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



      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.


      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.


      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.


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bush N.C.
        • Xu L.
        • Brown B.J.
        • Holzer M.S.
        • Gingrich A.
        • Schuler B.
        • et al.
        Hospitalizations for pediatric stone disease in United States, 2002–2007.
        J Urol. 2010; 183: 1151-1156
        • Dwyer M.E.
        • Krambeck A.E.
        • Bergstralh E.J.
        • Milliner D.S.
        • Lieske J.C.
        • Rule A.D.
        Temporal trends in incidence of kidney stones among children: a 25-year population based study.
        J Urol. 2012; 188: 247-252
        • Sas D.J.
        • Hulsey T.C.
        • Shatat I.F.
        • Orak J.K.
        Increasing incidence of kidney stones in children evaluated in the emergency department.
        J Pediatr. 2010; 157: 132-137
        • Tasian G.E.
        • Ross M.E.
        • Song L.
        • Sas D.J.
        • Keren R.
        • Denburg M.R.
        • et al.
        Annual incidence of nephrolithiasis among children and adults in South Carolina from 1997 to 2012.
        Clin J Am Soc Nephrol. 2016; 11: 488-496
        • Pietrow P.K.
        • Pope JCt
        • Adams M.C.
        • Shyr Y.
        • Brock 3rd, J.W.
        Clinical outcome of pediatric stone disease.
        J Urol. 2002; 167: 670-673
        • Kalorin C.M.
        • Zabinski A.
        • Okpareke I.
        • White M.
        • Kogan B.A.
        Pediatric urinary stone disease–does age matter?.
        J Urol. 2009; 181 (discussion 71): 2267-2271
        • Routh J.C.
        • Graham D.A.
        • Nelson C.P.
        Trends in imaging and surgical management of pediatric urolithiasis at American pediatric hospitals.
        J Urol. 2010; 184: 1816-1822
        • Hollingsworth J.M.
        • Rogers M.A.
        • Kaufman S.R.
        • Bradford T.J.
        • Saint S.
        • Wei J.T.
        • et al.
        Medical therapy to facilitate urinary stone passage: a meta-analysis.
        Lancet. 2006; 368: 1171-1179
        • Hollingsworth J.M.
        • Davis M.M.
        • West B.T.
        • Wolf Jr., J.S.
        • Hollenbeck B.K.
        Trends in medical expulsive therapy use for urinary stone disease in U.S. Emergency Departments.
        Urology. 2009; 74: 1206-1209
        • Scales C.D.
        • Bergman J.
        • Carter S.
        • Jack G.
        • Saigal C.S.
        • Litwin M.S.
        Quality of acute care for patients with urinary stones in the United States.
        Urology. 2015; 86: 914-921
        • Tasian G.E.
        • Cost N.G.
        • Granberg C.F.
        • Pulido J.E.
        • Rivera M.
        • Schwen Z.
        • et al.
        Tamsulosin and spontaneous passage of ureteral stones in children: a multi-institutional cohort study.
        J Urol. 2014; 192: 506-511
        • Mokhless I.
        • Zahran A.R.
        • Youssif M.
        • Fahmy A.
        Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study.
        J Pediatr Urol. 2012; 8: 544-548
        • Velazquez N.
        • Zapata D.
        • Wang H.S.
        • Wiener J.S.
        • Lipkin M.E.
        • Routh J.C.
        Medical expulsive therapy for pediatric urolithiasis: systematic review and meta-analysis.
        J Pediatr Urol. 2015; 11: 321-327
        • Hansen L.
        • Chang S.
        Health research data for the real world: the MarketScan databases.
        (White paper)July 2012: 2013
        • Feudtner C.
        • Christakis D.A.
        • Connell F.A.
        Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997.
        Pediatrics. 2000; 106: 205-209
        • Fulgham P.F.
        • Assimos D.G.
        • Pearle M.S.
        • Preminger G.M.
        Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment.
        J Urol. 2013; 189: 1203-1213
        • Kusumi K.
        • Becknell B.
        • Schwaderer A.
        Trends in pediatric urolithiasis: patient characteristics, associated diagnoses, and financial burden.
        Pediatr Nephrol. 2015; 30: 805-810
        • Hernandez J.D.
        • Ellison J.S.
        • Lendvay T.S.
        Current trends, evaluation, and management of pediatric nephrolithiasis.
        JAMA Pediatr. 2015; 169: 964-970
        • Aydogdu O.
        • Burgu B.
        • Gucuk A.
        • Suer E.
        • Soygur T.
        Effectiveness of doxazosin in treatment of distal ureteral stones in children.
        J Urol. 2009; 182: 2880-2884
        • Hollingsworth J.M.
        • Wolf Jr., J.S.
        • Faerber G.J.
        • Roberts W.W.
        • Dunn R.L.
        • Hollenbeck B.K.
        Understanding the barriers to the dissemination of medical expulsive therapy.
        J Urol. 2010; 184: 2368-2372
        • Pickard R.
        • Starr K.
        • MacLennan G.
        • Lam T.
        • Thomas R.
        • Burr J.
        • et al.
        Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial.
        Lancet. 2015; 386: 341-349
        • Erturhan S.
        • Bayrak O.
        • Sarica K.
        • Seckiner I.
        • Baturu M.
        • Sen H.
        Efficacy of medical expulsive treatment with doxazosin in pediatric patients.
        Urology. 2013; 81: 640-643
        • Tasian G.E.
        • Pulido J.E.
        • Keren R.
        • Dick A.W.
        • Setodji C.M.
        • Hanley J.M.
        • et al.
        Use of and regional variation in initial CT imaging for kidney stones.
        Pediatrics. 2014; 134: 909-915
        • Johnson E.K.
        • Graham D.A.
        • Chow J.S.
        • Nelson C.P.
        Nationwide emergency department imaging practices for pediatric urolithiasis: room for improvement.
        J Urol. 2014; 192: 200-206
        • Stratton K.L.
        • Pope JCt
        • Adams M.C.
        • Brock 3rd, J.W.
        • Thomas J.C.
        Implications of ionizing radiation in the pediatric urology patient.
        J Urol. 2010; 183: 2137-2142
        • Semins M.J.
        • Trock B.J.
        • Matlaga B.R.
        Validity of administrative coding in identifying patients with upper urinary tract calculi.
        J Urol. 2010; 184: 190-192
        • Preminger G.M.
        • Tiselius H.-G.
        • Assimos D.G.
        • Alken P.
        • Colin Buck A.
        • Gallucci M.
        • et al.
        2007 guideline for the management of ureteral calculi.
        Eur Urol. 2007; 52: 1610-1631

      Linked Article