Treatment Setting Influences Treatment Modality for Urinary Stone Disease



      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.


      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.


      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).


      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Uhlman MA
        • Gruca TS
        • Jarvie CA
        • et al.
        Taking the procedure to the patient: increasing access to urological procedural care through outreach.
        Urol Pract. 2017; 4: 335-341
        • Uhlman MA
        • Gruca TS
        • Tracy R
        • et al.
        Improving access to urologic care for rural populations through outreach clinics.
        Urology. 2013; 82 (Epub 2013/12/04): 1272-1276
        • Ziemba JB
        • Matlaga BR.
        Epidemiology and economics of nephrolithiasis.
        InvestigClinUrol. 2017; 58 (Epub 2017/09/05): 299-306
        • Scales Jr., CD
        • Smith AC
        • Hanley JM
        • et al.
        Prevalence of kidney stones in the United States.
        EurUrol. 2012; 62 (Epub 2012/04/14): 160-165
        • Assimos D
        • Krambeck A
        • Miller NL
        • et al.
        Surgical management of stones: americanurological association/endourologicalsociety guideline, Part II.
        J Urol. 2016; 196 (Epub 2016/05/31): 1161-1169
        • Assimos D
        • Krambeck A
        • Miller NL
        • et al.
        Surgical management of stones: American urological association/endourologicalsociety guideline, Part I.
        J Urol. 2016; 196 (Epub 2016/05/31): 1153-1160
        • Aboumarzouk OM
        • Kata SG
        • Keeley FX
        • et al.
        Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi.
        Cochrane Database Syst Rev. 2012; (Epub 2012/05/18)CD006029
        • Dauw CA
        • Swarna K
        • Qi J
        • et al.
        Shockwave lithotripsy use in the state of michigan: American urological association guideline adherence and clinical implications.
        Urology. 2020; 137 (Epub 2019/12/18): 38-44
        • Rezaee ME
        • Tundo GN
        • Goodney PP
        • et al.
        Regional variation in shock wave lithotripsy utilization among medicarepatients with nephrolithiasis.
        Urology. 2019; 133 (Epub 2019/08/05): 103-108
        • Scales Jr., CD
        • Krupski TL
        • Curtis LH
        • et al.
        Practice variation in the surgical management of urinary lithiasis.
        J Urol. 2011; 186 (Epub 2011/05/18): 146-150
        • El-Nahas AR
        • Ibrahim HM
        • Youssef RF
        • et al.
        Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10-20 mm.
        BJU Int. 2012; 110 (Epub 2012/03/01): 898-902
        • Pearle MS
        • Nadler R
        • Bercowsky E
        • et al.
        Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.
        J Urol. 2001; 166 (Epub 2001/09/08.eng): 1255-1260
        • Omar M
        • Tarplin S
        • Brown R
        • et al.
        Shared decision making: why do patients choose ureteroscopy?.
        Urolithiasis. 2016; 44 (Epub 2015/07/26): 167-172
      1. U.S. Census Bureau: 2010 Census urban and rural classification and urban area criteria [cited 2019 December 10]. Available from:

        • Goldfarb DS.
        The exposome for kidney stones.
        Urolithiasis. 2016; 44 (Epub 2015/11/30): 3-7
        • Goldfarb DS
        • Hirsch J
        Hypothesis: urbanization and exposure to urban heat islands contribute to increasing prevalence of kidney stones.
        Med Hypotheses. 2015; 85 (Epub 2015/09/16): 953-957
        • Choi SY
        • Lee SY
        • Chi BH
        • et al.
        Urbanization may affect the incidence of urolithiasis in South Korea.
        Springer Plus. 2016; 5 (Epub 2016/11/16): 1891
      2. USDA Rural-Urban Commuting Area Codes [updated 7/3/2019; cited 2019 December 10]. Available from:

        • Austin PC
        • Merlo J.
        Intermediate and advanced topics in multilevel logistic regression analysis.
        Stat Med. 2017; 36 (Epub 2017/05/26): 3257-3277
        • Hoffman KE
        • Niu J
        • Shen Y
        • et al.
        Physician variation in management of low-risk prostate cancer: a population-based cohort study.
        JAMA Intern Med. 2014; 174 (Epub 2014/07/16): 1450-1459
        • Shahinian VB
        • Y-f Kuo
        • Freeman JL
        • et al.
        Characteristics of urologists predict the use of androgen deprivation therapy for prostate cancer.
        J Clin Oncol. 2007; 25 (eng.): 5359-5365
        • Lee YH
        • Tsai JY
        • Jiaan BP
        • et al.
        Prospective randomized trial comparing shock wave lithotripsy and ureteroscopic lithotripsy for management of large upper third ureteral stones.
        Urology. 2006; 67 (discussion 4.Epub 2006/03/11): 480-484
        • Sarkissian C
        • Noble M
        • Li J
        • et al.
        Patient decision making for asymptomatic renal calculi: balancing benefit and risk.
        Urology. 2013; 81 (Epub 2013/02/05): 236-240