Determining Variable Costs in the Acute Urolithiasis Cycle of Care Through Time-Driven Activity-Based Costing.

OBJECTIVE: To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing. METHODS: We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway. RESULTS: Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS. CONCLUSION: We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.

Initial single centre experiences of a radiographer advanced practitioner led nephrostomy exchange programme.

INTRODUCTION: To evaluate the technical success, radiation dose, complications and costs from the introduction of a radiographer-led nephrostomy exchange service. METHODS: Post-graduate qualified interventional radiographers with several years' experience in performing other interventional procedures began performing nephrostomy exchanges. Training was provided by an interventional radiologist. Each radiographer performed ten procedures under direct supervision followed by independent practice with remote supervision. Each radiographer was then responsible for the radiological report, discharge, re-referral for further exchange and, where indicated, sending urine samples for culture and sensitivity. Data extraction included the time interval between exchanges, radiation dose/screening time and complications. RESULTS: Thirty-eight long-term nephrostomy patients had their histories interrogated back to the time of the initial insertion. The mean (range) age at nephrostomy insertion was 67 (35-93) years and 65% were male. Indications for nephrostomy were prostatic or gynaecological malignancy, ureteric injury, bulky lymphoma and post-transplant ureteric stricture. A total of 170 nephrostomy exchanges were performed with no statistically significant differences in the radiation dose, fluoroscopy time nor complication rates between consultants and radiographers. There was, however, a statistically significant reduction in the time interval between nephrostomy exchanges for the radiographer group (P = 0.022). CONCLUSION: Interventional radiographers can provide a safe, technically successful nephrostomy exchange program with radiation doses equivalent to radiologists. This is a cost-effective solution to the capacity issues faced in many departments, whilst providing career progression, job satisfaction and possibly improved care. IMPLICATIONS FOR PRACTICE: Radiographer-led interventional services should be considered by other institutions as a means of providing effective nephrostomy exchanges.

Initial prospective study of ambulatory mPCNL on upper urinary tract calculi.

OBJECTIVE: To explore the feasibility and safety of ambulatory mPCNL (mini percutaneous nephrolithotomy) on upper urinary tract calculi. METHODS: Clinical data of 18 patients received ambulatory mPCNL during Aug. 2017 to Jan. 2018 and 23 patients treated with routine inpatient mPCNL of the corresponding period were collected. All the patients included received 16Fr channel PCNL under the guidance of Doppler ultrasound. A 6Fr double J stent was placed in the ureter for internal drainage, and either an indwelling 14Fr open nephrostomy tube was placed or the puncture channel was filled with absorbable hemostatic materials alone, depends on the bleeding condition of the puncture channel and the intraoperative conditions. Preoperative parameters and surgery time, complications, total hospitalization costs and hospital stay time between the two groups were compared. RESULTS: Preoperative parameters regarding age (P=0.057), sex distribution (P=0.380), ASA score (P=0.388), Calculi CT value (P=0.697), and the S.T.O.N.E. score (P=0.122) were comparable between the two groups. Maximum diameter of calculi (cm) of the conventional hospitalization group, however, was larger than the ambulatory surgery group (P=0.041). There were no significant differences in the mean surgery time (P=0.146), postoperative hemoglobin drop (P=0.865), Calculi-free rate on the next day after surgery (P=0.083) and postoperative fever rate (P=0.200) between the two groups. With regard to tubeless rate (P<0.001), total hospitalization costs (P=0.003) and hospital stay time (P<0.001), there were significant advantage favored ambulatory mPCNL. CONCLUSIONS: For patients with simple upper urinary tract calculi and relatively good performance status, ambulatory mPCNL is feasible as it's equally safe and efficient as compared with routine inpatient mPCNL. Moreover, ambulatory mPCNL decreases hospitalization costs and hospital stay time. Nevertheless, perioperative management should be carefully conducted, and well-designed studies are warranted.

Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.

Changing Trends in the Treatment of Nephrolithiasis in the Real World.

