Ellison Jonathan S, Merguerian Paul A, Fu Benjamin C, Holt Sarah K, Lendvay Thomas S, Gore John L, Shnorhavorian Margarett
Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
J Pediatr Urol. 2017 Oct;13(5):509.e1-509.e7. doi: 10.1016/j.jpurol.2017.03.022. Epub 2017 Apr 20.
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.
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.
早期数据支持在儿童中使用药物排石疗法（MET）。然而，对于儿科特定诊疗范围之外MET的使用情况或相关结果知之甚少。我们利用一个全国性的行政数据集，试图描述MET的使用模式，并评估与MET暴露相关的结果。
我们查阅了MarketScan商业索赔和病历数据库，以确定18岁以下因任何上尿路结石（UUTC，包括肾结石和输尿管结石）诊断而前往急诊科（ED）就诊的儿童。MET暴露定义为在急诊就诊后1周内开具了MET药物的处方。定义了接受MET治疗的儿童的特征，并比较了有和没有MET暴露的儿童的结果。
在纳入研究的1325名儿童中，13.2%接受了MET，其中诊断为“输尿管结石”的儿童中有15.4%接受了MET。在整个研究期间，MET的使用显著增加（p = 0.004），尽管在研究的最后一年（2013年），只有30.4%被认为是MET潜在候选者的儿童接受了MET。在所有患者中，接受MET与男性、合并症的存在、医疗服务提供者类型（泌尿科医生）和诊断年份有关，尽管在那些具体诊断为“输尿管结石”的患者中，只有诊断年份仍然是一个显著因素。两组间计划外医生就诊和手术干预的发生率相似。接受MET治疗的儿童更有可能接受后续影像学检查，尽管无论是否有MET暴露，只有46%的输尿管结石儿童在90天内进行了适当的后续影像学检查。与MET暴露相关的因素和结果的比值比见表。
尽管早期数据支持MET在儿童中的安全性和有效性，但在MET的潜在候选者中，全国范围内儿童的使用率较低。对于输尿管结石儿童，只有诊断年份是与MET使用相关的一个显著因素。未观察到计划外医生就诊或手术干预方面的差异。然而，最值得注意的是，急性UUTC患儿在90天内进行后续影像学检查的比例较低。
输尿管结石患儿使用MET的情况正在增加，尽管仍不到三分之一被认为是潜在候选者的儿童接受了这种治疗。许多输尿管结石儿童未进行后续影像学检查。未来需要开展工作，规范急性肾绞痛患儿的管理和随访方案。
