Work Absence and Productivity Loss of Patients Undergoing a Trial of Spontaneous Passage for Ureteral Stones

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Lipkin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4265036/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Aug, 2024 Read the published version in Urolithiasis → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Patients with ureteral stones are often managed with a spontaneous trial of passage. While cost effective, the current literature has not examined the effects of a trial of passage on patients’ work productivity. In this study, we aim to characterize work absence and productivity losses in a cohort of patients undergoing a trial of passage for ureteral stones. Materials and Methods Actively employed patients aged 18 to 64 and discharged from Duke emergency departments without surgical intervention for ureteral stones ≤ 10mm were contacted by phone four weeks after their presentation. Participants completed the Institute for Medical Technology Assessment Productivity Cost Questionnaire which assesses three domains: absenteeism — missed work; presenteeism —productivity when returning to work; and unpaid work — assistance with household work. Linear regression associated demographic and stone factors with productivity losses. Results 109 patients completed the survey. In total, 67% of patients missed work, 46% had decreased productivity when returning to work, and 55% required assistance with unpaid work. 59% of patients with stones ≤ 5mm missed work versus 84% with stones > 5mm (p = 0.009). African American race (coefficient 23.68, 95% confidence interval 2.24–45.11, p = 0.031), first-time stone formers (coefficient 20.28, 95% confidence interval 2.50-38.07, p = 0.026), and patients with stones > 5mm (coefficient 25.34, 95% CI 5.25–45.44, p = 0.014) were associated with increased productivity losses. Conclusions The majority of patients miss work while undergoing a trial of passage and many have decreased productivity when returning to work. This information may help counsel patients in emergency departments, especially first-time stone formers, and prevent return visits. Figures Figure 1 Introduction Nephrolithiasis affects almost 9% of the U.S. population with an expected economic burden of at least $ 3 billion by 2030 [ 1 , 2 ] Many patients with an obstructing ureteral stone present to an emergency department (ED), resulting in 1.2 million visit annually [ 3 ]. Patients with well controlled pain and without signs of infection or renal failure are often offered a trial of spontaneous stone passage. Guidelines recommend observation or medical expulsive therapy for ureteral stones ≤ 10mm which has been shown to be cost effective and safe compared to urgent surgical intervention [ 4 – 6 ]. While studies have evaluated a trial of passage in regards to health system expenditures, the effects of a trial of passage on patients and their lifestyles remain largely unexplored. Patients with nephrolithiasis are increasingly recognized to suffer from financial toxicity and have worse quality of life compared to healthy patients [ 7 , 8 ]. In addition to the direct costs associated with medical care, patients may experience indirect costs such as lost income from missed work or requiring caregivers to miss work due to their illnesses. Work absence may particularly affect patients of low socioeconomic status who have less of a financial buffer or those who are self-employed. Information on work absence may help counsel patients on options for management of their ureteral stones while in the emergency department. Knowledge of expected time off work may help patients choose between primary endoscopic management and a trial of spontaneous passage. Additionally, setting accurate patient expectations may help prevent return visits to the ED. Using a prospective survey, we characterize work productivity losses for patients undergoing a trial of spontaneous passage for ureteral stones. Methods The Duke University Health system consists of three hospitals: a quaternary referral center, a metropolitan community hospital, and a suburban community hospital. We identified actively employed patients from ages of 18 to 64 presenting to Duke University EDs with ureteral stones confirmed by computerized tomography (CT) scans between February 7, 2022 and February 7, 2023. Patients were excluded if they were non-English speaking or had bilateral ureteral stones. To identify patients who were discharged from the ED on a trial of passage, we excluded any patients admitted to the hospital or those who underwent procedural intervention (ureteral stent placement, ureteroscopy, or percutaneous nephrostomy tube placement) during the initial presentation to the ED. Patients with stones > 10mm were also excluded, as these would not be expected to pass spontaneously. Observation status for patients was allowed. Only the initial ED visit was used to determine eligibility for the study, however we also identified patients with subsequent ED presentations and those requiring intervention or admission during subsequent episodes of care. Using the primary phone number provided at the time of ED presentation, all patients were contacted by phone four weeks following their initial ED presentation. For those that did not initially answer, we again attempted phone contact one week later. Participants were consented by phone for the study. Participants were verbally asked the Institute for Medical Technology Assessment Productivity Cost Questionnaire (PCQ), a validated survey to assess health related productivity losses [ 9 ]. The survey has been validated to assess health related productivity losses and assess three domains: absenteeism — missed work following the ED visit; presenteeism — reduced productivity when returning to work; and loss of productivity related to requiring assistance with unpaid work — such as household work, child care, and volunteer work. Participants were also asked if they were a first-time stone former, if they had sick leave through their work, income and household demographic information, and how many hours and days a week they worked. Patients could opt out of providing annual income. Number of work hours per day were calculated by dividing the hours per week by the days per week worked. Subjective passage of the stone was assessed and defined as visualizing the stone in a toilet or a distinct time point where symptoms resolved and did not return. Patients undergoing surgical intervention, whether elective or urgent, after being discharged from the ED were identified. These patients were classified as having not passed their stone. We also identified patients on an alpha blocker at the time of ED presentation or prescribed an alpha blocker. Demographic information was obtained from the patient’s medical record. Charlson comorbidity index was calculated based on the patient’s history in the medical record [ 10 ]. Stone characteristics including size and location were measured by the research team from CT scans at the time of ED presentation. Stone size was measured as the largest diameter on either coronal or axial views. Patients were divided into two groups based on size of the stone. Patients with size ≤ 5mm are expected to have a higher chance at passing their stone compared to patients with stone size > 5mm. Size cutoffs were drawn from the SUSPEND trial [ 11 ]. Stones below the iliac vessels were determined to be distal, with those above the vessels characterized as proximal. Patients were deemed to have an additional ED visit within 30 days of the first ED visit if they presented to a Duke ED for any reason within 30 days. Primary endpoints included the percentage of patients reporting absenteeism, presenteeism, and loss of unpaid work. For patients who reported productivity losses, we also evaluated the number of days this occurred while undergoing spontaneous passage of their stone. Secondary endpoint was the total productivity loss measured in hours. Total productivity losses were calculated with the following equation: ((number of days absent) x (hours per day of work)) + ((days of productivity affected) x (1-(percentage of productivity on days productivity