Evaluating the Rising Use of Ureteroscopy in New England among Medicare Beneficiaries
Amanda R. Swanton, MD, PhD; Gina N. Tundo, MD; Vernon M. Pais, Jr., MD
Dartmouth-Hitchcock Medical Center, Lebanon, NH
Background
For decades, extracorporeal shockwave lithotripsy has been the leading treatment method for nephrolithiasis. However, advancement in ureteroscopy and laser lithotripsy has allowed for alternative minimally-invasive approaches to treating stone disease. The rise in rates of ureteroscopy has led to a concomitant decrease in shockwave lithotripsy. The purpose of this project is to examine how rates of ureteroscopy in Medicare beneficiaries differ throughout New England and to determine how uptake of ureteroscopy in New England compares to changes nationally.
Methods
Administrative data from the Centers for Medicare and Medicaid Services (CMS) were used to identify cases of instances of shockwave lithotripsy (CPT 50590) and ureteroscopy (CPT 52352, 52353, 52356) for stone disease for the years 2006, 2009, and 2014. Rates were constructed by hospital referral regions in CT, MA, ME, NH, RI, and VT using the population of Medicare beneficiaries with known nephrolithiasis as the denominator (ICD9 592.0). Rates are presented for each year with adjustment for age, sex, and race. For 2014, the national rates of shockwave lithotripsy and ureteroscopy were used to calculate the expected number of cases in each hospital referral region. The ratio of observed to expected cases is presented geographically.
Results
From 2006 to 2014, the national rate of ureteroscopy rose from 17 to 27 per 1,000 among Medicare beneficiaries with stones, while the rate of shockwave lithotripsy fell from 59 to 45 per 1,000. During this time period, rates for ureteroscopy increased in all hospital referral regions (that were able to be calculated) with the largest absolute increase from 13 to 39 per 1,000 occurring in Portland, ME. Also during this time period, rates of shockwave lithotripsy declined in all hospital referral regions with the largest decrease from 67 to 18 per 1,000 occurring in Lebanon, NH. In 2014, the hospital referral regions in ME, NH, and VT had more ureteroscopies than predicted by national estimates, while hospital referral regions in CT and RI had fewer.
Conclusions
Management of nephrolithiasis is changing in the United States with increased use of ureteroscopy supplanting shockwave lithotripsy. While trends in New England generally show that the use of ureteroscopy among Medicare beneficiaries is rising in most hospital referral regions, uptake varies regionally with accelerated uptake of ureteroscopy in northern New England states. Further work is needed to determine the contribution of access and practice patterns on patient outcomes.
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