Medical Expulsive Therapy for Ureteral Calculi in the Real World: Targeted Education Increases Use and Improves Patient Outcome

Purpose: In controlled trials medical expulsive therapy has improved outcomes in patients with ureteral stones but its real-world use and effectiveness outside a clinical trial have not been thoroughly examined. We studied the impact of targeted education of emergency department physicians about medical expulsive therapy and analyzed its impact on patient outcomes and cost. Materials and Methods: In 2006 emergency department physicians at our institution were formally educated about medical expulsive therapy. Retrospective emergency department data were collected on patients with ureteral stones from 2003 and 2005 (before educational intervention), and 2007 (after intervention). Cost and 90-day post-emergency department event data were gathered from a health maintenance organization owned and operated by our medical center. Medical expulsive therapy prescribing trends, adverse outcome (repeat emergency department visit, hospital admission or surgery) and total cost related to ureteral calculus diagnosis were analyzed. Results: Of 166 health maintenance organization patients with ureteral calculi who met all study requirements 97 (58.4%) were prescribed medical expulsive therapy and 53 (31.9%) filled the medical expulsive therapy prescription, while 113 did not. Analysis revealed a 2-fold increase in medical expulsive therapy prescribing and a 4-fold increase in prescribing alpha-blockers in each time increment. Bivariate analysis showed that the frequency of adverse outcomes was lower in the medical expulsive therapy group (37.7% vs 53.1%) and medical expulsive therapy was associated with a lower mean total cost per patient ($1,805 vs $2,372). Conclusions: Targeted educational intervention can increase the use of preferred medical expulsive therapy (a-blockers) in the emergency department. Medical expulsive therapy decreases the incidence of adverse events by 29% and decreases the total cost associated with ureteral stones by 24%.