The NHTAP considers that extracorporeal shock wave lithotripsy ( ESWL) is an important, safe and effective technology for treatment of upper urinary tract stones and supports its introduction into Australia. Decisions on reimbursement for use of the technology need not await further assessment.
Cost per treatment using ESWL will depend on utilisation rate and a number of other variables. At a throughput per machine of 1,000 patients a year all up cost per ESWL treatment would be in the range $3,000 to $3,750, which includes a fixed cost canponent of $765 to $1,025.
In comparison with alternative procedures ESWL is a cost effective technique for stone removal. Although it is more expensive than percutaneous stone removal it appears to involve less cost than open surgery and offers significant patient benefit compared with both of these alternatives.
There will be a need to maintain expertise in the alternative procedures (percutaneous stone removal and open surgery) , which will still be required after ESWL becomes available.
Second generation machines will probably becane available in the next few years, but present planning has to be based on the Dornier lithotripter.
On the basis of existing workload and machine performance, not more than three ESWL units appear necessary for Australia at present. This situation might change in future with availability of lower cost machines, increase in workload and influence of geographical factors.
The placement of ESWL machines presents problems because of the population distribution in this country. The Panel reccmrends that appropriate arrangements are made for all suitable patients in Australia to have access to ESWL treatment. This implies significant transportation costs.
One machine should be located in Sydney and another in Melbourne. Location of a third machine will depend on nunbers and distribution of patients in the smaller States, cost of transportation, spare capacity on the Sydney and Melbourne units, and availability of second generation technology.
The Panel considers it appropriate for urologists to be the specialists responsible for the use of ESWL.
ESWL units should be sited in hospitals which have well developed radiology and urology facilities. Either private or public hospitals could be used, but the interests of both the public and private sectors should be considered in any arrangerrents that are made.
On the basis of overseas experience, the Panel would expect most patients undergoing ESWL to return to the care of their referring specialists very shortly after treatment. Careful consideration will need to be given to ensuring good communication between all specialists involved and the establishment of suitable hospital network arrangements.
The number of persons undergoing treatment for removal of upper urinary tract stones will almost certainly increase following the introduction of ESWL, and this will influence the number of machines which may be required in the future. Use of ESWL machines and developments in the technology should be monitored, and efforts made by governments and professional bodies to agree on criteria for the appropriate application of the technology.