was affected)) x (hours per day of work)) + ((number of days of assistance with unpaid work) x (hours per day of assistance with unpaid work)). If a patient underwent surgery after the initial ED visit, productivity losses included time spent recovering from surgery. Chi-squared tests were used to compare the number of patients with productivity losses between those with stones ≤ 5mm and those with stones > 5mm. Linear regression was used to associate age, sex, race, health insurance, primary income earner, first-time stone former, stone size, and stone location with total productivity losses. Statistical analysis was performed with Stata 15.1 (College Station, TX). This study was approved by the Duke University Institutional Review Board (Pro00109982). Results A total of 404 patients met initial screening criteria. We were able to contact 180 (45%) patients and 109 (27%) patients agreed to participate. Patient demographic variables are shown in Table 1 . Table 1 Characteristics of survey participants (n = 109). Variable n (%) Age, mean (standard deviation) 41 (12) Sex, male 68 (62) Race • White 70 (64) • African American 29 (27) • Asian 3 (3) • Other/unknown 7 (6) Ethnicity • Not Hispanic/latino 99 (91) • Hispanic/latino 4 (4) • Not reported 6 (6) Health Insurance • Private 90 (83) • Medicaid 6 (6) • Uninsured 13 (12) Education • Some high school 1 (1) • Completed high school 7 (6) • Some college or associates degree 44 (40) • Complete college 35 (32) • Graduate or professional degree 22 (20) Paid sick leave through work 71 (65) Primary income earner 87 (80) Household members, median (IQR) 3 (2–4) Annual household income, median (IQR) $ 85,000 ( $ 55,000-150,000)* Work days per week, median (IQR) 5 (5–5) Work hours per week, median (IQR) 40 (40–50) Charlson Comorbidity index, median (IQR) 0 (0–1) First-time stone former 55 (50) Stone size • ≤ 5mm 76 (70) • > 5mm 33 (30) Stone location • Proximal 32 (29) • Distal 77 (71) Alpha blocker prescription 85 (78%) Stone symptoms at time of survey 22 (20) Passed stone at time of survey 69 (63) Days until stone passed, median (interquartile range) 3 (1–7) Surgical procedure prior to survey 12 (11) Days until surgical procedure, median (IQR) 21.5 (8-26.5) Additional ED visit within 30 days of first visit 16 (15) *n = 92 for annual household income as 17 patients opted out of providing this information Patients had an average age of 41 (standard deviation 12 years), were 62% (68/109) male, and 64% (70/109) white. 70% (76/109) of patients had stones ≤ 5mm and 71% (77/109) were located in the distal ureter. For patients with stones ≤ 5mm, 72% (55/76) of patients reported stone passage, and median time to passage was 3 days (interquartile range [IQR] 1–5 days). For patients with stones > 5mm, 42% (14/33) of patients reported stone passage, and median time to passage was 8.5 days (IQR 3–21 days). In total, 11% (12/109) of patients had surgery before the time of survey with a median of 21.5 days (IQR 8-26.5 from the ED visit to surgery. Additionally, 15% (16/109) had an additional ED visit within 30 days of their initial visit. The number of patients who endorsed decreased productivity based on the domains of the PCQ are shown in Table 2 . Table 2 Number of patients who endorsed decreased productivity by stone size. Absenteeism Total Cohort n = 109 Stone ≤ 5mm n = 76 Stone > 5mm n = 33 p* • Missed work, n (%) 73 (67) 45 (59) 28 (84) 0.009 Presenteeism • Decreased productivity, n (%) 50 (46) 37 (49) 13 (42) 0.373 Assistance with unpaid work • Required assistance with unpaid work, n (%) 60 (55) 45 (59) 15 (45) 0.187 *p values calculated with chi-squared test In total, 67% (73/109) of patients missed work, 46% (50/109) of patients had decreased productivity when returning to work, and 55% (60/109) required assistance with unpaid work. Out of the entire cohort, 13% (14/109) of patients did not have any productivity losses. Compared to those with stones > 5mm, patients with stones ≤ 5mm were less likely to miss work (59% vs. 84%, p = 0.009). For patients who had work productivity losses, answers from the PCQ stratified by stone size are shown in Supplemental Table 1. The number of days affected for each PCQ category are shown in Fig. 1 . Patients who reported a work absence with stones ≤ 5mm missed a median of 2 days of work (interquartile range [IQR] 1–3 days). Those with stones > 5mm missed a median of 3 days (IQR 1–7 days) of work. In total, 49% of patients with stones ≤ 5mm reported decreased productivity at work compared to 42% for those with stones > 5mm (p = 0.373). Decreased productivity was reported for a median of 3 days (IQR 2–5 days) for stones ≤ 5mm and a median of 4 days (IQR 2–7 days) for stones > 5mm. Assistance with unpaid work was reported by 59% of patients with stones ≤ 5mm and 45% of patients with stones > 5mm (p = 0.187). For those with productivity losses, total losses were a median of 20 hours (IQR 8–52) for stones ≤ 5mm and a median of 38 hours (IQR 13–89) for patients with stones > 5mm. Results of the linear regression for total productivity losses are shown in Table 3 . Table 3 Factors associated with hours of productivity loss. Variable Coefficient (95% CI) p Age -0.61 (-1.44, 0.22) 0.149 Sex • Male - - • Female 4.76 (-13.44, 22.96) 0.605 Race • White - - • African American 23.68 (2.24, 45.11) 0.031 • Asian 21.67 (-32.19, 75.52) 0.427 • Other/unknown -0.17 (-37.73, 37.39) 0.993 Health Insurance • Private - - • Medicaid -24.96 (-64.16, 14.25) 0.209 • Uninsured 0.21 (-27.63, 28.04) 0.988 Primary income earner • No - - • Yes 1.81 (-21.06, 24.67) 0.875 First time stone former • No - - • Yes 20.28 (2.50, 38.07) 0.026 Stone size - ≤5mm - - - >5mm 25.34 (5.25, 45.44) 0.014 Stone location • Distal - - • Proximal 13.60 (-6.04,33.25) 0.173 First time stone formers were associated with higher productivity losses compared to recurrent stone formers (coefficient 20.28, 95% confidence interval [95% CI] 2.50-38.07, p = 0.026). Additionally, African American race (coefficient 23.68, 95% CI 2.24–45.11, p = 0.031) and patients with stones > 5mm (coefficient 25.34, 95% CI 5.25–45.44, p = 0.014) were associated with higher productivity losses. Discussion This novel study examining work productivity loss during a spontaneous trial of passage for ureteral stones demonstrates that the majority of patients miss work following an ED visit though most return to work within a couple days. Patients returning to work still demonstrate a decrease in productivity and require help with daily tasks at home while undergoing a trial of passage. Financial toxicity has become an important healthcare consideration. It is divided into multiple components such as direct and indirect costs. Direct costs include the patient payments for surgery, imaging, medications, and office visits. Indirect costs include less tangible items, such as time off work, drive time to appointments, and cost of caregiver support. Nephrolithiasis affects patients of working ages and approximately 50% of first-time stone formers will go on to form another stone [ 12 , 13 ]. Financial toxicity is an especially relevant and recurrent problem for this population. In a sample of privately employed patients, approximately 30% of patients missed work due to nephrolithiasis and missed 19 hours of working time annually [ 14 ]. However, this study did not stratify missed work by office visits versus surgical care. In addition, Cabo et al. found that 25% of patients with nephrolithiasis met criteria for financial toxicity using a large online survey [ 7 ]. This was followed up with a cross-sectional primary study at their clinic which demonstrated 20% of patients seeking care for nephrolithiasis experience financial toxicity [ 15 ]. Indirect costs contribute to financial toxicity, however have not been studied in nephrolithiasis. Patients of low socioeconomic status may be particularly vulnerable to indirect costs. They may have less savings to fall back on, increasing the importance of each working day. They are also less likely to have paid leave [ 16 ]. Our study highlights the burden of indirect costs for patients undergoing a trial of stone passage. After being discharged from the ED, the majority of patients miss work, even those