INTRODUCTION: Changes in the surgical treatment of nephrolithiasis, owing to recent technical advances and innovations, have made treatments more effective and less invasive. In this retrospective, observational cohort study, we identified the changing trends in the treatment of nephrolithiasis. MATERIALS AND METHODS: We included patients with newly diagnosed nephrolithiasis who received any treatment in the United States, including extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and open surgery, from January 2007 to December 2014. Demographic factors, such as age, sex, region, surgical treatment type, and cost data, were analyzed. RESULTS: The median age of patients at treatment was 52 years, and the ratio of men and women was similar. There were definite changes in the trends of all treatment modalities (p < 0.01). Both the number and percentage tended to increase for RIRS, whereas for SWL, the number increased, but the percentage showed a steady decrease. In PCNL, both number and percentage increased to a minor degree. The overall cost of nephrolithiasis treatments during the study period nearly doubled (from $30,998,726 to $57,310,956). The number of treatments and average cost per treatment increased annually for each treatment modality. RIRS was the least expensive; the other procedures in decreasing order of their mean costs were as follows: SWL, PCNL, and open surgery. CONCLUSIONS: There was a gradual but constant change in treatment trends of nephrolithiasis, with an increasing trend for RIRS and a decreasing trend for SWL. Although PCNL has relatively invasive characteristics, it is still in steady demand.

Propensity Score-Matched Analysis Comparing Retrograde Intrarenal Surgery with Percutaneous Nephrolithotomy for Large Stones in Patients with a Solitary Kidney.

PURPOSE: To evaluate the clinical efficacy, safety, and cost of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in the treatment for large renal stones in patients with a solitary kidney. PATIENTS AND METHODS: In this study, 117 patients with a solitary kidney who had undergone PCNL or RIRS for renal stones larger than 2 cm between January 2010 and December 2016 were retrospectively evaluated. The patients' demographic data, clinical characteristics, and perioperative outcomes were collected through a review of their medical records. Forty-three patients treated with PCNL were compared to 43 patients treated with RIRS by propensity score-matched analysis. The stone-free rate, retreatment rate, complication rate, and efficacy quotient (EQ) were assessed in both groups. RESULTS: Initial stone-free rate of the PCNL group after a single procedure was significantly higher compared with the RIRS group (74.42% vs 34.88%, p < 0.001), whereas there was no significant difference in the final stone-free rate after repeated procedures (90.70% vs 88.37%, p = 0.713). PCNL had a significantly lower retreatment rate than RIRS (16.28% vs 63.79%, p < 0.001), and the PCNL group underwent fewer procedures than the RIRS group (p < 0.001). Thus, PCNL group had a higher EQ (78.00% vs 53.52%). Although cost per procedure of PCNL was significantly higher compared with RIRS (p < 0.001), the total costs were comparable. Complication rate of RIRS was lower compared with PCNL with no statistical significance (p = 0.193), and acute kidney injury rates were also comparable (PCNL vs RIRS: 13.95% vs 6.98%, p = 0.533). CONCLUSIONS: With fewer repeated surgical procedures, higher EQ, and comparable total costs, PCNL is recommended as the first choice for the treatment of large renal calculi in patients with a solitary kidney. As for specific indications such as anticoagulant drugs, RIRS is a safer choice with fewer complications and acceptable final stone-free rate.

Long-Term Percutaneous Nephrostomy Management of Malignant Urinary Obstruction: Estimation of Optimal Exchange Frequency and Estimation of the Financial Impact of Patient Compliance.

PURPOSE: To estimate the least costly routine exchange frequency for percutaneous nephrostomies (PCNs) placed for malignant urinary obstruction, as measured by annual hospital charges, and to estimate the financial impact of patient compliance. MATERIALS AND METHODS: Patients with PCNs placed for malignant urinary obstruction were studied from 2011 to 2013. Exchanges were classified as routine or due to 1 of 3 complication types: mechanical (tube dislodgment), obstruction, or infection. Representative cases were identified, and median representative charges were used as inputs for the model. Accelerated failure time and Markov chain Monte Carlo models were used to estimate distribution of exchange types and annual hospital charges under different routine exchange frequency and compliance scenarios. RESULTS: Long-term PCN management was required in 57 patients, with 87 total exchange encounters. Median representative hospital charges for pyelonephritis and obstruction were 11.8 and 9.3 times greater, respectively, than a routine exchange. The projected proportion of routine exchanges increased and the projected proportion of infection-related exchanges decreased when moving from a 90-day exchange with 50% compliance to a 60-day exchange with 75% compliance, and this was associated with a projected reduction in annual charges. Projected cost reductions resulting from increased compliance were generally greater than reductions resulting from changes in exchange frequency. CONCLUSIONS: This simulation model suggests that the optimal routine exchange interval for PCN exchange in patients with malignant urinary obstruction is approximately 60 days and that the degree of reduction in charges likely depends more on patient compliance than exact exchange interval.

