Abstract Purpose Delivery of recommended care is an important quality measure insufficiently studied within the field of urology. Obstructive pyelonephritis is a suitable case study for this focus because despite guidelines advocating decompression many do not receive such care. We sought to determine the influence of hospital factors, in particular familiarity with urolithiasis, on likelihood of decompression for such patients. Materials and Methods The Nationwide Inpatient Sample (2002-2011) was used to retrospectively identify patients admitted to community hospitals with severe infections and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (decompression rate among patients with ureteral calculi and no infection). After calculating national estimates, logistic regression was performed to determine the association between receipt of decompression and hospital stone volume controlling for treatment intensity as well as other covariates thought to be associated with receipt of recommended care. Results Among 107,848 estimated patients with obstructive pyelonephritis, 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs. 25%, Odds Ratio 2.77 (95% Confidence Interval 1.94 – 3.96, p<0.01) as well as high and low treatment intensity (78% vs. 37%, p<0.01). Conclusions High hospital stone volume and treatment intensity were associated with increased likelihood of receiving decompression. Such findings might be useful in identifying hospitals and regions where access to quality urologic care should be augmented.