with small stones that are expected to pass. The expectation of productivity loss should factor into shared decision making while in the ED. First-time stone formers had higher productivity losses which indicates that expectations and coping strategies may reduce productivity losses for recurrent stone formers. We also found that African American patients had higher total productivity losses. Previous studies have shown that African American patients receive less opioids in emergency departments and were less likely to receive ketorolac for nephrolithiasis, however this study did not assess outpatient prescriptions [ 17 ]. Amongst visits for all pain conditions, whites have been shown to have increased prescription of opioids compared to African Americans, Hispanics, and Asians [ 18 ]. It is possible that inadequate pain control leads to increased productivity losses in African Americans undergoing a trial of passage. Additionally, almost half of patients will have decreased productivity, when returning to work. Productivity losses may significantly affect patients who may by self-employed or rely on revenue generation for their compensation. Finally, our data shows that the majority of patients will rely on social support for unpaid labor such as chores around the house, taking care of children, or getting groceries. Patients who live alone may find these tasks especially difficult when undergoing a trial of passage. Caregivers who must take off work may decrease the total household productivity and further contribute to financial burden. Our results have several implications for counselling in emergency departments. Approximately 11% of patients with ureteral stones present back to EDs within 30 days, usually due to recurrent pain [ 19 ]. Primary emergent ureteroscopy has been shown to be safe with a stone free rate of 90% [ 20 ]. Patients who cannot miss work may view primary surgical treatment as an alternative to expulsive therapy for their stone. However, patients undergoing ureteroscopy may have a ureteral stent which can continue to cause pain and impact quality of life through post-operative day 7 [ 21 ]. In our study, patients who reported work absence missed a median of 2 days of work which, based on pain duration with a ureteral stent, may be less than those undergoing primary surgical treatment. Adding 2 days of work absence and 3 days of decreased productivity together yields 5 days of impairment following an acute stone episode, which is similar to when pain intensity returns to baseline after ureteroscopy and stent placement [ 21 ]. Patient knowledge that they may miss work or have decreased productivity may prevent return ED visits. Patients with stones > 5mm may be candidates for primary ureteroscopy, however we demonstrate that 42% of these patients report passing their stone and they only miss a median of 3 days of work. While, patients with stones > 5mm may still be candidates for delayed elective surgery over primary urgent ureteroscopy, both physicians and patients should understand that these individuals have higher productivity losses compared to those with stones ≤ 5mm. This study has several limitations. As a survey, it relies on accurate patient responses and does not use employer collected data. It is subject to recall bias as the severity of stone event may affect how patients remember their missed working days, productivity, or help around the house. Subjective stone passage or resolution of symptoms may not correspond with actual stone passage and some of these patients may develop “silent hydronephrosis.” However, resolution of stone symptoms may be a more important measure when assessing decreased productivity in patients undergoing a trial of passage as this is likely what drives return to work over actual passage of the stone. Work absence may be underestimated as some patients may undergo their trial of passage on weekend days or vacation days where they were not scheduled to work. While we only include working patients in our study, we do not stratify by the type of work. Those that are self-employed may be less likely to miss work as there is not backup. Additionally, we did not assess whether manual labor affects missed work compared to those that work from home or have a non-manual labor job. Income dependence may influence patients to work, even when in pain. The median income in our study was $ 85,000 which is greater than the U.S. median of $ 74,580 [ 22 ]. However, 17 patients declined to provide information on annual household income, so we could not evaluate the effect of income on productivity losses. This may reflect our study using a single academic hospital system. Our results may be affected by the local demographic and socioeconomic factors. While our demographics are similar to the overall employed population, the results may not be generalizable to all individuals [ 23 ]. Finally, we were only able to measure repeat ED visit to Duke affiliated facilities. This may be an underestimate as some patients may present to other emergency departments not captured in our medical record. Conclusions Patients presenting to emergency departments with ureteral stones and undergoing a trial of passage should expect to miss work and have decreased productivity when they return to work. This information may inform shared decision making in EDs and help prevent return visits. Declarations Funding Statement: No funding Author Contribution: IB, RM, CS, and DK contributed to the design of this research. IB, JA, ML, RM, EM CS, DK were involved in data management and statistical analysis. IB drafted the manuscript. IB, RM, EM, JA, ML, CS, and DK contributed to revision of the manuscript. References Antonelli JA, Maalouf NM, Pearle MS, Lotan Y (2014) Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030. Eur Urol 66(4):724–729 Scales CD Jr., Smith AC, Hanley JM, Saigal CS (2012) Urologic Diseases in America P. Prevalence of kidney stones in the United States. Eur Urol 62(1):160–165 Eaton SH, Cashy J, Pearl JA, Stein DM, Perry K, Nadler RB (2013) Admission rates and costs associated with emergency presentation of urolithiasis: analysis of the Nationwide Emergency Department Sample 2006–2009. J Endourol 27(12):1535–1538 Portis AJ, Lundquist EL, Portis JL et al (2016) Unsuccessful Medical Expulsive Therapy: A Cost to Waiting? Urology. ;87:25–32 Hollingsworth JM, Norton EC, Kaufman SR, Smith RM, Wolf JS Jr., Hollenbeck BK (2013) Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis. J Urol 190(3):882–887 Assimos D, Krambeck A, Miller NL et al (2016) Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 196(4):1161–1169 Cabo J, Gelikman DG, Hsi RS (2023) The Financial Burden of Nephrolithiasis and Predictors of Disease-specific Financial Toxicity. Urology 171:57–63 Bensalah K, Tuncel A, Gupta A, Raman JD, Pearle MS, Lotan Y (2008) Determinants of quality of life for patients with kidney stones. J Urol 179(6):2238–2243 discussion 2243 Bouwmans C, Krol M, Severens H, Koopmanschap M, Brouwer W, Hakkaart-van Roijen L (2015) The iMTA Productivity Cost Questionnaire: A Standardized Instrument for Measuring and Valuing Health-Related Productivity Losses. Value Health 18(6):753–758 Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383 Pickard R, Starr K, MacLennan G et al (2015) Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 386(9991):341–349 Pearle MS, Calhoun EA, Curhan GC (2005) Urologic Diseases of America P. Urologic diseases in America project: urolithiasis. J Urol 173(3):848–857 Trinchieri A, Ostini F, Nespoli R, Rovera F, Montanari E, Zanetti G (1999) A prospective study of recurrence rate and risk factors for recurrence after a first renal stone. J Urol 162(1):27–30 Saigal CS, Joyce G, Timilsina AR (2005) Urologic Diseases in America P. