Trends in Medical Expulsive Therapy Use for Urinary Stone Disease in U.S. Emergency Departments

doi:10.1016/j.urology.2009.03.050

Urology

Volume 74, Issue 6, December 2009, Pages 1206-1209

https://doi.org/10.1016/j.urology.2009.03.050 Get rights and content

Objectives

Between 2000 and 2006, 11 randomized controlled trials were published, demonstrating the efficacy of medical expulsive therapy (MET) for promoting upper tract stone passage. Although its use is gaining traction among urologists, they evaluate a minority of patients who present to the emergency department (ED) for acute renal colic before discharge. As such, measuring the uptake of MET into the broader medical community is important.

Methods

Data were analyzed (2000-2006) from the National Hospital Ambulatory Medical Care Survey. Sampled ED visits for stones were identified. The use of MET was ascertained by the prescription of a calcium channel or α blocker at the ED visit. National estimates of the prevalence of MET use were computed. Logistic regression was used to examine linear and nonlinear time trends in MET prescription.

Results

The use of MET increased throughout the study period. In fact, the odds of being treated with this approach more than doubled with each successive year (OR, 2.15; 95% CI, 1.31-3.5; P < .001 for the linear trend). However, the overall prevalence of use was exceedingly low at 1.1% (95% CI, 0.6%-1.9%). Given the number needed to treat of 4, this implies a missed opportunity to spare approximately 260 000 individuals annually from stone surgery and its risks.

Conclusions

Despite the growing body of evidence to support its safety and efficacy, our analysis reveals the sluggish dissemination of MET into the broader medical community. The observed underuse represents a block in the translation of clinical science into practice and raises a quality of care concern.

Section snippets

Material and Methods

Data were analyzed from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Designed by the National Center for Health Statistics and administered by the US Census Bureau, the NHAMCS is an annual 4-stage probability sample of outpatient or ED visits to randomly selected, nonfederal short-stay hospitals in the U.S. All aspects of each visit are weighted, and the weights are adjusted to account for nonresponse and nonparticipation, allowing for extrapolation to the universe of

Results

The frequency of ED visits for urinary stone disease was stable over the study period, ranging from 3.2 visits (95% confidence interval (CI), 2.5-3.8) per 1000 US population in 2006 to 4.2 visits (95% CI, 3.3-5.1) per 1000 US population in 2004. Mean age was comparable between patients who were treated with MET and those who were not (41.0 vs 41.4 years, respectively). Although 39.6% of eligible visits were made by women, they accounted for only 21% of the encounters at which MET was

Comment

Despite the growing body of evidence to support its safety and efficacy for promoting upper tract stone passage,10, 11 our analysis reveals the sluggish dissemination of MET into the broader medical community. The exceedingly low prevalence of use (prescribed at only 1.1% of eligible ED visits during the 7-year study period) implies a missed opportunity to spare approximately 260 000 individuals annually from surgery and its risks. Taken together, the observed underuse of MET represents a block

Conclusions

Despite the growing body of evidence to support its safety and efficacy, our analysis reveals the sluggish dissemination of MET into the broader medical community. Given the low cost of MET ($28) and the expense of stone procedures ($4773 for ureteroscopy),²⁰ these observed trends likely have significant economic implications for the US health care system. Further, this underuse represents a block in the translation of clinical science into practice and raises a quality of care concern.

References (20)

R. Sierakowski et al.
The frequency of urolithiasis in hospital discharge diagnoses in the United States
Invest Urol.
(1978)
C.M. Johnson et al.
Renal stone epidemiology: a 25-year study in Rochester, Minnesota
Kidney Int.
(1979)
J.M. Teichman
Clinical practiceAcute renal colic from ureteral calculus
N Engl J Med.
(2004)
G.M. Preminger et al.
Guideline for the management of ureteral calculi
J Urol.
(2007)
S.J. Parekattil et al.
External validation of outcome prediction model for ureteral/renal calculi
J Urol.
(2006)
A.F. Bierkens et al.
Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopyA comparison of costs, morbidity, and effectiveness
Br J Urol.
(1998)
W.W. Hochreiter et al.
Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve
J Urol.
(2003)
G.F. Daniels et al.
Ureteroscopic results and complications: experience with 130 cases
J Urol.
(1988)
A.E. Krambeck et al.
Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of follow up
J Urol.
(2006)
A. Singh et al.
A systematic review of medical therapy to facilitate passage of ureteral calculi
Ann Emerg Med.
(2007)

There are more references available in the full text version of this article.

