A Tale of Two Eras: The Effect of the COVID-19 Pandemic on Stone Disease Presentations.

The novel coronavirus disease-19 (COVID-19) pandemic triggered a national emergency declaration in the United States on March 13, 2020. The resultant diversion of healthcare and public attention toward disease exposure avoidance, propagated a concerning reduction in emergency department (ED) presentations for many serious medical conditions. Urinary stone disease (USD) is a frequent cause of ED visits and can be life or organ threatening if not treated in a timely manner. One small Italian study showed that the pandemic had no effect on USD emergency presentation rates but its effect in a larger US cohort remains unknown.

Following Institutional Board Review approval, we analyzed all primary USD presentations to the Cleveland Clinic ED of 4 large hospital campuses (Main Campus, Fairview, Avon, Hillcrest) serving the wider Cleveland Area during the current “COVID-era” (March 16-April 30, 2020) and compared this with an equivalent “Pre-COVID era” from exactly a year ago (March 16-April 30, 2019). We analyzed baseline clinical characteristics at ED presentation and subsequent stone management.

During the COVID-era, there was a 36% reduction in emergent USD presentations compared to an equivalent pre-COVID era. Interestingly, there was no difference in baseline characteristics or clinical severity at presentation (measured by systemic inflammatory response syndrome criteria, serum creatinine, urinary tract infection or need for emergent intervention; Table 1 ). However, a higher proportion of COVID-era patients did have evidence of acute kidney injury (AKI) based on RIFLE classification (4.7% vs 2.6%) potentially suggestive of a delay in presentation.

Table 1

Comparison of characteristics of patients presenting to Cleveland area emergency departments with a primary stone diagnosis during a pre-COVID Era (March 16-April 30, 2019) and a COVID era (March 16-April 30, 2020)

	Pre-COVID Era	COVID Era	P Value
Total ED presentations	269	172	N/a
Initial ED presentation characteristics
Age†	51.3 (18-93)	52.6 (18-93)	.4454§
Sex‡			.4003║
Male	147 (55%)	101 (59%)
Female	122 (45%)	71 (41%)
Race‡			.1464║
White	216 (80%)	148 (86%)
Black	25 (9%)	9 (5%)
Mixed/Other	23 (9%)	9 (5%)
Unknown	5 (2%)	6 (4%)
BMI (kg/m2)†	30.8 (17-62)	30.3 (18-56)	.4197§
MyChart use‡			.4796║
User	179 (66.5%)	120 (70%)
Non user	90 (33.5%)	52 (30%)
Prior stone history‡			.2438║
Yes	131 (49%)	74 (43%)
No	138 (51%)	98 (57%)
Maximum stone diameter (mm)†	5.2 (1-30)	4.5 (1-18)	*.0296§
Imaging modality‡			.3963║
CT	255 (95%)	164 (95.3%)
US	14 (5%)	7 (4.1%)
X-ray	0	1 (0.6%)
Stone laterality‡			*.02║
Right	119 (44%)	98 (57%)
Left	140 (52%)	71 (41%)
Bilateral	10 (4%)	3 (2%)
Stone location‡			.2544║
Kidney	21 (8%)	14 (8%)
UPJ	20 (7.4%)	6 (3.5%)
Proximal ureter	63 (23.4%)	37 (21.5%)
Mid ureter	30 (11.2%)	14 (8%)
Distal ureter/UVJ	135 (50%)	101 (59%)
SIRS criteria at presentation‡			.1162║
0	156 (58%)	84 (49%)
1	84 (31%)	71 (41%)
2	24 (9%)	16 (9%)
3	5 (2%)	1 (1%)
4	0	0
Serum creatinine at presentation (mg/dL)†	0.99 (0.23-3.2)	1.00 (0.55-4.4)	.4284§
Evidence of AKI‡,¶	7 (2.6%)	8 (4.7%)	N/a
Positive urine culture (>10,000 CFU/mL)‡	20 (7%)	12 (7%)	N/a
Emergent intervention‡	49 (18%)	37 (22%)	.0987║
Stent	30	20
Nephrostomy tube	8	2
SWL	4	2
URS	7	13
Post-ED management
Immediate ED management‡			.3984║
Conservative	27 (10%)	14 (8.2%)
Conservative with MET	180 (67%)	109 (63.4%)
Admission	62 (23%)	49 (28.4%)
ICU admissions‡	3 (1%)	0
Time to clinic visit (days)†	7 (0-64)	15 (0-76)	*<.0001§
Types of visit‡
Total	115	65
In-person	115 (100%)	4 (6%)
Virtual visit	0	58 (89%)
Telephone	0	3 (5%)	*<.0001║
Time to definitive management (days)†	17 (0-82)	20 (0-86)	.2545§
Definitive management‡			*.0130║
Awaiting	0	7 (4%)
Observation	20 (7%)	9 (5%)
Stone passage	150 (56%)	104 (60%)
URS	79 (29%)	43 (25%)
SWL	15 (6%)	7 (4%)
PCNL	5 (2%)	1 (1%)
Nephrectomy	0	1 (1%)
Postoperative stent management‡			*<.0001║
No stent	10 (12%)	29 (66%)
Stent	65 (77%)	8 (18%)
Stent with string	6 (7%)	7 (16%)
Nephrostomy tube	3 (4%)	0

AKI, acute kidney injury; BMI, body mass index; CT, computed tomography; ED, emergency department; ICU, intensive care unit; MET, medical expulsive therapy; PCNL, percutaneous nephrolithotomy; SIRS, systemic inflammatory response syndrome; SWL, shockwave lithotripsy; UPJ, uretero-pelvic; URS, ureteroscopy; US, ultrasound; UVJ, uretero-vesical junction.

Statistically significant difference.

Mean (range in brackets).

Number(percentage in brackets).

t test.

Chi-square test.

Acute kidney injury defined as a >1.5 times increase in creatinine from baseline.

The COVID-era resulted in a measurable shift in subsequent patient management. There were significant delays having a Urology clinic visit (mean 15 days vs 7 days pre-COVID, P < .0001) and a seismic shift toward these being virtual or telephone visits (from 0% to 94%) despite availability of this technology during both periods. Given most stone cases require prompt management to avoid a sequelae of complications, this delay did not affect the time to receive definitive management which is in part due to the structured Cleveland Clinic Operative Tier system created to stratify urology cases based on emergent need during the pandemic. For those undergoing ureteroscopy or percutaneous nephrolithotomy, where postprocedure ureteral stent placement is common, we found a considerable practice shift toward not leaving stents (12%-66%) and also more stents left with a string (7%-16%), both removing a further patient encounter for stent removal, in addition to eliminating potential COVID exposure risk. Of note, none of these patients had a subsequent ED visit or resultant complication suggestive of this being a suitable future management change consideration for appropriate patients.

To our knowledge, this represents the first US-based analysis of the effect of the pandemic on USD presentations and highlighted a measurable reduction in ED presentations with higher rates of AKI and also interesting changes in Urology practice management patterns. With the pandemic still raging on with no clear end in sight, the true impact this will have on our stone clinical practice remains to be fully determined.