- Email: [email protected]
Providing Access to Care through a 24-Hour Dedicated Stone Line
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urologypracticejournal.com
Providing Access to Care through a 24-Hour Dedicated Stone Line David E. Rapp,* Nada L. Wood, Jacob A. Wright, Brigette A. Booth, Andrew Colhoun and Eugene V. Kramolowsky From the Department of Urology, Virginia Urology (NLW, JAW, BAB) and Virginia Commonwealth University School of Medicine (AC), Richmond (DER, EVK), Virginia
Abstract
Abbreviations and Acronyms
Introduction: Many patients with urolithiasis are seen acutely in the emergency department for initial treatment. In an effort to improve cost and quality of care increasing focus has been placed on shifting management of low acuity conditions from emergency departments to outpatient settings. One barrier to such initiatives is timely access to outpatient services. We established a telephone stone line to provide access to outpatient urological care of kidney stones and we report our initial experience.
ED = emergency department ESWL = extracorporeal shock wave lithotripsy SL = telephone stone line
Methods: A 24-hour dedicated telephone stone line was created with calls answered by dedicated staff. A computer program was created to track stone line calls and post-call care. We retrospectively analyzed all stone line calls received in a 4-year period with the focus on utilization and cost. An e-mail survey was performed to assess patient satisfaction. Results: Between January 2009 and July 2013 the mean call volume was 2,107 per year. A significant distribution of calls was seen across all days and hours. Duration was less than 15 minutes in 7,761 calls (82%). Patients or family members placed 77% of calls and physicians placed 16%. As a result of a stone line call, 4,173 patients (76%) were seen by a urologist within 48 hours. Of the patients 88% reported satisfaction with the stone line. The mean annual cost of providing the telephone stone line was $233,425. Conclusions: Our experience demonstrates sustained utilization of and satisfaction with the telephone stone line. Further, stone line use results in timely outpatient evaluation in the majority of patients. Further analysis to assess for a cost benefit is ongoing. Key Words: kidney calculi, telephone, triage, health services accessibility, costs and cost analysis
Submitted for publication December 6, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided 2352-0779/17/41-1/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. Presented at annual meeting of American Urological Association, Orlando, Florida, May 16-21, 2014. * Correspondence: Department of Urology, Virginia Urology, 9105 Stony Point Dr., Richmond, Virginia 23235 (telephone: 804-385-9511; FAX: 804746-4015; e-mail address: [email protected]).
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2016.02.001 Vol. 4, 1-5, January 2017 Published by Elsevier
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Providing Access to Care through Dedicated Stone Line
Urolithiasis represents an increasing health care problem across the world. The prevalence of kidney stones in the United States is estimated to be 10.6% in men and 7.1% in women.1 Further, the prevalence and incidence of kidney stone disease are increasing.2 Given the prevalence of kidney stones, the financial impact is significant. The presentation of kidney stones is often acute with associated renal colic, causing patients to frequently seek care in emergency facilities as opposed to primary care settings. While managing renal colic in the ED is effective, it is often inefficient and costly. The annual medical expenditure for urolithiasis in the United States is estimated to be more than $5 billion with a large percent due to ED evaluation and treatment.3 In addition, evaluation of patients with stone disease often delays definitive treatment, which is most commonly performed in an outpatient setting. Numerous health policy changes are focused on decreasing ED utilization in an effort to reduce cost and improve quality of care. Such measures include financial incentives, patient education and managed care methods.4 Other measures focus on improving access to outpatient services through outreach clinics and adding capacity in nonED settings.4,5 In an effort to provide increased access for patients with kidney stones we established a dedicated SL for these patients. The SL enables 24-hour access for patients and providers to provide efficient and directed care of acute kidney stone disease in an outpatient setting. This analysis is a preliminary assessment of the SL with a focus on utilization and cost outcomes.
would also be associated with higher cost. The SL program was overseen by a supervising physician and physician supervision was available at all times. In the brief summary of SL policy and direction provided staff members were instructed to record complete demographic and clinical details for each call and were provided with a list of required details. Patients reporting defined symptoms of concern (fever, retention, nausea and/ or uncontrollable pain) were referred immediately to a supervising urologist. Patients not reporting these symptoms were offered expedient evaluation in clinic (same day or next day). Staff were instructed not to provide medical advice regarding clinical scenarios such as the use of prescription pain medications, or fluid consumption or restriction. Importantly, staff were provided with a detailed list of options for clinical assessment depending on the day and time of call and they made these arrangements for all patients. When ED referral was deemed necessary, they were responsible for calling the ED charge nurse and providing patient clinical and demographic information. All patients were offered the option of speaking to the physician on call if concerns or questions remained after SL triage. In an effort to improve outreach and access the SL number was advertised to the general public via radio and print media. Letters introducing the SL service were sent to existing patients and referring physicians. Finally, SL business cards were distributed to established patients with stone, and local ED and primary care physicians.
