Figure. Percent of patients undergoing a trial of passage who (1) missed work, (2) had decreased productivity at work, and (3) required assistance with unpaid work after being discharged from the emergency department.

Introduction

Ureteral stones commonly affect patients of working ages. Medical care for kidney stones is estimated to cost the U.S. economy 3.1 million working days and $775 million each year.¹ Patients presenting to emergency departments (EDs) whose pain is well controlled are often offered a spontaneous trial of passage. A trial of passage decreases direct medical costs compared to immediate surgical treatment during an acute stone episode.² However, indirect costs of a trial of passage, such as time off from work and burden on caregivers, are more difficult to quantify. Given that stones are common in the employed population, these indirect costs can have important consequences. We sought to evaluate the indirect costs of a spontaneous trial of passage for ureteral stones using a validated survey focused on work absence and productivity.

Methods

We identified all patients presenting to Duke University Health System EDs with ureteral stones between February 7, 2022 and February 7, 2023. Patients were excluded if they were not currently employed, were non-English speaking, had bilateral ureteral stones, were admitted from the ED, or underwent procedural intervention (ureteral stent placement, ureteroscopy, or percutaneous nephrostomy tube placement) during the initial presentation to the ED. All patients were contacted by phone 4 weeks after their ED visit. We attempted to contact those who could not initially be reached at 5 weeks after their ED visit. Patients who consented to the study completed the Institute for Medical Technology Assessment Productivity Cost Questionnaire, a validated survey to assess health-related productivity losses. The survey covers 3 domains of productivity loss: absenteeism—missed work; presenteeism—decreased productivity at work; and unpaid work—household work, care of patient or children, and volunteer work.³ Patients were also asked when they passed their stone, defined as visualizing the stone or a distinct time point where symptoms resolved and did not return.

Results

Of the 407 patients who qualified, 112 (28%) were able to be reached and agreed to participate. Stones were an average of 4.9 mm in diameter (SD 3.3 mm), and 69% (79/112) were distal. Sixty-two percent (69/112) of participants reported passing their stone, with a median of 3 days until passage (IQR 1-7). Thirteen percent (14/112) of participants had surgery before survey completion. In total, 68% (76/112) of participants reported missing work (see Figure), with a median absence of 2 days (IQR 1-5). Participants who passed their stone missed a median of 50% (IQR 21%-100%) of working days until their stone passed. Forty-six percent (52/112) of participants endorsed decreased productivity when they returned to work, reporting their effectiveness at a median of 70% (IQR 50%-80%). Participants experienced a median of 3 days of decreased effectiveness (IQR 2-6). Finally, 55% (62/112) of participants reported requiring unpaid work, or help with tasks around the house. These patients required help for a median of 3 days (IQR 2-7) and a median of 4 hours a day (IQR 2-5).

Conclusions

Our study demonstrates that missed work and decreased productivity when returning to work are common among patients undergoing a trial of passage for ureteral stones. However, many patients only miss a couple days of work. While direct comparative data for ureteroscopy are lacking, our study suggests that immediate surgical treatment during an acute stone episode may not significantly decrease work absence over a trial of passage. Additionally, patients who return to work should expect to have a period of decreased productivity and may need to reduce their workload. This may particularly affect those who are self-employed. Finally, most patients require help around the house, which is especially relevant for parents who may need assistance to take care of children and for individuals who do not have in-household support. Patients who live alone may rely on social support systems for tasks such as visiting the grocery store during a trial of passage. This information will be important to appropriately counsel patients in EDs on options for management during an acute stone episode.