Dr. Nakada, a Urology Times editorial consultant, is professor and chairman of the department of urology, University of Wisconsin, Madison.
At this stage, it is generally accepted that urolithiasis is a chronic disease. The recurrence rates, the confounded and controversial “stone-free” rates, the use of shock wave lithotripsy, and even dusting in ureteroscopy have in total led to the need for more responsible follow-up imaging of our stone patients. Fortunately, the AUA guidelines are clear on this, and Dauw and associates recently reported a clinical gap in this matter, to the tune of 52% (48% get imaged) in the Michigan collaborative dataset (see article here).
This report and others bring up several questions: Do the urologists not order the tests, or do patients not show up for the tests? Are finances to blame, insurance coverage, or even distance to care? Is this more common in big group practices or smaller practices? Are patients afraid of ionizing radiation or concerned with rising health care costs, or too busy to make time for testing? Moreover, are patients so disgruntled with their stent pain, or time away from work, that they choose not to follow up as a result?
So what is the solution? At first glance, a lower cost, simple approach would be best. At this point in time, the urology community has struggled to offer this. In addition to imaging gaps, what about medical management of stones? This is also time consuming and costly, and Hollingsworth reported an even larger “gap” between clinical practice and the guidelines (J Urol 2015; 193:885-90). It is my opinion that we must better identify patients with higher risk factors for recurrence and follow them more effectively.
Better use of patient and family education is another important area of improvement to bridge the guidelines gap in managing stone patients. In today’s medical world, there must be a compromise between what is recommended by the guidelines and what is possible in a given clinical scenario, and in my view this may be the new “best possible” care.