Stone Line Analysis Methods
The SL was established in the setting of a large (30 physicians) urology practice. This practice, which has more than 45,000 active patients, provides imaging services, ambulatory surgery and ESWL. Calls to the SL were answered by a staff of 3 dedicated personnel 24-hours a day, 7 days a week. The full-time nonmedical clerical staff was trained, provided with a policy manual and equipped with a wireless phone and laptop computer to allow for access to the office and hospital electronic medical records. In the office electronic medical records a computer program was created to document SL calls and track post-call care. Importantly, the function of the SL was to help efficiently direct appropriate patients with acute renal colic to the clinic setting for outpatient evaluation instead of delivering care via telephone. For this reason clerical staff highly trained in practice scheduling software were chosen, in contrast to medical personnel (eg physician assistants and nurses), who
We retrospectively reviewed all SL calls received between January 2009 and July 2013 with the focus on feasibility, utilization, cost and patient satisfaction. Institutional review board exemption was granted for this analysis. Data assessed included total number of calls, day and time of call, and duration of call. Financial analysis was performed to determine the overall cost of providing the SL service. Patient satisfaction was assessed using e-mail survey provided to a cohort of patients who used the SL between October 2013 and July 2014. The survey consisted of 4 items assessing satisfaction with the SL with an additional free text item for comment (see Appendix). Data are presented as the mean SD. Results
Between January 2009 and July 2013 the SL received 9,482 calls. The mean annual volume of calls was 2,107 103
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Providing Access to Care through Dedicated Stone Line
199½T1 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 ½T2 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249
(range 1,892 to 2,319). Table 1 lists data on call day and duration. A mean of 5.8 calls per day were received during the study period. Most calls were received on Monday and a majority were received during office hours. Nonetheless, a significant distribution of calls was seen across all days and hours. Duration was less than 15 minutes in 7,761 calls (82%). Patients or a family member placed 77% of SL calls and a physician placed 16%. A total of 5,451 unique patients were evaluated as a result of SL calls with a mean of 1.7 calls per patient. As a result of a call to the SL, 4,173 patients (76%) were seen by a urologist within 48 hours. Of these patients 771 (18%) underwent ureteroscopy within 2 weeks and in 52% it was performed within 48 hours. Similarly, 733 patients (18%) underwent ESWL within 2 weeks, of whom 269 underwent ESWL within 2 days. The remaining 2,669 SL related office visits (64%) did not result in scheduled surgical intervention within the first 2 weeks following evaluation. To determine the impact of the SL on the total patient population seen for stone disease we compared utilization data related to the SL to that of nonSL patients (table 2). A total of 51,212 patient encounters associated with a diagnosis of urolithiasis (ICD-9 592.0/592.1) were seen during the study period. Patient visits related to SL use comprised 16,270 of these 51,212 encounters (32%). Likewise, 771 of 4,766 ureteroscopic (16%) and 733 of 4,711 ESWL encounters (16%) were related to SL calls. The questionnaire response rate was 12% (51 of 426 participants). Overall, 88% and 100% of patients reported satisfaction with SL and courteous treatment by SL staff. Of SL users 91% responded that they would use the service again. The most common reason for dissatisfaction was being referred to the ED, given a patient expectation that care could be completed in an outpatient setting. Table 1. SL call timing and duration No. Calls (%) Overall Call Timing (wk day): Sunday Monday Tuesday Wednesday Thursday Friday Saturday Call timing (office hrs): During After Call duration (mins): 15 or Less Greater than 15
9,482 1,176 1,813 1,336 1,347 1,381 1,351 1,078
(12.4) (19.1) (14.1) (14.2) (14.6) (14.2) (11.4)
5,067 (53.4) 4,415 (46.6) 7,761 1,721
(82) (18)
3
Table 2. SL vs nonSL practice utilization patterns No. SL/NonSL (%) Office visits* Imaging: Plain x-ray of kidneys, ureters þ bladder Computerized tomography Surgical: Ureteroscopy ESWL
16,270/51,212 (32) 4,173/49,847 (8) 615/6,972 (9) 771/4,766 (16) 733/4,711 (16)
*Encounters with 4,173 unique patients.
