Scales CD Jr et al, 2014: Comparative Effectiveness of Shock Wave Lithotripsy and Ureteroscopy for Treating Patients With Kidney Stones.

Monday, 26 May 2014

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Scales CD Jr, Lai JC, Dick AW, Hanley JM, van Meijgaard J, Setodji CM, Saigal CS; for the Urologic Diseases in America Project
Robert Wood Johnson Foundation Clinical Scholars Program, University of California, Los Angeles, Los Angeles2Veterans Affairs Greater Los Angeles Healthcare System, US Department of Veterans Affairs, Los Angeles, California3Department of Urology, David Ge.
RAND Corporation, Santa Monica, California.
RAND Corporation, Boston, Massachusetts.
Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles.
RAND Corporation, Pittsburgh, Pennsylvania.6Department of Urology, David Geffen School of Medicine, University of California, Los Angeles
RAND Corporation, Santa Monica, California.

Abstract

IMPORTANCE Shock wave lithotripsy (SWL) and ureteroscopy (URS) account for more than 90% of procedural interventions for kidney stones, which affect 1 in 11 persons in the United States. Efficacy data for SWL are more than 20 years old. Advances in URS, along with emerging evidence of reduced efficacy of modern lithotripters, have created uncertainty regarding the comparative effectiveness of these 2 treatment
options. OBJECTIVE To compare the effectiveness of SWL and URS to fragment or remove urinary stones in a large private payer cohort. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of privately insured beneficiaries who had an emergency department visit for a kidney stone and subsequently underwent SWL or URS. Using an instrumental variable approach to control for observed and unobserved differences between the 2 groups, we created a bivariate probit model to estimate the probability of repeat intervention following an initial procedure. MAIN OUTCOMES AND MEASURES A second procedure (SWL or URS) within 120 days of an initial intervention to fragment or remove or a kidney stone. RESULTS Following an acute care visit for a kidney stone, 21 937 patients (45.8%) underwent SWL and 25 914 patients (54.2%) underwent URS to fragment or remove the stone. After the initial URS, 4852 patients (18.7%) underwent an additional fragmentation or removal procedure compared with 5186 patients (23.6%) after the initial SWL (P < .001). After adjusting for observed and unobserved variables, the estimated probabilities of repeat intervention were 11.0% (95% CI, 10.9-11.1) following SWL and 0.3% (95% CI, 0.325-0.329) following URS. CONCLUSIONS AND RELEVANCE Among privately insured beneficiaries requiring procedural intervention to
remove a symptomatic stone, repeat intervention is more likely following SWL. For the marginal patient (as opposed to the average patient), the probability of repeat intervention is substantially higher.

JAMA Surg. 2014 May 16. doi: 10.1001/jamasurg.2014.336. [Epub ahead of print]

Comments 1

Peter Alken on Tuesday, 26 August 2014 12:08

These are important but messages. Get the original publication to enable you to precisely understand what a marginal patient is and how the statistics allowed the conclusions the authors have made! They only have limited data but their “analytic approach should control for observable factors (eg, patient age, sex, comorbid conditions, and census region) and factors that we could not observe in our analysis (eg, patient obesity, race/ethnicity, size and location of the targeted stone, ureteral stent placement, bilateral stones,…”
The authors state that reimbursement for ESWL is higher than for URS and quote a 10 year old paper: Lotan Y, Cadeddu JA, Roehrborn CG, Stage KH. The value of your time: evaluation of effects of changes in Medicare reimbursement rates on the practice of urology. J Urol. 2004;172(5, pt 1):1958-1962. Are there no new data?
They go on:”Even when surgeon fees are limited by a global payment period, substantial ancillary costs (ie, anesthesia and facility payments) still pertain. This misaligned economic structure would seem to exacerbate the costs of treating patients with kidney stones.”
Is the difference between URS and SWL a strong cost driving force? For those interested in costs I add the abstract of a publication I have just read. I do not think that the stone business in the US works different than the prostate cancer business.
Pate SC, Uhlman MA, Rosenthal JA, Cram P, Erickson BA.: Variations in the open market costs for prostate cancer surgery: a survey of US hospitals. Urology. 2014 Mar;83(3):626-30.
OBJECTIVE To examine variation in the open market cost of a radical prostatectomy (RP) procedure in the US hospitals for an uninsured patient, as many proposals for health care reform highlight the importance of individuals actively participating in selecting care. However, reports suggest that obtaining procedure prices remains challenging and highly variable.

MATERIALS AND METHODS
We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3 + 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited.
RESULTS Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%).
CONCLUSION There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure.

MATERIALS AND METHODS
We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3 + 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited.
RESULTS Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%).
CONCLUSION There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure.

These are important but messages. Get the original publication to enable you to precisely understand what a marginal patient is and how the statistics allowed the conclusions the authors have made! They only have limited data but their “analytic approach should control for observable factors (eg, patient age, sex, comorbid conditions, and census region) and factors that we could not observe in our analysis (eg, patient obesity, race/ethnicity, size and location of the targeted stone, ureteral stent placement, bilateral stones,…” The authors state that reimbursement for ESWL is higher than for URS and quote a 10 year old paper: Lotan Y, Cadeddu JA, Roehrborn CG, Stage KH. The value of your time: evaluation of effects of changes in Medicare reimbursement rates on the practice of urology. J Urol. 2004;172(5, pt 1):1958-1962. Are there no new data? They go on:”Even when surgeon fees are limited by a global payment period, substantial ancillary costs (ie, anesthesia and facility payments) still pertain. This misaligned economic structure would seem to exacerbate the costs of treating patients with kidney stones.” Is the difference between URS and SWL a strong cost driving force? For those interested in costs I add the abstract of a publication I have just read. I do not think that the stone business in the US works different than the prostate cancer business. Pate SC, Uhlman MA, Rosenthal JA, Cram P, Erickson BA.: Variations in the open market costs for prostate cancer surgery: a survey of US hospitals. Urology. 2014 Mar;83(3):626-30. OBJECTIVE To examine variation in the open market cost of a radical prostatectomy (RP) procedure in the US hospitals for an uninsured patient, as many proposals for health care reform highlight the importance of individuals actively participating in selecting care. However, reports suggest that obtaining procedure prices remains challenging and highly variable. MATERIALS AND METHODS We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3 + 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited. RESULTS Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%). CONCLUSION There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure.

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