Guidelines in urology: Lights and shadows

Unwarranted Between-hospital Variation in Mortality, Readmission, and Length of Stay of Urological Admissions: An Important Trigger for Prioritising Quality Targets

BACKGROUND

Unwarranted between-hospital variation is a persistent health care quality issue. It is unknown whether urology patients are prone to this variation.

OBJECTIVE

To examine between-hospital variation in mortality, readmission, and length of stay for all 22 urological All Patient Refined Diagnosis Related Groups (APR-DRGs).

DESIGN, SETTING, AND PARTICIPANTS

This study included administrative data from 320640 urological admissions in 99 (98%) Belgian acute-care hospitals between 2016 and 2018.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used hierarchical mixed-effect logistic regression models to estimate hospital-specific and APR-DRG-specific risk-standardised rates for in-hospital mortality, 30-d readmission, and length of stay above the APR-DRG-specific 90th percentile. Between-hospital variation was assessed based on the estimated variance components. Associations of outcomes with patient and hospital characteristics and time trends were examined.

RESULTS AND LIMITATIONS

Our analysis revealed important between-hospital variation in mortality, readmission, and length of stay for urological pathologies, particularly for medical diagnoses. Significant variation was shown in all three outcomes for kidney and urinary tract infections; other kidney and urinary tract diagnoses, signs, and symptoms; urinary stones and acquired upper urinary tract obstruction; and kidney and urinary tract procedures for nonmalignancy. Lowering of mortality rates in upper-quartile hospitals to the median could potentially save 41.5% of deaths in these hospitals, with the largest absolute gain for kidney and urinary tract infections and kidney and urinary tract malignancy. Limitations included a likely underestimation of readmission rates.

CONCLUSIONS

Urological patient outcomes are characterised by unwarranted between-hospital variation. We recommend improvement initiatives to prioritise kidney and urinary tract infections because of significant variation across the three outcomes and the largest potential gain in lives saved.

PATIENT SUMMARY

We found notable between-hospital variation in mortality, readmission, and length of stay for urological hospital admissions in Belgium. As much as 41.5% of deaths could potentially be avoided if underperforming hospitals improved. Targeting kidney and urinary tract infections could help reduce variation.

Clinical Validation of the Greek Version of the Acute Cystitis Symptom Score (ACSS)-Part II

The Acute Cystitis Symptom Score (ACSS) is a patient self-reporting questionnaire for the clinical diagnosis and patient-reported outcome (PRO) in women with acute uncomplicated cystitis (AC). The aim of the current study (part II) is the clinical validation of the Greek ACSS questionnaire. After linguistic validation according to internationally accepted guidelines and cognitive assessment (part I), the clinical validation was performed by using the Greek ACSS study version in 92 evaluable female participants including 53 patients with symptoms suspicious of AC and 39 controls. The clinical outcome using the ACSS questionnaire at different points in time after the start of treatment was demonstrated as well. The age (mean ± SD) of the 53 patients (44.7 ± 17.0 years) and 39 controls (49.3 ± 15.9 years) and their additional conditions at baseline visits, such as menstruation, premenstrual syndrome, pregnancy, menopause, diabetes mellitus, were comparable. There was, however, a significant difference (p < 0.001) between patients and controls at baseline visit regarding sum score of the ACSS domains, such as typical symptoms and quality of life. The clinical outcome of up to 7 days showed a fast reduction of the symptom scores and improvement of quality of life. The optimal thresholds for the patient-reported outcome of successful therapy could be established. The linguistically and clinically validated Greek ACSS questionnaire can now be used for clinical or epidemiological studies and also for patients' self-diagnosis of AC and as a PRO measure tool.