The cost of providing SL access was categorized into personnel, marketing and supply costs. The largest expense was personnel with a cost of $143,321 ($31,849 per year). Marketing and supply costs were $76,166 ($16,926 per year) and $13,938 ($3,098 per year), respectively. The total cost of providing SL access to patients during the study period was $233,425 ($51,873 per year). The cost per urologist per year was $1,853 and the itemized cost per call received was $24.62.
Discussion
A significant focus has been recently placed on reducing ED visits in an effort to control health care costs and improve quality of care. A published literature review identified numerous studies assessing nonED interventions implemented to decrease ED utilization for low acuity conditions.4 Such interventions include the creation of additional capacity in nonED settings and prehospital diversion, of which each has been demonstrated to decrease ED utilization. Concurrently, growing health care costs have resulted in increasing emphasis on the quality and value of the services delivered. Importantly, access to health care services is fundamental to achieving health care quality and value.6 While access can be impeded by financial barriers and the supply of health care providers, a lack of physical accessibility and timeliness can restrict access even when there is a sufficient supply of health care providers. Accordingly, many patients then seek access through the ED even for low acuity conditions. Kidney stone disease results in a significant portion of health care expenditures in the United States. Contemporary estimates suggest that kidney stones result in approximately 1.3 million ED visits annually, of which approximately 12% result in hospital admission.7 Further, the likelihood of recurrent stone disease within 10 years is estimated to be as high as 50%.8 Given the high prevalence of kidney stones, the associated cost is significant. In 2000 the annual medical
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Providing Access to Care through Dedicated Stone Line
expenditures for urolithiasis in the United States were estimated to be $2.1 billion and they rose rapidly in subsequent years.3,9 While certain patients will require emergent intervention, more commonly patients are provided with pharmacotherapy to achieve pain relief and assist with medical expulsive therapy. The tendency for outpatient treatment by urologists is supported by numerous data. Foremost, investigation demonstrated that only 12% to 20% of ED patients are admitted to the hospital after a diagnosis of kidney stones.3,7 Further data demonstrated that significant findings of sepsis, renal failure and/or pregnancy are found in only 1% of the patients who are admitted.3 Finally, other data revealed that approximately 60% of patients undergo procedures during hospitalization (eg ureteral stenting or ureteroscopy), suggesting that the remaining patients are discharged home after pain relief has been achieved.7 When combined, these data underscore the fact that the majority of patients with stone disease can be treated in an outpatient setting. Although ED treatment of kidney stones may be effective for achieving pain relief, it is inefficient and costly. Ghani et al reported that charges for ED visits with kidney stones were greater than $5 billion in 2009 with a notable 10% increase annually during the 4-year study period of 2006 through 2009.3 Caldwell et al found a median charge of $3,437 for ED encounters for stone disease in their analysis of charges associated with the top 10 most common outpatient conditions treated in the ED.10 Notably, this median charge for stone disease was the highest charge of all assessed diagnoses, including upper respiratory infection, sprains and pregnancy related visits. Finally, ED wait times are a well reported problem with data showing that the percent of patients being seen by a physician in the time recommended at triage is only 75% and it is continuing to decrease.11 Since the majority of patients are discharged with plans for urology outpatient evaluation, these data suggest that ED treatment of stone disease often increases cost, is inefficient and delays definitive management. Our data demonstrate several important findings. Foremost, sustained utilization of this service was found. This utilization was consistent throughout the days of the week, and during and after office hours. As expected, calls were most commonly placed by patients and family, although significant utilization was seen by primary care physicians as well. With more than 75% of patients then evaluated by a urologist within 48 hours we believe that the SL achieved our goal of providing timely access to urological services in an outpatient setting. Associated with this access was a high level of patient satisfaction as seen on the survey analysis.
In addition, the SL also demonstrated benefit in the management of ongoing and recurrent stone disease. Despite an initial outpatient urological evaluation, patients often present to the ED due to acute breakthrough pain while being treated with medical expulsive therapy. Further, stents are commonly placed in combination with surgical intervention and were reported to cause significant pain and other bothersome symptoms in 80% of patients.12 Accordingly, despite education on expected symptoms related to stent insertion, patients may also use the ED for the treatment of related pain. In our experience patients also used the SL for this purpose, which enabled us to prevent ED visits. The SL received a mean of 1.7 calls per patient, highlighting its use in these scenarios in addition to patients with recurrent stone episodes. Indeed, a significant cost is associated with a dedicated SL. Notably, this cost may not increase practice profitability or patient accrual as it is expected that most of these patients might ultimately have been seen in clinic. However, we believe that the SL provides efficient access to this patient population, thereby avoiding unnecessary ED visits and more timely care of those patients in need of intervention. Our practice also fields more than 300,000 general calls annually. We believe that a dedicated SL helps provide more direct access to patients who are generally in more acute situations. As provider payments shift to value based models, initiatives such as a SL are increasingly important. Future study is necessary to further determine whether the SL is associated with additional benefits. Foremost, cost analysis is needed to determine the cost savings associated with the avoidance of ED visits in this patient subset. Further, cost comparison would be helpful to determine whether an initial outpatient evaluation of kidney stones is associated with lower cost and utilization of services compared to patients seen initially in the ED. These analyses are ongoing. In conclusion, despite the lack of these data, we believe that this initial pilot study demonstrates that the SL is an effective method of providing efficient access to outpatient urological evaluation of kidney stone disease.
