The impact and associated costs of new urolithiasis treatment methods, including extracorporeal shock wave lithotripsy (ESWL), were examined in a series of 1781 patients treated between March 1, 1983, and February 28, 1985. An accounting cost methodology was used to derive estimates of direct and indirect hospital costs, as distinct from charges billed to the patient. The average hospital cost per case for ESWL was lower by 27% and significantly different (P less than 0.05) than the average cost for surgically treated patients. The difference in cost between ESWL and percutaneous lithotripsy was not statistically significant. The invasiveness of the treatments studied was directly related to length of hospital stay and cost. Projecting our findings to the entire urolithiasis population of the United States, we estimate that the usage of ESWL, if applied only to patients who would otherwise receive surgery, could result in an annual hospital cost savings of $124,436,520. We conclude that although the institutional cost of acquiring ESWL is high, its application results in a significant cost savings for patients previously requiring surgery, it is no more expensive than percutaneous stone removal, and it has the advantage of being less invasive than any other treatment method. The potential national savings in health care costs may not be realized if the indications for this less invasive technology are defined more broadly than are those for open surgical procedures, as seems likely, and unless limits are placed on the number of lithotripters made available nationally. Indications for ESWL need to be clearly defined based on careful studies of risks, potential benefits, and costs.
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"Preoperative costs were excluded from the estimate because of variability in patient status prior to surgery (some patients had their preoperative workup as outpatients or during a previous hospital stay and were at home prior to surgery); variability in preoperative cost-finding methodology (some patients received part of their preoperative care at other local hospitals); and the mix of inpatient and outpatient services provided preoperatively, which would have necessitated an arbitrary definition concerning the actual onset of illness. To estimate the average cost for each patient, we used the traditional accounting method of multiplying each patient's recorded charge by an adjusted ratio of department cost to charge (Berman and Weeks 1982; Neumann, Suver, and Zeilman 1984; Lingeman et al. 1986; Woods, Saywell, and Benson 1988). The costs of labor, supplies, and other direct expenses for the hospital as a whole, for each fiscal year, were divided among 29 major cost-center groupings. "
[Show abstract][Hide abstract] ABSTRACT: The effect of learning on hospital outcomes such as mortality or adverse events (the so-called "practice makes perfect" hypothesis) has been studied by numerous investigators. The effect of learning on hospital cost, however, has received much less attention. This article reports the results of a multiple regression model demonstrating a nonlinear, decreasing trend in operative and postoperative hospital costs over time in a consecutive series of 71 heart transplant patients, all treated in the same institution. The cost trend is shown to persist even after controlling for various preoperative demographic and clinical risk factors and the specific experience of individual surgeons. Using a reference case, the model predicts a cost of $81,297 for the first heart transplant procedure performed at the hospital. If this same patient had been the tenth case rather than the first, with the hospital having benefited from the experience gained in nine previous cases, the model predicts the cost would now be only $48,431, or approximately 60 percent of the cost of the first case. Had this patient been the twenty-fifth case, the predicted cost would be $35,352 (43 percent of the original cost), and had this been the fiftieth case, the cost would be $25,458 (31 percent of the original cost). The longitudinal study design used in this analysis greatly reduces the likelihood that the observed cost reduction is due to economies of scale rather than learning. The results have implications for a policy of regionalization as a tactic for containing hospital cost. Whereas others have pointed to a volume-cost relationship as an argument for the regionalization of expensive and complex hospital procedures, the present data isolate a learning-cost relationship as a separate argument for regionalization.
Health Services Research 07/1992; 27(2):219-38. · 2.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence from animal, clinical and epidemiological studies suggests that high blood pressure is associated with abnormalities of calcium metabolism, leading to increased calcium loss, secondary activation of the parathyroid gland, increased movement of calcium from bone and increased risk of urinary tract stones. Some of these abnormalities are detectable in children and young people and continue throughout adult life. The cluster of abnormalities may be due either to a primary renal tubular defect ('renal calcium leak' hypothesis) or to the effect of central volume expansion seen in hypertension ('central blood volume' hypothesis). A high salt intake is known to aggravate these abnormalities and their consequences. If substantial calcium loss related to high blood pressure is sustained over many decades, increased excretion of calcium in the urine may result in an increased risk of urinary tract stones, and the increased movement of calcium from bone may result in higher rates of bone mineral loss, thereby increasing the risk of osteoporosis. The present review summarises the evidence, suggests a unifying hypothesis and discusses clinical and public health implications.
Journal of nephrology 05/2000; 13(3):169-77. · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Extracorporeal shock wave lithotripsy (ESWL) for upper urinary stones has been in use in the United States since 1984. It was accepted immediately by hospitals and physicians, and its diffusion has been and continues to be rapid. Government payment and planning policies do not seem to have slowed this diffusion, although they have had some effect on the ownership of lithotripters and the manner in which ESWL is provided. An unintended but foreseeable result of ESWL's popularity with hospitals, physicians, and patients is that ESWL is not only rapidly replacing traditional surgery but is being used on many patients who would not have had surgery. It is likely that many more upper urinary stones are being treated aggressively now than before ESWL was introduced.
International Journal of Technology Assessment in Health Care 02/1987; 3(3):397-404. DOI:10.1017/S0266462300001215 · 1.31 Impact Factor