The economics of urinary stone treatment

Urinary stones have a significant impact on the global economy, as their high prevalence and recurrence rates make the cost of treatment a non-negligible issue. Given the large differences in the cost of treating urinary stones from country to country, conclusions drawn from the perspective of one country or institution alone may not be universal. This also means that the global research on the economics of urinary stone treatment needs to be more comprehensive and detailed.

Exploring the establishment of a model for the cost of urinary stone treatment will open up a new way for the economic management of urinary stone disease. By incorporating healthcare costs and efficacy components into the model, we can tailor a healthcare strategy that is tailored to the realities of the country to achieve efficient and cost-effective treatments. It is worth mentioning that the choice of clinical pathway for the treatment of urinary stones has become a wise move to achieve efficient and low-cost medical treatment in Western countries. This will not only help improve the quality of medical care, but also effectively control medical costs and bring tangible benefits to patients.

Have you ever wondered why the cost of medical care is always frighteningly high for a single visit, especially for some seemingly ordinary minor illnesses? In fact, the medical expenses of various diseases have a huge impact on the burden on the entire health care system. Taking stone disease in the United States as an example, as the prevalence of stones has increased year by year, in 2000 alone, the medical expenses for stone disease amounted to $2.1 billion! How was the $2.1 billion distributed? Of these, $971 million was spent on hospitalization expenses for stone patients, $607 million was spent on outpatient and doctor's office expenses, and $490 million was spent on emergency treatment of patients. This is just the tip of the iceberg, as there is also a portion of the cost that comes from those who are unable to work due to illness, and their lost time pay is also a significant amount. The most worrying thing is that these high costs are mainly concentrated in people aged 20-60 with a high incidence of stones. Imagine that they are in the prime of life and are the breadwinners of the family, because a small illness can put the whole family in financial difficulty. So, how to reduce medical costs and allow more people to enjoy high-quality medical services? This is not only a medical problem, but also a social problem. Let's focus together and work for a healthier future!

"In China, more than 60 million people visit the hospital every year for stone disease, and 6 million of them need to be hospitalized. The average hospitalization cost per patient is as high as 7,000 yuan, which means that the total cost of inpatient treatment of stone disease in the country is as high as 42 billion yuan, and the number of outpatient and emergency visits is even more staggering, as high as 54 million, and the average outpatient and emergency cost per patient is 200 yuan, totaling 10.8 billion yuan. Taken together, the total medical cost of stone disease is as high as 53 billion yuan, or about 8.8 billion U.S. dollars!

Surprising differences in the cost of stone disease treatment in different countries You must not have imagined that the cost of stone disease treatment can vary so much between different countries! A prospective study shows that although the costs associated with stone disease mainly include surgical interventions, extracorporeal lithotripsy machines, and various endoscopic applications, it seems that the cost of treatment should be similar in different countries. But in fact, the cost of stone disease treatment varies greatly from country to country. International economic studies such as Chandhoke have revealed an astonishing fact: the cost of treatment for extracorporeal lithotripsy and ureteroscopy and laser lithotripsy can vary as much as 20 times between different countries! What is even more surprising is that even within the same country, there are significant differences in the cost of these treatments, such as in India and China. Let's look at the specific figures: Ureteroscopes cost only $160 in Germany and $1,900 in Switzerland. In China, the cost is between $900 and $1,000. It turns out that Switzerland and China need to import ureteroscopes, which has led to a significant increase in the cost of treatment. It can be seen that the cost of treatment for stone disease varies significantly in different countries and in different parts of the same country. This not only puts financial pressure on patients, but also challenges the healthcare system. In the future, we hope that the cost of stone disease treatment will be more equitable and reasonable, so that more patients can receive timely and effective treatment.

Uncover the truth behind the difference in treatment costs: (1) if the country can produce its own medical equipment such as ureteroscopes, it can be purchased at a lower price, which can greatly reduce the cost of treatment, and (2) the salary of doctors in the country is much lower than in other countries, which also helps to reduce the cost of treatment. In the United States, for example, the salaries of surgeons and physicians are strictly regulated, and it is up to insurance companies, government-operated, and fund-backed medical institutions to determine the cost of hospitalization and surgery, as well as the salaries of doctors.