Appendix. SL Survey Subjective Assessment 1. Were you treated courteously and respectfully on the stone line? 2. Were you satisfied with the service provided by the stone line? 3. How well did the stone line meet your expectations and needs? 4. Would you use this service again? 5. Please use this space to provide additional comments and feedback about the stone line.
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References 1. Scales CD Jr, Lin L, Saigal CS et al: Emergency department revisits for patients with kidney stones in California. Acad Emerg Med 2015; 22: 468. 2. Romero V, Akpinar H and Assimos D: Kidney stones: a global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010; 12: 86. 3. Ghani KR, Roghmann F, Sammon JD et al: Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges. J Urol 2014; 191: 90. 4. Morgan SR, Chang AM, Alqatari M et al: Non-emergency department (ED) interventions to reduce ED utilization: a systematic review. Acad Emerg Med 2013; 20: 969. 5. Uhlman MA, Gruca TS, Tracy R et al: Improving access to urological care for rural populations through outreach clinics. Urology 2013; 82: 1272. 6. Gulliford M, Figueroa-Munoz J, Morgan M et al: What does ‘access to health care’ mean? J Health Serv Res Policy 2002; 7: 186e188.
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7. Foster G, Stocks C and Borofsky MS: Emergency Department Visits and Hospital Admissions for Kidney Stone Disease, 2009: Statistical Brief No. 139. Healthcare Costs and Utilization Project Statistical Briefs. Rockville: Agency for Healthcare Policy and Research, February 2012. 8. Worcester EM and Coe FL: Nephrolithiasis. Prim Care 2008; 35: 369. 9. Lotan Y: Economics and cost of care of stone disease. Adv Chronic Kidney Dis 2009; 16: 5. 10. Caldwell N, Srebotnjak T, Wang T et al: “How much will I get charged for this?” Patient charges for top ten diagnoses in the emergency department. PLoS One 2013; 8: e55491. 11. Horwitz LI and Bradley EH: Percentage of US emergency department patients seen within the recommended triage time. Arch Intern Med 2009; 169: 1857. 12. Sivalingam S and Monga M: Management of ureteral stent discomfort in contemporary urology practice. Urol Pract 2014; 1: 141.
Editorial Commentary
The prevalence of nephrolithiasis almost doubled between 1994 and 20101 with a similar increase in the rate of ED visits for nephrolithiasis.2 In the current climate of health care reform the ability to minimize ED visits is tantamount. Nephrolithiasis can largely be treated in the outpatient setting but many patients seek care in the ED, leading to substantial medical expenditures. In addition to the financial burden, the utilization of EDs by low acuity patients slows not only the triage of patients with nephrolithiasis but also the treatment of patients with more acute conditions. Rapp et al describe their experience with establishing a telephone stone line with the aim of expediting outpatient urological care for patients with acute nephrolithiasis, decreasing unnecessary ED utilization and decreasing cost. Although they state that a cost analysis is ongoing, their findings suggest that this will certainly be a high value endeavor that benefits institutions and patients. Interestingly, they found that 16% of callers were primary care physicians, highlighting the function of the SL as an expedited referral system. Regarding the financial cost, the average call cost $25 compared with a median charge of $3,437 for a ED encounter.
The innovative model of these authors can now be adapted by other health care systems. Using clinical prediction tools such as the STONE score3 may help risk stratify patients, guiding the triaging of referrals. Stephanie Chu and Jonathan Bergman Department of Urology UCLA David Geffen School of Medicine Los Angeles, California
References 1. Scales CD, Smith AC, Hanley JM et al: Prevalence of kidney stones in the United States. Eur Urol 2012; 62: 160. 2. Fwu CW, Eggers PW, Kimmel PL et al: Emergency department visits, use of imaging and drugs for urolithiasis have increased in the United States. Kidney Int 2013; 83: 479. 3. Moore CL, Bomann S, Daniels B et al: Derivation and validation of a clinical prediction rule for uncomplicated ureteral stonedthe STONE score: retrospective and prospective observational cohort studies. BMJ 2014; 348: g2191.
