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Cone EB et al, 2016: Cost-effectiveness comparison of ureteral calculi treated with ureteroscopic laser lithotripsy versus shockwave lithotripsy.

Cone EB, Pareek G, Ursiny M, Eisner B.
Division of Urology, Duke University School of Medicine, Durham, NC, USA.
Division of Urology, Warren Alpert School of Medicine of Brown University, Providence, RI, USA.
Department of Urology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.

Abstract

PURPOSE: To evaluate the cost-effectiveness of shockwave lithotripsy (SWL) versus ureteroscopic lithotripsy (URS) for patients with ureteral stones less than 1.5 cm in diameter.
METHODS: Patient age, stone diameter, stone location, and stone-free status were recorded for patients treated with SWL or URS for ureteral stones under 1.5 cm over a 1 year period. Institutional charges were obtained from in-house billing. A decision analysis model was constructed to compare the cost-effectiveness of SWL and URS using our results and success rates for modeling. Three separate models were created to reflect differing practice patterns.
RESULTS: A total of 113 patients were included-51 underwent SWL and 62 underwent URS as primary treatment. Single procedure stone-free rates for SWL and URS were 47.1 and 88.7 %, respectively (p < 0.002). Decision analysis modeling demonstrated cost-effectiveness of SWL when SWL single procedure stone-free rates (SFR) were greater than or equal to 60-64 % or when URS single procedure SFRs were less than or equal to 57-76 %, depending on practice patterns.
CONCLUSIONS: This retrospective study revealed superior SFR for ureteral stones less than 1.5 cm treated with URS compared to SWL. Our decision analysis model demonstrated that when SFR for SWL is less than 60-64 % or is greater than 57-76 % for URS, SWL is not a cost-effective treatment option. Based on these findings, careful stratification and selection of stone patients may enable surgeons to increase the cost-effectiveness of SWL. 

World J Urol. 2016 May 5. [Epub ahead of print]

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Comments 1

Peter Alken on Tuesday, 11 October 2016 15:14

An interesting publication with a lot of information. Who is interested in the ever increasing pressure costs have on medical decision should read the short article referenced in the present paper (Dean LA, Adashi EY. Repealed and replaced: SGR gives way to value-based Medicare payment reform. Am J Med. 2015 Oct;128(10):1052-3. doi: 10.1016/j.amjmed.2015.04.027.).
I am always surprised that the cost of those helping the urologist to do the work - anaesthesiology - are higher than those of urology.
The limitations mentioned by the authors shed another light on the conclusions:
It is a ”patient/surgeon-driven treatment study”, “ a single urologist performed all of the URS procedures versus multiple urologists performing SWL.” At least one of them did not perform more than 11 cases per year, which I would call a very low volume experience, despite the fact that the urologists “overviewed” an experienced technician.
Finally and most important: “There were 12 patients in our series who received SWL and had residual fragments at follow-up, yet were asymptomatic and required no auxiliary procedures. If these 12 patients were added to the other 24 who were stone-free, the SFR of SWL would rise from 47 to 70 %.” and thus would be cost effective.

How effective a devoted urologist-technician can be is best demonstrated in the series of Tiselius (Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008 Feb;22(2):249-55): “One treatment session was sufficient in 73.1% of the proximal, 66.7% of the middle, and 84.1% of the distal ureteral stones.” ESWL would have been more cost effective than URS in all ureteral stones.

An interesting publication with a lot of information. Who is interested in the ever increasing pressure costs have on medical decision should read the short article referenced in the present paper (Dean LA, Adashi EY. Repealed and replaced: SGR gives way to value-based Medicare payment reform. Am J Med. 2015 Oct;128(10):1052-3. doi: 10.1016/j.amjmed.2015.04.027.). I am always surprised that the cost of those helping the urologist to do the work - anaesthesiology - are higher than those of urology. The limitations mentioned by the authors shed another light on the conclusions: It is a ”patient/surgeon-driven treatment study”, “ a single urologist performed all of the URS procedures versus multiple urologists performing SWL.” At least one of them did not perform more than 11 cases per year, which I would call a very low volume experience, despite the fact that the urologists “overviewed” an experienced technician. Finally and most important: “There were 12 patients in our series who received SWL and had residual fragments at follow-up, yet were asymptomatic and required no auxiliary procedures. If these 12 patients were added to the other 24 who were stone-free, the SFR of SWL would rise from 47 to 70 %.” and thus would be cost effective. How effective a devoted urologist-technician can be is best demonstrated in the series of Tiselius (Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008 Feb;22(2):249-55): “One treatment session was sufficient in 73.1% of the proximal, 66.7% of the middle, and 84.1% of the distal ureteral stones.” ESWL would have been more cost effective than URS in all ureteral stones.
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