PROJECT SUMMARY Value-based purchasing (VBP) reforms in the United States (e.g. pay-for-performance) seek to improve care efficiency by reducing wasteful health care practices, which may harm patients and account for ~30% of the $4.1 trillion spent annually on US healthcare. Surgical care, which comprises over 50% of Medicare spending, is a logical target for these reforms given it’s episodic and cost-intensive nature. However, surgical episodes are targeted by just one-third of VBP arrangements, none of which have achieved net cost savings. As such, there is a critical need to identify novel models of surgical care that provide insights/solutions to the failings of existing surgical VBP efforts. Symptomatic urinary stone disease—aka renal colic—is a common (1 in 10 US adults) and costly ($10 billion annually) surgical condition characterized by high levels of variation in perioperative outcomes and costs, making it a condition ideally suited to evaluate drivers of perioperative care variation. Current surgical VBP arrangement shortcomings may in part be due to misguided policies that reward strategies seeking to minimize post-operative care variation rather than streamlining the sequence of episode-specific clinical events preceding surgery. For example, there is growing literature demonstrating an association between improved pre-operative functional status and post-operative health outcomes. Similarly, addressing patients’ social needs ahead of surgery appears to improve 30-day post-operative outcomes. Consequently, developing and deploying value-based interventions in the pre-operative period that target clinical and non-clinical risk factors may be particularly effective at reducing variation in perioperative care, and by proxy surgical disparities. This proposal will employ an explanatory sequential mixed-methods design using a combination of claims data and patient/provider interviews to 1) identify social risk factors associated with variation in both pre- and post- operative expenditures/outcomes related to an episode of renal colic (Aim 1), 2) assess patient/provider perspectives on facilitators/barriers to timely and effective surgical care provided for an episode of renal colic (Aim 2), and 3) design and pilot a clinical decision support tool that personalizes follow-up for patients discharged from the emergency department with renal colic and who will subsequently undergo surgery (Aim 3). Ultimately, these efforts will 1) inform how social risk impacts surgical outcomes, 2) align surgical VBP efforts with the patient-provider experience, and 3) serve as the basis for a future R01-funded trial assessing the impact of a risk-adjusted clinical decision support tool on perioperative outcomes/expenditures following a renal colic diagnosis.