostolithotomy (PCNL), and ureteroscopy. While these treatment options are becoming the standard of care in the pediatric population, children with a bleeding dyscrasia must be approached differently. We report our flexible ureteroscopic experience in children with von Willebrand disease (vWd). PATIENTS AND METHODS A review of a prospectively maintained database of stone patients was performed. Children with a bleeding diathesis were identified. Stone burden, operative access, intraoperative complications, postoperative complications, stone-free status, and perioperative medical management were evaluated. RESULTS During a 7-year period, a total of five children with a bleeding disorder underwent 7 ureteroscopic and 10 cystoscopic procedures for urinary calculi. The mean patient age was 72.4 months (range 49-123 mos) at the time of the procedure. There were three boys and two girls. Mean follow-up was 29.7 months (range 8-79 mos). Mean stone burden was 6.1 mm (range 3-14 mm) with an average of 1.3 stones per patient. Four patients were known to have vWd before surgical intervention and were pretreated with desmopressin acetate. The remaining patient was found to have vWd based on significant bleeding after ureteral stent placement. No ureters were actively dilated. Flexible ureteroscopy was performed in all cases regardless of stone location. Stone clearance was 100% (7/7). Complications occurred in 6% of procedures (1/17). CONCLUSIONS Ureteroscopy is a safe and efficacious modality in the management of urolithiasis in children with a bleeding abnormality. Perioperative medical management of the bleeding diathesis may help reduce complications.