Does the Multidisciplinary Stone Center Improve Outcomes?
The multidisciplinary Stone Center at Cincinnati Children’s offers efficient, well-coordinated care, but does it improve clinical outcomes? Common sense says “yes,” and now a retrospective study at Cincinnati Children’s provides evidence in three key areas.
The Stone Center opened in 2014, in response to a rise in urolithiasis among pediatric patients. Last year, the team conducted a retrospective cohort study to assess clinical outcomes. A total of 182 of the center’s first 208 patients met the inclusion criteria of being under 21 years of age (mean age was 14) and having more than six months of follow up. Specifically, the study found that during the one year before and at any time after the first visit:
- The number of patients undergoing surgical procedures (such as ureteroscopy and extracorporeal shock wave lithotripsy) decreased from 40% to 18%.
- The average number of emergency department visits per year decreased from 1.5 to 0.5.
- Computed tomography usage decreased from 32% to 25%.
Evidence of benefit “Our multidisciplinary team works hard to manage risk factors for kidney stones, with the goal of reducing trips to emergency department, surgical procedures, exposure to ionizing radiation, pain and narcotics use,” says Bob DeFoor, MD, a pediatric urologist and co-director of the Stone Center. “While we cannot draw direct correlations, we believe these numbers reflect the fact the Stone Center provides beneficial clinical care. We plan to explore the data further to determine whether aggressive medical management will improve urinary metabolic indices and decrease kidney stone recurrence rates.”
The Stone Center is a joint venture of the Divisions of Pediatric Urology and Nephrology, and includes physicians, nurses, dietitians, genetic counselors and social workers from emergency medicine, human genetics, interventional radiology, laboratory medicine, radiology, nephrology and urology. During their first clinic visit, patients see all providers in one setting, and undergo a thorough evaluation. The team develops a personalized treatment plan that can include medication and/or surgery, but always includes extensive education and recommendations to help children reduce their risk of recurrent stones and minimize complications.
The Stone Center has a full-time nurse coordinator and a dedicated phone “hot line” (513-803-ROCK) for patients and clinicians to make referrals, get test results, make appointments, and schedule surgery.
Unique risk factors Children are at higher risk than adults for recurrent kidney stones, and their risk factors are different as well. For example, children are more likely to have an underlying urinary metabolic abnormality such as hypercalciuria, hypocitraturia or cystinuria; this was true in about half of the patients in the clinical outcomes study. Other risk factors for pediatric patients include having a chronic bowel disorder, a past gastric bypass surgery and certain seizure medications. Of course, diet, fluid intake and activity level play a role as well.
Managing these medically complex patients can be challenging, and requires careful surveillance for stone formation. While ultrasound provides good diagnostic information, CT scans are sometimes necessary. “We are actively working with radiology to develop a low-dose CT scan protocol to decrease radiation exposure,” DeFoor explains. “The study involves imaging kidney stone samples in the lab to fine tune the CT scan technique. We also are performing comparative research on CT scans versus ultrasound in diagnosing kidney stones.”
DeFoor and his colleagues will present results from the study at the American Urological Association’s Annual Meeting in May 2018.
