Socioeconomic Disparities in the Acute Management of Stone Disease in the United States.
INTRODUCTION
Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality.


MATERIALS AND METHODS
The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared.


RESULTS
We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients.


CONCLUSION
Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.
['Kirshenbaum|Eric J|EJ|', 'Doshi|Chirag|C|', 'Dornbier|Ryan|R|', 'Blackwell|Robert H|RH|', 'Bajic|Petar|P|', 'Gupta|Gopal N|GN|', 'Gorbonos|Alex|A|', 'Turk|Thomas M T|TMT|', 'Flanigan|Robert C|RC|', 'Baldea|Kristin G|KG|']
D000328:Adult D016208:Databases, Factual D004636:Emergency Service, Hospital D005260:Female D054625:Healthcare Disparities D006801:Humans D007669:Kidney Calculi D017602:Lithotripsy, Laser D008297:Male D008875:Middle Aged D010343:Patient Admission D012959:Socioeconomic Factors D014481:United States D018666:Ureteroscopy
socioeconomic disparities urolithiasis ureteroscopy kidney stones weekend effect