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urologypracticejournal.com
Providing Access to Care through a 24-Hour Dedicated Stone Line David E. Rapp,* Nada L. Wood, Jacob A. Wright, Brigette A. Booth, Andrew Colhoun and Eugene V. Kramolowsky From the Department of Urology, Virginia Urology (NLW, JAW, BAB) and Virginia Commonwealth University School of Medicine (AC), Richmond (DER, EVK), Virginia
Abstract
Abbreviations and Acronyms
Introduction: Many patients with urolithiasis are seen acutely in the emergency department for initial treatment. In an effort to improve cost and quality of care increasing focus has been placed on shifting management of low acuity conditions from emergency departments to outpatient settings. One barrier to such initiatives is timely access to outpatient services. We established a telephone stone line to provide access to outpatient urological care of kidney stones and we report our initial experience.
ED = emergency department ESWL = extracorporeal shock wave lithotripsy SL = telephone stone line
Methods: A 24-hour dedicated telephone stone line was created with calls answered by dedicated staff. A computer program was created to track stone line calls and post-call care. We retrospectively analyzed all stone line calls received in a 4-year period with the focus on utilization and cost. An e-mail survey was performed to assess patient satisfaction. Results: Between January 2009 and July 2013 the mean call volume was 2,107 per year. A significant distribution of calls was seen across all days and hours. Duration was less than 15 minutes in 7,761 calls (82%). Patients or family members placed 77% of calls and physicians placed 16%. As a result of a stone line call, 4,173 patients (76%) were seen by a urologist within 48 hours. Of the patients 88% reported satisfaction with the stone line. The mean annual cost of providing the telephone stone line was $233,425. Conclusions: Our experience demonstrates sustained utilization of and satisfaction with the telephone stone line. Further, stone line use results in timely outpatient evaluation in the majority of patients. Further analysis to assess for a cost benefit is ongoing. Key Words: kidney calculi, telephone, triage, health services accessibility, costs and cost analysis
Submitted for publication December 6, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided 2352-0779/17/41-1/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. Presented at annual meeting of American Urological Association, Orlando, Florida, May 16-21, 2014. * Correspondence: Department of Urology, Virginia Urology, 9105 Stony Point Dr., Richmond, Virginia 23235 (telephone: 804-385-9511; FAX: 804746-4015; e-mail address: [email protected]).
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2016.02.001 Vol. 4, 1-5, January 2017 Published by Elsevier
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Providing Access to Care through Dedicated Stone Line
Urolithiasis represents an increasing health care problem across the world. The prevalence of kidney stones in the United States is estimated to be 10.6% in men and 7.1% in women.1 Further, the prevalence and incidence of kidney stone disease are increasing.2 Given the prevalence of kidney stones, the financial impact is significant. The presentation of kidney stones is often acute with associated renal colic, causing patients to frequently seek care in emergency facilities as opposed to primary care settings. While managing renal colic in the ED is effective, it is often inefficient and costly. The annual medical expenditure for urolithiasis in the United States is estimated to be more than $5 billion with a large percent due to ED evaluation and treatment.3 In addition, evaluation of patients with stone disease often delays definitive treatment, which is most commonly performed in an outpatient setting. Numerous health policy changes are focused on decreasing ED utilization in an effort to reduce cost and improve quality of care. Such measures include financial incentives, patient education and managed care methods.4 Other measures focus on improving access to outpatient services through outreach clinics and adding capacity in nonED settings.4,5 In an effort to provide increased access for patients with kidney stones we established a dedicated SL for these patients. The SL enables 24-hour access for patients and providers to provide efficient and directed care of acute kidney stone disease in an outpatient setting. This analysis is a preliminary assessment of the SL with a focus on utilization and cost outcomes.
would also be associated with higher cost. The SL program was overseen by a supervising physician and physician supervision was available at all times. In the brief summary of SL policy and direction provided staff members were instructed to record complete demographic and clinical details for each call and were provided with a list of required details. Patients reporting defined symptoms of concern (fever, retention, nausea and/ or uncontrollable pain) were referred immediately to a supervising urologist. Patients not reporting these symptoms were offered expedient evaluation in clinic (same day or next day). Staff were instructed not to provide medical advice regarding clinical scenarios such as the use of prescription pain medications, or fluid consumption or restriction. Importantly, staff were provided with a detailed list of options for clinical assessment depending on the day and time of call and they made these arrangements for all patients. When ED referral was deemed necessary, they were responsible for calling the ED charge nurse and providing patient clinical and demographic information. All patients were offered the option of speaking to the physician on call if concerns or questions remained after SL triage. In an effort to improve outreach and access the SL number was advertised to the general public via radio and print media. Letters introducing the SL service were sent to existing patients and referring physicians. Finally, SL business cards were distributed to established patients with stone, and local ED and primary care physicians.
