RESUMO
INTRODUCTION: We sought to identify predictors of index surgical care setting and to determine if care setting influences risk adjusted perioperative costs and/or 30-day revisits following elective surgery for urinary stones. METHODS: Using 2014 HCUP (Healthcare Cost and Utilization Project) all payer claims data from New York and Florida, we retrospectively identified 29,433 patients undergoing index ureteroscopy or shock wave lithotripsy. We used inverse probability of treatment weighting adjusted multivariable logistic and gamma regression to assess the association between index surgical care setting and 30-day revisits and total costs, respectively. RESULTS: Most urinary stone procedures (70.8%) were performed in the ambulatory setting. Underinsurance was associated with lower odds of undergoing surgery in the ambulatory setting (Medicaid vs private: OR 0.44, 95% CI 0.37-0.53; p <0.001; self-pay vs private: OR 0.21, 95% CI 0.17-0.26; p <0.001). Adjusted mean index surgical and 30-day acute care costs were significantly lower among ambulatory vs inpatient/emergency department cases ($4,746.10 vs $10,669.26 and $5,434.42 vs $11,729.39, both p <0.001), respectively. Ambulatory surgery was independently associated with lower odds of experiencing a 30-day revisit (OR 0.82, 95% CI 0.72-0.94; p=0.005). CONCLUSIONS: Urinary stone cases managed surgically in an ambulatory setting had lower risk adjusted costs and odds of a 30-day revisit compared to those managed in an inpatient setting. Our findings support use of ambulatory rather than inpatient based elective surgery for uncomplicated urinary stones. We invite clinicians and policymakers alike to reconsider clinical and nonclinical factors that influence pathways of care.
