Hsi RS, Valicevic AN, Patel SR, et al. Specialist care, metabolic testing, and testing completeness among U.S. veterans with urinary stone disease. Urol Pract. 2023;10(1):48-57.

Study Need and Importance

Under contemporary practice guidelines for urinary stone disease (USD) prevention, 24-hour urine testing plays an important role in the management strategy to reduce future recurrence episodes. However, several recent observational studies have reported no differences in rates of recurrent stone events between patients with and without 24-hour testing. While it is possible that clinicians may have difficulty interpreting 24-hour urine results, a plausible explanation is that these studies assumed patients received testing for all components of the 24-hour urine as outlined by clinical guidelines. Therefore, we conducted an observational study of adults with USD with data from the Veterans Health Administration (VHA) to examine whether testing and testing completeness were associated with facility-level variation in the evaluation for USD prevention.

What We Found

In this study of U.S. veterans who used the VHA for their USD from 2012 to 2019, we found that 24-hour urine testing rates occurred in approximately 1 in 12 individuals, similar to the testing rate previously reported for those with employer-based insurance. Rates of testing within the VHA declined 2 percentage points over the study interval, despite the introduction of clinical guidelines during it. Additionally, among those receiving 24-hour urine testing, approximately half had complete testing, and this figure increased from approximately 40% in 2012 to 60% in 2019. Finally, we observed that facility level variation significantly contributes to the observed variation independent of patient characteristics (see Figure). Where veterans with USD receive their care strongly influences whether 24-hour urine testing is performed and whether testing includes a full panel of urinary analytes.

Limitations

Administrative data are susceptible to omitted variable bias and misclassification bias. Due to the observational study design, we lack information on granular details that may shed more information on which provider and facility factors relate to when testing is performed and testing completeness. These data are limited to care provided within the Veterans Administration, so care provided (eg, 24-hour urine tests) outside of the Veterans Administration would not be captured.

Interpretation for Patient Care

Individual facilities contribute a substantial degree to the observed variation in 24-hour urine testing and testing completeness. When 24-hour urine components cannot be ordered together as a panel, providers may need to order each component individually, which can be burdensome and time intensive. With the widespread use of electronic health records and order entry, panel-based testing can be developed at the facility level, as suggested by our observation of some facilities with very high rates of testing completion. Reducing facility level variation in testing completeness may improve USD preventive care.