Vulnerability to Financial Toxicity From Stone Surgery.

PURPOSE: Financial toxicity has been described in stone formers however little is understood regarding its causes and how it may relate to stone surgery. We therefore aimed to longitudinally describe markers of financial strain in stone formers from the preoperative to postoperative time points. MATERIALS AND METHODS: A prospective cohort study was conducted from January 2022 to April 2023. Patients were enrolled in the waiting area prior to undergoing elective ureteroscopy or percutaneous nephrolithotomy. Participants completed the Commonwealth Fund's Biennial Health Insurance Survey at this time point and at 30 days postop. Items were pre-selected from the survey to capture markers of financial strain due to healthcare costs. RESULTS: One hundred nine participants were enrolled. Participants were a majority white (70%), college educated (62%), and privately ensured (72%). Despite these traditionally protective sociodemographic features, 42% of patients reported some marker of financial strain at the preoperative timepoint. Patients with Medicaid reported even higher financial stress (67%). Furthermore, 46% of patients did not know their deductible amount. Response rate was low at 30 days postop (35%) but suggested some patients were experiencing new financial strains. CONCLUSIONS: This paper shows that a significant proportion of stone patients are already displaying markers of financial strain from healthcare bills even prior to surgery as well as poor understanding of the costs they may incur. This makes them vulnerable to experiencing financial toxicity postoperatively and emphasizes the importance of understanding all contributing factors when developing future strategies to intervene in financial toxicity.

Results of the patient report of intermittent catheterization experience (PRICE) study.

AIMS: Patient satisfaction is paramount to health-related quality of life (HR-QoL) outcomes. High quality, quantitative data from the US describing patients' actual experiences, difficulties, and HR-QoL while on an intermittent self-catheterization (ISC) regimen is very scarce. Our objective was to better understand patient practices with and attitudes towards ISC. METHODS: This is a cross-sectional, multi-centered, clinical study of adult men and women performing ISC in the United States. Data collected included demographics, medical history, catheter characteristics, specific self-catheterization habits and two validated HR-QoL questionnaires: The Intermittent Self-Catheterization Questionnaire (ISC-Q) and the Intermittent Catheterization Difficulty Questionnaire (ICDQ). RESULTS: Two hundred participants were recruited from six sites; 70.0% were male, 73.5% were Caucasian with a median age was 51.0 years (range 19-90 years). The ISC-Q showed that the vast majority of participants reported ease with ISC (82.0% satisfaction score) had confidence in their ability to perform ISC (91.9% satisfaction score); yet, many felt self-conscious about doing so (58.3% satisfaction score) and had concerns about long-term adverse effects (58.1% satisfaction score). The ICDQ indicated little to no difficulty for most participants with all routine ISC practices. A small minority of participants reported some difficulty with a "blocking sensation" during initiation of catheterization, leg spasticity, and painful catheterization. Multivariate linear regression results are also reported. DISCUSSION/CONCLUSION: Participants are confident with ISC and have little overall difficulty, which may be a product of successful education and/or catheter design. urinary tract infections (UTIs) were common (yet variable) and may contribute to the noted long-term ISC concerns. Limitations exist including various selection biases leading to concerns of external validity. Future educational interventions in this population may further improve HR-QoL, optimize UTIs prevention, and diminish concerns with long-term ISC.

Emergency department and hospital revisits after ambulatory surgery for kidney stones: an analysis of the Healthcare Cost and Utilization Project.

Our objective was to identify the rate of revisit to either emergency department (ED) or inpatient (IP) following surgical stone removal in the ambulatory setting, and to identify factors predictive of such revisits. To this end, the AHRQ HCUP ambulatory, IP, and ED databases for NY and FL from 2010 to 2014 were linked. Cases were selected by primary CPT for shock-wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL) with accompanying ICD-9 for nephrolithiasis. Cystoscopy (CYS) was selected as a comparison group. The risk of revisit was explored using multivariate models. The overall unplanned revisit rate following stone removal was 6.4% (4.2% ED and 2.2% IP). The unadjusted revisit rates for SWL, URS, and PNL are 5.9%, 6.8%, and 9.0%, respectively. The adjusted odds of revisit following SWL, URS, and PNL are 1.93, 2.25, and 2.70 times higher, respectively, than cystoscopy. The majority of revisits occurred within the first two weeks of the index procedure, and the most common reasons for revisit were due to pain or infection. Younger age, female sex, lower income, Medicare or Medicaid insurance, a higher number of chronic medical conditions, and hospital-owned surgery centers were all associated with an increased odds of any revisit. The most important conclusions were that ambulatory stone removal has a low rate of post-operative revisits to either the ED or IP, there is a higher risk of revisit following stone removal as compared to urological procedures that involve only the lower urinary tract, and demographic factors appear to have a moderate influence on the odds of revisit.

