Shock wave lithotripsy (SWL) for kidney stones is declining nationally among Medicare beneficiaries, but its use varies by where patients receive their urologic care, according to a new study.

In 2006, 2009, and 2014, 511,495, 604,493, and 806,652 beneficiaries were diagnosed with nephrolithiasis, respectively, Michael E. Rezaee, MD, MPH, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues reported in Urology. The adjusted rate of SWL per 1000 beneficiaries decreased from 59.4 in 2006 to 52.2 and 45.5 in 2009 and 2014, respectively. The investigators found up to a 12-fold difference between hospital referral regions (HRRs): 9.2 per 1000 in Winchester, Virginia, compared with 105.8 per 1000 in Lincoln, Nebraska. HRRs are distinct tertiary medical care networks that have been used repeatedly to study variation in health care use, the authors explained. The United States has 306 HRRs.

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Meanwhile, the adjusted rate of ureteroscopy (URS) per 1000 beneficiaries rose from 17.4 in 2006 to 18% in 2009 and 27.2 in 2014. The percent decrease in SWL use, however, did not correlate with the percent increase in URS use when examined by hospital referral region, according to Dr Rezaee and his team.

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The variation in the use of SWL is likely secondary to a series of supply, urologist, and patient-specific factors, the investigators concluded. “Stone procedure type is highly dependent on where patients receive their urologic care.”


Rezaee ME, Tundo GN, Goodney PP, et al. Regional variation in shock wave lithotripsy utilization among Medicare patients with nephrolithiasis. Urology. 2019.