Distressed communities with high risk stone formers may benefit more from multidisciplinary kidney stone clinic model
Ji Whae Choi, BA1, Sai Allu, BA1, Joshua Tanzer, PhD2, Frances Kazal, BA1, Rebecca Ortiz, BA3, Philip Caffery, PhD3, Christopher Tucci, MS1, Jie Tang, MD1, Gyan Pareek, MD1, David Sobel, MD1.
1The Warren Alpert Medical School of Brown University; Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI, USA, 2Lifespan Biostatistics Epidemiology Research Design Core, Providence, RI, USA, 3Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI, USA.
Introduction Recent studies have shown disparities in the management and outcome of patients with kidney stones based on their socioeconomic status (SES). Adverse markers on the 24-hour urine collections have been associated with a lower SES. A multidisciplinary kidney stone clinic (MSC) is an emerging approach that provides an individualized care especially to high-risk stone formers by a team of urologist, nephrologist, and dietitian in a single encounter. The goal of this study is to evaluate whether the MSC approach is effective in promoting socioeconomic equity among these patients. Our hypothesis is that the patients with a lower SES will be more responsive to the MSC approach and demonstrate a greater improvement in the 24-hour urine parameters than those with a higher SES.
Materials & Methods A retrospective review of patient records from an MSC affiliated with a single academic medical center was conducted. Patient demographics such as age, insurance status, and distressed communities index score (DCI) along with 24-hour urine volume, pH, sodium, and calcium were collected. Growth curve modeling within generalized mixed effects modeling was used. Regression coefficients were standardized so that they can be interpreted like a correlation coefficient and directly compared to each other.
Results A total of 192 patients who completed an average of 3.01 24-hour urine collections (SD = 3.14) were included. They were treated at the MSC for 1.91 years (SD = 3.01). A summary of patient characteristics is in Table 1. In patients with a high DCI and Medicare/Medicaid, there was a significant increase in urine volume (β = 0.16, p = 0.0146) and decrease in urine calcium (β = -0.10, p = 0.0488) throughout the duration of their treatment, irrespective of age. However, younger patients with a high DCI and Medicare/Medicaid had a significant decrease in sodium (β = -0.12, p = 0.0157), compared to older patients with identical DCI and insurance status (β = 0.14, p = 0.0076). All patients had a significant increase in urine pH throughout the duration of their treatment (β = 0.12, p = 0.0288).
Conclusions Among patients who were treated at the MSC, those with a high DCI and Medicare/Medicaid had a significant improvement in urine volume, pH, sodium, and calcium, but the effect of age on these parameters was unclear. These results suggest that an MSC model may address the socioeconomic inequities that exist in the management of kidney stones possibly by providing highly streamlined and individualized care to these patients. Therefore, urologists should consider increasing the accessibility of MSC to their patients. However, it is necessary to further investigate this relationship by analyzing a complete 24-hour urine panel in a more diverse population over a longer duration of treatment. An additional experimental manipulation and a control group could strengthen the validation of these findings.
Table 1. Sample Characteristics at First 24 Hour Metabolic Urinalysis Kit
| Measure | Mean | SD | Skew | Kurtosis | % Missing |
| Distressed Communities Index | 44.50 | 27.93 | 0.66 | -0.96 | 0.00 |
| Age (years) | 49.40 | 15.78 | -0.08 | -0.79 | 0.00 |
| Urine Volume (mL/day) | 1734.10 | 796.04 | 0.61 | -0.34 | 1.56 |
| Urine pH | 6.35 | 0.64 | 0.05 | -0.92 | 11.98 |
| Urine Calcium (mg/day) | 208.93 | 138.53 | 1.83 | 5.07 | 5.73 |
| Urine Sodium (mg/day) | 151.78 | 72.55 | 1.17 | 2.34 | 9.90 |
| Kits completed (kits) | 3.01 | 3.14 | 2.08 | 4.05 | 0.00 |
| Treatment duration (years) | 1.91 | 3.01 | 2.39 | 6.93 | 0.00 |
| Measure | Status | N | % | ||
| Insurance | Medicare/Medicaid | 34 | 17.71 | ||
| Private insurance | 158 | 82.29 | |||
| Note: Patient health characteristics are reported at baseline. The exceptions are kits completed and treatment duration, which represents the number of kits | |||||
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