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Paul CJ. et al., 2020: Treatment Setting Influences Treatment Modality for Urinary Stone Disease

Paul CJ, Gruca TS, Morrison PG, Ghareeb GM, Kim SH, Erickson BA.
University of Iowa Hospitals & Clinics, Department of Urology, Iowa City, IA.
University of Iowa, Tippie College of Business, Iowa City, IA.
United Regional Physician Group, Wichita Falls, TX.
Emory University, Department of Urology, Atlanta, GA.
University of Iowa Hospitals & Clinics, Department of Urology, Iowa City, IA.

Abstract

Objective: To determine whether selection of treatment modality for urinary stone disease differs between primary and outreach healthcare centers, and if patient rurality predicts treatment modality.


Methods: We retrospectively evaluated ESWL and URS procedural data from the Iowa Office of Statewide Clinical Education Programs (OSCEP) and Iowa Hospital Association (IHA) databases from 2007-2014. Geographical data was used to analyze travel metrics and patient proximity to sites of stone treatment. Rural-urban commuting area (RUCA) codes were used to characterize patient rurality. Chi-square tests and t-tests were used to compare ESWL and URS patients, and multilevel logistic regression model was used to assess influence of treatment setting on surgical modality.


Results: 18,831 stone procedures were performed by urologists in Iowa on patients from Iowa (10,495 URS; 8,336 ESWL). 2,630 procedures occurred at outreach centers. Ureteroscopy comprised 59.7% of procedures at primary centers, but only 31.2% at outreach centers. On multilevel analysis, outreach location was associated with 2.236 OR towards ESWL (p<0.001). Individual physician treatment patterns accounted for 32% of treatment variation. Patient rurality was not significantly associated with treatment modality as an independent factor (p=0.879).


Conclusion: Wide variation exists in urolithiasis treatment modality selection between outreach and primary centers. Outreach locations perform a significantly higher frequency of ESWL compared to URS, and much of the variation in treatment selection (32%) arises from individual physician practice patterns.
Urology. 2020 May 24:S0090-4295(20)30585-9. doi: 10.1016/j.urology.2020.05.024. Online ahead of print.PMID: 32461168

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Comments 1

Hans-Göran Tiselius on Friday, July 31 2020 08:35

The article describes the surgical care of patients with urolithiasis in Iowa; a state with a large rural area in which 14% of all stone removing procedures are carried out. The message is that patients were treated differently depending of where they lived. Thus, the analysis showed that as an effect of the variable experience of urologists, ~31% of patients in the rural/outreach areas were treated with URS compared with ~60% in the primary centres of Iowa. The interpretation was that the treatment modality was dependent on the individual urologist’s practice. Accordingly, it was noted that in some areas SWL was used more commonly also for indications beyond the recommended limits in guidelines. Is that always bad? From my own personal experience, it is not. SWL has a wide range of applications and it certainly is better to be treated by somebody who definitely masters SWL than to be treated endoscopically by a urologist with limited experience of that treatment modality and perhaps with suboptimal equipment. With an appropriate device SWL can be applied to stone problems also outside the range of indications generally covered by guidelines.

Hans-Göran Tiselius

The article describes the surgical care of patients with urolithiasis in Iowa; a state with a large rural area in which 14% of all stone removing procedures are carried out. The message is that patients were treated differently depending of where they lived. Thus, the analysis showed that as an effect of the variable experience of urologists, ~31% of patients in the rural/outreach areas were treated with URS compared with ~60% in the primary centres of Iowa. The interpretation was that the treatment modality was dependent on the individual urologist’s practice. Accordingly, it was noted that in some areas SWL was used more commonly also for indications beyond the recommended limits in guidelines. Is that always bad? From my own personal experience, it is not. SWL has a wide range of applications and it certainly is better to be treated by somebody who definitely masters SWL than to be treated endoscopically by a urologist with limited experience of that treatment modality and perhaps with suboptimal equipment. With an appropriate device SWL can be applied to stone problems also outside the range of indications generally covered by guidelines. Hans-Göran Tiselius
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Thursday, October 29 2020

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