Have you ever suffered from a sudden kidney stone? The cramping pain in the abdomen is unbearable. In the process of treatment, you will not only have to face the pain, but also pay high medical bills. In the United States, 226 people are admitted to the emergency room each year for stone disease, and 1/4 of patients with acute abdomen in China are also suffering from renal colic. Treatment of acute stone disease requires a complex range of tests and procedures, such as plain x-rays and laboratory tests, as well as possible intravenous fluids and analgesic management. For inpatients, this also involves higher costs. In the United States, while most stone patients are treated on an outpatient basis, the cost of inpatient treatment has a significant impact on the total cost. Hospitalization rates worldwide vary from region to region. Hospitalization rates are lower in the United States and Sweden, while in Germany, up to 69% of urolithiasis patients opt for hospitalization. The urolithiasis inpatient rate at Edinburgh Western General Hospital is 43.5%. A study more than 10 years ago found that the average length of hospital stay for patients with urolithiasis who underwent medical treatment was 2.65 days and cost $2,153. In recent years, studies by the U.S. Urology Program have found that the average length of hospital stay has been reduced to 2.2 days in 2000. Even if hospitalization is chosen, only 25% of patients end up requiring surgery. This suggests that reducing unnecessary hospitalizations and deciding the need for surgery as early as possible is an effective way to reduce the cost of treatment.

In addition, the decision to continue to observe and wait for natural stone removal or to take surgical intervention can also increase the cost of stone disease treatment. From an economic point of view, waiting for the patient to pass the stone naturally is the cheapest treatment, but it also increases the frequency of emergency treatment, surgical intervention is still required if the stone passage fails, and complications such as infection and ureteral blockage may occur during observation. A meta-analysis of 2704 patients showed that the rate of natural stone passage of distal ureteral stones was 45%, 22% in the middle segment, and 12% in the proximal segment. The study also showed that the size of the stones had a great influence on the natural passage of stones, and that two-thirds of stones were naturally expelled 4 weeks after the onset of stone disease symptoms.

Lotan and his colleagues developed a cost-efficiency model that used the probable rate of natural stone passage, stone location, stone size, and the success rate of SWL or URS as influencing factors, and found that waiting for observation in the expectation of natural passage of ureteral stones was the most cost-efficient approach, such as $1200 for distal ureteral stones and $400 for proximal ureteral stones, although the rate of natural passage of proximal ureteral stones was quite low. In addition, for proximal stones that are less likely to pass spontaneously, additional emergency department visits and indirect losses due to missed work will reduce the cost-effectiveness of waiting for observational treatment. Increasing the natural excretion rate of stones can improve the low cost and high efficiency of observation and treatment. There is evidence that pharmacotherapy, such as the combination of steroids and α-adrenergic antagonists or calcium channel antagonists, may increase the likelihood of natural stone passage of ureteral stones. Treatment with less toxic drugs can increase the rate of natural passage of stones, which will reduce the use of expensive surgical treatments, so drug therapy can reduce the medical costs of acute stone disease.

In a survey of 6783 cases of upper urinary tract stones in China, 37.83% (2566/6783) of the patients received the treatment intervention for stones. Interventions for the treatment of stones include ESWL, ureteroscopy, percutaneous nephroscopy, open surgery, and medical therapy with a-blockers to promote stone expulsion. ESWL was the main means of therapeutic intervention, accounting for 68.3% (1753/2566), drug stone expulsion in 17.6% (451/2566), ureteroscopy in 11.7% (299/2566), percutaneous nephroscopy in 2% (51/2566), and open surgery in 4.7% (12/2566). Drug stone expulsion refers to stones ≤ less than 9 mm, and the use of A-receptor blockers tamsulosin or naftopidil to promote stone expulsion is 68%; ESWL is suitable for patients who cannot pass stones with drugs or stones > 9mm<20mm, with an overall stone clearance rate of 72% and an efficiency quotient of 65, and ureteroscopy is suitable for patients who still cannot pass stones after two ESWL sessions, or the stones are located in the middle of the ureter, or the stones are incarcerated, and the hydronephrosis is more obvious, with an overall stone clearance rate of 90% and an efficiency quotient of 75. Percutaneous nephroscopic holmium laser lithotripsy is suitable for renal cast stones > 20 mm, with an overall stone expulsion rate of 85% and an efficiency quotient of 78. 62.17% (4247/6783) of the patients did not use the treatment intervention for stones, of which 3618 patients were watchful waiting because the diameter of the stones was ≤6mm, and 629 patients were not treated or transferred to other hospitals for treatment due to physical condition and economic factors. Among the 3618 patients on watchful wait, 2894 patients were followed up for three months, with a three-month follow-up rate of 80%, and the results of follow-up were stone exclusion in 1752 patients, with a self-discharge rate of 60.5%, and 1483 patients were followed up for half a year, with a half-year follow-up rate of 41%, and the follow-up results showed that 1123 patients were eliminated with a self-discharge rate of 75.7%.

