Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Diagnosis

Abstract

Key Points:

1. Only 6% of patients with urinary stone disease visit a nephrology clinic within 6 months of a stone event in the Veterans Health Administration.

2. Nephrology care within 6 months of a stone event can vary by as much as 72% across different Veterans Health Administration facilities.

3. Efforts to increase access to nephrology, in addition to urology, may improve quality of health care to patients with urinary stone disease.

Background: Prevention is a cornerstone for the management of recurrent urinary stone disease. Current guidelines recommend metabolic evaluation, lifestyle modification, and medical treatment of patients with urinary stone disease. Nephrologists are uniquely qualified to evaluate stone risk and formulate treatment strategies to reduce that risk. The objective of this study was to determine the frequency of nephrology visits after a urinary stone diagnosis, a key window of opportunity to assess stone risk.

Methods: We used nationwide data from the US Veterans Health Administration to identify patients who had an incident stone diagnosis between 2016 and 2018. We examined the proportion of patients who visited a nephrology clinic within 6 months of stone diagnosis.

Results: We identified 42,927 veterans with urinary stone disease. Only 2432 (5.6%) visited a nephrology clinic within 6 months of the index diagnosis. The proportion of patients who visited a nephrology clinic after their stone diagnosis ranged between 0.7% and 20.7% across 104 Veterans Health Administration sites, with a median of 4.6% (25%–75% range, 3.4%–7.0%). The median rate ratio for a nephrology follow-up visit after a stone diagnosis was 1.72. Veterans with CKD were significantly more likely to visit a nephrology clinic relative to veterans without CKD (odds ratio, 5.19; 95% confidence interval, 4.69 to 5.74).

Conclusions: Nephrologists are infrequently and variably involved in the care of patients after a urinary stone diagnosis, suggesting potential for quality improvement.

Graphical abstract

Figure 1

CONSORT diagram of the inclusion and exclusion criteria of the primary analytic cohort and the companion analysis of patients with a prior nephrology visit. CONSORT, Consolidated Standards of Reporting Trials.

Figure 2

Proportion of patients who visited a VA nephrology clinic after a stone event by VHA facility. Proportion of patients in the total cohort who visited a VA nephrology clinic within 6 months of a stone diagnosis ranked by VHA facility (black). Proportion of patients with a prior nephrology visit in 1 year before the incident stone event who visited a VA nephrology clinic in the 6 months after an incident stone diagnosis (gray). VA, Veterans Affairs; VHA, Veterans Health Administration.