No AccessJournal of UrologyAdult Urology1 Dec 2010

Understanding the Barriers to the Dissemination of Medical Expulsive Therapy

    View All Author Information


    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.

    Materials and Methods:

    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.


    • 1 : Medical therapy to facilitate urinary stone passage: a meta-analysis. Lancet2006; 368: 1171. Google Scholar
    • 2 : 2007 Guideline for the management of ureteral calculi. Eur Urol2007; 52: 1610. Google Scholar
    • 3 : 2007 Guideline for the management of ureteral calculi. J Urol2007; 178: 2418. LinkGoogle Scholar
    • 4 : Trends in medical expulsive therapy use for urinary stone disease in U.S. emergency departments. Urology2009; 74: 1206. Google Scholar
    • 5 : Urologic diseases in America project: urolithiasis. J Urol2005; 173: 848. LinkGoogle Scholar
    • 6 : Multilevel Analysis. Thousand Oaks, California: Sage Publications, Inc1999. Google Scholar
    • 7 : Missing Data. Thousand Oaks, California: Sage Publications, Inc2002. Google Scholar
    • 8 : Rational prescribing and interpractitioner variation: A multilevel approach. Int J Technol Assess Health Care1995; 11: 428. Google Scholar
    • 9 : Current practice patterns in the management of upper urinary tract calculi in the north central United States. J Endourol2008; 22: 631. Google Scholar
    • 10 : Emergency room follow-up trends in urolithiasis: single-center report. Urology2009; 73: 1195. Google Scholar
    • 11 : Emergency physicians report infrequent use of alpha-blockade for the treatment of ureteral stones. Am J Emerg Med2009; 27: 776. Google Scholar
    • 12 : Medical expulsive therapy for ureteral calculi in the real world: targeted education increases use and improves patient outcome. J Urol2010; 183: 585. LinkGoogle Scholar
    • 13 : Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med2009; 169: 364. Google Scholar
    • 14 : Improving lipid evaluation and management in medicare patients hospitalized for acute myocardial infarction. Arch Intern Med2001; 161: 839. Google Scholar
    • 15 : Medical management of acute urolithiasis in one American academic emergency room. BJU Int2010; 105: 856. Google Scholar