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Abstract: SA-PO028

Facility-Level Variation in Care of Veterans with Urinary Stone Disease

Session Information

Category: Diversity and Equity in Kidney Health

  • 900 Diversity and Equity in Kidney Health

Authors

  • Shahzad, Sheikh Raza, Stanford University School of Medicine, Stanford, California, United States
  • Ganesan, Calyani, Stanford University School of Medicine, Stanford, California, United States
  • Thomas, I-Chun, Stanford University School of Medicine, Stanford, California, United States
  • Montez-Rath, Maria E., Stanford University School of Medicine, Stanford, California, United States
  • Soerensen, Simon John Christoph, Stanford University School of Medicine, Stanford, California, United States
  • Chertow, Glenn, Stanford University School of Medicine, Stanford, California, United States
  • Pao, Alan C., Stanford University School of Medicine, Stanford, California, United States
  • Leppert, John, Stanford University School of Medicine, Stanford, California, United States
Background

Urologic care after kidney stone procedure presents an opportunity to implement stone prevention measures, but the frequency of urologic follow up and stone prevention measures are not known. We studied variation in urology visits and stone prevention measures within 6 months after a urinary stone procedure.

Methods

We used data from the Veterans Health Administration (VHA) to identify patients from 97 facilities who had a stone procedure between 2016 and 2018. We constructed multilevel regression models to estimate Median Odds Ratio (MOR) for facility-level variation for urology follow up visits and stone prevention measures. The base model was a random intercept for facility. The 2nd model was adjusted for patient covariates (age, sex, race, driving distance to nearest VA, comorbidities). The 3rd model was adjusted for patient and facility characteristics (geographic region, complexity). We used MOR to quantify facility-level variation and variance partition coefficient (VPC) to quantify the sources of unexplained variation.

Results

Our cohort included 24,057 Veterans who were predominantly white (78.7%) and male (93.8%), with a mean age of 63.8 years. Within 6 months of stone procedure, 93.8% had urology follow-up, 7.4% completed 24-hour urine testing, 7.8% had serum PTH measurement, and 26.2% received stone-related medications. The fully adjusted MOR for urology follow-up, 24-hour urine testing, PTH measurement, and medication prescriptions was 1.59, 1.98, 1.40 and 1.20 respectively. The fully adjusted VPC was 0.19, 0.33, 0.11 and 0.03 respectively.

Conclusion

Sizable variation exists in stone disease care across VHA facilities. Variation due to between-facility differences was higher for 24-hour urine testing (33%) and urology follow-up (18.6%) and lower for PTH measurement (10.8%) and prescription of stone-related medications (3%). Variation across facilities was 1.6-fold in rates of urology follow-up, 2-fold in rates of 24-hour urine testing, 1.4-fold in obtaining PTH levels, and 1.2-fold in stone-related medication prescriptions. There is a need for standardization of urinary stone disease care across facilities. More work is needed to establish clear guidelines for stone prevention and the factors underlying variation in stone prevention care in the VHA and civilian healthcare systems.

Funding

  • Veterans Affairs Support