Presentation Authors: Scott Wiener*, David Bayne, San Francisco, CA, David Tzou, Tuscon, AZ, Thomas Chi, Marshall Stoller, San Francisco, CA
Introduction: According to the 2017 American Urological Association census, 62.2% of counties in the United States are without any practicing urologists and 89.3% of urologists practice in metropolitan areas. We aimed to determine the pattern and factors associated with kidney stone patients traveling within the state of California (CA) to undergo ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL).
Methods: We investigated CA&[prime]s Office of Statewide Health Planning and Development (OSHPD) public inpatient and ambulatory surgical databases from 2005-2016 for URS, SWL, and PCNL. Aggregated data was then split into three cohorts based on patient and hospital county: patients a) receiving care in the same county, b) traveling within and c) traveling outside a CA labor market region. Multivariate logistic regression was performed using variables of age, race, gender, payer group, number of surgeries, urologists, and comorbid conditions. ArcMap 10.5 created choropleth and radial flow maps.
Results: 356,829 surgeries were performed for stones in CA from 2005-2016. Patients left their county for 61,679 (17.3%) surgeries, traveling an average of 70 miles (112 km). SWL was associated with a decreased likelihood of travel independent of age, race, gender, and payer group (p < 0.01 for all). URS and PCNL were not associated with travel out of the patient&[prime]s county. Independent of procedure type, and controlling for the number of urologists, private insurance or Medicare was associated with travel within (p < 0.001; OR 11.4) and out of a region (p=0.008; OR = 2.67). Non-white race was inversely correlated with travel within (p < 0.001; OR 0.07) or out of (p=0.034; OR = 0.45) a region. Overall, patients tended to travel from areas with few urologists to areas with many urologists and rarely travel great distance (Figure).
Conclusions: Stone patients are significantly more likely to receive SWL locally than PCNL or URS. Non-white patients or those on Medicaid are significantly more likely to receive care locally, if available, when compared to white patients or those with private insurance or Medicare. The predictable pattern of travel observed in our study is relevant to identify patient populations who may not have adequate access to care, the establishment of hospital network satellite facilities, and targeted marketing.