Stone Line Analysis Methods
The SL was established in the setting of a large (30 physicians) urology practice. This practice, which has more than 45,000 active patients, provides imaging services, ambulatory surgery and ESWL. Calls to the SL were answered by a staff of 3 dedicated personnel 24-hours a day, 7 days a week. The full-time nonmedical clerical staff was trained, provided with a policy manual and equipped with a wireless phone and laptop computer to allow for access to the office and hospital electronic medical records. In the office electronic medical records a computer program was created to document SL calls and track post-call care. Importantly, the function of the SL was to help efficiently direct appropriate patients with acute renal colic to the clinic setting for outpatient evaluation instead of delivering care via telephone. For this reason clerical staff highly trained in practice scheduling software were chosen, in contrast to medical personnel (eg physician assistants and nurses), who
We retrospectively reviewed all SL calls received between January 2009 and July 2013 with the focus on feasibility, utilization, cost and patient satisfaction. Institutional review board exemption was granted for this analysis. Data assessed included total number of calls, day and time of call, and duration of call. Financial analysis was performed to determine the overall cost of providing the SL service. Patient satisfaction was assessed using e-mail survey provided to a cohort of patients who used the SL between October 2013 and July 2014. The survey consisted of 4 items assessing satisfaction with the SL with an additional free text item for comment (see Appendix). Data are presented as the mean SD. Results
Between January 2009 and July 2013 the SL received 9,482 calls. The mean annual volume of calls was 2,107 103
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148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198
Providing Access to Care through Dedicated Stone Line
199½T1 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 ½T2 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249
(range 1,892 to 2,319). Table 1 lists data on call day and duration. A mean of 5.8 calls per day were received during the study period. Most calls were received on Monday and a majority were received during office hours. Nonetheless, a significant distribution of calls was seen across all days and hours. Duration was less than 15 minutes in 7,761 calls (82%). Patients or a family member placed 77% of SL calls and a physician placed 16%. A total of 5,451 unique patients were evaluated as a result of SL calls with a mean of 1.7 calls per patient. As a result of a call to the SL, 4,173 patients (76%) were seen by a urologist within 48 hours. Of these patients 771 (18%) underwent ureteroscopy within 2 weeks and in 52% it was performed within 48 hours. Similarly, 733 patients (18%) underwent ESWL within 2 weeks, of whom 269 underwent ESWL within 2 days. The remaining 2,669 SL related office visits (64%) did not result in scheduled surgical intervention within the first 2 weeks following evaluation. To determine the impact of the SL on the total patient population seen for stone disease we compared utilization data related to the SL to that of nonSL patients (table 2). A total of 51,212 patient encounters associated with a diagnosis of urolithiasis (ICD-9 592.0/592.1) were seen during the study period. Patient visits related to SL use comprised 16,270 of these 51,212 encounters (32%). Likewise, 771 of 4,766 ureteroscopic (16%) and 733 of 4,711 ESWL encounters (16%) were related to SL calls. The questionnaire response rate was 12% (51 of 426 participants). Overall, 88% and 100% of patients reported satisfaction with SL and courteous treatment by SL staff. Of SL users 91% responded that they would use the service again. The most common reason for dissatisfaction was being referred to the ED, given a patient expectation that care could be completed in an outpatient setting. Table 1. SL call timing and duration No. Calls (%) Overall Call Timing (wk day): Sunday Monday Tuesday Wednesday Thursday Friday Saturday Call timing (office hrs): During After Call duration (mins): 15 or Less Greater than 15
9,482 1,176 1,813 1,336 1,347 1,381 1,351 1,078
(12.4) (19.1) (14.1) (14.2) (14.6) (14.2) (11.4)
5,067 (53.4) 4,415 (46.6) 7,761 1,721
(82) (18)
3
Table 2. SL vs nonSL practice utilization patterns No. SL/NonSL (%) Office visits* Imaging: Plain x-ray of kidneys, ureters þ bladder Computerized tomography Surgical: Ureteroscopy ESWL
16,270/51,212 (32) 4,173/49,847 (8) 615/6,972 (9) 771/4,766 (16) 733/4,711 (16)
*Encounters with 4,173 unique patients.
The cost of providing SL access was categorized into personnel, marketing and supply costs. The largest expense was personnel with a cost of $143,321 ($31,849 per year). Marketing and supply costs were $76,166 ($16,926 per year) and $13,938 ($3,098 per year), respectively. The total cost of providing SL access to patients during the study period was $233,425 ($51,873 per year). The cost per urologist per year was $1,853 and the itemized cost per call received was $24.62.