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int 68(4):1808–1814 Setia SA, Gelikman DG, Cabo J, Hsi RS (2023) Patient-Reported Financial Toxicity Associated With Management of Nephrolithiasis. Urology 174:52–57 U.S. Bureau of Labor Statistics. Employee Benefits. (2021) https://www.bls.gov/news.release/archives/ebs2_09232021.pdf . Accessed 17 September, 2022 Berger AJ, Wang Y, Rowe C et al (2021) Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States. Am J Emerg Med 39:71–74 Pletcher MJ, Kertesz SG, Kohn MA et al (2008) Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA 299(1):70–78 Ganesan V, Loftus CJ, Hinck B et al (2016) Clinical Predictors of 30-Day Emergency Department Revisits for Patients with Ureteral Stones. J Urol 196(5):1467–1470 Picozzi SC, Ricci C, Gaeta M et al (2012) Urgent ureteroscopy as first-line treatment for ureteral stones: a meta-analysis of 681 patients. Urol Res 40(5):581–586 Harper JD, Desai AC, Maalouf NM et al (2023) Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS. J Urol 209(5):971–980 United States Census Bureau. Income in the United States (2022) 2023; https://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-279.pdf . Accessed 17 September, 2022 U.S. Bureau of Labor Statistics. Labor force characteristics by race and ethnicity (2022) Labor force characteristics by race and ethnicity, 2022: BLS Reports: U.S. Bureau of Labor Statistics. Accessed 4 April, 2024 Additional Declarations No competing interests reported. Supplementary Files SupplementalTable1.docx Cite Share Download PDF Status: Published Journal Publication published 06 Aug, 2024 Read the published version in Urolithiasis → Version 1 posted Editorial decision: Revision requested 16 May, 2024 Reviews received at journal 20 Apr, 2024 Reviewers agreed at journal 18 Apr, 2024 Reviewers invited by journal 16 Apr, 2024 Submission checks completed at journal 15 Apr, 2024 Editor assigned by journal 15 Apr, 2024 First submitted to journal 14 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4265036","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292786954,"identity":"86745381-d70a-4137-b787-5b6ee4449185","order_by":0,"name":"Ian Berger","email":"","orcid":"","institution":"Duke University Medical Center DUMC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Berger","suffix":""},{"id":292786955,"identity":"a0db2795-3791-4ac2-8eef-18afe62bd8d5","order_by":1,"name":"Robert Medairos","email":"","orcid":"","institution":"Duke University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Medairos","suffix":""},{"id":292786956,"identity":"8593b684-73dd-4377-9fd2-dbc6f663d4c9","order_by":2,"name":"Ezra Margolin","email":"","orcid":"","institution":"Duke University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ezra","middleName":"","lastName":"Margolin","suffix":""},{"id":292786957,"identity":"80689abb-36d4-4aad-bf1e-9b1711630a8d","order_by":3,"name":"Jodi Antonelli","email":"","orcid":"","institution":"Duke University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jodi","middleName":"","lastName":"Antonelli","suffix":""},{"id":292786959,"identity":"5eea0418-29cb-40e4-bbaa-b2f47f3b4652","order_by":4,"name":"Michael E. Lipkin","email":"","orcid":"","institution":"Duke University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michael","middleName":"E.","lastName":"Lipkin","suffix":""},{"id":292786961,"identity":"96329a37-2b3a-48f3-afc3-97815d07efb9","order_by":5,"name":"Charles D. Scales","email":"","orcid":"","institution":"Duke University Medical Center, Duke University National Clinician Scholars Program, Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Charles","middleName":"D.","lastName":"Scales","suffix":""},{"id":292786963,"identity":"75a1da47-bf1e-4bfa-9974-a30a411d3355","order_by":6,"name":"Deborah R. Kaye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDCCAzxgkkECRH1gYzAA0RJEa2GcQbIWZh5itPAd7z34uKLmDoNk+xnDxzZlh435GZgP3ubBo0XyzLlkwzPHnjFI8+QYG+ecO2wm2cCWbI1Pi8GNHJCiwwxyDDlm0rlth20MDvCYSePVcv8NUMs/oBb+N+a/LYFa7A/wf8Ov5QaPmWRj22EGaYkcM2bGtsNmBgw8bHi1SJ7JSzZs7DvMIznjWbFkz7l0Y4nDbMaWc/Bo4Tt+9uDDhm+H5STOJ2/88KPM2rC/vfnhjTd4tMAA0CUcBhAmMxHKoYD9AfFqR8EoGAWjYEQBAM5KTMtIiwx2AAAAAElFTkSuQmCC","orcid":"","institution":"Duke University Medical Center, Duke University School of Medicine, Duke University School of Medicine, Duke University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"R.","lastName":"Kaye","suffix":""}],"badges":[],"createdAt":"2024-04-14 13:14:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4265036/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4265036/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00240-024-01608-w","type":"published","date":"2024-08-06T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55098546,"identity":"6595e030-2083-41a8-9ae4-5b149cf06405","added_by":"auto","created_at":"2024-04-22 15:04:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54961,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of patients who report each number of days absent from work, days of decreased productivity and days requiring assistance with unpaid work.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4265036/v1/a93f4accef19952a3a065fc4.png"},{"id":62298620,"identity":"1e87840c-41e8-4323-8cf2-7c3b697318ad","added_by":"auto","created_at":"2024-08-12 16:15:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513491,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4265036/v1/6f5faada-0bb4-4065-8fed-724f8a40d7a9.pdf"},{"id":55098544,"identity":"de63c469-1c5b-492b-8376-4cb3f0fd8ead","added_by":"auto","created_at":"2024-04-22 15:04:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16160,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4265036/v1/feba842b35bc16b9967b8bdf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Work Absence and Productivity Loss of Patients Undergoing a Trial of Spontaneous Passage for Ureteral Stones","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNephrolithiasis affects almost 9% of the U.S. population with an expected economic burden of at least \u003cspan\u003e$\u003c/span\u003e3\u0026nbsp;billion by 2030 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Many patients with an obstructing ureteral stone present to an emergency department (ED), resulting in 1.2\u0026nbsp;million visit annually [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients with well controlled pain and without signs of infection or renal failure are often offered a trial of spontaneous stone passage. Guidelines recommend observation or medical expulsive therapy for ureteral stones\u0026thinsp;\u0026le;\u0026thinsp;10mm which has been shown to be cost effective and safe compared to urgent surgical intervention [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile studies have evaluated a trial of passage in regards to health system expenditures, the effects of a trial of passage on patients and their lifestyles remain largely unexplored. Patients with nephrolithiasis are increasingly recognized to suffer from financial toxicity and have worse quality of life compared to healthy patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition to the direct costs associated with medical care, patients may experience indirect costs such as lost income from missed work or requiring caregivers to miss work due to their illnesses. Work absence may particularly affect patients of low socioeconomic status who have less of a financial buffer or those who are self-employed.\u003c/p\u003e \u003cp\u003eInformation on work absence may help counsel patients on options for management of their ureteral stones while in the emergency department. Knowledge of expected time off work may help patients choose between primary endoscopic management and a trial of spontaneous passage. Additionally, setting accurate patient expectations may help prevent return visits to the ED. Using a prospective survey, we characterize work productivity losses for patients undergoing a trial of spontaneous passage for ureteral stones.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Duke University Health system consists of three hospitals: a quaternary referral center, a metropolitan community hospital, and a suburban community hospital. We identified actively employed patients from ages of 18 to 64 presenting to Duke University EDs with ureteral stones confirmed by computerized tomography (CT) scans between February 7, 2022 and February 7, 2023. Patients were excluded if they were non-English speaking or had bilateral ureteral stones. To identify patients who were discharged from the ED on a trial of passage, we excluded any patients admitted to the hospital or those who underwent procedural intervention (ureteral stent placement, ureteroscopy, or percutaneous nephrostomy tube placement) during the initial presentation to the ED. Patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;10mm were also excluded, as these would not be expected to pass spontaneously. Observation status for patients was allowed. Only the initial ED visit was used to determine eligibility for the study, however we also identified patients with subsequent ED presentations and those requiring intervention or admission during subsequent episodes of care.