Practice patterns of primary care providers and urologists for use of medical expulsion therapy.

Purpose: alpha-blockers and calcium channel blockers have shown promise for medical expulsion therapy (MET) of distal ureteral calculi <1 cm in size. Although MET has been discussed in urology for some time, little has been written about MET in the emergency medicine and primary care literature. We sought to evaluate current practice patterns of MET among urologists, emergency medicine physicians, other primary care providers, and frontline military care providers. Methods: Web-based, self-developed survey to assess the current practice patterns of providers for the initial management of uncomplicated ureteral calculi, and specifically, their frequency of using MET. Cross-tabulation strategies utilizing compiled survey results were used to assess survey outcomes and determine prevalence values for understanding, familiarity, and therapeutic interventions for nephrolithiasis. Results: Of 293 medical professionals, 114 (39%) were urologists, 55 (48%) of which were fellowship trained in endourology. Fifty-six (19%) were emergency medicine physicians, 22(8%) were family practitioners, and 19(7%) were internists and other primary care physicians. Other physician subspecialists and medical paraprofessionals comprised the remaining 34%. Overall 27% of respondents were unfamiliar with MET for expulsion of uncomplicated ureteral stones, including 13% of staff physicians, 21% of emergency medicine doctors, 56% of family practitioners, 40% of internists, and 43% of other primary care providers. The overall prevalence of use of MET was 45%. All urologists were familiar with MET, but 31% rarely, never, or only sometimes used this therapy. Specifically, urologists, emergency physicians, family practitioners, internists, and other providers, usually or always used MET 69%, 55%, 16%, 16%, and 27%, of the time, respectively. In academic institutions, 71.6% use MET usually or almost always compared to 36% in military healthcare settings and 47% in other practice settings. Tamsulosin is the most widely used medication for MET, accounting for 57% of MET use. Factors identified that inhibit more widespread use of MET include, physician unfamiliarity with MET (72%), the belief that MET is not effective (10%), patient unwillingness to undergo MET (5%), and medications not covered by insurance plans (4%). Conclusion: While MET has been established as a reasonable adjunct for management of uncomplicated ureteral stones, it may be underutilized due to physician unfamiliarity with this type of treatment and perceived ineffectiveness. This therapy may be of particular benefit to forward deployed forces. Education programs and practice-specific guidelines to target this audience may help to improve the dispersion of MET into the medical community.