Discussion
A significant focus has been recently placed on reducing ED visits in an effort to control health care costs and improve quality of care. A published literature review identified numerous studies assessing nonED interventions implemented to decrease ED utilization for low acuity conditions.4 Such interventions include the creation of additional capacity in nonED settings and prehospital diversion, of which each has been demonstrated to decrease ED utilization. Concurrently, growing health care costs have resulted in increasing emphasis on the quality and value of the services delivered. Importantly, access to health care services is fundamental to achieving health care quality and value.6 While access can be impeded by financial barriers and the supply of health care providers, a lack of physical accessibility and timeliness can restrict access even when there is a sufficient supply of health care providers. Accordingly, many patients then seek access through the ED even for low acuity conditions. Kidney stone disease results in a significant portion of health care expenditures in the United States. Contemporary estimates suggest that kidney stones result in approximately 1.3 million ED visits annually, of which approximately 12% result in hospital admission.7 Further, the likelihood of recurrent stone disease within 10 years is estimated to be as high as 50%.8 Given the high prevalence of kidney stones, the associated cost is significant. In 2000 the annual medical
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Providing Access to Care through Dedicated Stone Line
expenditures for urolithiasis in the United States were estimated to be $2.1 billion and they rose rapidly in subsequent years.3,9 While certain patients will require emergent intervention, more commonly patients are provided with pharmacotherapy to achieve pain relief and assist with medical expulsive therapy. The tendency for outpatient treatment by urologists is supported by numerous data. Foremost, investigation demonstrated that only 12% to 20% of ED patients are admitted to the hospital after a diagnosis of kidney stones.3,7 Further data demonstrated that significant findings of sepsis, renal failure and/or pregnancy are found in only 1% of the patients who are admitted.3 Finally, other data revealed that approximately 60% of patients undergo procedures during hospitalization (eg ureteral stenting or ureteroscopy), suggesting that the remaining patients are discharged home after pain relief has been achieved.7 When combined, these data underscore the fact that the majority of patients with stone disease can be treated in an outpatient setting. Although ED treatment of kidney stones may be effective for achieving pain relief, it is inefficient and costly. Ghani et al reported that charges for ED visits with kidney stones were greater than $5 billion in 2009 with a notable 10% increase annually during the 4-year study period of 2006 through 2009.3 Caldwell et al found a median charge of $3,437 for ED encounters for stone disease in their analysis of charges associated with the top 10 most common outpatient conditions treated in the ED.10 Notably, this median charge for stone disease was the highest charge of all assessed diagnoses, including upper respiratory infection, sprains and pregnancy related visits. Finally, ED wait times are a well reported problem with data showing that the percent of patients being seen by a physician in the time recommended at triage is only 75% and it is continuing to decrease.11 Since the majority of patients are discharged with plans for urology outpatient evaluation, these data suggest that ED treatment of stone disease often increases cost, is inefficient and delays definitive management. Our data demonstrate several important findings. Foremost, sustained utilization of this service was found. This utilization was consistent throughout the days of the week, and during and after office hours. As expected, calls were most commonly placed by patients and family, although significant utilization was seen by primary care physicians as well. With more than 75% of patients then evaluated by a urologist within 48 hours we believe that the SL achieved our goal of providing timely access to urological services in an outpatient setting. Associated with this access was a high level of patient satisfaction as seen on the survey analysis.
In addition, the SL also demonstrated benefit in the management of ongoing and recurrent stone disease. Despite an initial outpatient urological evaluation, patients often present to the ED due to acute breakthrough pain while being treated with medical expulsive therapy. Further, stents are commonly placed in combination with surgical intervention and were reported to cause significant pain and other bothersome symptoms in 80% of patients.12 Accordingly, despite education on expected symptoms related to stent insertion, patients may also use the ED for the treatment of related pain. In our experience patients also used the SL for this purpose, which enabled us to prevent ED visits. The SL received a mean of 1.7 calls per patient, highlighting its use in these scenarios in addition to patients with recurrent stone episodes. Indeed, a significant cost is associated with a dedicated SL. Notably, this cost may not increase practice profitability or patient accrual as it is expected that most of these patients might ultimately have been seen in clinic. However, we believe that the SL provides efficient access to this patient population, thereby avoiding unnecessary ED visits and more timely care of those patients in need of intervention. Our practice also fields more than 300,000 general calls annually. We believe that a dedicated SL helps provide more direct access to patients who are generally in more acute situations. As provider payments shift to value based models, initiatives such as a SL are increasingly important. Future study is necessary to further determine whether the SL is associated with additional benefits. Foremost, cost analysis is needed to determine the cost savings associated with the avoidance of ED visits in this patient subset. Further, cost comparison would be helpful to determine whether an initial outpatient evaluation of kidney stones is associated with lower cost and utilization of services compared to patients seen initially in the ED. These analyses are ongoing. In conclusion, despite the lack of these data, we believe that this initial pilot study demonstrates that the SL is an effective method of providing efficient access to outpatient urological evaluation of kidney stone disease.