\u003c/p\u003e \u003cp\u003e Using the primary phone number provided at the time of ED presentation, all patients were contacted by phone four weeks following their initial ED presentation. For those that did not initially answer, we again attempted phone contact one week later. Participants were consented by phone for the study. Participants were verbally asked the Institute for Medical Technology Assessment Productivity Cost Questionnaire (PCQ), a validated survey to assess health related productivity losses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The survey has been validated to assess health related productivity losses and assess three domains: absenteeism \u0026mdash; missed work following the ED visit; presenteeism \u0026mdash; reduced productivity when returning to work; and loss of productivity related to requiring assistance with unpaid work \u0026mdash; such as household work, child care, and volunteer work. Participants were also asked if they were a first-time stone former, if they had sick leave through their work, income and household demographic information, and how many hours and days a week they worked. Patients could opt out of providing annual income. Number of work hours per day were calculated by dividing the hours per week by the days per week worked. Subjective passage of the stone was assessed and defined as visualizing the stone in a toilet or a distinct time point where symptoms resolved and did not return. Patients undergoing surgical intervention, whether elective or urgent, after being discharged from the ED were identified. These patients were classified as having not passed their stone. We also identified patients on an alpha blocker at the time of ED presentation or prescribed an alpha blocker. Demographic information was obtained from the patient\u0026rsquo;s medical record.\u003c/p\u003e \u003cp\u003eCharlson comorbidity index was calculated based on the patient\u0026rsquo;s history in the medical record [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Stone characteristics including size and location were measured by the research team from CT scans at the time of ED presentation. Stone size was measured as the largest diameter on either coronal or axial views. Patients were divided into two groups based on size of the stone. Patients with size\u0026thinsp;\u0026le;\u0026thinsp;5mm are expected to have a higher chance at passing their stone compared to patients with stone size\u0026thinsp;\u0026gt;\u0026thinsp;5mm. Size cutoffs were drawn from the SUSPEND trial [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Stones below the iliac vessels were determined to be distal, with those above the vessels characterized as proximal. Patients were deemed to have an additional ED visit within 30 days of the first ED visit if they presented to a Duke ED for any reason within 30 days.\u003c/p\u003e \u003cp\u003ePrimary endpoints included the percentage of patients reporting absenteeism, presenteeism, and loss of unpaid work. For patients who reported productivity losses, we also evaluated the number of days this occurred while undergoing spontaneous passage of their stone. Secondary endpoint was the total productivity loss measured in hours. Total productivity losses were calculated with the following equation: ((number of days absent) x (hours per day of work)) + ((days of productivity affected) x (1-(percentage of productivity on days productivity was affected)) x (hours per day of work)) + ((number of days of assistance with unpaid work) x (hours per day of assistance with unpaid work)). If a patient underwent surgery after the initial ED visit, productivity losses included time spent recovering from surgery. Chi-squared tests were used to compare the number of patients with productivity losses between those with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm and those with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm. Linear regression was used to associate age, sex, race, health insurance, primary income earner, first-time stone former, stone size, and stone location with total productivity losses. Statistical analysis was performed with Stata 15.1 (College Station, TX). This study was approved by the Duke University Institutional Review Board (Pro00109982).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 404 patients met initial screening criteria. We were able to contact 180 (45%) patients and 109 (27%) patients agreed to participate. Patient demographic variables are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of survey participants (n\u0026thinsp;=\u0026thinsp;109).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, mean (standard deviation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex, male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Other/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Not Hispanic/latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Hispanic/latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Not reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Uninsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Some high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Completed high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Some college or associates degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Complete college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Graduate or professional degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaid sick leave through work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary income earner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold members, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnnual household income, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e85,000 (\u003cspan\u003e$\u003c/span\u003e55,000-150,000)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWork days per week, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWork hours per week, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (40\u0026ndash;50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCharlson Comorbidity index, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst-time stone former\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStone size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026le;\u0026thinsp;5mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;5mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStone location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Distal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlpha blocker prescription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStone symptoms at time of survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePassed stone at time of survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays until stone passed, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical procedure prior to survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays until surgical procedure, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5 (8-26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdditional ED visit within 30 days of first visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e*n\u0026thinsp;=\u0026thinsp;92 for annual household income as 17 patients opted out of providing this information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePatients had an average age of 41 (standard deviation 12 years), were 62% (68/109) male, and 64% (70/109) white. 