Who Will Follow Up? Predictors of Compliance with Nephrolithiasis Follow up After Emergency Room Visits
Brandon S. Childs, MD1, Roger B. Davis, ScD2, Ruslan Korets, MD2, Peter L. Steinberg, MD2
1Lahey Hospital and Medical Center, Burlington, MA, 2Beth Israel Deaconess Medical Center, Boston, MA
Introduction:
Many patients with nephrolithiasis who present to the emergency department (ED) will spontaneously pass a kidney stone and have a low risk of future kidney stones; however, outpatient urology consultation may be of benefit, either to manage the inciting stone or reduce the risk of future stone events. A proportion of discharged patients fail to follow-up. Many of these patients are pain free and/or have passed their kidney stones, while others have barriers to attending their outpatient appointments, and are at high risk of repeat ED visits. We sought to identify factors predicting which patients will follow up with urology within 90 days of an index ED visit for nephrolithiasis.
Materials & Methods:
Using data gathered from an urban academic center ED database from 2013 to 2018, we identified 1096 patients with kidney stones. Data was collected in regards to demographics and follow-up visits with urology and/or a PCP within 90 days. Univariate and multivariate regression analyses were conducted to identify factors associated with increased odds of following up.
Results:
Increasing age was associated with greater odds of urology follow-up in univariate and multivariate analyses (p < .0001, Table 1). The 18-29 year age group demonstrated the lowest odds of follow up (0.47, 95% CI 0.32-0.68, Table 2). Female gender predicted urologic follow-up as well. There were no significant differences in follow-up based on income, ethnicity, and insurance type (government vs. private).
Increasing age, female gender, African American race, and a 4-year college degree predicted increasing odds of following up with a PCP (Table 2). Again, there were no significant differences seen based upon ethnicity, income level, and insurance type.
Table 1- Univariate analysis findings
| Follow up with Urology (%) | P Value | Follow up with PCP (%) | P Value | |
| Age (years) -18-29 -30-39 -40-49 -50-59 -60-69 -70-79 -80+ | 36.1 42.9 45.9 54.9 59.9 62.5 69.0 | < .0001 | 15.0 34.4 39.7 35.4 46.2 51.8 44.8 | < .0001 |
| Sex Female Male | 50.2 48.8 | 0.0468 | 39.2 32.0 | 0.0001 |
| Race Asian African American Caucasian Other | 59.5 46.1 50.6 39.3 | 0.0099 | 20.2 45.5 34.4 32.1 | < .0001 |
| Ethnicity Hispanic Non-Hispanic | 50.3 49.1 | 0.0475 | 36.6 34.0 | - |
| Education Level Less than high school High school or GED Associate or some college 4- year degree or higher | 54.8 45.6 38.2 55.5 | 0.0012 | 36.6 31.5 27.3 39.6 | 0.0056 |
Table 2- Odds Ratios of Follow-up
| Follow up with Urology- OR (95% CI) | Follow up with PCP- OR (95% CI) | |
| Age (years) -18-29 vs. 50-59 -30-39 vs. 50-59 -60-69 vs. 50-59 -70-79 vs. 50-59 | 0.47 (0.32- 0.68) 0.61 (0.41- 0.92) - - | 0.32 (0.21- 0.51) - 1.57 (1.06- 2.32) 1.96 (1.09- 3.53) |
| Female vs. Male | 1.31 (1.01- 1.71) | 1.73 (1.31- 2.28) |
| Asian vs. Caucasian | 2.02 (1.22- 3.34) | - |
| African American vs. Caucasian | - | 2.30 (1.57-3.36) |
| Hispanic vs. non-Hispanic | 1.55 (1.01- 2.39) | - |
| Associate vs. 4-yr degree | 0.55 (0.39- 0.77) | 0.68 (0.47- 0.98) |
| High school vs. 4-yr degree | 0.62 (0.44- 0.86) | 0.54 (0.37- 0.77) |
Conclusion:
Increasing age is associated with higher rates of urologic follow-up after an ED visit for nephrolithiasis. In addition, women and patients with higher education levels are more likely to seek follow-up after an ED visit for nephrolithiasis. Incorporating these factors when scheduling patients for return visits and enhancing outreach to younger patients, who are less likely to follow up, may improve rates of return and ultimately decrease kidney stone related morbidity.
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