Optimal treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus ureteroscopy.

BACKGROUND: The optimal treatment for distal ureteral calculi remains controversial. We present data from our institution to compare the efficacy of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy with different lithotripsy modalities (URSL). METHODS: From January 1994 to September 1997, 954 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar) in 524 patients and ureteroscopy (Wolf 8.0F instrument and Swiss Lithoclast) in 430 patients. Stone sizes and patient ages were similar in these two groups. RESULTS: In the SWL group, the 3-month stone-free rate was 87%, and the effectiveness quotient (EQ) was 68.7%. In the URSL group, there was a 96% stone-free rate with an EQ of 92.1%. The SWL treatment was more expensive than URSL. CONCLUSION: At our institution, ureteroscopy is more efficacious than SWL for the treatment of distal ureteral calculi. In selected patients who had stones >10 mm with evidence of impaction and severe colic pain, we strongly suggest that URSL is the best choice.

Adapting the HCUP QIs for hospital use: the experience in New York State.

BACKGROUND: The Agency for Healthcare Research and Quality developed the Healthcare Cost and Utilization Project (HCUP) quality indicators (QIs) in 1994. The Healthcare Association of New York State (HANYS; Albany), which represents more than 500 nonprofit and public hospitals, long-term care facilities, and home health care agencies, has adapted the HCUP QIs since 1997 to produce annual comparative reports for its member hospitals. Specifically designed for internal use, the reports have been well received and have drawn interest from other hospital associations and state health departments. METHODS: The HCUP QIs were applied to the New York State hospital discharge abstract. A risk adjustment model was constructed for each complication measure. Measures of utilization and access to care were adjusted for differences in patient demographics and payer status by indirect standardization. Data are presented in graphic format. Each hospital receives its own report (in both paper copy and CD-ROM) with comparisons to statewide norms, regional averages, and peer group averages. Report prepared for hospital systems include data for each affiliated hospital. CONCLUSIONS: When used appropriately, the HCUP QIs provide valuable information for individual hospitals to assess quality of care and target potential areas for improvement. The HCUP QIs also give hospitals a broad perspective to look beyond their own institutions and develop community-based quality improvement initiatives. Nevertheless, given the limitations that commonly exist with administrative databases and the lack of standard risk adjustment systems, the HCUP QIs are best used for internal purposes and not for public reporting.

Regional variation in physician practice pattern: an examination of technical and cost efficiency for treating sinusitis.

OBJECTIVE: An examination of the physician efficiency and resulting cost patterns by region. DATA SOURCES: Virginia Medicaid sinusitis related claims for 1993 were aggregated to physician level (n = 178), and Area Resources File for 1993 was used to identify regions for evaluation. STUDY DESIGN: The best practice performance in the usage of five resources (i.e., primary care physician visits, referral services, emergency room visits, prescriptions, laboratory tests) was identified using Data Envelopment Analysis (DEA). Five regions in Virginia were identified according to regional planning to evaluate the variation in efficiency across these regions. PRINCIPAL FINDINGS: Inefficient physicians consumed significantly more resources and were 48% more costly than efficient physicians. Substantial regional variation was found and mainly attributed to the differences in use of prescriptions and laboratory procedures. Urban-rural discrepancy may explain part of the variation. CONCLUSIONS: As this study reveals the existence of substantial variation in physician efficiency, actions should be taken to minimize the variation that is more affected by personal and structural factors. For example, information on efficient use of resources and corresponding patient outcomes can be disseminated to the attending physicians. Educational workshops can be conducted to allow sharing of experience between efficient and inefficient physicians. Efforts should also be directed to help inefficient physicians to adhere to practice guidelines.

Do primary care physicians or specialists provide more efficient care?

Sinusitis is a common health complaint and expenditures for its treatment are high; thus, it is necessary to promote efficient practice behaviours in managing patient care. This study compares resource utilization between primary care physicians and specialists in the treatment of Medicaid sinusitis patients in Virginia. Physician-level data from Virginia Medicaid claim files for 1993 were analysed. The efficiency frontier, representing the best achievable performance in the use of resources for treating sinusitis, is identified using Data Envelopment Analysis. Resource utilization (primary care physician visits, specialist visits, emergency room usage, prescriptions and laboratory tests) and corresponding costs are compared between generalists and otolaryngologists. It was concluded from this study that there are no discernible differences in technical efficiency between generalists and specialists in the treatment of sinusitis. Nevertheless, otolaryngologists are found to be more costly than generalists in treating sinusitis. Variation in both caseload and patient mix might explain variation in use of resources.