Introduction
The prevalence of urinary stone disease is high and is estimated to be 2–3% amongst the general population. The disease is a common cause for emergency hospital admissions with over 30,800 hospital admissions reported in England annually and 550,000 emergency room visits in the US in 2009 [
1,
2]. The peak age of incidence is between 35 and 55 years. The recent evidence suggests that in western nations the incidence of renal stones has increased and women might be nearly as affected as men [
3‐
5]. Risk of recurrence is estimated to be 50% within 5 years of the first stone episode. Given their age, patients with urinary stone disease are often working, productive members of society and if they require a leave of absence from employment, it could have economic ramifications on the individual, their family and on a wider, societal level [
6].
Urinary stones present with a myriad of clinical features ranging from the pain of acute ureteric colic and systemic sepsis to minimal or asymptomatic disease. Once emergency treatment has been completed (treatment of infection, acute kidney injury and amelioration of pain), definitive treatment must be planned. This treatment pathway can be complex, multi-staged and can involve multiple hospital visits and admissions. Many patients suffer with recurrent/multiple stones requiring ongoing treatments. Stone disease and its treatment(s) can have an adverse effect on patients’ health-related quality of life (HRQoL) [
7‐
12].
Various interventional treatments (shock wave lithotripsy and ureteroscopy) and non-interventional treatments exist, including expectant treatments. Patients with larger renal stones have the option of percutaneous nephrolithotomy (PNCL) and additional treatment options [
13]. The treatment pathways’ success rates, as well as risks, are different with each treatment route.
The current pathway of care is suboptimal, considering the need to incorporate patient-reported outcomes, patient treatment preferences and resource efficiency. Most of the evidence is focused on the limited aspects of clinical management. In spite of clear indications from the literature for the need to understand patient perspectives in a scientific way on patients’ HRQoL (including the impact of disease and interventions), very few research groups have published peer-reviewed papers in this field [
7‐
12]. This has made it difficult to evaluate and compare different treatments and technologies effectively. Many aspects of the treatments could be changed and traded if patient perspectives could be better understood. Currently, this results in the treatments being offered on an ad hoc basis, with patients being inadequately informed, while often putting them through protracted treatment journeys. There are also economic implications for possible inefficient use of resources.
Patient-reported outcome measures attempt to quantify patients’ health-related quality of life in a valid and reproducible way. Patients’ expectations of treatment and the impact of disease and their treatments on HRQoL are important outcome parameters. AUA guidelines on the treatment of urinary calculi state that treatment decisions should incorporate patient preferences to treatments, which would be influenced by quality of life [
14]. Generic measures such as the SF-36 and the EQ-5D have been used to measure HRQoL but these measures tend to evaluate narrow aspects of the impact and often fail to elaborate on the clinically relevant domains. The impact of urinary calculi has been studied in more detail (using predominantly quantitative methods), in the recent years. These studies include Wisconsin Quality of Life (WISQOL), as well as questionnaires using the items from the PROMIS (Patient Reported Outcomes Information System) question bank in acute or chronic stages of stone disease [
8,
11]. It has been suggested that the best treatment decisions are made when tailored to the needs and choices of individual patients [
15,
16]. Qualitative research offers detailed understanding of patient views and is an essential first step in developing patient-centric measures. Qualitative research methods provide an opportunity for a systematic, in-depth evaluation of issues that may not be necessarily be answered through quantitative methods and are becoming increasingly common and valued in medical literature.
The aim of this study was to assess and understand the impact of urinary stone disease and treatments on patients’ quality of life from the perspective of patients and their family members. We expect the results to offer detailed insights into stone disease and form the foundations for the development of patient-centric measures and tools which will be used to facilitate good communication with patients about treatment options and ultimately improve patient care [
7,
17‐
19].
Discussion
Our study demonstrates that stone disease and interventions tend to have significant impact on different domains of health-related quality of life. We found that there were few differences between sub-groups in terms of the quality-of-life issues faced. Pain along with physical symptoms other than pain seems to have the greatest impact on the HRQoL of patients and issues regarding work seem to be important to all sub-groups. Missing days from work and the possible financial instability that may ensue has been highlighted by patients throughout the study. This might be because stone patients tend to be of working age with economic dependents.
In terms of the groups ‘with’ or ‘without’ current stones, patients without current stones were less likely to suffer from, or have lower intensity of physical symptoms (as expected), but did have impact of the stones or interventions on psychosocial domains. Overall, we did not find major differences in the themes. This warrants more research in future, quantitative studies.
