The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications From Kidney Stones (ROCKS) Quality Initiative

Introduction

Kidney stone disease is a common, recurrent, and often painful condition affecting 11% of the United States (U.S.) population. Ureteroscopy is a minimally invasive endoscopic procedure, performed mainly at ambulatory centers, where a semirigid or flexible scope is inserted into the ureter or kidney via the urethra to treat urinary stones. It is the most common surgical treatment for nephrolithiasis, with over 500,000 procedures performed annually in the U.S. After ureteroscopy (URS), a ureteral stent, which is a small flexible hollow tube that sits within the ureter and bladder, permits drainage of urine from the kidney and is commonly placed for a temporary period.

Postoperative complications represent a significant impact on morbidity and cost of care for patients undergoing kidney stone surgery. Unplanned postoperative healthcare encounters, such as emergency department (ED) visits, add to the patient and caregiver burden, and increase the cost of care. The rate of postoperative ED visits after treatment of kidney stones with URS can be as high as 15%. Because kidney stone disease is one of the costliest urological conditions to treat, with greater than $2.1 billion annual costs, efforts to reduce unplanned postoperative encounters after URS represent an area for quality improvement (QI).

The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications From Kidney Stones (ROCKS) Framework

The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a physician-led collaborative group made up of urology practices throughout the state of Michigan, supported through funding from Blue Cross Blue Shield of Michigan (BCBSM). The collaborative is designed to evaluate and improve the quality and cost efficiency of urological care to benefit patients, providers, and payers. Initially established to improve care for patients with prostate cancer, it has expanded to other conditions including kidney stones and renal masses/cancer. All patients in the state are eligible to be in MUSIC, regardless of insurance status. MUSIC's goal is to improve patient outcomes through continuous data collection, performance feedback, and sharing of best practices. By collecting clinically relevant and actionable data, comparing performance among peers, and implementing changes in clinical behavior, MUSIC is continually identifying efficient ways to use healthcare resources and improve care delivery for patients with urological disease.

The Reducing Operative Complications From Kidney Stones (ROCKS) program is an initiative within MUSIC, begun in 2016, that aims to improve the quality of care for patients with urinary stone disease. MUSIC ROCKS maintains a prospective clinical registry of URS cases that contains patient demographic, clinical, and operative data entered by trained abstractors at each participating practice. Each patient is followed for 60 days postprocedurally, and appropriate variables are recorded according to a manual of operations. Each practice has a physician clinical champion, and QI projects are developed from the ground up, in conjunction with numerous patient advocates. Providers, healthcare team members, and patient advocates meet three times a year, where the data are evaluated, projects are defined, and the success and challenges of ongoing initiatives are discussed. The MUSIC playbook for QI and how ROCKS is structured is shown in Fig. 44.1 .

Understanding the Problem

MUSIC ROCKS developed a QI program designed to understand the problem, enact change, and measure the outcomes. The initial early goal of MUSIC ROCKS was to measure the variation in postoperative ED visits after URS across the state, identify the reasons for these visits, and develop care processes that can reduce unplanned healthcare encounters.

In 2016 a pilot of a limited number of practices within ROCKS was established. The frequency of ED and unscheduled office visits was measured after URS for stones. Patient-, provider-, and practice-level factors were evaluated for predictive factors of an adverse outcome. Additionally, the MUSIC coordinating center performed site visits and structured interviews with the urology care team at ROCKS practices with the lowest rates of postoperative ED visits.

After establishment of the program, ROCKS assessed URS in 21 practices with at least 10 cases per year in the registry and found that the 30-day postoperative ED visit rate was 8.1% but varied from 0% to 14.8% ( Fig. 44.2 ); 70% of these visits occurred within 7 days of surgery. Complaints of pain, hematuria, and urinary symptoms accounted for 36% of these visits. These patients were evaluated in the ED and sent home, indicating that a good proportion of these postoperative ED visits were modifiable and potentially avoidable. Additionally, ureteral stent placement was identified as a predictor of ED visit. A deeper dive into practices with lower rates of these modifiable ED visits showed that they had better efforts at patient education.

Enact Change

As a result of these findings, ROCKS started three initiatives aimed at patient and surgeon education.