Cited by (22)

Medical Management of Renal and Ureteral Stones
2022, Comprehensive Pharmacology
Urolithiasis is a global widespread disease with an increasing incidence over the recent decades. Its prevalence differs geographically and is influenced by climatic conditions, age, genetics, diet and fluid intake. Stone composition and frequency vary depending on the etiology of stone formation. The type of the calculus, stone size, stone location, and accompanying symptoms determine therapeutic measures. Surgical stone removal is of great importance and ongoing innovations enable minimal-invasive procedures and improved success rates. However, pharmacological treatment is crucial in patients with acute renal colic and for prevention of recurrent stone formation. Conservative treatment may be warranted in patients with small ureteral calculi and absence of complications. Several drug classes have been investigated for promotion of spontaneous stone passage. Moreover, few stone types, especially uric acid stones, permit a medical dissolution therapy, also referred to as chemolitholysis. This article provides elementary knowledge about current pharmacological interventions for renal and ureteral stones.
Retrospective Review of Acute Renal Colic Management in the Emergency Department and Review of Guidelines
2018, Urology Practice
The influence of multispecialty guidelines on practice patterns in the emergency department is unknown. We documented practice patterns in our emergency department among patients presenting with acute renal colic.
We identified practice patterns in the treatment of nephrolithiasis in our emergency department via a retrospective chart review of 469 patients from 2013 to 2015. We compared practice patterns to available guidelines over the domains of 1) diagnostic and imaging studies, 2) medications and 3) referral to urology.
There was a slight preference toward noncontrast computerized tomography (29%) as a single modality imaging study compared to renal ultrasound (26%). Overall 74% of renal ultrasounds were completed at bedside by emergency department physicians. Alpha blockers were used for medical expulsive therapy in 47% of patients. However, 133 patients with ureteral stones did not receive medical expulsive therapy. Only 34% of the total cohort received a urology consultation in the emergency department or subsequent outpatient referral.
We noted variability in practice patterns for patients presenting with nephrolithiasis in the emergency department compared to guidelines provided by several professional organizations. There is inconsistent use of imaging studies, underuse of medical expulsive therapy and underuse of urology, highlighting a need for collaborative standardization of a diagnostic and treatment protocol to enhance quality of care.
Use of medical expulsive therapy in children: An assessment of nationwide practice patterns and outcomes
2017, Journal of Pediatric Urology
Early data support the use of medical expulsive therapy (MET) in children. However, little is known regarding use or outcomes associated with MET outside of pediatric-specific practices. Using a national administrative dataset, we sought to characterize utilization patterns of MET as well as assess outcomes associated with MET exposure.
We interrogated the MarketScan Commercial Claims and Encounters database to identify children under the age of 18 presenting to the emergency department (ED) with any diagnosis of upper urinary tract calculi (UUTC, including renal and ureteral calculi). MET exposure was defined as having a prescription filled for a MET agent within 1 week of the ED encounter. Characteristics of children receiving MET were defined and outcomes compared between children with and without MET exposure.
Of 1325 children included in the study, 13.2% received MET, including 15.4% of children with a diagnosis of “calculus of the ureter.” MET use increased significantly throughout the study period (p = 0.004), although only 30.4% of children considered potential MET candidates received MET in the final year of the study (2013). Among all patients, receipt of MET was associated with male gender, presence of comorbidity, provider-type (urologist), and year of diagnosis, although among those with a specific diagnosis of “calculus of the ureter,” only year of diagnosis remained a significant factor. Rates of unplanned physician visits and surgical interventions were similar between groups. Children receiving MET were more likely to receive follow-up imaging, although only 46% of children with ureteral calculi had appropriate follow-up imaging within 90 days, regardless of MET exposure. Odds ratios of factors and outcomes associated with MET exposure are shown in the Table.
Although early data support safety and efficacy MET in children, nationwide use in children is low among potential candidates for MET. For children with ureteral calculi, only year of diagnosis was a significant factor associated with MET use. No difference in unplanned physician visits or surgical interventions was noted. Most notable, however, was the low rate of follow-up imaging within 90 days for children presenting acutely with UUTC.
Use of MET for children with ureteral calculi is increasing, although still fewer than a third of children considered potential candidates receive this treatment. Follow-up imaging is not obtained for many children with ureteral calculi. Future work is needed to standardize management and follow-up protocols for children with acute renal colic.
