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Commentary to ‘Utilization of medical expulsive therapy in children: An assessment of nationwide practice patterns and outcomes’
Accepted Manuscript Commentary to Utilization of Medical Expulsive Therapy in Children: An Assessment of Nationwide Practice Patterns and Outcomes' Dr. Wolfgang Hans Cerwinka PII:
S1477-5131(17)30172-9
DOI:
10.1016/j.jpurol.2017.04.002
Reference:
JPUROL 2521
To appear in:
Journal of Pediatric Urology
Received Date: 3 April 2017 Accepted Date: 4 April 2017
Please cite this article as: Cerwinka WH, Commentary to Utilization of Medical Expulsive Therapy in Children: An Assessment of Nationwide Practice Patterns and Outcomes', Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2017.04.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
National databases are valuable tools with which to evaluate treatment outcomes while accounting for patient-related and healthcare-related barriers, and allowing a view of treatment patterns from 10,000 feet. Critical steps in utilizing databases, however, include accurate data entry and analysis. Consequently, if study results are not carefully interpreted, databases are at
RI PT
risk of transforming into ‘databiases’.
The current study’s conclusion that medical expulsive therapy (MET) is underutilized, yet
increasing in children (30%) is consistent with previous reports. There are several reasons why MET is not universally prescribed in the pediatric stone population: (1) contraindications to trial
SC
of passage; (2) large stone size; (3) renal stones; (4) physicians and/or parents adverse to offlabel use of MET medications in children; (5) poor tolerance of alpha-blockers in younger
M AN U
patients; and (6) physician unfamiliarity with MET.
Importantly, this study failed to show an increased rate of stone passage with MET, in contrast to three prospective, randomized trials and a meta-analysis showing clear benefit [1-4]. In the current study, the authors reported similar outcomes independent of MET use, which may have been related to inaccurate coding by database managers and/or inappropriate use of MET.
TE D
Coding errors may also have occurred at the physician level, with emergency department physicians interchangeably using the ICD-9 code for calculus of kidney and calculus of ureter. Secondly, MET was prescribed as often for kidney stones as for ureteral stones, the former expected to be ineffective. Lastly, the database did not capture time to stone passage, which may
EP
be reduced with MET, even if the overall rate of stone passage did not improve. In conclusion, this study suggested that more education, regarding medical expulsive therapy and
AC C
its indications, is needed for non-urologists who encounter children with renal colic.
References
[1] Mokhless I, Zahran AR, Youssif M, Fahmy A. Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study. J Pediatr Urol 2012;8:544-8. [2] Erturhan S, Bayrak O, Sarica K, Seckiner I, Baturu M, Sen H. Efficacy of medical expulsive treatment with doxazosin in pediatric patients. Urology 2013;81:640-3.
ACCEPTED MANUSCRIPT
[3] Aldaqadossi HA, Shaker H, Saifelnasr M, Gaber M. Efficacy and safety of tamsulosin as a medical expulsive therapy for stones in children. Arab J Urol 2015;13:107-11. [4] Velázquez N, Zapata D, Wang HH, Wiener JS, Lipkin ME, Routh JC. Medical expulsive therapy for pediatric urolithiasis: Systematic review and meta-analysis. J Pediatr Urol
AC C
EP
TE D
M AN U
SC
RI PT
2015;11:321-7.
S1477-5131(17)30172-9
DOI:
10.1016/j.jpurol.2017.04.002
Reference:
JPUROL 2521
To appear in:
Journal of Pediatric Urology
Received Date: 3 April 2017 Accepted Date: 4 April 2017
Please cite this article as: Cerwinka WH, Commentary to Utilization of Medical Expulsive Therapy in Children: An Assessment of Nationwide Practice Patterns and Outcomes', Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2017.04.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
National databases are valuable tools with which to evaluate treatment outcomes while accounting for patient-related and healthcare-related barriers, and allowing a view of treatment patterns from 10,000 feet. Critical steps in utilizing databases, however, include accurate data entry and analysis. Consequently, if study results are not carefully interpreted, databases are at
RI PT
risk of transforming into ‘databiases’.
The current study’s conclusion that medical expulsive therapy (MET) is underutilized, yet
increasing in children (30%) is consistent with previous reports. There are several reasons why MET is not universally prescribed in the pediatric stone population: (1) contraindications to trial
SC
of passage; (2) large stone size; (3) renal stones; (4) physicians and/or parents adverse to offlabel use of MET medications in children; (5) poor tolerance of alpha-blockers in younger
M AN U
patients; and (6) physician unfamiliarity with MET.
Importantly, this study failed to show an increased rate of stone passage with MET, in contrast to three prospective, randomized trials and a meta-analysis showing clear benefit [1-4]. In the current study, the authors reported similar outcomes independent of MET use, which may have been related to inaccurate coding by database managers and/or inappropriate use of MET.
TE D
Coding errors may also have occurred at the physician level, with emergency department physicians interchangeably using the ICD-9 code for calculus of kidney and calculus of ureter. Secondly, MET was prescribed as often for kidney stones as for ureteral stones, the former expected to be ineffective. Lastly, the database did not capture time to stone passage, which may
EP
be reduced with MET, even if the overall rate of stone passage did not improve. In conclusion, this study suggested that more education, regarding medical expulsive therapy and
AC C
its indications, is needed for non-urologists who encounter children with renal colic.
References
[1] Mokhless I, Zahran AR, Youssif M, Fahmy A. Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study. J Pediatr Urol 2012;8:544-8. [2] Erturhan S, Bayrak O, Sarica K, Seckiner I, Baturu M, Sen H. Efficacy of medical expulsive treatment with doxazosin in pediatric patients. Urology 2013;81:640-3.
ACCEPTED MANUSCRIPT
[3] Aldaqadossi HA, Shaker H, Saifelnasr M, Gaber M. Efficacy and safety of tamsulosin as a medical expulsive therapy for stones in children. Arab J Urol 2015;13:107-11. [4] Velázquez N, Zapata D, Wang HH, Wiener JS, Lipkin ME, Routh JC. Medical expulsive therapy for pediatric urolithiasis: Systematic review and meta-analysis. J Pediatr Urol
AC C
EP
TE D
M AN U
SC
RI PT
2015;11:321-7.