70% (76/109) of patients had stones\u0026thinsp;\u0026le;\u0026thinsp;5mm and 71% (77/109) were located in the distal ureter. For patients with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm, 72% (55/76) of patients reported stone passage, and median time to passage was 3 days (interquartile range [IQR] 1\u0026ndash;5 days). For patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm, 42% (14/33) of patients reported stone passage, and median time to passage was 8.5 days (IQR 3\u0026ndash;21 days). In total, 11% (12/109) of patients had surgery before the time of survey with a median of 21.5 days (IQR 8-26.5 from the ED visit to surgery. Additionally, 15% (16/109) had an additional ED visit within 30 days of their initial visit.\u003c/p\u003e\n\u003cp\u003eThe number of patients who endorsed decreased productivity based on the domains of the PCQ are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNumber of patients who endorsed decreased productivity by stone size.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAbsenteeism\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal Cohort\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;109\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStone\u0026thinsp;\u0026le;\u0026thinsp;5mm\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;76\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStone\u0026thinsp;\u0026gt;\u0026thinsp;5mm\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;33\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Missed work, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresenteeism\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Decreased productivity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.373\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssistance with unpaid work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Required assistance with unpaid work, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e*p values calculated with chi-squared test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn total, 67% (73/109) of patients missed work, 46% (50/109) of patients had decreased productivity when returning to work, and 55% (60/109) required assistance with unpaid work. Out of the entire cohort, 13% (14/109) of patients did not have any productivity losses. Compared to those with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm, patients with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm were less likely to miss work (59% vs. 84%, p\u0026thinsp;=\u0026thinsp;0.009). For patients who had work productivity losses, answers from the PCQ stratified by stone size are shown in Supplemental Table 1.\u003c/p\u003e\n\u003cp\u003eThe number of days affected for each PCQ category are shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003ePatients who reported a work absence with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm missed a median of 2 days of work (interquartile range [IQR] 1\u0026ndash;3 days). Those with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm missed a median of 3 days (IQR 1\u0026ndash;7 days) of work.\u003c/p\u003e\n\u003cp\u003eIn total, 49% of patients with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm reported decreased productivity at work compared to 42% for those with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm (p\u0026thinsp;=\u0026thinsp;0.373). Decreased productivity was reported for a median of 3 days (IQR 2\u0026ndash;5 days) for stones\u0026thinsp;\u0026le;\u0026thinsp;5mm and a median of 4 days (IQR 2\u0026ndash;7 days) for stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm. Assistance with unpaid work was reported by 59% of patients with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm and 45% of patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm (p\u0026thinsp;=\u0026thinsp;0.187). For those with productivity losses, total losses were a median of 20 hours (IQR 8\u0026ndash;52) for stones\u0026thinsp;\u0026le;\u0026thinsp;5mm and a median of 38 hours (IQR 13\u0026ndash;89) for patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm.\u003c/p\u003e\n\u003cp\u003eResults of the linear regression for total productivity losses are shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors associated with hours of productivity loss.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCoefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.61 (-1.44, 0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.76 (-13.44, 22.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eAfrican American\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e23.68 (2.24, 45.11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.67 (-32.19, 75.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Other/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.17 (-37.73, 37.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.993\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-24.96 (-64.16, 14.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Uninsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (-27.63, 28.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.988\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary income earner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81 (-21.06, 24.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst time stone former\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.28 (2.50, 38.07)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStone size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026le;5mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e- \u0026gt;5mm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e25.34 (5.25, 45.44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStone location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Distal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.60 (-6.04,33.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFirst time stone formers were associated with higher productivity losses compared to recurrent stone formers (coefficient 20.28, 95% confidence interval [95% CI] 2.50-38.07, p\u0026thinsp;=\u0026thinsp;0.026). Additionally, African American race (coefficient 23.68, 95% CI 2.24\u0026ndash;45.11, p\u0026thinsp;=\u0026thinsp;0.031) and patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm (coefficient 25.34, 95% CI 5.25\u0026ndash;45.44, p\u0026thinsp;=\u0026thinsp;0.014) were associated with higher productivity losses.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis novel study examining work productivity loss during a spontaneous trial of passage for ureteral stones demonstrates that the majority of patients miss work following an ED visit though most return to work within a couple days. Patients returning to work still demonstrate a decrease in productivity and require help with daily tasks at home while undergoing a trial of passage.\u003c/p\u003e \u003cp\u003eFinancial toxicity has become an important healthcare consideration. It is divided into multiple components such as direct and indirect costs. Direct costs include the patient payments for surgery, imaging, medications, and office visits. Indirect costs include less tangible items, such as time off work, drive time to appointments, and cost of caregiver support. Nephrolithiasis affects patients of working ages and approximately 50% of first-time stone formers will go on to form another stone [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Financial toxicity is an especially relevant and recurrent problem for this population. In a sample of privately employed patients, approximately 30% of patients missed work due to nephrolithiasis and missed 19 hours of working time annually [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, this study did not stratify missed work by office visits versus surgical care. In addition, Cabo et al. found that 25% of patients with nephrolithiasis met criteria for financial toxicity using a large online survey [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This was followed up with a cross-sectional primary study at their clinic which demonstrated 20% of patients seeking care for nephrolithiasis experience financial toxicity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Indirect costs contribute to financial toxicity, however have not been studied in nephrolithiasis. Patients of low socioeconomic status may be particularly vulnerable to indirect costs. They may have less savings to fall back on, increasing the importance of each working day. They are also less likely to have paid leave [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our study highlights the burden of indirect costs for patients undergoing a trial of stone passage. After being discharged from the ED, the majority of patients miss work, even those with small stones that are expected to pass.