The economics of stone disease.

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

Management of Ureteroenteric Stricture: Predictive Modeling to Compare Cost.

BACKGROUND: Ureteroenteric stricture occurs in as many as 15% of patients after cystectomy with urinary diversion. First-line management is typically percutaneous nephrostomy (PCN) drainage. We sought to compare costs of a urologic approach of retrograde stenting through flexible endoscopy and an interventional radiology (IR) approach of PCN and antegrade stenting using predictive modeling. The purpose of this study is to inform best practice for initial stricture management based on existing literature regardless of the benign stricture rate following radical cystectomy. Our hypothesis is that initial management by a urologist may be superior to IR management. MATERIALS AND METHODS: The primary outcome measure was cost based on 2015 Medicare reimbursement rates by Current Procedural Technology codes with a secondary endpoint of number of procedures a patient undergoes. We developed a simulation model to replicate the experience of stricture patients. The model describes three arms: urologic management with retrograde stent placement, sequential management by IR, and single-stage IR management. We simulated 10,000 patients through the model with the percentage of patients pursuing each treatment arm and success rates chosen based on a review of relevant literature and clinic experience. RESULTS: The average cost of urologic management is $703.23 compared with the average cost of $838.09 for patients using radiologic management. Within radiologic management, the average cost is $862.98 for sequential IR management and $639.44 for single-stage IR management. Patients would undergo an average of 2.53 procedures for those patients initially sent to urology and 2.91 procedures for those sent to radiology. For sequential IR, the average is 3.02 procedures, and for single-stage IR, it is 2.03 procedures. From a cost perspective, the success rate at which retrograde stent placement becomes worth attempting is 35%. If radiologic management is attempted initially, sequential IR management represents a cost-conscious option that limits the total number of procedures. CONCLUSION: The disparity in cost between IR and urologic management of ureteral stricture provides a rationale for rural practices that may not have immediate access to IR to manage the patient.

Comparison of efficacy of laser lithotripter with ultrasonic lithotripter in mini percutaneous nephrolithotomy.

OBJECTIVE: The aim of the study was to compare the efficacy of the laser lithotripter with the ultrasonic lithotripter in mini percutaneous nephrolithotomy (miniperc). MATERIAL AND METHODS: From June 2013 to January 2014; medical records of 77 consecutive patients who underwent miniperc operation were retrospectively evaluated. Ultrasonic lithotripter was used in 22 patients (Group 1), while laser was used in 55 patients. In the laser group, 22 patients were randomly selected who had same characteristics compared to group 1 (Group 2). Success rate, total operative time, complications according to modified Clavien classification, fluoroscopy time, haemoglobin drop, hospital stays and cost analysis were assessed. Success rates were evaluated on the second postoperative day and after the first month. RESULTS: Total operative time (p = 0.635) and fluoroscopy time (p = 0.248) were not significantly different between the two groups. In the laser group, the success rate (81.8%) was notably more than in the ultrasonic lithotripter group (68.2%) but there was no statistically significance (p = 0.296). Ten reusable ultrasonic probe were used for 22 patients, due to thinness and sensitiveness of the probe. Conversely, one single laser fiber (550 micron) was used for 22 patients. When the cost analysis of lithotripsy was considered, the cost per case was 190 dollar in group 1 and 124 dollar in group 2. (p = 0.154) Complication rate, hospital stay and haemoglobin drop were similar in both groups. CONCLUSION: Laser lithotripsy seems to be more cost effective than ultrasonic lithotripsy for miniperc but larger number of patients are required to confirm this estimation.

