Krampe Noah, Oerline Mary K, Hsi Ryan S, Crivelli Joseph J, Asplin John R, Shahinian Vahakn B, Hollingsworth John M
Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan.
Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee.
Urol Pract. 2024 Jan;11(1):218-225. doi: 10.1097/UPJ.0000000000000480. Epub 2023 Oct 30.
Despite compelling clinical trial evidence and professional society guideline recommendations, prescription rates of preventative pharmacological therapy (PPT) for urinary stone disease are low. We sought to understand how patient- and clinician-level factors contribute to the decision to prescribe PPT after an index stone event.
We identified Medicare beneficiaries with urinary stone disease who had a 24-hour urine collection processed by a central laboratory. Among the subset with a urine chemistry abnormality (ie, hypercalciuria, hypocitraturia, hyperuricosuria, or low urine pH), we determined whether PPT was prescribed within 6 months of their collection. After assigning patients to the clinicians who ordered their collection, we fit multilevel models to determine how much of the variation in PPT prescription was attributable to patient vs clinician factors.
Of the 11,563 patients meeting inclusion criteria, 33.6% were prescribed PPT. There was nearly sevenfold variation between the treating clinician with the lowest prescription rate (11%) and the one with the highest (75%). Nineteen percent of this variation was attributable to clinician factors. After accounting for measured patient differences and clinician volume, patients had twice the odds of being prescribed PPT if they were treated by a nephrologist (odds ratio [OR], 2.15; 95% CI, 1.79-2.57) or a primary care physician (OR, 1.78; 95% CI, 1.22-2.58) compared to being treated by a urologist.
These findings suggest that the type of clinician whom a patient sees for his stone care determines, to a large extent, whether PPT will be prescribed.
尽管有令人信服的临床试验证据和专业协会指南建议，但尿路结石病预防性药物治疗（PPT）的处方率仍然很低。我们试图了解患者和临床医生层面的因素如何影响在首次结石事件后开具PPT的决定。
我们确定了患有尿路结石病且其24小时尿液收集由中央实验室处理的医疗保险受益人。在尿液化学异常（即高钙尿症、低枸橼酸尿症、高尿酸尿症或低尿pH值）的子集中，我们确定在收集尿液后的6个月内是否开具了PPT。在将患者分配给开具尿液收集医嘱的临床医生后，我们采用多层次模型来确定PPT处方的差异在多大程度上可归因于患者因素与临床医生因素。
在符合纳入标准的11563名患者中，33.6%的患者开具了PPT。处方率最低（11%）的治疗临床医生与最高（75%）的临床医生之间存在近7倍的差异。这种差异的19%可归因于临床医生因素。在考虑了测量的患者差异和临床医生工作量后，如果患者由肾病科医生（优势比[OR]，2.15；95%置信区间[CI]，1.79 - 2.57）或初级保健医生（OR，1.78；95% CI，1.22 - 2.58）治疗，与由泌尿科医生治疗相比，他们开具PPT的几率是两倍。
这些发现表明，患者因结石治疗而就诊的临床医生类型在很大程度上决定了是否会开具PPT。