\u003c/p\u003e \u003cp\u003eThe expectation of productivity loss should factor into shared decision making while in the ED. First-time stone formers had higher productivity losses which indicates that expectations and coping strategies may reduce productivity losses for recurrent stone formers. We also found that African American patients had higher total productivity losses. Previous studies have shown that African American patients receive less opioids in emergency departments and were less likely to receive ketorolac for nephrolithiasis, however this study did not assess outpatient prescriptions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Amongst visits for all pain conditions, whites have been shown to have increased prescription of opioids compared to African Americans, Hispanics, and Asians [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It is possible that inadequate pain control leads to increased productivity losses in African Americans undergoing a trial of passage. Additionally, almost half of patients will have decreased productivity, when returning to work. Productivity losses may significantly affect patients who may by self-employed or rely on revenue generation for their compensation. Finally, our data shows that the majority of patients will rely on social support for unpaid labor such as chores around the house, taking care of children, or getting groceries. Patients who live alone may find these tasks especially difficult when undergoing a trial of passage. Caregivers who must take off work may decrease the total household productivity and further contribute to financial burden.\u003c/p\u003e \u003cp\u003eOur results have several implications for counselling in emergency departments. Approximately 11% of patients with ureteral stones present back to EDs within 30 days, usually due to recurrent pain [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Primary emergent ureteroscopy has been shown to be safe with a stone free rate of 90% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Patients who cannot miss work may view primary surgical treatment as an alternative to expulsive therapy for their stone. However, patients undergoing ureteroscopy may have a ureteral stent which can continue to cause pain and impact quality of life through post-operative day 7 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, patients who reported work absence missed a median of 2 days of work which, based on pain duration with a ureteral stent, may be less than those undergoing primary surgical treatment. Adding 2 days of work absence and 3 days of decreased productivity together yields 5 days of impairment following an acute stone episode, which is similar to when pain intensity returns to baseline after ureteroscopy and stent placement [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Patient knowledge that they may miss work or have decreased productivity may prevent return ED visits. Patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm may be candidates for primary ureteroscopy, however we demonstrate that 42% of these patients report passing their stone and they only miss a median of 3 days of work. While, patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm may still be candidates for delayed elective surgery over primary urgent ureteroscopy, both physicians and patients should understand that these individuals have higher productivity losses compared to those with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm.\u003c/p\u003e \u003cp\u003eThis study has several limitations. As a survey, it relies on accurate patient responses and does not use employer collected data. It is subject to recall bias as the severity of stone event may affect how patients remember their missed working days, productivity, or help around the house. Subjective stone passage or resolution of symptoms may not correspond with actual stone passage and some of these patients may develop \u0026ldquo;silent hydronephrosis.\u0026rdquo; However, resolution of stone symptoms may be a more important measure when assessing decreased productivity in patients undergoing a trial of passage as this is likely what drives return to work over actual passage of the stone. Work absence may be underestimated as some patients may undergo their trial of passage on weekend days or vacation days where they were not scheduled to work. While we only include working patients in our study, we do not stratify by the type of work. Those that are self-employed may be less likely to miss work as there is not backup. Additionally, we did not assess whether manual labor affects missed work compared to those that work from home or have a non-manual labor job. Income dependence may influence patients to work, even when in pain. The median income in our study was \u003cspan\u003e$\u003c/span\u003e85,000 which is greater than the U.S. median of \u003cspan\u003e$\u003c/span\u003e74,580 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, 17 patients declined to provide information on annual household income, so we could not evaluate the effect of income on productivity losses. This may reflect our study using a single academic hospital system. Our results may be affected by the local demographic and socioeconomic factors. While our demographics are similar to the overall employed population, the results may not be generalizable to all individuals [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Finally, we were only able to measure repeat ED visit to Duke affiliated facilities. This may be an underestimate as some patients may present to other emergency departments not captured in our medical record.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePatients presenting to emergency departments with ureteral stones and undergoing a trial of passage should expect to miss work and have decreased productivity when they return to work. This information may inform shared decision making in EDs and help prevent return visits.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eNo funding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u0026nbsp;\u003c/strong\u003eIB, RM, CS, and DK contributed to the design of this research. IB, JA, ML, RM, EM CS, DK were involved in data management and statistical analysis. IB drafted the manuscript. IB, RM, EM, JA, ML, CS, and DK contributed to revision of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAntonelli JA, Maalouf NM, Pearle MS, Lotan Y (2014) Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030. Eur Urol 66(4):724\u0026ndash;729\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScales CD Jr., Smith AC, Hanley JM, Saigal CS (2012) Urologic Diseases in America P. Prevalence of kidney stones in the United States. Eur Urol 62(1):160\u0026ndash;165\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEaton SH, Cashy J, Pearl JA, Stein DM, Perry K, Nadler RB (2013) Admission rates and costs associated with emergency presentation of urolithiasis: analysis of the Nationwide Emergency Department Sample 2006\u0026ndash;2009. J Endourol 27(12):1535\u0026ndash;1538\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePortis AJ, Lundquist EL, Portis JL et al (2016) Unsuccessful Medical Expulsive Therapy: A Cost to Waiting? Urology. ;87:25\u0026ndash;32\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHollingsworth JM, Norton EC, Kaufman SR, Smith RM, Wolf JS Jr., Hollenbeck BK (2013) Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis. J Urol 190(3):882\u0026ndash;887\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssimos D, Krambeck A, Miller NL et al (2016) Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 196(4):1161\u0026ndash;1169\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCabo J, Gelikman DG, Hsi RS (2023) The Financial Burden of Nephrolithiasis and Predictors of Disease-specific Financial