Trends in the Setting and Cost of Ambulatory Urological Surgery: An Analysis of 5 States in the Healthcare Cost and Utilization Project.

INTRODUCTION: With the rising costs of health care, surgical procedures have migrated from the inpatient to outpatient setting with more than 60% of urological procedures performed in the ambulatory setting. Ambulatory surgical centers have the potential to reduce costs but may also lead to overutilization. We assessed utilization of ambulatory surgical centers for urological procedures, case mix distribution compared to hospital based outpatient surgery departments and cost implications. METHODS: All outpatient urological procedures were identified from 5 states in the United States (2010 to 2014) using all payer data. Patient demographics, regional data, facility type (ambulatory surgical center vs hospital based outpatient surgery department) and total charges (converted to costs and inflation adjusted to 2014 USD) were determined. Analyses of overall number of procedures, population adjusted rates, annual percent change and adjusted linear regression models were performed. RESULTS: Of more than 37 million surgical procedures 1,842,630 (4.9%) were urological with overall annual percent change +0.97% (+1.09% hospital based outpatient surgery departments vs +0.41% ambulatory surgical centers) and 20.0% performed in ambulatory surgical centers. The proportion performed in ambulatory surgical centers decreased slightly with time (-0.48% per year, p <0.001). Overall costs totaled $4.78 billion, representing 7.6% of all ambulatory surgery (average cost per procedure $2,603.76). All procedures demonstrated reduced costs per case when performed in ambulatory surgical centers (range -$800 to -$1,800). Unadjusted net cost increase per procedure per year was +$147.79 (+$113.98 adjusted). Providers performing the top quartile (Q1) of procedures demonstrated reduced costs. CONCLUSIONS: Ambulatory urological surgery represents 5% of all surgical cases but 7.6% of costs. The rate of procedures is increasing steadily with performance in ambulatory surgical centers outpaced by those in hospital based outpatient surgery departments. The cost of ambulatory urological surgery is rising out of proportion to explanation by inflation, patient factors or case mix.

Epidemiology and economics of nephrolithiasis.

Nephrolithiasis is a disease common in both the Western and non-Western world. Several population based studies have demonstrated a rising prevalence and incidence of the disease over the last several decades. Recurrence occurs frequently after an initial stone event. The influence of diet on the risk of nephrolithiasis is important, particularly dietary calcium and fluid intake. An increasing intake of dietary calcium and fluid are consistently associated with a reduced risk of incident nephrolithiasis in both men and women. Increasing evidence suggests that nephrolithiasis is associated with systemic diseases like obesity, diabetes, and cardiovascular disease. Nephrolithiasis places a significant burden on the health care system, which is likely to increase with time.

Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial.

Importance: Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration. Objective: To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. Design, Setting, and Participants: The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions. Interventions: Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. Main Outcomes and Measures: Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. Results: The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001). Conclusions and Relevance: Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees. Trial Registration: clinicaltrials.gov Identifier: NCT02355496.

Residents' self-report on why they order perceived unnecessary inpatient laboratory tests.

Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2015;11:869-872. © 2015 Society of Hospital Medicine.

Understanding the costs of flexible ureteroscopy.

Ureteroscopy (URS) is the first line treatment for the majority of symptomatic renal and ureteral stones. This review summarizes the current literature on the costs associated with URS. A high initial investment is required for scope acquisition. Once purchased, maintenance and repair costs continue to accrue. Durability of the scopes is an important consideration as more durable scopes will remain functional for longer and thus have lower overall repair costs. Currently available, newer generation scopes appear highly durable compared to their predecessors. Ancillary equipment, mostly disposable items represent the highest per procedure cost of URS. Despite these costs, URS remains highly profitable. However, it is also efficacious demonstrating superior cost-effectiveness with higher stone free rates at a lower cost relative to shock wave lithotripsy.