Comparison of flexible ureteroscopy and micropercutaneous nephrolithotomy in terms of cost-effectiveness: analysis of 111 procedures.

The objective of this study was to audit the costs of retrograde intrarenal surgery (RIRS) and micropercutaneous nephrolithotomy (microperc) and compare them in terms of cost-effectiveness. We performed a retrospective analysis of 63 patients who underwent microperc and 48 patients who underwent RIRS. The cases, performed between first use and first repair, were used for this initial study. The costs associated with performing RIRS and microperc, including the costs of devices, disposables, hospitalization, and additional required treatments, were audited. The main perioperative and postoperative parameters were collected, including operation time, JJ stent requirements, used disposables, stone-free rates, and complications. Statistical analyses of the means of continuous variables were performed using Student's t test and the Mann-Whitney U test. Categorical variables were analyzed using Chi-squared tests. The mean cost of RIRS was $917.13 ± 73.62 and the mean cost of microperc was $831.58 ± 79.51; this difference was statistically significant (p < 0.001). The mean operation time of the RIRS group was significantly shorter than the microperc group (55.62 ± 19.62 min and 98.50 ± 29.64 min, respectively, p < 0.001). The assessment of required additional treatment showed that it was significantly higher in the RIRS group than the microperc group (p = 0.02). The stone-free rate for RIRS was 66.6 and 80.9 % for microperc; this difference was not statistically significant (p = 0.12). In our series, the use of microperc is less expensive than RIRS due to additional required treatments and ancillary equipment in RIRS. RIRS is more effective than microperc in terms of operation time and more effective use of operation rooms.

The optimal minimally invasive percutaneous nephrolithotomy strategy for the treatment of staghorn stones in a solitary kidney.

The objective of the study was to analyze the treatment outcomes for staghorn stones in patients with solitary kidney using either the single-tract or the multi-tract minimally invasive percutaneous nephrolithotomy (MPCNL). We retrospectively reviewed 105 patients who underwent MPCNL for staghorn calculi in solitary kidney from 2012 to 2014. The patients who underwent the single-tract approach (71 patients) were assigned to Group 1. The 34 patients who underwent the multi-tract approach (34 patients) were assigned to Group 2. We recorded and compared the patient's demographics, intraoperative parameters, and post-operative outcomes. We also analyzed any complications as a result of the particular procedure, as well as any resulting stone-free rates (SFRs). The mean number of access tracts was 2.38 ± 0.70 (range 2-4) for Group 2. The mean operative time was longer for Group 2, p = 0.01. The initial SFR was 52.1% for Group 1 and 47.1% for Group 2 after the one-session procedure, p = 0.63.The final SFR improved to 83.1 and 79.4% for both groups following auxiliary treatment, p = 0.65. The mean hemoglobin drop was higher in Group 2 as compared to Group 1, p < 0.01. There was no significant difference in the change of mean serum creatinine in either group. There were fewer overall complications in Group 1 than in Group 2 (23.9 vs. 44.1%). Almost half of the patients who underwent multi-tract MPCNL required an additional procedure to achieve satisfactory stone clearance. The results showed that single-tract MPCNL might be a better treatment option for staghorn stones in a solitary kidney with the same therapeutic outcome, but with less complications.

Simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy for ureteral calculi combined with renal staghorn calculi.