Medical expulsive therapy use in emergency department patients diagnosed with ureteral stones
2017, American Journal of Emergency Medicine
Recent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones < 10 mm not requiring an urgent intervention. Prior studies have reported low rates of use of MET by emergency physicians. We sought to describe patterns of alpha-blocker use and to determine factors associated with utilization in patients diagnosed with ureterolithiasis in the ED.
We used data from a randomized trial of CT scan vs. ultrasound in participants with suspected urolithiasis enrolled at 15 EDs between October 2011 and February 2013. The use of medical expulsive therapy was identified by the prescription of an alpha-blocker, calcium channel blocker, or steroid at the ED visit. The prevalence of alpha-blocker use in participants with ureteral stones on imaging was calculated, and multivariable models were used to examine risk factors for utilization.
Of the 524 participants who were identified with a ureteral stone on CT scan and discharged from the ED, 375 (71.4%) received an alpha-blocker, and 2 (< 1%) received a steroid. There was no significant difference in alpha-blocker use for participants based on stone size or location. However, there was a 3.6-fold difference in alpha-blocker use between the lowest and highest use ED sites. In the multivariable analysis, ED site was independently associated with utilization of alpha-blockers.
Alpha-blockers were prescribed in more than two-thirds of patients with a distal ureteral stone on imaging, a much higher prevalence than previously reported. There was substantial variability in alpha-blocker use based on ED site.
Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis
2017, Annals of Emergency Medicine
Citation Excerpt :
It is estimated there are now more than 2 million annual outpatient visits for urolithiasis in the United States.11 Although urologists have been proponents of α-blocker use, other clinicians who manage urolithiasis have used α-blockers at low rates.11,12 A clear understanding of the value of tamsulosin would help clinicians to decide whether to offer this therapy to patients with a common, recurrent, painful, and costly problem.
Tamsulosin is recommended for patients receiving a diagnosis of a ureteral stone less than 10 mm who do not require immediate urologic intervention. Because of conflicting results from recent meta-analyses and large randomized controlled trials, the efficacy of tamsulosin is unclear. We perform a systematic review and meta-analysis to investigate the effect of tamsulosin on stone passage in patients receiving a diagnosis of ureteral stone.
MEDLINE, EMBASE, and CENTRAL databases were searched without language restriction through November 2015 for studies assessing the efficacy of tamsulosin and using a double-blind, randomized, controlled trial design. Meta-analysis was conducted with a random-effects model and subgroup analyses were conducted to determine sources of heterogeneity.
Eight randomized controlled trials (N=1,384) contained sufficient information for inclusion. The pooled risk of stone passage in the tamsulosin arm was 85% versus 66% in the placebo arm, but substantial heterogeneity existed across trials (I²=80.2%; P<.001). After stratifying of studies by stone size, the meta-analysis of the large stone subgroup (5 to 10 mm; N=514) indicated a benefit of tamsulosin (risk difference=22%; 95% confidence interval 12% to 33%; number needed to treat=5). The meta-analysis of the small stone subgroup (<4 to 5 mm; N=533) indicated no benefit (risk difference=–0.3%; 95% confidence interval –4% to 3%). Neither meta-analysis for the occurrence of dizziness or hypotension showed a significant effect.
Tamsulosin significantly improves stone passage in patients with larger stones, whereas the effect of tamsulosin is diminished in those with smaller stones, who are likely to pass their stone regardless of treatment.
Editorial Comment
2015, Urology

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: Supported by: PhRMA Foundation Research Starter Grant (to B. K. H.).

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Endourology and StonesTrends in Medical Expulsive Therapy Use for Urinary Stone Disease in U.S. Emergency Departments

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

The frequency of urolithiasis in hospital discharge diagnoses in the United States

Invest Urol.

Renal stone epidemiology: a 25-year study in Rochester, Minnesota

Kidney Int.

Clinical practiceAcute renal colic from ureteral calculus

N Engl J Med.

Guideline for the management of ureteral calculi

J Urol.

External validation of outcome prediction model for ureteral/renal calculi

J Urol.

Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopyA comparison of costs, morbidity, and effectiveness

Br J Urol.

Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve

J Urol.

Ureteroscopic results and complications: experience with 130 cases

J Urol.

Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of follow up

J Urol.

A systematic review of medical therapy to facilitate passage of ureteral calculi

Ann Emerg Med.

Endourology and Stones
Trends in Medical Expulsive Therapy Use for Urinary Stone Disease in U.S. Emergency Departments