Due to the high prevalence of stones and the lack of effective treatments to eradicate most stones, most patients still require surgical treatment, which directly leads to the increase in costs. Data from the Centers for Medicare & Medicaid Services (CMS) and CHCPE show that 339 to 486 people per 100,000 people in the United States undergo surgical treatment for stone disease, and the data also illustrate the use of surgical treatments: SWL 54% (similar data for CMS and CHCPE), 41% and 42% for URS and CHCPE, respectively, and 4% and 6% for percutaneous renal lithotomy (PCNL). Whereas, the method of surgical treatment is determined by several factors, including the nature of the stone (size, location and composition), the anatomy of the kidneys/ureters, the state of the patient and the level of the doctor and the available techniques (ureteroscopy, holmium laser). The total cost of treatment for stone disease includes not only the cost of starting treatment, but also the cost of ancillary tests and even hospitalization if treatment fails. It is difficult to outline the economics of the management of surgical stones. The success rate and cost of surgical treatment vary depending on the ureteral and kidney stones, and the size of the stones. Chandhoke surveyed the economies of 10 countries and found that the cost of SWL ranged from $373 to $9,924, while URS ranged from $491 to $8,108. SWL costs more than URS in Australia, Germany, Japan, the UK and the US, about the same in Canada, Italy and Sweden, and more in Switzerland and Turkey. In China, SWL costs only $100, but URS costs around $2000.

In the AUA guidelines, the recommendation for the management of kidney stones is that PCNL is the treatment of choice for staghorn stones. In addition, several studies have compared the effects of SWL, URS, and PCNL in the treatment of lower pole stones. A multicenter randomized study showed that the stone avalescence rates after treatment for lower pole stones < 1 cm were 35% and 50%, respectively (p No significant difference). In another randomized trial, the effects of SWL and PCNL were compared in the treatment of symptomatic ≤ 30 mm lower pole stones, and the results showed that PCNL was much more effective than SWL (95% and 37%, respectively, p<0.001). Because the total cost of treatment is heavily dependent on the stone free rate after treatment, the difference in the rate of successful stone removals will significantly affect the overall potency ratio. Some studies have assessed the cost of different regimens for the treatment of kidney stones. Only one prospective, randomized trial comparing the cost of treatment for calcium-containing nephrolithiasis with SWL and PCNL was conducted in 49 patients with nephrolithiasis, each with a medium-sized stone between 10 and 30 mm in diameter, and compared 21 patients with PCNL with 28 patients with SWL. The results showed that the average cost of treatment was lower for patients who preferred SWL, but the results of follow-up after 1 year showed that the cost gap between the two methods was reduced. Another prospective, randomized trial comparing 'tubeless' PCNL with 'mini-PNCL' and standard PCNL showed that 'tubeless' PCNL had the highest potency ratio.

Due to the lack of prospective study data, a number of models based on treatment effects and cost over the course of treatment have been developed to assess the estimated cost of a particular treatment program. The application of these models is limited because they were established prior to recent studies and because the studies on which they are based do not assess the stone absence rate after treatment under uniform standards. For example, if plain x-rays are used as a standard instead of CT to assess the stone absence rate after treatment, the stone absence rate will be higher. However, May and Chandhoke et al. compared the cost of treating a single kidney stone at their hospital for SWL and PCNL (US$ 8,213 for SWL versus US$ 26,622 for PCNL; including follow-up visits and management of complications). In their model, PCNL was followed by PCNL once the first surgical treatment failed. For stones < 1 cm and 1-2 cm at the lower pole of the kidney, the cost of SWL is lower, while the cost of PCNL is $11,099 and $12,258, respectively, but for stones > 2 cm, the cost of PCNL is lower, still below $21,059. Because PCNL without complications cost less than $15,000 in their institution, the authors conclude that PCNL is the most cost-effective method for a single stone > 2 cm in diameter at the lower pole of the kidney, and that SWL is the most cost-effective method when the stone diameter is < 2 cm, despite the lower rate of stone free after SWL treatment.

Retrospective literature found that the mean recurrence rates of ureteral stones were 2.2% and 12.1%, respectively, while the rates requiring general/local spinal anesthesia were 94.3% and 28.3%, respectively. In addition, if patients can be treated on an outpatient basis, the cost of treatment will be significantly reduced. In the US, both SWL and URS are routine outpatient treatments, and URS costs less for first-episode ureteral stones than SWL because of the high rate of stone agenesis and the high recurrence rate of SWL, resulting in an increase in the cost of subsequent treatment. In some countries, such as Greece and the Netherlands, URS must be performed after hospitalization, which significantly increases the cost of treatment for this method, and in China, URS must also be performed after hospitalization. There are a number of relevant studies evaluating the cost of treatment for proximal ureteral stones. Parker and his colleagues found that URS costs $6,205 less than SWL in the U.S. because URS has a 91 percent success rate compared to 55 percent for SWL. Wu et al. also found that URS is a more cost-effective method, as its stone-free rate is as high as 83.2% (84/101), while SWL is only 63.9% (76/119).

