Economic evaluation of surgical treatments for women with stress urinary incontinence: a cost-utility and value of information analysis

Comparison of acupuncture and moxibustion related non-surgical therapies for women with stress urinary incontinence: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Stress urinary incontinence (SUI) significantly impacts women's health and imposes substantial mental and socio-economic burdens. Acupuncture and moxibustion, either alone or in combination with other non-surgical therapies, are recognized as effective treatments for SUI. This study aimed to assess the efficacy of various treatments for women with SUI using network meta-analysis (NMA).

METHOD

We systematically searched databases up until June 30, 2022, to identify relevant randomized controlled trials (RCTs) focusing on SUI in women. Subsequently, the quality of the included studies was assessed. NMA was performed using STATA 14.0 software.

RESULTS

A total of 31 RCTs involving 2922 participants were included in the analysis. A total of 18 treatment plans were identified. The treatment plan consisting of Moxibustion + PFMT + EB demonstrated the most significant reduction in ICIQ-UI-SF. Due to lack of consistency across studies, a NMA was not performed for the outcomes of effectiveness and the 1 h pad test.

CONCLUSIONS

The combined intervention of Moxibustion + PFMT + EB appears to be the most effective in reducing patients' reported symptoms and improving their quality of life. However, due to the limitations of the included studies, further high-quality RCTs are necessary to reinforce the current evidence.

Sequential combined approach in patients with mixed urinary incontinence: surgery followed by posterior tibial nerve stimulation

BACKGROUND

The aim of the study was to demonstrate the efficacy of sequential combined treatment with transobturator tape (TOT) followed by posterior tibial nerve stimulation (PTNS) in patients with mixed urinary incontinence (MUI); quality of life and patients' satisfaction was also assessed.

METHODS

Retrospective analysis on women affected by MUI with prevalent Stress Urinary Incontinence (SUI) component. Women, divided in 2 groups, underwent different treatments, TOT vs. TOT+PTNS. Population was assessed by medical history, previous pelvic surgery, clinical exam, urodynamic exams, pelvic ultrasound examination, and questionnaires (The International Consultation on Incontinence Questionnaire Short Form, Overactive Bladder Questionnaire, Health Related Quality of Life) comparing them before and after 12 weeks after treatment.

RESULTS

One hundred twelve women were enrolled in the study. The mean age was 57.96±7.34 in the first group (N.=60) and 58.29±6.14 in the second group (N.=52). Peak flow (mL/s) statistically improved after treatment, 22.23±4.29 (TOT) vs. 24.81±5.8 (TOT+PTNS). First voiding desire (mL) improved significantly between the two groups 108.72±19.24 vs. 142.43±19.98. Maximum cystometric capacity (mL) in the TOT group at 12-weeks was 328.76±82.44 vs. TOT+PTNS group of 396.26±91.21. Detrusor pressure at peak flow(cmH2O) showed a greater improvement in TOT+PTNS than TOT alone 14.45±6.10 vs. 11.89±54.49. At 12-week, urinary diary and quality of life improved in terms of urgent urination events, mean number of voids, urge symptoms and nocturia events. The Patient Impression of Global Improvement (PGI-I) after 3 months was better in combined group.

CONCLUSIONS

Combined and sequential TOT+PTNS is more effective compared to TOT alone in MUI patients with prevalent SUI component.

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery

IMPORTANCE

There are no guidelines regarding the ideal timing of midurethral sling (MUS) placement following prolapse repair.

OBJECTIVE

The objective of this study was to estimate the cost-utility of concomitant MUS versus staged MUS among women undergoing apical suspension surgery for pelvic organ prolapse.

STUDY DESIGN

Cost-utility modeling using a decision analysis tree compared concomitant MUS with staged MUS over a 1-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER). Six scenarios were modeled to estimate cost-utilities for women with preoperative overt, occult, or no stress urinary incontinence (SUI) who underwent either minimally invasive sacrocolpopexy or vaginal native tissue apical suspension. Possible complications of de novo overactive bladder, urinary retention requiring sling lysis, mesh exposure, and persistent SUI were included. Costs from a third-party payer perspective were derived from Medicare 2022 reimbursements. One-way sensitivity analyses were performed.

RESULTS

Among women without preoperative SUI, staged MUS was the dominant strategy for both surgical routes with higher utility and lower costs. For women with either occult or overt SUI undergoing sacrocolpopexy or vaginal repair, concomitant MUS was cost-effective (ICER = $21,114-$96,536 per quality-adjusted life-year). Therefore, concomitant MUS is preferred for patients with preoperative SUI as higher costs were offset by higher effectiveness. One-way sensitivity analyses demonstrated that ICERs were most affected by probability of cure following MUS.

CONCLUSIONS

A staged MUS procedure is the dominant strategy for women undergoing apical prolapse repair without preoperative SUI. In women with either overt or occult SUI, the ICER was below the willingness-to-pay threshold of $100,000 per quality-adjusted life-year, suggesting that concomitant MUS surgery is cost-effective.

Single Incision Midurethral Sling Site of Care: Office-based Ambulatory Surgical Unit versus Hosptial-based Ambulatory Surgical Unit Setting

STUDY OBJECTIVE

To compare the economic difference in terms of overall costs between two Ambulatory Surgical Unit (ASU) settings in which a midurethral single incision sling (MSIS) can be performed.

