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Use of medical expulsive therapy in children: An assessment of nationwide practice patterns and outcomes

      Summary

      Introduction

      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.

      Study design

      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.

      Results

      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.

      Discussion

      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.

      Conclusions

      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.
      TableOR and CI for factors associated with use of MET.
      Demographic Whole group (n = 1325) Calculus of the ureter (n = 527)
      OR (95% CI) OR (95% CI)
      Factors associated with receipt of MET
      Age 1.05 (1.00–1.10) 1.02 (0.95–1.10)
      Female 0.64 (0.46–0.90) 0.77 (0.47–1.28)
      Urologist provider 2.04 (1.32–3.15) 1.60 (0.88–2.90)
      Year of diagnosis 1.31 (1.19–1.44) 1.34 (1.15–1.56)
      Outcomes associated with receipt of MET
      ED visit 0.63 (0.34–1.19) 1.36 (0.59–3.12)
      Hospital admission 0.94 (0.59–1.48) 1.28 (0.64–2.56)
      Appropriate imaging 1.67 (1.21–2.32) 1.69 (1.03–2.77)
      Surgical intervention 1.11 (0.77–1.60) 0.96 (0.57–1.63)
      Top of table shows factors associated with initial MET exposure. Bottom of table shows 90-day outcomes associated with MET exposure at initial visit.

      Keywords

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