OBJECTIVES: To investigate the efficacy, safety, and cost-effectiveness of simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy for ureteral calculi combined with contralateral renal staghorn calculi. METHODS: The present prospective controlled trial had been registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR-ONRC-13004146). Patients with ureteral calculi and contralateral renal staghorn calculi were enrolled into the staged (ureteroscopic lithotripsy first followed by a staged percutaneous nephrolithotomy) or the simultaneous (synchronous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy) treatment group according to the odd or even number of the last hospitalization number. All patients signed informed consent. The primary outcomes were the stone-free rate and total hospital costs. The second outcomes were the operative and anesthesia times, the complication rate, and hospital stay. RESULTS: A total of 51 patients were enrolled into the staged group and 52 patients were enrolled into the simultaneous group. There were no statistically significant differences in patients' characteristics. The overall stone-free rate was 94.1% in the staged group and 92.3% in the simultaneous group. No severe complication was observed. The total hospital stay of the staged group was longer, and it was negatively correlated to different procedures. The cost in the staged group was higher, and it was correlated with total operation time and postoperative hospital stay. CONCLUSIONS: Simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy represent safe and effective procedures, and they can be considered as a first-line treatment for selected patients presenting with ureteral calculi combined with contralateral renal calculi.

Totally tubeless versus standard percutaneous nephrolithotomy for renal stones: analysis of clinical outcomes and cost.

PURPOSE: To evaluate the safety and cost-effectiveness of a totally tubeless percutaneous nephrolithotomy (PCNL) by comparing the clinical outcomes and cost analysis between standard PCNL and totally tubeless PCNL for renal stones. PATIENTS AND METHODS: From June 2012 to September 2013, a total of 121 patients with renal stones who underwent totally tubeless or standard PCNL by two experienced surgeons were retrospectively evaluated by group. According to the surgeon's preference for the nephrostomy tube and/or ureteral stent, the present study was designed to be divided into Group 1 and Group 2. Group 1 was performed by one surgeon (H.J. Cho) who preferred a totally tubeless PCNL and Group 2 was performed by the other surgeon (S.H. Hong) who preferred a standard PCNL. We excluded bilateral renal stones, multiple approach, whole staghorn calculi, and previous renal surgery. Patient and stone characteristics, intraoperative and postoperative parameters, and cost analysis were compared between the two groups. RESULTS: There were no significant differences in the patient demographics between groups. Mean stone burden was 501.5±361.1 mm(2) in Group 1 v 535.2±353.1 mm(2) in Group 2 (P=0.651). Length of hospital stay (1.72±0.58 v 4.10±1.88 days, P<0.001), postoperative pain scores using a visual analog scale (day 0: P<0.001, day 1: P=0.002), and analgesia requirements (33.2±21.3 v 45.2±19.5 mg, P=0.005) for Group 1 v Group 2 showed significant differences. The stone-free rate was 86.4% v 89.8% in Group 1 and Group 2, respectively (P=0.609). There were no significant differences in overall complications between groups (P=0.213). Mean total medical treatment costs in Groups 1 and 2 were 2398.22±549.1 USD and 2845.70±824.2 USD, respectively (P=0.002). CONCLUSIONS: Many clinical outcomes in the totally tubeless PCNL showed comparable or better results than standard PCNL. We believe that totally tubeless PCNL is an acceptable, safe, and cost-effective alternative to standard PCNL for the treatment of renal stones.

Clinical efficacy, safety, and costs of percutaneous occlusive balloon catheter-assisted ureteroscopic lithotripsy for large impacted proximal ureteral calculi: a prospective, randomized study.

PURPOSE: To evaluate the clinical efficacy, safety, and costs of percutaneous occlusive balloon catheter-assisted ureteroscopic lithotripsy (POBC-URSL) for large impacted proximal ureteral calculi. PATIENTS AND METHODS: 156 patients with impacted proximal ureteral stones ≥1.5 cm in size were randomized to ureteroscopic lithotripsy (URSL), POBC-URSL, and percutaneous nephrolithotomy (PNL) group between May 2010 and May 2013. For URSL, the calculi were disintegrated with the assistance of anti-retropulsion devices. POBC-URSL was performed with the assistance of an 8F percutaneous occlusive balloon catheter. PNL was finished with the combination of an ultrasonic and a pneumatic lithotripter. A flexible ureteroscope and a 200 µm laser fiber were used to achieve stone-free status to a large extent for each group. Variables studied were mean operative time, auxiliary procedure, postoperative hospital stay, operation-related complications, stone clearance rate, and treatment costs. RESULTS: The mean lithotripsy time for POBC-URSL was shorter than URSL, but longer than PNL (42.6±8.9 minutes vs 66.7±15.3 minutes vs 28.1±6.3 minutes, p=0.014). The auxiliary procedure rate and postoperative fever rate for POBC-URSL were significantly lower than URSL and comparable to PNL (p<0.01, p=0.034). POBC-URSL was superior to URSL with regard to the stone clearance rate at 3 days postoperatively, and as good as PNL (98.1% vs 75.0% vs 96.2%, p<0.01). The postoperative hospital stay and hematuria rate were lower in POBC-URSL group than PNL group and similar to URSL group (p=0.016, p<0.01). The treatment costs were lowest in POBC-URSL group ($1205.0±$113.9 vs $1731.7±$208.1 vs $2446.4±$166.4, p=0.004). CONCLUSIONS: For large impacted proximal ureteral calculi, POBC-URSL was associated with a higher stone clearance rate, fewer complications and costs. POBC-URSL combined the advantages of URSL and PNL.

