An observational study of the management of kidney stone disease in New South Wales (between February and September 2007)Urinary stones are very common in Australia [1]. Some of these stones cause considerable morbidity. However there has been little discussion or publication regarding the time taken to treat. The GMCT Urology Network [2] assessed access to treatment in a group of patients presenting with urolithiasis. The study’s main aim was to gather evidence on the current pattern and chronology of treatment for these patients. Between 80-90% of stones pass spontaneously or require minimum conservative management [3]. The Network was concerned was with those patients presenting to emergency departments in need of specialist care. Ninety two patients entered the study between February and September 2007, 64 were men. Approximately half the group had treatment within the public system. The remainder used either private health insurance or had treatment performed in a private hospital at their own expense. The treatment options were non-operative +/- Calcium channel blockers, rigid ureteroscopy with grasper or lithoclast, rigid ureteroscopy with laser, flexible ureteroscopy with laser, percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (ESWL) or specified ‘other’. The preferred treatment option was not used in 65% of patients because that modality was not available in their hospital. The average length of treatment was 7.5 weeks in the private system and 20 weeks in the public system. Thirty-nine patients were stented after presentation to the emergency department. The average time between initial presentation and commencing definitive treatment in this group was 18.8 weeks for public patients versus 5.7 weeks for private patients. (95%CI: 5.5-20.8, t33df=3.54, P<0.01). Fourteen of these thirty-nine patients had stents for more than 3 months from initial presentation and commencement of treatment requiring a change of stent to avoid encrustation. Thirteen out of these 14 patients were uninsured. Despite the relatively small number of participants in this study, access for public patients to timely treatment should not be ignored. Management of ureteric stones is heavily influenced by insurance status. Those patients who were stented at their initial presentation to the emergency department had a 65% chance of still having a stent three months later thus requiring a change of stent before definitive management. These are unnecessary interventions increasing hospital readmissions. Patients would be treated more efficiently and effectively with timely access to appropriate resources.
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This is an unacceptable burden of morbidity to patients with kidney stones. Urgent action is required to improve the current state of care for public patients with ureteric stones in NSW.
References1. Miller NL, Lingeman JE, Management of kidney stones, BMJ. 2007 Mar 3; 334(7591): 468-472 2. Stewart GJ, Dwyer JM, Goulston KJ, The Greater Metropolitan Clinical Taskforce: an Australian model for clinician governance, MJA.2006 Jun 19; 184(12): 597-599 3. Parmar MS, Kidney Stones, BMJ. 2004 Jun 12; 328(7453): 1420-1424
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Table 1 Comparison of length of treatment of public and private patients with a PUJ or upper ureteric stone who required more than one treatment episode.
Public Patients Private Patients
n 18 18
Average Length of treatment (weeks)
Range (weeks)
95% Confidence Interval (weeks)
18.3
3 – 49.5
12.9 – 23.7
6.2
0.6 – 25
3.0 – 9.4
Difference (weeks)
t34df1
P
95% Confidence Interval (weeks)
12.1
3.76
<0.001
5.5 – 18.7
1. t-statistic with 34 degrees of freedom
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