Editorial Comment on: Payer Type,Race/Ethnicity,and the Timing of Surgical Management of Urinary Stone Disease by Brubaker et al .(From: Brubaker WD,Dallas KB,Elliott CS,et al. J Endourol 2019;33:152–158;DOI: 10.1089/end.2018.0432)

This population-based study from California should encourage endourologists and general urologists to carefully re-examine the barriers to timely access for surgical interventions for the treatment of stone disease for all patients regardless of insurance coverage, race, or ethnicity. Current urological literature is replete with many examples of disparity in health care delivery. ¹ Most of the recent literature has been more concentrated in the fields of oncology for all of the major genitourinary malignancies, including prostate, kidney, bladder, and testicular cancer therapy options. ² There have been relatively few studies addressing the access to most basic surgical stone treatment options of ureteroscopy, extracorporeal shockwave lithotripsy, or percutaneous stone removal. Even though the data set is from 2010 to 2012, the authors document significant delays in obtaining surgical treatment for Medicare, Medicaid, and uninsured cohorts of patients seeking emergency room care for stone disease in the time interval studied with a population of >15,000 patients. The median time from emergency department discharge to operative intervention was 28 days (4 weeks) for the insured population, but significantly longer in the Medicare, Medicaid, and self-pay cohorts (median of 7.7–9.7 weeks). In these more vulnerable populations, there were significantly more readmissions, more imaging studies performed, and increased need for temporizing interventions, including upper tract decompression with either stent or nephrostomy tube placement. All of these extra interventions add significant cost to an already stressed health care system. In addition, patients of black and Hispanic race/ethnicity experienced significantly longer adjusted mean times to surgery than white patients.

Almost 10% of the patients presented for emergency room (ER) care three or more times before definitive stone treatment and similar proportions of the vulnerable patients required an intervention for decompression or were admitted with a clinical diagnosis of sepsis. The authors readily acknowledge that there are many details that cannot be obtained from the data set, but they are to be commended for drawing attention to the marked disparities in care for these disadvantaged population subsets within the defined geography of California. This study should encourage similar data analysis in other geographical regions of the United States and compare similar insurance demographics with more contemporary data. Are the conclusions from this study generalizable to the rest of the United States or to other countries? Clearly, we should be able to do a better job in prioritizing patients with stone disease and delivering timely treatments. The current American Urological Association and Endouorlogical Society guidelines advocate for interventions within 4 to 6 weeks for patients presenting with a ureteral stone. ³

There are clearly some interventions and system changes that we can employ to decrease these long waiting times for intervention. As a group of specialized experts in stone disease, we should work to analyze our own regional data and work to streamline the access to care. Our center has invoked a “two-strike” philosophy to capture such return visits and offer more prompt surgical interventions, whereas minimizing additional imaging studies. If a patient has been seen at another urgent care or ER facility and is transferred to our center, we make special effort to schedule definitive stone treatment within 2 to 4 weeks from presentation. In many instances, we endeavor to treat the stone at the same admission. Although not always achievable, we have seen fewer patients with similar insurance constraints subjected to excessively long waiting times for their more definitive stone treatments.