OBJECTIVE: To assess barriers to guideline-concordant metabolic kidney stone evaluations in a diverse, low-resource, urban population. American Urological Association (AUA) Guidelines recommend that recurrent, high-risk, and interested first-time kidney stone formers undergo metabolic evaluation. Patients with low socioeconomic status are less likely to complete 24-hour urine studies. METHODS: We retrospectively identified recurrent or high-risk kidney stone patients who required stone surgery between 2016-2022 and completed a validated social needs screening tool. Clinical notes, orders, pharmacy and laboratory records were reviewed the year before and after surgery. Guideline compliance was assessed with respect to each of: recommendation for and completion of 24-hour urine, results counseling, dietary/pharmacologic compliance, and repeat 24-hour urine recommendation and completion. RESULTS: Two hundred eighty patients met inclusion criteria, of whom 25.4% were Black and 51.8% were Hispanic/Latino. Median age was 57 years (IQR 48-65). Of those eligible, 123 (43.9%) were recommended to undergo metabolic evaluation, 70 (25%) completed the collection, 45 (16.1%) had dietary/pharmacologic counseling, 25 (8.9%) were recommended to repeat 24-hour urine, 13 (4.6%) completed this repeat collection, and 10 (3.6%) had a visit to discuss repeat results. On univariate analysis, Asian race, hyperparathyroidism, female sex, increased age, and private insurance were associated with increased likelihood of guideline-concordant care (p<
0.05). Barriers identified by the social needs screener were not associated with likelihood of metabolic evaluation. CONCLUSION: A very small subset (3.6%) of patients in this high-risk population receive best-practice care based on AUA Guidelines. Prospective study is necessary to develop interventions to address barriers to care.