Category: Epidemiology, Health Policy, Socioeconomics & Outcomes
Introduction & Objective :
To assess the cost-effectiveness of ureteroscopic laser fragmentation techniques for the treatment of renal stones using a decision analysis model.
Outcomes data from a prospective trial of “dusting” versus “basketing” trial performed by the EDGE consortium were utilized. A decision analysis model was constructed to compare the cost-effectiveness of two methods of ureteroscopic lithotripsy: dusting stones completely versus fragmentation with basket removal. For basketing procedure costs, a basket, ureteral stent, and ureteral access sheath were used for each procedure; for dusting costs, a ureteral stent was used in 16% of procedures and there was no basket use. Expected value calculations with Markov modeling and sensitivity analysis was used to determine the optimal method based on overall cost-effectiveness inclusive of equipment, time, secondary costs from complications, emergency department visits, hospital readmission, and re-interventions. Cost of operating room disposables were obtained from manufacturers. Costs of emergency department visits, readmissions, immediate and delayed re-interventions were calculated based on published figures from the literature and carried out to 3 years post-operatively.
One hundred fifty nine patients were included in the study – 84 ureteroscopy with dusting, 75 ureteroscopy with basketing. Decision analysis modeling demonstrated that on a per-procedure basis, dusting and basketing procedures had average costs of $6,324 and $7,667, respectively. The difference in cost for the 2 procedures was largely driven by differences in operative time (mean operative time for basketing = 67 min, mean operative time for dusting = 37 min). This represents an estimated savings of $1343 per procedure when using the dusting technique.
Our decision analysis model demonstrates superior cost-effectiveness for ureteroscopy with dusting compared to ureteroscopy with basketing for intrarenal stones. The cost-savings are primarily due to a substantially shorter operative time. Based on these findings, careful stratification and selection of stone patients may enable surgeons to improve cost-effectiveness of ureteroscopic lithotripsy for intrarenal stones.
Michal Ursiny– Boston, Massachusetts
Alan Yaghoubian– Urologic Surgery Resident, Massachusetts General Hospital, Boston, Massachusetts
Mitchell Humphries– Phoenix, Arizona
Benjamin Chew– Vancouver, British Columbia, Canada
Manoj Monga– Head of the Endourology Unit, Cleveland Clinic Foundation, Cleveland, Ohio
Amy Krambeck– Professor, Indiana University School of Medicine, Indianapolis, Indiana
Roger Sur– Professor of Urology, UC San Diego Department of Urology, San Diego, California
Nicole Miller– Associate Professor of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
Yui Hui Chang– Rochester, Minnesota
Bodo Knudsen– Director, Comprehensive Kidney Stone Program, Ohio State University, Columbus, Ohio
Brian Matlaga– Baltimore, Maryland
Ojas Shah– Professor of Urology, New York Presbyterian-Columbia University Medical Center, New York, New York
Vernon Pais– Associate Professor, Associate Program Director, Dartmouth, Lebanon, New Hampshire
Brian Eisner– Head Endourology Unit, Mass General Hospital, Needham, Massachusetts
Urologic Surgery Resident
Massachusetts General Hospital
Professor of Urology
UC San Diego Department of Urology
San Diego, California
Associate Professor of Urology
Vanderbilt University Medical Center
Director, Comprehensive Kidney Stone Program
Ohio State University
Professor of Urology
New York Presbyterian-Columbia University Medical Center
New York, New York
Dr. Ojas Shah is the George F. Cahill Professor of Urology at Columbia University College of Physicians and Surgeons. He also serves as the Director of the Division of Endourology and Stone Disease at Columbia University Medical Center. His clinical and research interests include surgical and metabolic treatments of kidney stone disease, minimally invasive urologic surgery, upper urinary tract urothelial carcinoma (transitional cell carcinoma), ureteral strictures, ureteropelvic junction (UPJ) obstruction, and ureteral/renal reconstructive surgery. He serves as the principal investigator in many clinical research trials regarding the surgical or medical management of stone disease.
He is a graduate of the Honors Program in Medical Education at Northwestern University School of Medicine. He completed his general surgical and urologic training at New York University Medical Center. He spent an additional year at Wake Forest University Health Sciences Center as a fellow in endourology, laparoscopy and metabolic stone disease.
Dr. Shah is a nationally and internationally recognized expert in the medical and surgical management of patients with urinary stone disease. He recently served as a member of the American Urological Association’s Surgical Management of Stones Guidelines Committee. He was also recently appointed to the American Board of Urology’s Examination Committee. He is an active member of the Endourological Society, EDGE (Endourology Disease Group for Excellence) Research Consortium, and ROCK (Research on Calculous Kinetics) Society.
Dr. Shah is an Assistant Editor for the Journal of Urology, the most highly cited and amongst the most respected international journals in the field. He is also co-editor of the 5th Edition of Taneja’s Complications of Urologic Surgery which was released in 2018.
Associate Professor, Associate Program Director
Lebanon, New Hampshire
Vernon Pais is an endourologist with clinical and research focuses on urolithiasis. He is an associate professor at the Geisel School of Medicine at Dartmouth and serves as the director of urologic research and associate program director for the urology residency at Dartmouth.