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Downstream Costs of Traditional and Suction Ureteral Access Sheaths: A Decision Analysis
Jonathan J. Song, BS1, Samuel Z. Lee, BA1, Juliana Villanueva Congote, MD2, Daniel A Wollin A. Wollin, MD2.
1Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA, 2Department of Urology, Brigham and Women's Hospital, Boston, MA, USA.
Introduction: Ureteral access sheath (UAS) use for laser lithotripsy varies greatly. It is unknown whether improved stone clearance with Flexible and Navigable Suction UAS (FANS) offsets substantial material cost. We assessed cost and social implications of UAS vs FANS use strategies.
Methods: We created a decision analysis model from the provider perspective. Outcome rates and costs were determined from weighted-average estimates from published literature, including sheath placement, ureteral dilatation, ureteral perforation, postoperative stenting, ED returns, rehospitalizations, stone-free rate, and delayed stricture. Monte Carlo simulations of a yearly US cohort (n=60,000) were performed over 1,000 iterations. We reported average incremental costs (95% CI) per patient for different sheath strategies relative to no sheath use.
Results: Routine UAS use added $1140.42 (1139.6-1141.23) and 0.25 days off work per patient. Routine FANS use was less cost-adding, with added cost of $1006.28 (1005.62-1006.95) and additional 0.04 days off work. Using UAS for stones <2cm and FANS for stones 2cm resulted in added cost of $1054.17 (1053.41-1054.93) and 0.17 days off, while omitting sheath for stones <2cm while using FANS for stones 2cm resulted in average added cost of $340.74 (340.05-341.43) and 0.02 days off.
Conclusions: Routine use of FANS led to relative cost savings compared to UAS. Use of FANS while omitting sheath use for stones <2cm minimized incremental costs and productivity impact. While routine FANS use was not cost saving, judicious omission of sheath for smaller stones can decrease added costs and social impact.
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