Suzanne Neises

Unsuccessful Medical Expulsive Therapy: A Cost to Waiting?

OBJECTIVE To compare clinical outcomes between patients with ureteral stones who underwent an unsuccessful trial of medical expulsive therapy (MET) and patients who did not attempt MET. METHODS We reviewed the clinical records of all potential candidates for MET who were referred from the emergency department to a subspecialty stone clinic. RESULTS Of 348 potential candidates, 133 patients (38%) went directly to surgery (NMET) and 215 patients (62%) initiated MET. In the latter group, MET was unsuccessful in 45 patients (21%) (UMET). Stone symptoms were the primary rationale for surgery in 20 (44%) UMET patients and 69 (52%) NMET patients. The UMET patients were more likely to be younger and have smaller, more distal stones than NMET patients. All stones were cleared by ureteroscopy. The average interval from stone clinic assessment to surgery was longer in the UMET patients (17 days) than in the NMET patients (1 day; P <.001). The UMET patients underwent more preoperative computed-tomography scans (2.1) than did the NMET patients (1; P <0.001). There were no differences between the 2 groups in the residual stone burden, pre- or postoperative repeat visits to the emergency department, or repeat surgery. CONCLUSION In this population, we did not observe any detrimental impact of an unsuccessful trial of MET (beyond the additional time and imaging costs). If more confident and effective symptom control could be achieved, expansion of utilization and duration of MET may be a path to improved patient outcomes and cost control.

Patient-Reported Outcomes Measurement System (PROMIS®) for Patients with Urolithiasis: Initial Report

Purpose: Health related quality of life is increasingly important in quality improvement efforts for medical conditions. However, it has proved challenging to measure health related quality of life for urolithiasis, given the distinct chronic and acute phases of this disease. We evaluated the use of PROMIS® (Patient‐Reported Outcomes Measurement System) to assess the patient experience through acute stone episode stages. Materials and Methods: PROMIS pain measures (intensity and interference) were obtained from patients at a subspecialty kidney stone clinic. Four types of clinical encounters were considered, including emergency department followup, trial of passage, stent removal and 1‐month postoperative findings. Raw scores were translated into population normed T‐scores with a T‐score of 50 considered the reference population mean and a score of 60 considered 1 SD above the mean. T‐scores were compared across encounter types on univariate and multivariate analysis. Results: A total of 2,018 complete surveys were available from 1,162 patients. Mean pain intensity and pain interference T‐scores differed significantly by encounter type (p <0.001). On multivariate analysis the OR of T‐scores greater than 60 was higher for pain intensity and interference for all encounter types relative to postoperative findings, including emergency department followup 37.9 vs 124.9, passage trial 5.4 vs 10.5 and stent removal 9.4 vs 30.2 (p <0.001). Additionally, female gender and younger age were independent risk factors for T‐scores greater than 60. Conclusions: PROMIS pain measures are responsive to the phase of care during symptomatic stone events. Further application of this instrument holds great potential as a valuable tool to improve the quality of urolithiasis care.

Pain is Independent of Stone Burden and Predicts Surgical Intervention in Patients with Ureteral Stones

Purpose: Patients with obstructing ureteral stones typically experience sudden onset, severe pain. We examined the use of the NIH (National Institutes of Health) PROMIS® (Patient‐Reported Outcome Measurement Information System) pain instruments in patients with acute ureteral stones. Materials and Methods: PROMIS pain measures were obtained from a complete cohort of patients who presented to a subspecialty kidney stone clinic after emergency department discharge. Patients were followed longitudinally through the course of care. Raw scores were translated into population normed T‐scores with a T‐score of 50 indicating the mean pain population in the United States. Objective and patient centered factors were evaluated with reference to T‐score thresholds for pain intensity with 60 equal to 1 SD above the mean and pain interference with 70 equal to 2 SD. Results: Multivariable logistic regression in 650 patients demonstrated an absent association between pain scores and stone size or location. Pain scores were associated with patient age, gender and emergency department pain scores (p <0.05). Initial stone surgery was predicted by a stone size less than 4 mm (OR 0.14, 95% CI 0.07–0.3), greater than 6 mm (OR 19.1, 95% CI 0.22–39.58), proximal location (OR 1.75, 95% CI 1.34–2.3) and pain intensity greater than 60 (OR 7.03, 95% CI 3.63–13.6) but not pain interference (p <0.001). Failed attempted stone passage was less likely for stones less than 4 mm (OR 0.26, 95% CI 0.14–0.48, p <0.001) and more likely for proximal stones (OR 1.61, 95% CI 1.21–2.14, p <0.01) and pain intensity greater than 60 (OR 2.74, 95% CI 1.23–6.07, p <0.05). Conclusions: PROMIS pain scores are independent of stone size and location. Attention to emergency department discharge symptom control offers the potential to improve patient care. PROMIS pain intensity is an independent predictor of surgical intervention in patients with ureteral stones 1 cm or less.

Beyond medical expulsive therapy: evolution to supported stone passage for ureteric stones

To evaluate the impact of removing tamsulosin from standardized ureteric stone clinical protocols on rate of stone surgery.