The impact of unplanned postprocedure visits in the management of patients with urinary stones.

BACKGROUND: Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease. METHODS: We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates. RESULTS: We identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval [95% CI] 0.74-0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 [95% CI $30,453-33,859]) than after ureteroscopy ($23,436 [95% CI $22,281-24,590]). CONCLUSION: Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.

Surgeon volume for percutaneous nephrolithotomy is associated with medical costs and length of hospital stay: a nationwide population-based study in Taiwan.

BACKGROUND AND PURPOSE: To investigate the factors associated with outcomes and medical costs for percutaneous nephrolithotomy (PCNL). METHODS: The present study uses a subset of the National Health Insurance Research Database (NHIRD), known as the Longitudinal Health Insurance Database 2005 (LHID 2005), which contains the data of all medical benefit claims from 1997 to 2010 for a subset of 1 million enrollees randomly drawn from the population of 22.72 million persons who were enrolled in 2005. The claims data for all subjects with a diagnosis of urolithiasis who underwent PCNL were analyzed. Hospital and surgeon case volume were classified by quartile. The correlations of all patient, surgeon, and hospital variables with the outcomes and medical costs of PCNL were analyzed by generalized estimating equations. RESULTS: A total of 995 subjects received PCNL. In univariate analysis, PCNL performed by high-volume surgeons (≥12) cost 26% less ($2684 vs $1986) and resulted in a 34.3% shorter hospital stay (6.5 vs 9.9 days) compared with low-volume surgeons (≤3). In multivariate analysis, surgeon volume was a significant predictor for medical cost, length of stay, and intensive care unit transfer but not complications and mortality. CONCLUSIONS: Surgeon volume was associated with lower medical costs and shorter length of stay after PCNL. Surgeon volume, however, was not an independent predictor of complications and mortality. Our findings have important implications for urologists and policymakers with regard to the cost and effectiveness of PCNL.

Postoperative complications after percutaneous nephrolithotomy: a contemporary analysis by insurance status in the United States.

BACKGROUND AND PURPOSE: No published data to date have assessed the insurance-related disparities among patients undergoing percutaneous nephrolithotomy (PCNL). Our objective was to examine whether being uninsured is associated with more perioperative complications after PCNL in the United States and to determine possible risk factors that influence PCNL outcomes. PATIENTS AND METHODS: This retrospective cohort study evaluated 13,982 patients who underwent PCNL and were included in Nationwide Inpatient Sample from 1998 through 2010. The main outcome measure was ≥1 perioperative complication stratified by insurance status. Associations between this outcome and insurance status were examined using logistic regression models. RESULTS: The overall percentage of patients with ≥1 perioperative complication after PCNL was 14.4% (n=2008). When stratified by insurance status, the unadjusted analysis showed significantly higher complication rates among Medicare (17.1%) and Medicaid (16.9%) beneficiaries than privately insured (12.3%) and uninsured (13.4%) patients (P<0.001). In a fully adjusted analysis of patients without medical comorbidity, however, these differences were no longer statistically significant, even when stratified by hospital teaching status. Multivariable-adjusted analysis of preoperative medical comorbidity showed that pulmonary disorders (odds ratio [OR], 7.77; 95% confidence interval [CI], 4.54-13.31), coagulopathy (OR, 6.16; 95% CI, 4.27-8.89), deficiency anemias (OR, 3.82; 95% CI, 3.29-4.44), and paralysis (OR, 2.16; 95% CI, 1.78-2.61) were the strongest predictors of ≥1 perioperative complication. CONCLUSIONS: Perioperative morbidity after PCNL varied significantly with insurance status, but this variation was explained mostly by differences in overall health status.

Laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for a solitary renal pelvis stone larger than 3 cm: a prospective cohort study.

To prospectively compare the outcome of laparoscopic pyelolithotomy (LP) versus percutaneous nephrolithotomy (PCNL) in patients with a solitary renal pelvis stone larger than 30 mm. We analyzed demographic and perioperative parameters and intermediate outcome in 30 adults who underwent transperitoneal LP for solitary renal pelvis stone larger than 30 mm (Group I) and compared the results with 30 patients who underwent PCNL (Group II). The two groups were matched for age, sex and stone size (Group I 35.3 ± 7.33 mm, Group II 36.6 ± 7.0 mm; P = 0.47). Mean operative time was significantly longer in LP group (120.5 ± 39.94 min versus 98.1 ± 23.28 min; P = 0.01, 95 % CI 5.43-39.23). Stone-free rate after LP was significantly higher than after PCNL (100 % versus 76.7 %; P = 0.01). On the discharge day, no residual stone was found in LP group, and significant residual stone (mean size 9.8 mm, range 7-15 mm) was found in seven patients (23.3 %) in PCNL group. After the ancillary procedures, the stone-free rates were 100 % in LP and 96.6 % in PCNL group at the end of follow-up. The average overall treatment cost was significantly lower in LP (683.9 USD versus 815.9 USD; P < 0.001). Mean postoperative decreases in hemoglobin was similar in both groups. Given adequate laparoscopic experience, for patients with a solitary renal pelvis stone larger than 3 cm, LP can be considered as an appropriate second choice to PCNL. It can be a potentially cost-effective treatment option in terms of one-session stone-free rate and postoperative complications. However, the potential benefits of LP need to be weighed against the more invasive nature of this procedure.

RIRS versus mPCNL for single renal stone of 2-3 cm: clinical outcome and cost-effective analysis in Chinese medical setting.

The aim of the study was to compare the clinical outcome and the cost-effectiveness between retrograde intra renal surgery (RIRS) and mini-percutaneous nephrolithotripsy (mPCNL) for the management of single renal stone of 2-3 cm in Chinese medical setting. From May 2005 to February 2011, 115 patients with solitary renal calculi were treated either by RIRS or mPCNL. 56 patients were in RIRS group while 59 were in mPCNL group. Patients' demographics between the two groups, in terms of gender, age, BMI, history of ESWL as well as stone side, stone location and stone size were comparable. Peri-operative course, clinical outcome, complication rates and medical cost were compared. The effective quotient (EQ) of two groups was calculated. Data were analyzed using Fisher's exact test, Chi-square test and Student's t test. EQ for RIRS and mPCNL were 0.52 and 0.90. The initial stone-free rate (SFR) of RIRS group and mPCNL group was 71.4 and 96.6 %, respectively (P = 0.000). The mean procedure number was 1.18 in RIRS group and 1.03 in mPCNL group, respectively (P = 0.035). The operative time for RIRS was longer (P = 0.000) while the mean hospital stay was shorter (P = 0.000). There was no statistical difference in peri-operative complications between the groups. The initial hospitalization cost, laboratory and radiology test cost of RIRS group were lower (P = 0.000). However, counting the retreatment cost in the two groups, the total medical expenditure including the overall hospitalization cost, overall laboratory and radiology test cost and post-operative out-patient department (OPD) visit cost was similar between two groups. In conclusion, with similar total medical cost, mPCNL achieved faster stone clearance and lower retreatment rate without major complications, which implied higher cost-effectiveness for the treatment of single renal stone of 2-3 cm in Chinese medical setting. RIRS is also a safe and reliable choice for patients having contraindications or preference against mPCNL.