Appendix. SL Survey Subjective Assessment 1. Were you treated courteously and respectfully on the stone line? 2. Were you satisfied with the service provided by the stone line? 3. How well did the stone line meet your expectations and needs? 4. Would you use this service again? 5. Please use this space to provide additional comments and feedback about the stone line.
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References 1. Scales CD Jr, Lin L, Saigal CS et al: Emergency department revisits for patients with kidney stones in California. Acad Emerg Med 2015; 22: 468. 2. Romero V, Akpinar H and Assimos D: Kidney stones: a global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010; 12: 86. 3. Ghani KR, Roghmann F, Sammon JD et al: Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges. J Urol 2014; 191: 90. 4. Morgan SR, Chang AM, Alqatari M et al: Non-emergency department (ED) interventions to reduce ED utilization: a systematic review. Acad Emerg Med 2013; 20: 969. 5. Uhlman MA, Gruca TS, Tracy R et al: Improving access to urological care for rural populations through outreach clinics. Urology 2013; 82: 1272. 6. Gulliford M, Figueroa-Munoz J, Morgan M et al: What does ‘access to health care’ mean? J Health Serv Res Policy 2002; 7: 186e188.
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7. Foster G, Stocks C and Borofsky MS: Emergency Department Visits and Hospital Admissions for Kidney Stone Disease, 2009: Statistical Brief No. 139. Healthcare Costs and Utilization Project Statistical Briefs. Rockville: Agency for Healthcare Policy and Research, February 2012. 8. Worcester EM and Coe FL: Nephrolithiasis. Prim Care 2008; 35: 369. 9. Lotan Y: Economics and cost of care of stone disease. Adv Chronic Kidney Dis 2009; 16: 5. 10. Caldwell N, Srebotnjak T, Wang T et al: “How much will I get charged for this?” Patient charges for top ten diagnoses in the emergency department. PLoS One 2013; 8: e55491. 11. Horwitz LI and Bradley EH: Percentage of US emergency department patients seen within the recommended triage time. Arch Intern Med 2009; 169: 1857. 12. Sivalingam S and Monga M: Management of ureteral stent discomfort in contemporary urology practice. Urol Pract 2014; 1: 141.
Editorial Commentary
The prevalence of nephrolithiasis almost doubled between 1994 and 20101 with a similar increase in the rate of ED visits for nephrolithiasis.2 In the current climate of health care reform the ability to minimize ED visits is tantamount. Nephrolithiasis can largely be treated in the outpatient setting but many patients seek care in the ED, leading to substantial medical expenditures. In addition to the financial burden, the utilization of EDs by low acuity patients slows not only the triage of patients with nephrolithiasis but also the treatment of patients with more acute conditions. Rapp et al describe their experience with establishing a telephone stone line with the aim of expediting outpatient urological care for patients with acute nephrolithiasis, decreasing unnecessary ED utilization and decreasing cost. Although they state that a cost analysis is ongoing, their findings suggest that this will certainly be a high value endeavor that benefits institutions and patients. Interestingly, they found that 16% of callers were primary care physicians, highlighting the function of the SL as an expedited referral system. Regarding the financial cost, the average call cost $25 compared with a median charge of $3,437 for a ED encounter.
The innovative model of these authors can now be adapted by other health care systems. Using clinical prediction tools such as the STONE score3 may help risk stratify patients, guiding the triaging of referrals. Stephanie Chu and Jonathan Bergman Department of Urology UCLA David Geffen School of Medicine Los Angeles, California
References 1. Scales CD, Smith AC, Hanley JM et al: Prevalence of kidney stones in the United States. Eur Urol 2012; 62: 160. 2. Fwu CW, Eggers PW, Kimmel PL et al: Emergency department visits, use of imaging and drugs for urolithiasis have increased in the United States. Kidney Int 2013; 83: 479. 3. Moore CL, Bomann S, Daniels B et al: Derivation and validation of a clinical prediction rule for uncomplicated ureteral stonedthe STONE score: retrospective and prospective observational cohort studies. BMJ 2014; 348: g2191.
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