Cost-effectiveness of extracorporeal shock wave lithotripsy in a poor resource setting: The Okada, Nigeria experience

Abstract

Background:The first extracorporeal shock wave lithotripsy (ESWL) used in Nigeria was at Igbinedion Hospital and Medical Research Centre (IHMRC), Okada in 1992 and it functioned for 6 consecutive years. The objectives of this study were to analyze the cost-effectiveness of the procedure and highlight the associated factors that led to its failure.Methods:A retrospective study of medical records and publications associated with the use of ESWL at IHMRC, Okada, for the period of 1992 to 1998. The study was conducted between January 2003 and November 2008. Unclassified authentic information relating to the use of ESWL and treatment of upper urinary tract stones was obtained from the IHMRC Okada and some government hospitals on hospital bills. Relevant documents in public domains related to the national and international wages and emoluments of medical workers and socioeconomic development of Nigeria within the time the ESWL functioned were studied.Result:A total of 32 patients were treated with 51 treatment sessions which is an average of nine patients per year and an average of two treatment sessions per patient were involved. The reasons for the low patronage were the extremely low stone formation rate of Nigerians, poverty, and out-of-pocket payment system. In addition, each treatment session of ESWL at Okada cost an average of $681.8 compared to $227.3 for open nephrolithotomy in a nearby high profile teaching hospital. The IHMRC, Okada, paid an average annual salary of ₦180,000 ($8,181.8) for each medical consultant compared to ₦120,000 ($5,454.5) paid by federal teaching hospitals in Nigeria within the period. Expatriate consultant doctors from Europe and USA who initially manned the lithotriptor at IHMRC, Okada, were paid much higher salaries. Average annual income of $5,909 for each of the 6 years amounting to a total of $34,771.7 for the six years was realized which could not maintain staff salaries in the hospital leading to staff emigration, decline of the hospital services, and eventual closure of the ESWL procedure center in the hospital in 1998.Conclusion:ESWL at Okada was not cost-effective both to patients and the hospital management. Despite these, ESWL is desirable in poor-resource countries because of its noninvasiveness, low morbidity, and usability in patients who are unfit for open surgery. Purchasing high technological medical equipment as commodities by sub-Saharan Africans without considering the prevalence of diseases they are meant to cater for, their maintenance for steady function during useful lifespan, their cost-effectiveness and how to recoup the money spent on investments depletes the scarce foreign exchange reserve of the home countries and is eventually counterproductive as exemplified by this case.

A 5-Year Review of the Presentation and Management of Urolithiasis in a Nigerian Teaching Hospital

“…Some authors have indeed documented that some of these minimally invasive treatment options for urolithiasis may actually not be cost effective for patients and hospital management in some resource poor regions like Nigeria. [33] When safely done, open stone surgery still holds a strong position in the management of urolithiasis especially for complicated cases and complex stone burden. [34]…”

Open Stone Surgery: Still-in-Use Approach for Complex Stone Burden

“…In this review, possible cost-effective applications of open surgery in developing countries were reported [ 14 ]. Open surgery was also offered as a cost-effective treatment modality for developing countries with respectively low urinary stone prevalence [ 16 ]. In their report including 43 urinary stone patients, Esen et al compared patients who were managed with SWL monotherapy, SWL and PCNL combination therapy or open stone surgery.…”

Stone disease in low‐ and middle‐income countries: could augmented reality have a role in its management?

“…In lower-incidence countries in SSA, the economic consequences of nephrolithiasis are still marked. LMICs can rarely afford a HIC standard of care, at a governmental or institutional level [3] and, in a country without UHC, its impact on the individual is substantial. Coupled with difficulties in accessing healthcare, patients in LMICs, therefore, often present late with a significant calculus burden, or complications from their stone, which is usually treated by an open surgical approach due to a significant reduction in the availability of less-invasive management options.…”

“…Although the preferred management options when stones demand surgical intervention in HICs, the availability of minimally invasive techniques is limited in LMICs for a variety of economic reasons. First, the relatively low prevalence of nephrolithiasis and the higher incidence of bladder stones in the large paediatric population, makes ESWL an uneconomic proposition for most low-resource settings [3]. Second, endoscopic stone surgery is not widely practiced due to difficulties in funding the capital, or maintenance, costs of relatively high-tech equipment, and the imaging modalities required to facilitate less invasive surgery [35].…”

“…Urinary stone disease can affect the upper or lower urinary tracts. In high-income countries (HICs) urolithiasis predominantly affects the kidney, in both sexes, between the ages of 20 and 60 years [1], whereas there is a much greater incidence of lower urinary tract stones, in a younger age group, in countries in Sub-Saharan Africa (SSA) [2,3]. Paediatric vesical calculi are endemic in communities where there is a low dietary protein intake, poor hydration, and recurrent diarrhoea, which leads to the development of ammonium acid urate stones in the bladder; it is virtually unknown in HIC environments [4].…”