The impact of unplanned postprocedure visits in the management of patients with urinary stones

Published:December 18, 2013DOI:


      Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease.


      We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates.


      We identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval [95% CI] 0.74–0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 [95% CI $30,453–33,859]) than after ureteroscopy ($23,436 [95% CI $22,281–24,590]).


      Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Scales Jr., C.D.
        • Smith A.C.
        • Hanley J.M.
        • Saigal C.S.
        Prevalence of Kidney stones in the United States.
        Eur Urol. 2012; 62: 160-165
        • Stamatelou K.K.
        • Francis M.E.
        • Jones C.A.
        • Nyberg L.M.
        • Curhan G.C.
        Time trends in reported prevalence of kidney stones in the United States: 1976-1994.
        Kidney Int. 2003; 63: 1817-1823
        • Fwu C.W.
        • Eggers P.W.
        • Kimmel P.L.
        • Kusek J.W.
        • Kirkali Z.
        Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States.
        Kidney Int. 2013; 83: 479-486
      1. Litwin M.S. Saigal C. Urologic Diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. US Government Printing Office, Washington, DC2012 (NIH Publication No. 12-7865)
        • Jencks S.F.
        • Williams M.V.
        • Coleman E.A.
        Rehospitalizations among patients in the Medicare fee-for-service program.
        N Engl J Med. 2009; 360: 1418-1428
        • Epstein A.M.
        Revisiting readmissions—changing the incentives for shared accountability.
        N Engl J Med. 2009; 360: 1457-1459
        • Joynt K.E.
        • Jha A.K.
        Thirty-day readmissions—truth and consequences.
        N Engl J Med. 2012; 366: 1366-1369
        • Joynt K.E.
        • Jha A.K.
        A path forward on Medicare readmissions.
        N Engl J Med. 2013; 368: 1175-1177
        • Joynt K.E.
        • Jha A.K.
        Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program.
        JAMA. 2013; 309: 342-343
        • Jacobs B.L.
        • Zhang Y.
        • Tan H.J.
        • Ye Z.
        • Skolarus T.A.
        • Hollenbeck B.K.
        Hospitalization trends after prostate and bladder surgery: implications of potential payment reforms.
        J Urol. 2013; 189: 59-65
        • Hollingsworth J.M.
        • Saigal C.S.
        • Lai J.C.
        • Dunn R.L.
        • Strope S.A.
        • Hollenbeck B.K.
        Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery.
        J Urol. 2012; 188: 1274-1278
        • Pearle M.S.
        • Calhoun E.A.
        • Curhan G.C.
        Urologic diseases in America project: urolithiasis.
        J Urol. 2005; 173: 848-857
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Birman-Deych E.
        • Waterman A.D.
        • Yan Y.
        • Nilasena D.S.
        • Radford M.J.
        • Gage B.F.
        Accuracy of ICD-9-CM codes for identifying cardiovascular and stroke risk factors.
        Med Care. 2005; 43: 480-485
        • Scales Jr., C.D.
        • Krupski T.L.
        • Curtis L.H.
        • et al.
        Practice variation in the surgical management of urinary lithiasis.
        J Urol. 2011; 186: 146-150
        • Wick E.C.
        • Shore A.D.
        • Hirose K.
        • et al.
        Readmission rates and cost following colorectal surgery.
        Dis Colon Rectum. 2011; 54: 1475-1479
        • van Walraven C.
        • Jennings A.
        • Taljaard M.
        • et al.
        Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.
        CMAJ. 2011; 183: E1067-E1072
        • van Walraven C.
        • Bennett C.
        • Jennings A.
        • Austin P.C.
        • Forster A.J.
        Proportion of hospital readmissions deemed avoidable: a systematic review.
        CMAJ. 2011; 183: E391-E402
        • Lindenauer P.K.
        • Lagu T.
        • Rothberg M.B.
        • et al.
        Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study.
        BMJ. 2013; 346: f521
        • Siu W.
        • Daignault S.
        • Miller D.C.
        • et al.
        Understanding differences between high and low volume hospitals for radical prostatectomy.
        Urol Oncol. 2008; 26: 260-265
        • Hollenbeck B.K.
        • Daignault S.
        • Dunn R.L.
        • Gilbert S.
        • Weizer A.Z.
        • Miller D.C.
        Getting under the hood of the volume-outcome relationship for radical cystectomy.
        J Urol. 2007; 177 (discussion 2099): 2095-2099
        • Hollenbeck B.K.
        • Wei Y.
        • Birkmeyer J.D.
        Volume, process of care, and operative mortality for cystectomy for bladder cancer.
        Urology. 2007; 69: 871-875
        • Preminger G.M.
        • Tiselius H.G.
        • Assimos D.G.
        • et al.
        2007 guideline for the management of ureteral calculi.
        J Urol. 2007; 178: 2418-2434
        • Lotan Y.
        • Gettman M.T.
        • Roehrborn C.G.
        • Cadeddu J.A.
        • Pearle M.S.
        Management of ureteral calculi: a cost comparison and decision making analysis.
        J Urol. 2002; 167: 1621-1629