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Introduction and Objective: Prior literature had demonstrated increased stone burden and higher rates of staged surgery in individuals of lower socioeconomic status (SES). Low SES individuals are more likely to experience delays in definitive stone surgery after initial presentation to the emergency department (ED) for kidney stones. This study aims to investigate the relationship between delays in definitive kidney stone surgery and the subsequent need for percutaneous nephrolithotomy (PNL) and/or staged surgical procedures using a statewide data set. Methods: This retrospective cohort study gathered longitudinal data from 2009 to 2018 using the California Department of Health Care Access and Information data set. Patient demographic characteristics, comorbidities, diagnosis/procedure codes, and distance were analyzed. Complex stone surgery was defined as initial PNL and/or undergoing more than one procedure within 365 days of initial intervention. Results: A total of 1,816,093 billing encounters from 947,798 patients were screened, resulting in 44,835 patients with ED visits for kidney stones followed by a urologic stone procedure. Multivariable analysis revealed that relative to patients who underwent surgery within 1 month of initial ED visit for stone disease, patients were at increased odds of undergoing complex surgery if waiting ≥6 months (odds ratio [OR] 1.18, p  = 0.022), ≥1 year (OR 1.29, p  < 0.001), and ≥3 years (OR 1.43, p  < 0.001). Conclusions: Delays in definitive stone surgery after initial ED encounter for stone disease were associated with increased likelihood of undergoing a complex stone treatment.

Introduction and Objectives: Lack of access to urologic specialists is approaching crisis levels as the number of urologists is decreasing, while the demand for urologic care is increasing. The financial implications of this have not been explored. The objective of this study is to examine the impact of access and other patient factors on cost to treat urolithiasis. We hypothesized that markers of poor access would associate with higher costs of surgical encounters for patients presenting with urolithiasis. Methods: A retrospective review of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) from September 2015 to July 2018 was conducted to investigate characteristics of surgical patients treated for urinary stone disease. Univariate analysis was performed using the Welch two-sample t -test. Multivariate analysis was performed using logistic regression. Statistical analysis was performed in R version 3.5. Results: When taking into account age, delayed presentation, procedure type, stone size >20 mm, American Society of Anesthesiologists (ASA) code, gender, race, income, distance, urologist density, body mass index, diabetes, infection, education, language, insurance, and stone complexity, patients undergoing percutaneous nephrolithotomy procedure ( p  < 0.001; odds ratio [OR] 12.9, confidence interval [CI] 4.05-48.5), urologist density in the bottom quartile ( p  = 0.014; OR 4.66, CI 1.40-16.9), diabetes ( p  = 0.018; OR 4.38, CI 1.32-15.6), and infection ( p  = 0.007; OR 4.51, CI 1.55-14.0) were the only variables statistically significant for association with top quartile of total cost. Conclusions: Surgical encounter costs are largely dictated by patient clinical factors, but low regional urologist density appears to independently predicted for high-cost stone surgery. Increasing patients' access to a urologist may prove to be financially beneficial in the longitudinal reduction in health care costs for stone disease.