Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.     

Piezo-electric lithotripsy technic with echographic guidance (EDAP LT 01)

Piezo-electric extracorporeal lithotripsy with ultrasonographic detection is performed with the following material according to the following technique: 1) A mobile firing head connected to the lumbar region by a simple inflatable cushion filled with sterile water. At the centre of the firing head, a 5 MHz real time transducer is used to locate the stone. 320 piezo-electric elements, arranged around the transducer, can induce, when focussed, a pressure of about 900 bars at the focal point in vitro. The focus is 15 mm X 5 mm. The generators are electronic. 2) The technique requires: understanding of ultrasonography in order to precisely locate the stone which, when it is intrarenal, is only missed in 1% of cases in our experience. Stones of the iliac ureter are not visible. Treatment requires the patient's confidence so that, due to the quality of the piezo-electric wave, no anaesthesia is necessary. The firing time should be relatively long (45 min to 1 hr) in order to ensure good fragmentation. 26% of patients require retreatment. Secondary complications are rare (3% of endoscopic treatments). The technique is now proposed in 90% of cases without admission to hospital. The simplicity of the manipulation of the apparatus must not mask the fact that it is a technique which requires perfect mastery. Only urologists familiar with stone pathology and who are able to treat the complications of lithotripsy by endoscopy or by surgery should perform extracorporeal lithotripsy.     

Endoscopic treatment of benign tumors of the nose and paranasal sinuses.

OBJECTIVE: The endoscopic approach can be successfully employed for the treatment of benign tumors such as fibroosseus and vascular lesions, pleomorphic adenomas, gliomas, and schwannomas. STUDY DESIGN AND SETTING: Nineteen patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were retrospectively reviewed. The endoscopic approach was used exclusively in 15 cases and was associated with an external approach in 4 cases (due to an intracranial extension of the tumor in 3 patients and its location at the level of the anterior wall of the frontal sinus in the last case). RESULTS: The resection of the lesions was radical in 18 patients and subtotal in 1 case. The mean follow-up was 27 months and only 1 recurrence (5%) was observed in the juvenile angiofibroma group 20 months postoperatively. CONCLUSION: and significance In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.     

Extracorporeal piezoelectric lithotripsy by ultra-short waves using the EDAP LT01 device

Three hundred and sixty one extracorporeal lithotripsies for renal, ureteric and bladder stones have been performed by means of a system of ultrasonographic detection and piezoelectric destruction (EDAP LT01). The localisation of the stone is achieved by a 5 MHz real time sectorial transducer situated in the centre of a small dish containing 320 piezoelectric elements concentrated in a source 5 mm wide by 15 mm high. The pressure recorded in vitro is 900 bars. The stone is easily detected in 87.2% of cases, difficult to detect in 10% of cases and impossible to detect in 28% of cases. By using a frequency of 1.25 to 5 per second, extracorporeal lithotripsy can be performed without any local, regional or general anaesthesia and without premedication in the 120 patients with a renal stone, reviewed between 1 and 3 months, 88 (73%) were considered to be complete successes. Ten (8%) were considered to be failures and 19 (21%) were considered to be partial successes. The best results were obtained in stones of the renal pelvis less than 20 mm in diameter. These results relate to a mean series which must take into account the successive improvements made to the lithotripter. Today, stone fragmentation is obtained in 93% of cases. Thirty six stones of the lumber and pelvic ureter were treated with success rates of 93% and 50%, respectively. Six bladder calculi were treated with a 50% success rate. Forty two patients were treated without being admitted to hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Assay of cytomegalovirus susceptibility to ganciclovir in renal and heart transplant recipients

Ganciclovir (GCV) prophylaxis or pre-emptive therapy significantly reduce the rate of cytomegalovirus (CMV) disease and viremia, but increase the potential for emergence of ganciclovir-resistant CMV strains. The inhibitor concentration at 50% (IC(50)) of GCV from 156 CMV isolates from 59 renal or heart transplant recipients was calculated by means of a rapid phenotypic susceptibility assay. Twenty-seven strains were from 14 patients undergoing GCV therapy. The IC(50) was higher in patients under the prophylaxis regimen. One CMV strain, from a heart transplant recipient, became GCV-resistant after 1 month of therapy (IC(50)=13.7 micromol/l). These data, together with clinical and virological markers, suggested that a switch to foscarnet was necessary, and good evolution was observed. Thus, assay of CMV susceptibility to GCV could be helpful in clinical management.