Comparative costs of the various strategies of urinary stone disease management.

New technology is a major determinant of total healthcare costs. The assessment of alternative technologies from a cost-effectiveness perspective is important, although other considerations may finally determine which technology is used. The alternatives of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL) for the treatment of renal stone disease were compared by studying 1000 cases of ESWL and 133 cases of PCNL using a noncontemporaneous cohort study with PCNL representing the earlier cohort. The effectiveness, defined by success and stone-free rates, was higher with PCNL than with ESWL (96% success vs. 70%); PCNL was also accompanied by a lower burden of additional therapy, whereas ESWL had a higher retreatment rate. From the perspective of a third-party payer, total costs per case of ESWL ($2,746) were lower than those of PCNL ($4,087), but the figure varies with the annual volume. These represent the costs for complete treatment of a patient, including the costs of alternative technology such as PCNL or ureteroscopy that may ultimately be necessary in a patient initially managed by ESWL. The cost for a single ESWL treatment was $2,226 (at a volume of 1000 cases per year), but this increased to $2,746 when costs of retreatment and alternative treatment were prorated to each patient treated. The relative contribution of capital costs to the total cost of ESWL was always less than total professional fees and was only 12% at a volume of 2000 cases/year. Therefore ESWL is less expensive but it is also less effective in rendering patients stone-free.