Other important HRQoL issues that we elicited were those pertaining to patients’ general outlook on life and mental and emotional symptoms. Patients reported the most difficult issues being the fact that there seemed to be no end in sight with their disease and the fear of the unknown that comes with having such a debilitating disease, where acute exacerbations can occur at any time in an unpredictable manner.
It is also important to note that in many, patients with urinary stone disease tend to suffer on a chronic basis. Patients probably learn multiple coping mechanisms related to their stone disease and this will impact on the quantification of their quality of life—they may score the same quality-of-life issue more favourably after a period of time as their expectations have been readjusted after living with the disease. Schwatrz et al. described this as ‘Response Shift Theory’ in 2007 [
26]. With this in mind, it would be useful to undertake longitudinal studies to evaluate the longer term impact of urinary stone disease.
The data gathered from the FROM-16© questionnaire showed that urinary stone disease had little impact on family members in either domain. This could be accounted by the fact that patients tend to be most anxious before a diagnosis is made and the family members that were approached after initial diagnosis. Administering the FROM-16© questionnaire to patients in the emergency department could give a clearer picture of what effect the patient’s disease has on their relative(s) in the acute setting.
When considering the treatment of urinary stone disease, extra attention should be given with respect to patient education and quality of life. Patients with renal stones who are not experiencing an acute exacerbation may suffer slightly impaired quality of life (due to ‘niggling’ renal angle pain etc.), however, after treatment (ESWL, ureteroscopy), the HRQoL may deteriorate due to instrumentation/ureteric stone fragments. In this scenario, the HRQoL of the patient may be greatly impacted in the short term and may mimic the stone disease itself. Patients not warned of this prior to treatment may regret the decision to undergo any intervention in the first place. Good patient communication and pre-treatment counselling are the foundation of shared decision making and a studies has shown that good patient education may ameliorate ureteric stent-related symptom morbidity [
27]. Patient education prior to urolithiasis interventions could similarly help as there is a wide variety of potential influences on patient choice.
Penniston et al. reported in 2012 that the most important factors impacting on quality of life of their stone population were patients’ concern about general health, pain, anxiety about current and future disease, decreased ability to focus on work, difficulty sleeping and lack of freedom to travel and attend social events. Many of these themes were confirmed to be similar to the ones identified in our population. However, in addition, we identified new findings related to the disease as well as the interventions and their complex interaction. Our study suggests that in our population sample, there were many other or related issues important to the patients. Similarly, we identified that the impact of current or past interventions, and indwelling stents can influence the intensity and the type of impact on different domains. We found that on many occasions, the impact tends to change during the treatment journey.
The most import HRQoL issues were pain, other physical symptoms, lack of support network, difficulty of disease prevention, difficulties with work and career and anxiety about the future. The item generation process of this study was patient-centred with open-ended questions employed as to give the most accurate and in-depth view of what patients felt were their most important HRQoL issues.
Our study has limitations. The items generated from the study were produced from English-speaking patient population in the United Kingdom. Patients from other countries and healthcare settings might have issues that were not picked up within our population. However, our response rate was excellent and therefore our data fairly represents the urinary stone formers within our population.
Difficulties were seen when attempting to disentangle HRQoL issues created from treatment from those associated with ureteric stent-related symptoms (a common adjunct used during the treatment of stone disease). All but the most veteran patients are unable to say which HRQoL issues were caused by ureteric stents and which were caused by the treatment itself. A possible solution to this problem would be the use of a stent-specific outcome measure alongside the proposed outcome measure when a stent (or stents) are deployed within the ureter [
19].
Current methods of quantifying HRQoL in stone patients include the use of generic quality of life measures such as the SF-36 and EuroQol 5-Dimension (EQ-5D) [
7]. New data have emerged from the disease-specific measures such as WISQOL and the use of PROMIS question banks. Many of the themes that were identified in our patient population have been identified as important QoL domains, as discussed earlier in the discussion. Future data from the quantitative and interventional studies would help to confirm these findings.
The findings from the present study provide insights into aspects of HRQOL issues associated with the urinary stone disease and different treatments. It should be viewed as part of a fundamental shift in research from typical limited outcome studies, to a more patient-centred approach. It has formed the framework for our work on the new universal ‘Urinary Stone and Intervention Quality of Life measure’ (USI-QoL) patient-reported outcome measure. Similarly, it offers the basis for the development of patient-centric measures such as patient-reported experience measures, decision aids and patient information tools.
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