Understanding the barriers to the dissemination of medical expulsive therapy

Increasing trial evidence suggests that a course of medical expulsive therapy is warranted for patients with ureteral stones who are amenable to conservative treatment, and that this efficacious process of care is underused. To better understand the barriers to the dissemination of medical expulsive therapy we analyzed health care claims of working age adults with urinary stone disease.

Using MarketScan® data (2002 to 2006) we identified patients with urinary stone disease who were treated in the emergency department. We characterized differences between patients who were prescribed medical expulsive therapy and those who were not. After assigning patients to their principal providers we determined how much of the variation in medical expulsive therapy prescribing rates was attributable to patient vs provider level factors.

A total of 79,688 patients were seen for an acute stone episode. They received care from 12,328 providers. In general those patients prescribed medical expulsive therapy tended to be older (p<0.001) and were more likely male (p<0.001). A higher percentage of medical expulsive therapy recipients were salaried (p=0.003) and had full-time employment (p<0.001). Of the unexplained variation in medical expulsive therapy prescription 21% was accounted for by unmeasured provider factors and patient odds of receiving medical expulsive therapy were 5-fold higher if seen by a urologist (OR 4.94, 95% CI 2.96-8.28, p<0.001).

These data reveal that the provider seen for an episode of renal colic substantially determines whether the patient will receive medical expulsive therapy. As such, an educational intervention directed toward emergency department physicians might hasten the uptake of medical expulsive therapy within the broader medical community.