Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic

Importance: Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients\u27 likelihood of a subsequent urologic intervention could inform decision-making in this population. Objectives: To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. Design, Setting, and Participants: This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. Main Outcomes and Measures: The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. Results: A total of 66218 unique index visits by 55314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P \u3c .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P \u3c .001) compared with patients with all other insurance types. Conclusions and Relevance: In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients

Engaging Emergency Department Patients in the Creation of a Shared Decision-­Making Tool Regarding CT Scanning in Kidney Stones: Challenges to Traditional Stakeholder Engagement

Background: Every year approximately 2 million patients are seen in US EDs for suspected renal colic, and the majority receive CT scans. The objective of our study was to develop a stakeholder-informed conversation aid to help clinicians use SDM regarding CT scanning in patients with suspected renal colic. Methods: Using a published decision aid development framework, and under the direction of a multi-disciplinary Steering Committee, we engaged a diverse set of stakeholders via qualitative methods. EM clinicians, urologists, radiologists, researchers, and emergency department patients participated in focus groups and semi-structured interviews. All groups were recorded, transcribed, and analyzed in an iterative process by a four-person coding team. Emergent themes were identified and used to develop a decision aid which was iteratively refined. Results: A total of 8 interviews and 7 focus groups were conducted with 36 stakeholders (including local ED patients) The following three themes emerged: 1. Patient participants reported a desire to be involved in this decision and wanted more information regarding risks and benefits of CT scans. 2. Clinicians were comfortable diagnosing kidney stones without a CT scan, however, some felt that clinical uncertainty was a barrier to SDM. 3. All stakeholders identified strategies to facilitate this conversation such as check-lists and visual aids. Conclusion: Using stakeholder input, we developed a communication tool to facilitate an SDM conversation around the use of CT in suspected renal colic. Further testing will assess whether this tool can safely improve patient engagement and decrease low yield CT usage

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus

Background Renal colic is common, and CT is frequently utilized when the diagnosis of kidney stones is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. Methods In conjunction with the American College of Emergency Physicians (ACEP) eQual network, we formed a nine-member panel with three physician representatives each from ACEP, the ACR, and the American Urology Association. A systematic literature review was used as the basis for a three-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. Results From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasound in 9 (31%) and no further imaging needed in 12 (45%). Summary Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic

Re-engineering NASA's space communications to remain viable in a constrained fiscal environment

Along with the Red and Blue Teams commissioned by the NASA Administrator in 1992, NASA's Associate Administrator for Space Communications commissioned a Blue Team to review the Office of Space Communications (Code O) Core Program and determine how the program could be conducted faster, better, and cheaper. Since there was no corresponding Red Team for the Code O Blue Team, the Blue Team assumed a Red Team independent attitude and challenged the status quo, including current work processes, functional distinctions, interfaces, and information flow, as well as traditional management and system development practices. The Blue Team's unconstrained, non-parochial, and imaginative look at NASA's space communications program produced a simplified representation of the space communications infrastructure that transcends organizational and functional boundaries, in addition to existing systems and facilities. Further, the Blue Team adapted the 'faster, better, cheaper' charter to be relevant to the multi-mission, continuous nature of the space communications program and to serve as a gauge for improving customer services concurrent with achieving more efficient operations and infrastructure life cycle economies. This simplified representation, together with the adapted metrics, offers a future view and process model for reengineering NASA's space communications to remain viable in a constrained fiscal environment. Code O remains firm in its commitment to improve productivity, effectiveness, and efficiency. In October 1992, the Associate Administrator reconstituted the Blue Team as the Code O Success Team (COST) to serve as a catalyst for change. In this paper, the COST presents the chronicle and significance of the simplified representation and adapted metrics, and their application during the FY 1993-1994 activities

Quality of life impact and recovery after ureteroscopy and stent insertion: Insights from daily surveys in STENTS

BACKGROUND: Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains. METHODS: In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30. RESULTS: The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability. CONCLUSIONS: This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients\u27 experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS

Effect of subunit on allosteric modulation of ion channel function in stably expressed human recombinant -aminobutyric acidA receptors determined using 36Cl ion flux.

ABSTRACT Inhibitory ␥-aminobutyric acid (GABA) A receptors are subject to modulation at a variety of allosteric sites, with pharmacology dependent on receptor subunit combination. The influence of different ␣ subunits in combination with ␤3␥2s was examined in stably expressed human recombinant GABA A receptors by measuring 36 Cl influx through the ion channel pore. Muscimol and GABA exhibited similar maximal efficacy at each receptor subtype, although muscimol was more potent, with responses blocked by picrotoxin and bicuculline. Receptors containing the ␣3 subunit exhibited slightly lower potency. The comparative pharmacology of a range of benzodiazepine site ligands was examined, revealing a range of intrinsic efficacies at different receptor subtypes. Of the diazepam-sensitive GABA A receptors (␣1, ␣2, ␣3, ␣5), ␣5 showed the most divergence, being discriminated by zolpidem in terms of very low affinity, and CL218,872 and CGS9895 with different efficacies. Benzodiazepine potentiation at ␣3␤3␥2s with nonselective agonist chlordiazepoxide was greater than at ␣1, ␣2, or ␣5 (P Ͻ 0.001). The presence of an ␣4 subunit conferred a unique pharmacological profile. The partial agonist bretazenil was the most efficacious benzodiazepine, despite lower ␣4 affinity, and FG8205 displayed similar efficacy. Most striking were the lack of affinity/ efficacy for classical benzodiazepines and the relatively high efficacy of Ro15-1788 (53 Ϯ 12%), CGS8216 (56 Ϯ 6%), CGS9895 (65 Ϯ 6%), and the weak partial inverse agonist Ro15-4513 (87 Ϯ 5%). Each receptor subtype was modulated by pentobarbital, loreclezole, and 5␣-pregnan-3␣-ol-20-one, but the type of ␣ subunit influenced the level of potentiation. The maximal pentobarbital response was significantly greater at ␣4␤3␥2s (226 Ϯ 10% increase in the EC 20 response to GABA) than any other modulator. The rank order of potentiation for pregnanolone was ␣5 Ͼ ␣2 Ͼ ␣3 ϭ ␣4 Ͼ ␣1, for loreclezole ␣1 ϭ ␣2 ϭ ␣3 Ͼ ␣5 Ͼ ␣4, and for pentobarbital ␣4 ϭ ␣5 ϭ ␣2 Ͼ ␣1 ϭ ␣3

A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial

Philip Ayieko and colleagues report the outcomes of a cluster-randomized trial carried out in eight Kenyan district hospitals evaluating the effects of a complex intervention involving improved training and supervision for clinicians. They found a higher performance of hospitals assigned to the complex intervention on a variety of process of care measures, as compared to those receiving the control intervention