Tool seeks to aid in decision between shock wave lithotripsy and URS in kidney stones

“We aimed to develop a surgical decision aid to help facilitate this decision-making process for patients who are candidates for either shock wave lithotripsy or ureteroscopy with kidney stones,” says John Michael DiBianco, MD.

In this video, John Michael DiBianco, MD, discusses the background and findings of the recent Journal of Endourology paper, “Development of a Surgical Decision Aid for Patients with Nephrolithiasis: Shockwave Lithotripsy vs Ureteroscopy.” DiBianco is an assistant professor of urology at the University of Florida, Gainesville.


Please discuss the background for this study.

This represents work that I did as an endourology fellow at the University of Michigan.I was working in the Michigan Urological Surgery Improvement Collaborative, or MUSIC. I'd like to give shout-outs to Dr. Khurshid Ghani and Dr. Casey Dauw. Dr. Ghani directs MUSIC and Dr. Dauw is director of the MUSIC ROCKS [Reducing Operative Complications from Kidney Stones] program. They're also friends and mentors, and they certainly were very integral in this project. This specific work really focuses on shared decision-making. Shared decision-making is the process of balancing best-available evidence and best practices with the patient's values and perspective, to come together and to reach some sort of medical decision. It's not just in urology, but it's in a lot of different aspects of health care. Shared decision-making is recommended not only by the National Academy of Medicine, but also in several American Urological Association guideline statements. It's most relevant in decisional scenarios where the risks and benefits are not so cut and dried; either they're unknown, or perhaps even equivalent. So when I look at an AUA guideline for stones that recommends offering ureteroscopy or shock wave lithotripsy to symptomatic patients with renal stones less than or equal to 2 cm, or less than or equal to 1 cm in the lower pole, you theoretically should then see roughly a 50/50 split when it comes to surgical volume. We all know that isn't necessarily the case. And yet in the MUSIC data, we see wide variation in treatment choice. A lot of it depends on the practice or provider that patients see, with many urologists exclusively utilizing 1 modality or 1 procedure for these patients. And so even when we adjust for patient and stone factors, we still see this trend. So we looked at the data and saw that this identifies a really ideal area for potentially improving the quality of this decision-making process. Given MUSIC's history of excellence when it comes to patient-facing material and education, it seemed like MUSIC was the most appropriate organization to take on this work. We aimed to develop a surgical decision aid to help facilitate this decision-making process for patients who are candidates for either shock wave lithotripsy or ureteroscopy with kidney stones.

Could you talk a little bit about the decision aid you created and the research you conducted on it?

Luckily, the AUA has a white paper on shared decision-making, and there's a guideline from the Ottawa International Decision Aid Development Consortium. It's a relatively rigorous process. First, you identify the scope. What's the target decision that you want to facilitate? Then you form a steering committee, which is essentially a group of experts in the field that help drive all the different aspects of the tool that you're creating. Then you develop it and validate it to see if it actually does what it's intended to do. We first identified these domains that were deemed relevant to the decision-making process: anesthesia type, treatment effectiveness, number of procedures that may be required, risk of complications, pain of the procedure, and recovery time. We performed content and face validation, which had very promising results. Urologists reported very high content, so what's in the actual decision aid had very high validation scores, and patient advocates also reported very high levels of face validation.

This transcript was edited for clarity.

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