Urological Research

, Volume 33, Issue 3, pp 223–230

International comparison of cost effectiveness of medical management strategies for nephrolithiasis

  • Yair Lotan
  • Jeffrey A. Cadeddu
  • Margaret S. Pearle
Original Paper

Abstract

Although medical therapy is known to reduce the risk of kidney stone recurrence, the cost effectiveness of medical prophylaxis is controversial. We evaluated medical treatment strategies including dietary measures (conservative), empiric medical therapy (empiric) or directed medical therapy (directed) based on comprehensive metabolic evaluation (CME) for patients with recurrent kidney stones, and compared the costs of these strategies using cost data from ten different countries. We previously established rates of stone formation in recurrent stone-formers, risk reduction of medical therapy, sensitivity of CME and rates of spontaneous stone passage from a comprehensive literature search (Lotan et al. 2004 J Urol 172: 2275). The costs of medication, surgical therapy, emergency room visits and CME for ten different countries were obtained from a published report of an international cost survey (Chandhoke 2002 J Urol 168: 937) as well as from our own county hospital in the US. Medication costs in the US were obtained from two national pharmacy chains. A decision tree model was created to compare the costs of different treatment strategies assuming cost accrual for metabolic evaluation, medical therapy and surgery or emergency room visits. For medical therapy, we assumed the distribution of medication use described in the published report, consisting of potassium citrate (60%), thiazide (30%) and allopurinol (10%). A nearly 20-fold difference in the costs of shock-wave lithotripsy, ureteroscopy and medication was found among different countries. From the model (US dollars/patient/year), conservative therapy alone was the most cost effective approach followed by empiric and directed medical therapy in all countries except in the UK. In the UK, the cost of drug therapy (estimated at $29/patient/year) resulted in empiric therapy being the most cost effective strategy for recurrent stone formers. The low likelihood of surgical intervention, as well as the low relative cost of surgery to medication, contributed to the higher cost of empiric and directed medical therapy strategies. Of note, despite the higher cost, drug treatment strategies were associated with significantly lower stone recurrence rates. We found that drug treatment strategies are more costly than conservative treatment but produce good control of stone formation. In all but one country (UK), dietary therapy was the most cost effective approach due to the relatively low cost of surgery compared with medication. The differential resource allocation to different components of a healthcare system (i.e. subsidized medication versus surgical treatment) in different countries determines the cost effectiveness of various treatment strategies.

Keywords

Medical evaluation Nephrolithiasis Health economics International comparison 

References

  1. 1.
    Pearle MS, Curhan GC, Calhoun EA (2004) Urolithiasis. In: Litwin MS, Saigal CS (eds) Urologic diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, NIH publication no. 04-5512. US Government Publishing Office, Washington, p 3Google Scholar
  2. 2.
    Pearle MS, Roehrborn CG, Pak CY (1999) Meta-analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. J Endourol 13: 679PubMedGoogle Scholar
  3. 3.
    Tiselius H-G (2000) Comprehensive metabolic evaluation of stone formers is cost effective. In: Rodgers AL, Hibbert BE, Hess B, Kahn SR, Preminger GM (eds) Urolithiasis 2000, Proceedings of the 9th International Symposium on Urolithiasis, Cape Town, South Africa. University of Cape Town Press Cape Town, p 349Google Scholar
  4. 4.
    Parks JH, Coe FL (1996) The financial effects of kidney stone prevention. Kidney Int 50: 1706PubMedGoogle Scholar
  5. 5.
    Robertson WG (2000) The economic case for the biochemical screening of stone patients. In: Rodgers AL, Hibbert BE, Hess B, Kahn SR, Preminger GM (eds) Urolithiasis 2000, Proceedings of the 9th International Symposium on Urolithiasis, Cape Town, South Africa. University of Cape Town Press Cape Town, p 403Google Scholar
  6. 6.
    Strohmaier WL, Hormann M (2000) Economic aspects of urolithiasis (U) and metaphylaxis (M) in Germany. In: Rodgers AL, Hibbert BE, Hess B, Kahn SR, Preminger GM (eds) Urolithiasis 2000, Proceedings of the 9th International Symposium on Urolithiasis, Cape Town, South Africa. University of Cape Town Press Cape Town, p 406Google Scholar
  7. 7.
    Chandhoke PS (2002) When is medical prophylaxis cost-effective for recurrent calcium stones? J Urol 168: 937CrossRefPubMedGoogle Scholar
  8. 8.
    Hosking DH, Erickson SB, Van den Berg CJ, Wilson DM, Smith LH (1983) The stone clinic effect in patients with idiopathic calcium urolithiasis. J Urol 130: 1115PubMedGoogle Scholar
  9. 9.
    Keeley FXJr, Tilling K, Elves A, Menezes P, Wills M, Rao N et al. (2001) Preliminary results of a randomized controlled trial of prophylactic shock wave lithotripsy for small asymptomatic renal calyceal stones. BJU Int 87: 1CrossRefGoogle Scholar
  10. 10.
    Glowacki LS, Beecroft ML, Cook RJ, Pahl D, Churchill DN (1992) The natural history of asymptomatic urolithiasis. J Urol 147: 319PubMedGoogle Scholar
  11. 11.
    Streem SB, Yost A, Mascha E (1996) Clinical implications of clinically insignificant store fragments after extracorporeal shock wave lithotripsy. J Urol 155: 1186CrossRefPubMedGoogle Scholar
  12. 12.
    Ettinger B, Pak CY, Citron JT, Thomas C, Adams-Huet B, Vangessel A (1997) Potassium-magnesium citrate is an effective prophylaxis against recurrent calcium oxalate nephrolithiasis. J Urol 158: 2069PubMedGoogle Scholar
  13. 13.
    Lotan Y, Cadeddu JA, Roehrborn CG, Pak CYC, Pearle MS (2004) Cost-effectiveness of medical management strategies of nephrolithiasis. J Urol 172: 2275CrossRefGoogle Scholar
  14. 14.
    Ettinger B, Citron JT, Livermore B, Dolman LI (1988) Chlorthalidone reduces calcium oxalate calculous recurrence but magnesium hydroxide does not. J Urol 139: 679PubMedGoogle Scholar
  15. 15.
    Laerum E, Larsen S (215) Thiazide prophylaxis of urolithiasis. A double-blind study in general practice. Acta Med Scand 215: 383Google Scholar
  16. 16.
    Wilson DR, Strauss AL, Manuel MA (1984) Comparison of medical treatments for the prevention of recurrent calcium nephrolithiasis. Urol Res 12: 39Google Scholar
  17. 17.
    Robertson WG, Peacock M, Selby PL et al. (1985) A mulitcentre trial to evaluate three treatments for idiopathic calcium stone disease: a preliminary report. In: Schwille O, Smith L, Robertson WG, Vahlensieck W (eds) Urolithiasis and related clinical research. Plenum Press, New York, p 545Google Scholar
  18. 18.
    Trinchieri A, Ostini F, Nespoli R, Rovera F, Montanari E, Zanetti G (1999) A prospective study of recurrence rate and risk factors for recurrence after a first renal stone. J Urol 162: 27CrossRefPubMedGoogle Scholar
  19. 19.
    Yagisawa T, Chandhoke PS, Fan J (1999) Comparison of comprehensive and limited metabolic evaluations in the treatment of patients with recurrent calcium urolithiasis. J Urol 161: 1449CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Yair Lotan
    • 1
  • Jeffrey A. Cadeddu
    • 1
  • Margaret S. Pearle
    • 1
  1. 1.Department of UrologyThe University of Texas Southwestern Medical CenterUSA

Personalised recommendations