Safe and cost-effective approach to carotid surgery.

OBJECTIVE: To evaluate the safety and cost effectiveness of carotid surgery performed altering the perioperative protocol in an attempt to decrease resource utilisation. SETTING: Department of vascular surgery in a large metropolitan teaching hospital in northern Italy. DESIGN: Prospective, non-selective study. MATERIALS AND METHODS: Three hundred and eighty carotid procedures were performed in 1995 on 343 patients (274 males, 69 females, mean age 68.2 years, range 47-86 years). The most important cost containment measures, were: (i) limiting the use of contrast arteriography to cases of dubious ultrasonographic diagnosis; (ii) routine use of loco-regional anaesthesia; (iii) postoperative admission to an intensive care unit (ICU) only in selected cases; (iv) early postoperative discharge where possible. RESULTS: Mortality was 0.26% and neurological morbidity 1.58%. General anaesthesia was required in eight patients (2.1%), and only seven patients (1.8%) were admitted postoperatively to the ICU. Arteriography was performed in 56 cases (14.7%). The average hospital stay was 5 days with a global cost of 43,036 ECU, as compared with a cost of 6764 ECU for patients treated traditionally with routine arteriography, general anaesthesia and routine ICU admission. CONCLUSIONS: Selective use of arteriography and ICU, routine use of loco-regional anaesthesia and reduced hospital stay make it possible to lower the cost of carotid surgery without sacrificing quality.

Cost-efficacy comparison of extracorporeal shock wave lithotripsy and endoscopic laser lithotripsy in distal ureteral stones.

Distal ureteral stones are usually treated today by extracorporeal shock wave lithotripsy or extraction by retrograde ureteroscopy with or without previous fragmentation. We performed a cost-efficacy study of three methods to treat them: extracorporeal lithotripsy using either a spark gap lithotripter, the unmodified Dornier HM3 (SWL), or the piezoelectric Wolf Piezolith 2300 (EPL) and endoscopic lasertripsy (LISL) using an alexandrite pulsed laser, the HMT Alexantriptor. The records of 520 patients with distal ureteral stones treated by extracorporeal lithotripsy were reviewed to establish the mean cost of the procedure. Concerning LISL, the first 30 stone patients treated in our institution were evaluated. Four measures were examined: (1) number of sessions; (2) success rate; (3) auxiliary maneuvers; and (4) complications. The economics evaluation considered the direct costs related to personnel, consumables, depreciation, and maintenance. The EPL procedure was the cheapest: $873 US, and SWL the most expensive: $3,572 US. The best cost-efficacy rate was seen with LISL because of its 93% success rate and its cost of $1,390 US.