A Utility Maximization Model for Evaluation of Health Care Programs

A linear health utility scale is described, complete with measurement instruments, that allows assignment of utility values to health states for any disease or treatment program. Given that the change produced by a health care program in the health states of a population is determinable, this utility scale permits assessment of the effectiveness of that program in terms of the change it produces in overall health utility. This is the basis of a model that will rank programs by their effectiveness/cost ratios or select them into a subset achieving the maximum effectiveness under specific cost or other constraints. Two algorithms are described, suitable respectively for priority ranking and for selection of programs giving maximum effectiveness under constraints, and the application of the model is discussed.     

Percutaneous extraction of urinary calculi: use of the intercostal approach

The authors achieved successful percutaneous extraction of urinary calculi via an intercostal approach in 24 patients. In one patient, a large hydrothorax developed and thoracentesis was required; 2 patients had moderate and 6 minimal pleural fluid collections which did not require treatment. No patient had pneumothorax. Intercostal puncture provides direct access to the upper and middle poles of the kidney when they lie above the twelfth rib and subcostal angulation is not feasible. Such an approach is advantageous for stones in the ureter, as well as renal stones which are inaccessible from the lower pole. Fluoroscopy should be performed when planning the puncture in order to avoid the lung, and a working sheath is recommended.