Treatment Setting Influences Treatment Modality for Urinary Stone Disease.

OBJECTIVE: To determine whether selection of treatment modality for urinary stone disease differs between primary and outreach healthcare centers, and if patient rurality predicts treatment modality. METHODS: We retrospectively evaluated Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) procedural data from the Iowa Office of Statewide Clinical Education Programs (OSCEP) and Iowa Hospital Association (IHA) databases from 2007 to 2014. Geographical data was used to analyze travel metrics and patient proximity to sites of stone treatment. Rural-urban commuting area (RUCA) codes were used to characterize patient rurality. Chi-square tests and t tests were used to compare ESWL and URS patients, and multilevel logistic regression model was used to assess influence of treatment setting on surgical modality. RESULTS: A total of 18,831 stone procedures were performed by urologists in Iowa on patients from Iowa (10,495 URS; 8336 ESWL). Around 2630 procedures occurred at outreach centers. Ureteroscopy comprised 59.7% of procedures at primary centers, but only 31.2% at outreach centers. On multilevel analysis, outreach location was associated with 2.236 OR toward ESWL (P <.001). Individual physician treatment patterns accounted for 32% of treatment variation. Patient rurality was not significantly associated with treatment modality as an independent factor (P = .879). CONCLUSIONS: Wide variation exists in urolithiasis treatment modality selection between outreach and primary centers. Outreach locations perform a significantly higher frequency of ESWL compared to URS, and much of the variation in treatment selection (32%) arises from individual physician practice patterns.

Taking the Procedure to the Patient: Increasing Access to Urological Procedural Care through Outreach.

INTRODUCTION: We previously showed that urological outreach clinics significantly increase access to urological clinical care in rural populations. How such clinics affect access to urological procedural care is unknown. In this study we analyzed the use of outreach facilities for outpatient hospital based urological procedural care in a rural state. METHODS: Using information from the Office of Statewide Clinical Education Programs and the Iowa Hospital Association database, we analyzed provider level data in Iowa from 2010 to 2013. Based on CPT codes all outpatient urological procedural care was categorized by procedure type and intent. Cities containing an Iowa Hospital Association hospital were characterized as primary vs outreach. Geographic data were used for analysis of travel metrics and proximity to urological procedural care sites. Outreach urological procedures were then compared to urological procedural care at primary centers. RESULTS: During the study period 11,464 outreach urological procedures were performed, accounting for 15.0% of all outpatient urological procedures in the state. The yearly number of outreach procedures remained relatively stable during the study period. The majority (51.7%) of outreach urological procedures were therapeutic and endoscopic (62.9%) in nature. Extracorporeal shock wave lithotripsy was significantly more common for treating stone disease in the outreach setting compared to ureteroscopy (p <0.0001). CONCLUSIONS: A large percentage of the total urological procedural care in our state was done at outreach clinics and, while the majority was of low acuity, it was therapeutic. Changes in health care are projected to affect rural hospitals, which rely heavily on procedural care, and this study is the first to our knowledge to demonstrate the role that urological procedural care can have in such locations.