Letters
Urology Health services administration
Volume 189 - Issue 10

Management of kidney stone disease in New South Wales: an observational study

Authors:  Finlay Macneil, James W H Macneil, Kylie L Fraser and Andrew J Brooks

Med J Aust 2008; 189 (10): 596-597. || doi: 10.5694/j.1326-5377.2008.tb02194.x
Published online: 17 November 2008
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To the Editor: Urinary stones are very common, with a cumulative lifetime incidence of 5%–15% and a recurrence rate of about 50%.1 Many new treatment techniques have been developed, but availability, particularly in public hospitals, is variable.

The Greater Metropolitan Clinical Taskforce2 assessed patterns of treatment in patients requiring urological consultation who presented to the emergency departments (EDs) of 12 New South Wales public teaching hospitals in major centres that had a specialty urology registrar.

Between February and September 2007, the urology registrar or specialist completed a survey on consecutive patients presenting with urolithiasis who agreed to participate. The survey contained questions on patient demographics, the position and size of the stone, and the preferred treatment option. One of us (J W H M) conducted a telephone interview with each patient to obtain details of treatment, and follow-up interviews at 3-monthly intervals (until treatment was completed or the study ended) to determine the outcome. Ninety-two patients entered the study: 64 men (mean age, 50.4 years) and 26 women (mean age, 47.8 years) (sex was not reported for two patients). Thirty-seven patients were subsequently treated in the public system, and the remainder in the private system, either using private health insurance or at their own expense.

The preferred treatment option of the treating medical officer, usually the urology registrar, was nominated: non-operative (spontaneous stone expulsion) with or without calcium-channel blockers, 13 patients (received by 6); rigid ureteroscopy with grasper or lithoclast, 21 patients (18); rigid ureteroscopy with laser, 4 patients (4); flexible ureteroscopy with laser, 17 patients (2); percutaneous nephrolithotomy, 3 patients (3); extracorporeal shock wave lithotripsy, 6 patients (2); or “other”, 28 patients — of whom stent was specified in 24 (23).

The preferred treatment option was not used for 34% of patients because it was not available at the hospital. The mean duration of treatment (defined as the period between initial ED presentation and final treatment episode) for patients with pelvi-ureteric or upper ureteric stones requiring more than one treatment episode is shown in the Box.

Thirty-nine patients had stents inserted in the ED, of whom four did not reach definitive management by the end of the study. Of the remaining 35, 20 were public patients and 15 were private patients. Fourteen had stents in situ for more than 3 months and required a change of stent before initiation of definitive treatment to avoid encrustation; 12 of these patients had treatment in the public system.

Despite the relatively small number of participants in this study, its findings on access to timely treatment for public patients should not be ignored. Management of kidney stones was heavily influenced by insurance status. Ureteric stents are intended to be temporary, but patients treated in the public system who had a stent inserted at initial presentation had a 60% (12/20) chance of still having it 3 months later, thus requiring a change of stent before definitive intervention — an unnecessary procedure that increases hospital re-admissions. Patients would be treated more efficiently and effectively with more timely access to appropriate resources.

This is an unacceptable burden of morbidity for patients. Urgent action is required to improve the current state of care for public patients with kidney stones in NSW.

Duration of treatment of public and private patients with a pelvi-ureteric junction or upper ureteric stone who required more than one treatment episode*

Public patients (n = 18)

Private patients (n = 18)

Mean duration of treatment in weeks (95% CI)

18.3 (12.9–23.7)

6.2 (3.0–9.4)

Range (weeks)

3.0–49.5

0.6–25

Difference in weeks (95% CI)

12.1 (5.5–18.7)

P

< 0.001

* Up to four treatment episodes.

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