A number of decision analyses are currently being used to compare the cost of treatment for various approaches to the treatment of ureteral stones. While these models are based on a number of assumptions, they are highly valuable because their data is the product of a series of data combined, which avoids the singularity of the data. Wolf and colleagues evaluated data published between 1988 and 1994 and found that the stone free rate for URS was 92 percent compared to 74 percent for SWL, and the average cost of treatment was 21 percent higher for SWL than for URS. Their model takes into account the cost of complications and assumes the treatment flow after the first treatment failure: SWL first, URS after failure, and open surgery at the end. As a result of this analysis, the cost of treatment for SWL decreased by $1,107, which is close to the cost of treatment for URS. Lotan and colleagues used decision analysis to evaluate the least cost-effective treatment options for distal, interrupted, and proximal ureteral stones. The analysis assessed the average treatment success rate of the 3 treatments (observational, SWL, and URS) through published data, assessing treatment costs through data from their institutions. URS is less expensive to treat than SWL ($2,645 vs. $4,225).

Watchful waiting for ureteral stones is the least expensive treatment and does not require any cost until observation fails. The cost of URS for the treatment of ureteral stones was lower than that of SWL, and the difference in the cost of treating proximal calculi stones between the two methods was US$ 1440, US$ 1670 for the middle segment, and US$ 1750 for the distal segment. However, the cost advantage of URS is not present in all countries, and in some countries the cost of treatment for SWL is similar to or even less than that of URS. There is much debate about the role of medical evaluation and management in reducing the rate of stone recurrence. From a potency point of view, the cost of assessment and routine medical treatment is balanced with the direct and indirect cost of surgical treatment, as medical treatment reduces stone recurrence and thus reduces the chance of surgical treatment. Of course, the main influencing factor is the cost of medical and surgical treatment in each country. In the United States, most of the cost of surgical treatment is covered by insurance companies and health insurance, while a large part of the cost of drug treatment is borne by the patient, which makes the cost of drug treatment higher than the cost of surgical treatment, which requires daily medication and less surgical treatment. The cost of medication is up to $508 per year, which is 10% of the cost of a single session of URS ($4,185) or SWL ($6,697). In the UK, the subsidy for medical treatment is relatively high, resulting in a cost of only US$98 per year, which is only 4% of the average cost of a surgical approach compared to URS (US$3,442) and SWL (US$1,462). Therefore, in the UK, people prefer to be treated with medications.

According to MEPS data, spending on prescription drugs for urinary stones in the United States rose from $4 million to $14 million per year between 1996-1998. In addition to medical therapy, conservative treatments such as increased water intake and dietary modification can also reduce the recurrence of stones, and current medical therapy can further reduce the recurrence of stones. However, due to the non-standard nature of drug treatment, it significantly affects the compliance of patients with drug treatment. Some studies have shown the highest potency ratio for drug treatment of urinary stones. However, these studies are based on the main assumption that the rate of stone recurrence and the risk of drug therapy are reduced, and do not take into account other important factors, such as (1) dietary modification alone can reduce the rate of stone formation, and most drug regimens include dietary modification. (2) Only 10%-20% of patients with new onset of stones are symptomatic each year, and only half of symptomatic patients eventually require surgical treatment. Randomized studies that empirically treated patients with recurrent calculi in randomly selected patients without assessing their metabolic profile have shown a reduced rate of recurrence of calculi. Previous evaluations were for genetic disorders that did not respond to conservative treatments, which favored metabolic assessment and drug regimen selection. Conservative management is the least cost-effective approach for patients with first-episode stones. In patients with recurrent stones (0.3 stones/person/year), a single dietary modification with empiric therapy (without metabolic assessment) is a low-cost and efficient approach. In the international cost of stone surveys, it was found that in most countries (USA, Italy, Germany, Japan, Turkey, Australia, Canada, Switzerland and Sweden) the cost of direct drug therapy (drug treatment based on metabolic assessment) was lower than that of empirical treatment. In any case, despite the high cost of drug therapy, it can significantly reduce the rate of stone recurrence. At present, most of the literature focuses on the cost of calcium-containing stones, which are the most common type of stones in Western Europe and the United States. The impact of different stones has not yet been evaluated from an economic point of view. Uric acid stones are generally treated with drug litholysis, but the efficacy of this therapy for large stones, the side effects of the drug, and the cost of treatment and follow-up are still uncertain. In the UK, ultrasound costs three times as much as plain abdominal x-ray (US$170 and US$51, respectively). Chemical decomposition is not a cost-effective method for cystine stones because it requires hospitalization and has significant side effects, dietary and pharmacologic therapies may be considered, and surgical treatment is less effective for SWL and PCNL is too costly. For infectious stones (struvite stones), preventing recurrence of infection is a low-cost and efficient approach. PCNL is the mainstay of treatment, while SWL has limited efficacy.