Decision analysis for economic evaluation of the management of chronic obstructive uropathy

OBJECTIVES

To test which is the best treatment for chronic obstructive uropathy: urinary diversion using a conventional double-J ureteral stent or the metal thermo-expandable MemokathTM 051 prosthesis.

METHODS

We collected cost data of the insertion of a double-J stent taking into account preoperative and postoperative visits and surgery. Structural, medical, consumables and the prosthesis costs were considered. The estimated survival of the patient, number of spare stents and cost of each therapeutic measure were computed. Then, a simulation of the cost of inserting a MemokathTM 051 prosthesis was conducted, based on data of ureteral catheterization. We performed a decision tree and Cost Effectiveness economic analysis to measure the effectiveness of both health interventions.

RESULTS

Cost data of each procedure were: 1275.44 € for the double J catheter in a program of day case surgery (DCS), 4865.16 € for the metal thermo-expandable prosthesis as DCS, and 1424.52€for the double J stent with 1 day admission and 5014.24 € for the prosthesis with 1 day admission. The cost difference between ureteral stent and metal thermo-expandable prosthesis is 3589.72 € per treatment for the ureteral stent as DCS.

CONCLUSIONS

Despite its high initial cost, the metal thermo-expandable prosthesis potentially offers economic advantages over the conventional double-J ureteral stent in the treatment of long evolution ureteral obstruction. After the third change of double-J stent, and if the patient survival is long enough, the metal prosthesis as DCS should be the most cost effective option.

Stoma care nursing management: cost implications in community care

Successfully rehabilitating the stoma patient in the community means continuing the care provided by the hospital and preparing the patient for this new phase of life. It is well documented that this transition from hospital to home can often be a difficult time for the stoma patient and that home visits and ongoing support from the district nursing team are needed for many patients in the long term. This article aims to help community nurses understand the needs of the stoma patient in their homes and looks at the current situation, including costs, of supplying stoma appliances in the community.

Costs of radical cystectomy

OBJECTIVE

The total costs of radical cystectomy comprise a significant part of the total costs of bladder cancer treatment. The aims of this study were to determine the costs of cystectomy, with and without complications, and to investigate related prognostic factors.

MATERIAL AND METHODS

The clinical records and relevant economic files of 70 consecutive patients operated on between 1994 and 1998 were studied. Uni- and multivariate analyses were performed on 22 variables of possible prognostic significance to high total costs.

RESULTS

The total (median) costs for 53 uncomplicated and 17 complicated cystectomies were 181,096 and 290,625 SEK, respectively. The preoperative variables (patient characteristics) had no or minimal prognostic significance for high total costs. High peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy.

CONCLUSIONS

Total costs may be very high for a cystectomy with complications. Peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy due to bladder cancer. If the amount of bleeding can be influenced then substantial reductions in the total costs of cystectomy would seem possible.

A cost comparison of laparoscopic versus open radical cystoprostatectomy and orthotopic ileal neobladder at a single institution

AIM OF THE STUDY

To evaluate the specific cost components in two similar groups of patients who underwent laparoscopic or open radical cystoprostatectomy with orthotopic ileal neobladder at our Institution.

METHODS

Between November 2000 and July 2004, 20 men with transitional cell carcinoma of the bladder underwent laparoscopic (group 1) or open (group 2) radical cystoprostatectomy with orthotopic ileal neobladder. We evaluated the costs of hospital stay, surgical consumables and operating room occupation. At our Institution one day of hospital stay costs Euro 625 while one hour of operating room costs Euro 520 (professional fees included).

RESULTS

Hospital stay and operating room occupation in group 1 and 2 were statistically different (respectively 395.5 versus 275 min and 10.5 versus 18.9 days). Surgical consumables cost Euro 637 for patients in group 1 versus Euro 270 for patients in group 2. With the considered issues, at our Institution laparoscopic radical cystoprostatectomy costs Euro 10,626 whereas open radical cystoprostatectomy costs Euro 14,465.

CONCLUSIONS

Laparoscopic radical cystoprostatectomy seems associated with a shorter hospital stay and with a reduction of costs if compared to the open approach.

Two-surgeon versus single-surgeon radical cystectomy and urinary diversion: Impact on patient outcomes and costs

OBJECTIVES

To examine the difference in charges and outcomes between patients who underwent radical cystectomy and urinary diversion by a team of two surgeons versus a single surgeon.

METHODS

A total of 63 patients with bladder cancer who underwent the procedures were retrospectively analyzed. Two surgeons sequentially performed the cystectomy and ileal conduit (IC, n = 17) or neobladder (NBL, n = 18) or a single surgeon performed both the cystectomy and IC (n = 21) or NBL (n = 7). Procedure-related charges, hospital charges, operating room time, length of stay, and complications were compared between the two groups.

RESULTS

For the IC patients, the two-surgeon team had 60% greater mean surgeon charges (P <0.0001), 23% lower mean anesthesia charges (P <0.0001), 121 minutes shorter operating room time (P = 0.001), and 30% lower operating room charges (P = 0.001). For the NBL patients, the two-surgeon team had 32% greater surgeon charges (P <0.0001), 22% lower anesthesia charges (P = 0.003), 149 minutes shorter operating room time (P <0.0001), and 41% less operating room charges (P <0.0001). No differences were found in total hospital charges. The NBL patients who underwent surgery by two surgeons had a longer length of stay (P = 0.008). No differences were found in complications between the groups.

CONCLUSIONS

For IC patients, our data showed no differences in the average overall charges, whether a two-surgeon team or a single surgeon performed the procedure. Additional reductions in hospital charges could offset the greater physician charges in the NBL patients and allow full realization of the benefit from the shorter operative time with the two-surgeon team.

[Intestinal anastomosis in urology. Comparison of techniques]

BACKGROUND

Three different intestinal anastomosis were compared during reconstructive urologic surgery; time, cost and incidence of complications were evaluated.

METHODS

From November 1993 to February 1997, 45 patients (43 males and 2 females) were submitted to ileal resection to fashion 30 ileal neobladder, 8 ileal conduits and 7 augmentation ileocystoplasties. The patients were randomized in 3 groups. In the first group the intestinal continuity was performed by BAR; the second one was treated by GIA stapling device; the last underwent a manual suture with interrupted stitches double layer (vicryl).

RESULTS

The mean follow-up was 18 months. The mean time of canalization was 6.3 days. The complications were: one intestinal subocclusion (group 1); one abdominal wound infection (group 2); one anastomotic leak and one pulmonary embolism (group 3). The mean time of anastomosis was 18, 12 and 39 minutes respectively. The average total cost was 915,000 lire in group 1; 1,280,000 lire in group 2; 632,000 lire in group 3.

CONCLUSIONS

The conclusion is drawn that mechanical devices (BAR and stapler) are more convenient and advisable in reconstructive urologic surgery, for their quickness, effectiveness and final total cost.

Impact of a collaborative care approach to radical cystectomy and urinary reconstruction

PURPOSE

We report the results of a collaborative care program that has been developed for radical cystectomy and urinary reconstruction.

MATERIALS AND METHODS

All patients undergoing surgery after July 1993 were placed on a collaborative care pathway and were compared to patients undergoing the same procedure before this period.

RESULTS

Total adjusted hospital charges decreased from $31,174 to $19,479. Hospital stay decreased from 12.7 to 10.3 days. There were also decreases in duration of surgery, blood loss, intensive care unit use and postoperative morbidity rates.

CONCLUSIONS

Collaborative care pathways favorably affect the cost efficiency of care and provide favorable surgical outcomes.