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Seklehner S et al, 2013: Trends and Inequalities in the Surgical Management of Ureteral Calculi in the United States

Seklehner S, Laudano MA, Jamzadeh A, Del Pizzo JJ, Chughtai B, Lee RK
Department of Urology, Weill Medical College of Cornell University, New York, NY, USA; Department of Urology, Landesklinikum Baden-Mödling, Baden, Austria


Abstract

OBJECTIVE: To assess trends in surgical management of ureteral calculi over a ten year period.

MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007 and 2010) was performed to assess the use of URS, SWL and UL in treating ureteral calculi. Patients were identified using ICD-9 (cm) and CPT codes. Statistical analyses, including the Fisher, χ2 tests, and multivariate logistic regression analysis (dependent variables: URS, SWL, UL, treatment, no treatment; independent variables: age, gender, ethnicity, geography and year of treatment) were performed using SAS 9.3 (SAS Institute Inc., Cary, NC) and SPSS v20 (IBM Corp., rmonk, NY).

RESULTS: A total of 299,920 patients were identified with ureteral calculi. Of these, 115,200 underwent surgery. Men (OR=1.15, p<0.0001) were more, while minorities (OR=0.84, p=0.004) were less likely to be treated. Patients in the West were also less likely to be treated (OR=0.76, p<0.0001) as were patients aged 84 years old (p=0.29). URS represented the predominant surgical approach (65.2%), followed by SWL (33.6%) and UL (1.2%).The relative usage of URS increased over time, while SWL and UL declined. Women (OR=1.25, p<0.0001) were more likely to undergo URS. Patients in the South (OR=1.51, p<0.0001) and minorities were more likely to undergo SWL (OR=1.23, p=0.03).

CONCLUSIONS: The surgical treatment of ureteral calculi changed significantly from 2001-2010. The utilization of URS expanded at the expense of SWL and UL. Multiple inequalities existed in overall surgical treatment rates and in the choice of treatment: Age, gender, ethnicity, and geography influenced both whether patients underwent surgical intervention and the type of surgical approach used.

BJU Int. 2013 Jul 22. doi: 10.1111/bju.12372
PMID:24053734 [PubMed - as supplied by publisher]

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Hans-Göran Tiselius on Wednesday, 18 September 2013 13:10

This report summarizes how patients with ureteral stones have been treated in USA between 2001 and 2010. This period is characterized by a significantly increased incidence of stone disease in the population. The data were obtained from the Medicare file and the report is significantly limited by the fact that beneficiaries of that system, according to the authors´ report, mainly are older than 65 years! There are also several demographic peculiarities that might be typical for the US health care system and it is not possible to interpret the observations.

There are, however, two interesting findings that should be noted. Firstly and somewhat surprisingly is that the fraction of patients treated surgically (in this age group)is unchanged at 38% despite the expected increased incidence that should have been possible to note also among these patients. How the use of alpha-blocking agents has influenced the number of patients treated conservatively cannot be extracted from the report. The other observation that at least partially seems to reflect what happens worldwide is the increased popularity of URS compared with SWL. By giving preference to invasive rather than non-invasive procedures, insufficient attention is paid to the advantages of SWL particularly when older patients are treated. In most places SWL today is carried out without general anaesthesia as an outpatient procedure with a lower rate of complications than that seen with URS. Although it is not mentioned in the article it can be assumed that the more extensive use of general anaesthesia is used also for SWL. Such a routine also explains why SWL is considered more expensive than URS.

The major argument for using URS instead of SWL is dictated by the opinion that SWL is associated with a common need to retreat the patients. This is to some extent true, but it needs to be emphasized that in my own experience of SWL carried out in a large unselected group of patients with ureteral stones, more than 76 % were successfully treated with only one session.

Hans-Göran Tiselius

This report summarizes how patients with ureteral stones have been treated in USA between 2001 and 2010. This period is characterized by a significantly increased incidence of stone disease in the population. The data were obtained from the Medicare file and the report is significantly limited by the fact that beneficiaries of that system, according to the authors´ report, mainly are older than 65 years! There are also several demographic peculiarities that might be typical for the US health care system and it is not possible to interpret the observations. There are, however, two interesting findings that should be noted. Firstly and somewhat surprisingly is that the fraction of patients treated surgically (in this age group)is unchanged at 38% despite the expected increased incidence that should have been possible to note also among these patients. How the use of alpha-blocking agents has influenced the number of patients treated conservatively cannot be extracted from the report. The other observation that at least partially seems to reflect what happens worldwide is the increased popularity of URS compared with SWL. By giving preference to invasive rather than non-invasive procedures, insufficient attention is paid to the advantages of SWL particularly when older patients are treated. In most places SWL today is carried out without general anaesthesia as an outpatient procedure with a lower rate of complications than that seen with URS. Although it is not mentioned in the article it can be assumed that the more extensive use of general anaesthesia is used also for SWL. Such a routine also explains why SWL is considered more expensive than URS. The major argument for using URS instead of SWL is dictated by the opinion that SWL is associated with a common need to retreat the patients. This is to some extent true, but it needs to be emphasized that in my own experience of SWL carried out in a large unselected group of patients with ureteral stones, more than 76 % were successfully treated with only one session. Hans-Göran Tiselius
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