Toxicity. Urology 171:57\u0026ndash;63\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBensalah K, Tuncel A, Gupta A, Raman JD, Pearle MS, Lotan Y (2008) Determinants of quality of life for patients with kidney stones. J Urol 179(6):2238\u0026ndash;2243 discussion 2243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouwmans C, Krol M, Severens H, Koopmanschap M, Brouwer W, Hakkaart-van Roijen L (2015) The iMTA Productivity Cost Questionnaire: A Standardized Instrument for Measuring and Valuing Health-Related Productivity Losses. Value Health 18(6):753\u0026ndash;758\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373\u0026ndash;383\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePickard R, Starr K, MacLennan G et al (2015) Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 386(9991):341\u0026ndash;349\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePearle MS, Calhoun EA, Curhan GC (2005) Urologic Diseases of America P. Urologic diseases in America project: urolithiasis. J Urol 173(3):848\u0026ndash;857\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrinchieri A, Ostini F, Nespoli R, Rovera F, Montanari E, Zanetti G (1999) A prospective study of recurrence rate and risk factors for recurrence after a first renal stone. J Urol 162(1):27\u0026ndash;30\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaigal CS, Joyce G, Timilsina AR (2005) Urologic Diseases in America P. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int 68(4):1808\u0026ndash;1814\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSetia SA, Gelikman DG, Cabo J, Hsi RS (2023) Patient-Reported Financial Toxicity Associated With Management of Nephrolithiasis. Urology 174:52\u0026ndash;57\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Bureau of Labor Statistics. Employee Benefits. (2021) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bls.gov/news.release/archives/ebs2_09232021.pdf\u003c/span\u003e\u003cspan address=\"https://www.bls.gov/news.release/archives/ebs2_09232021.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 September, 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger AJ, Wang Y, Rowe C et al (2021) Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States. Am J Emerg Med 39:71\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePletcher MJ, Kertesz SG, Kohn MA et al (2008) Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA 299(1):70\u0026ndash;78\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGanesan V, Loftus CJ, Hinck B et al (2016) Clinical Predictors of 30-Day Emergency Department Revisits for Patients with Ureteral Stones. J Urol 196(5):1467\u0026ndash;1470\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePicozzi SC, Ricci C, Gaeta M et al (2012) Urgent ureteroscopy as first-line treatment for ureteral stones: a meta-analysis of 681 patients. Urol Res 40(5):581\u0026ndash;586\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarper JD, Desai AC, Maalouf NM et al (2023) Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS. J Urol 209(5):971\u0026ndash;980\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited States Census Bureau. Income in the United States (2022) 2023; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-279.pdf\u003c/span\u003e\u003cspan address=\"https://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-279.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 September, 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Bureau of Labor Statistics. Labor force characteristics by race and ethnicity (2022) Labor force characteristics by race and ethnicity, 2022: BLS Reports: U.S. Bureau of Labor Statistics. Accessed 4 April, 2024\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"urolithiasis","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ures","sideBox":"Learn more about [Urolithiasis](http://link.springer.com/journal/240)","snPcode":"240","submissionUrl":"https://submission.nature.com/new-submission/240/3","title":"Urolithiasis","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4265036/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4265036/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003ePatients with ureteral stones are often managed with a spontaneous trial of passage. While cost effective, the current literature has not examined the effects of a trial of passage on patients\u0026rsquo; work productivity. In this study, we aim to characterize work absence and productivity losses in a cohort of patients undergoing a trial of passage for ureteral stones.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eActively employed patients aged 18 to 64 and discharged from Duke emergency departments without surgical intervention for ureteral stones\u0026thinsp;\u0026le;\u0026thinsp;10mm were contacted by phone four weeks after their presentation. Participants completed the Institute for Medical Technology Assessment Productivity Cost Questionnaire which assesses three domains: absenteeism \u0026mdash; missed work; presenteeism \u0026mdash;productivity when returning to work; and unpaid work \u0026mdash; assistance with household work. Linear regression associated demographic and stone factors with productivity losses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e109 patients completed the survey. In total, 67% of patients missed work, 46% had decreased productivity when returning to work, and 55% required assistance with unpaid work. 59% of patients with stones\u0026thinsp;\u0026le;\u0026thinsp;5mm missed work versus 84% with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm (p\u0026thinsp;=\u0026thinsp;0.009). African American race (coefficient 23.68, 95% confidence interval 2.24\u0026ndash;45.11, p\u0026thinsp;=\u0026thinsp;0.031), first-time stone formers (coefficient 20.28, 95% confidence interval 2.50-38.07, p\u0026thinsp;=\u0026thinsp;0.026), and patients with stones\u0026thinsp;\u0026gt;\u0026thinsp;5mm (coefficient 25.34, 95% CI 5.25\u0026ndash;45.44, p\u0026thinsp;=\u0026thinsp;0.014) were associated with increased productivity losses.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe majority of patients miss work while undergoing a trial of passage and many have decreased productivity when returning to work. This information may help counsel patients in emergency departments, especially first-time stone formers, and prevent return visits.\u003c/p\u003e","manuscriptTitle":"Work Absence and Productivity Loss of Patients Undergoing a Trial of Spontaneous Passage for Ureteral Stones","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-22 15:04:49","doi":"10.21203/rs.3.rs-4265036/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-16T16:28:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-20T12:51:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"050ac30b-226d-41f3-ab2d-a0842e7ef9bb","date":"2024-04-18T12:40:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-16T06:32:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-15T12:38:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-15T12:38:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Urolithiasis","date":"2024-04-14T13:08:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"urolithiasis","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ures","sideBox":"Learn more about [Urolithiasis](http://link.springer.com/journal/240)","snPcode":"240","submissionUrl":"https://submission.nature.com/new-submission/240/3","title":"Urolithiasis","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e73ac75e-e8b9-49a9-b77f-23e1a624bbaa","owner":[],"postedDate":"April 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T16:07:10+00:00","versionOfRecord":{"articleIdentity":"rs-4265036","link":"https://doi.org/10.1007/s00240-024-01608-w","journal":{"identity":"urolithiasis","isVorOnly":false,"title":"Urolithiasis"},"publishedOn":"2024-08-06 15:58:14","publishedOnDateReadable":"August 6th, 2024"},"versionCreatedAt":"2024-04-22 15:04:49","video":"","vorDoi":"10.1007/s00240-024-01608-w","vorDoiUrl":"https://doi.org/10.1007/s00240-024-01608-w","workflowStages":[]},"version":"v1","identity":"rs-4265036","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4265036","identity":"rs-4265036","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}