“Financial toxicity” (FT) is the economic stress associated with the treatment of a condition.¹ First described by the oncology community in 2009, the concept sought to characterize financial consequences of treatment as an “adverse side effect.”² FT includes patients’ direct costs, like medical bills; indirect costs, like missed work and travel time; and the effects on quality of life. Other factors that influence FT include individual economic circumstance of the patient, patient-specific values, and expectation of possible financial burden (see Figure).³ FT is a patient-centered, clinically relevant outcome that has only recently been described for nononcologic disease treatment.⁴ Like cancer, kidney stone disease can exert a tremendous burden on patients due to its recurrent nature, need for ongoing treatments and surveillance, and unpredictable and emergent symptoms. Our group sought to study the FT associated with the treatment of kidney stone disease.

We performed a cross-sectional, multi-institutional study with in-person and online cohorts. The in-person cohort included patients treated for kidney stones at 2 urban urology clinics (Montefiore Medical Center, Bronx, New York and University of Alabama, Birmingham). Online participation in the study was solicited from the Reddit r/KidneyStones patient support forum. FT was measured using a survey, and the validated COST-FACIT tool (COmprehensive Score for financial Toxicity). The maximum score is 44, and lower scores indicate increased FT. Groups were defined as “moderate FT” for COST scores of 25 to 14 points and “severe FT” for scores <14 points. A total of 241 patients were interviewed, including 105 in person and 115 online.

The median COST score for all patients was 21. Moderate FT (score 25 to 14) was found in 44% and severe FT (score <14) was found in 26%. Compared to patients with low FT, those with moderate/severe FT were younger, had a lower level of education, missed more work (both patients and their caretakers), paid higher out-of-pocket expenses, and were less likely to use a personal car. The groups were comparable in racial composition, sex, number of kidney stone episodes, number of kidney stone procedures, usage of pharmacotherapy for stone prevention, insurance type, and employment status. Most patients being treated for kidney stones reported moderate-to-severe FT, which is comparable to the high burden of FT experienced by patients being treated for cancer.⁵

This finding is significant because FT has a well-documented correlation with other significant health outcomes including symptom burden, health-related quality of life, and hospital admissions.^5-8 Prior work has shown patients with moderate FT employ cost-coping strategies (eg medication rationing)⁹ and those with severe FT delay or avoid care because of the cost.¹⁰ For patients with nephrolithiasis, FT may translate into reduced compliance with prophylactic medications, increased frequency of stone recurrence, and more advanced disease at the time of presentation. Worse outcomes only propagate a cycle of FT.

Figure. Factors contributing to FT.

There are several steps urologists can take to mitigate FT associated with kidney stone treatment. First, urologists should learn about the specific costs of medications, tests, and procedures that they are providing. Understanding individual insurance coverage and out-of-pocket expenses can be enigmatic, but patients appreciate even rough estimates of costs. Next, urologists can investigate the financial context of their patients by initiating a discussion about the patients’ living and working situations. This discussion should also evaluate understanding of their insurance and how it works. During the discussion of risks and benefits for all treatment options, it is appropriate to disclose average cost of treatment. For patients at high risk for FT, the urologist should aim to reduce the cost of treatment while maintaining the quality of care as much as possible. Referral to a social worker or financial counselor may ease the burden of navigating possible resources as well.

In summary, patients being treated for kidney stones appear to be at high risk for FT and thus financial barriers to care. Urologists’ awareness of treatment costs and their patients’ financial situation will improve shared decisions and potentially improve health outcomes.

This study was presented at the AUA2022 in New Orleans and was awarded the Blue Ribbon for Best Poster. It was accepted for publication in Urology. For further details and examples of how to reduce FT in your kidney stone patients, see our final publication.¹¹

Acknowledgments

We thank our co-authors, Kevin Labagnara, Nathan Feiertag, Dr. Kavita Gupta, Dr. Jillian Donnelly, Dr. Kara Watts, Dr. Joseph Crivelli, and Dr. Dean Assimos. Explicit permission to write this AUANews article was granted by the editor of the journal Urology, where our study was accepted for publication.