DESIGN

A retrospective cohort study was carried out, examining the implanting of an MSIS performed at two different ASU settings by a single surgeon. Total cost was determined by assessing differences in charges and subsequent reimbursement associated with the procedure at each ASU setting. Time was measured using an EMR system for tracking both patient entry/exit from the facility as well as intraoperative time. Adverse events commonly associated with the procedure and patient-reported unanticipated adverse events were collected. A validated Surgical Satisfaction Questionnaire was administered postoperatively.

SETTING

University Health Network Teaching Hospital.

PATIENTS

A total of 125 women with stress urinary incontinence.

INTERVENTION

MSIS.

MEASUREMENT AND MAIN RESULTS

Between January 2016 until August 2020, 125 women underwent an MSIS procedure. The total office-based ASU (O-ASU) charges averaged $4564.00 (reimbursement of $2642.07). The total hospital-based ASU (H-ASU) charges averaged $40 136 (reimbursement of $9000), as well as an anesthesia average charge of $800 (reimbursement of $500). The average O-ASU total patient encounter time was 53.76 minutes versus 344.702 minutes for the H-ASU. There was no difference between commonly associated or unanticipated adverse events nor global patient satisfaction.

CONCLUSIONS

Based on overall cost, total encounter time, and global patient satisfaction, a certified O-ASU is an optimal site of care for MSIS for surgical management of female stress urinary incontinence.

Cost-effectiveness Analysis: Autologous Rectus Fascial Sling Versus Retropubic Midurethral Sling for Female Stress Urinary Incontinence

IMPORTANCE

There are limited data on the economic comparison between retropubic midurethral sling and autologous fascial sling.

OBJECTIVE

This study aims to evaluate the cost-effectiveness of autologous rectus fascial sling compared with retropubic midurethral sling from both hospital and health care perspectives.

STUDY DESIGN

A decision tree model was developed with 1 year of follow-up. We included variables such as objective success rate, complications and subsequent treatments, and retreatment for incontinence. The model included the index procedure and 1 retreatment for stress urinary incontinence. Cost estimates were calculated from both hospital and health care perspectives. The outcomes were expressed in incremental cost-effectiveness ratio (ICER) or cost per quality-adjusted life-year (QALY). An ICER <$50,000/QALY was considered cost-effective.

RESULTS

From a hospital perspective, the overall cost of retropubic midurethral sling was higher than autologous rectus fascial sling ($2,348.94 vs $2,114.06), but was more effective (0.82 vs 0.80 QALYs). The ICER was $17,452/QALY. From a health care perspective, the overall cost of autologous rectus fascial sling was higher than retropubic midurethral sling ($4,656.63 vs $4,630.47) and was less effective. Retropubic midurethral sling was the dominant strategy, with ICER of -$1,943.32/QALY. If the success rate of autologous rectus fascial sling was ≥84.39%, or the cost of retropubic midurethral sling surgery was > $2,654.36, then autologous rectus fascial sling would become cost-effective.

CONCLUSIONS

Retropubic midurethral sling is the cost-effective treatment from the hospital perspective and the dominant treatment from the health care perspective. However, changes in the costs and success rates of surgical procedures can alter the cost-effectiveness results.

Posttransplant Hepatocellular Carcinoma Surveillance: A Cost-effectiveness and Cost-utility Analysis

OBJECTIVE

Assess cost-effectiveness and -utility associated with posttransplant HCC surveillance compared to standard follow-up.

SUMMARY OF BACKGROUND DATA

Despite lack of prospective clinical data, expert consensus recommends posttransplant surveillance to detect HCC recurrence in a latent phase, while it might be amenable to curative-intent therapy.

METHODS

A Markov-based transition model was created to estimate life expectancy and quality-of-life among liver transplant patients undergoing HCC surveillance. Models were built for 2 cohorts: 1 undergoing HCC surveillance with contrast-enhanced computed tomography of chest and abdomen and serum alpha-fetoprotein analysis and the other receiving standard posttransplant follow-up. Primary model outputs included LY and QALY gains, incremental cost-effectiveness ratio, and incremental cost-utility ratio. Willingness-to-pay for a QALY gain (cost-effectiveness threshold) was used to estimate efficiency.

RESULTS

Surveillance was marginally more effective versus no surveillance, resulting in means of 0.069 LYs and 0.026 QALYs gained. Costs for surveillance were increased by an average of 988.32€, resulting in incremental cost-effectiveness ratio 14,410.15€/LY and incremental cost-utility ratio 37,547.97€/QALY. Surveillance did not seem cost-effective in our setting, considering willingness-to-pay threshold of 25,000€/QALY. Probabilistic sensitivity analysis indicated surveillance might be cost-effective in 42% of cases, but degree of uncertainty in the analysis was high.

CONCLUSIONS

Performing posttransplant HCC surveillance offers marginal clinical benefits and increases costs. Although expert consensus supports surveillance, results of this decision analysis raise doubt regarding the utility of such recommendations and support ongoing need for prospective clinical trials.

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study

OBJECTIVE

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up.

DESIGN

Prospective, two-arm cohort study with 2-year follow-up.

SETTING

International multicentre.

POPULATION

Women with moderate to severe SUI.

MAIN OUTCOME MEASURES

Primary outcome was subjective cure (Patient Global Impression of Improvement).

SECONDARY OUTCOMES

objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders).

RESULTS

In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L.

CONCLUSION

MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

Group-based pelvic floor muscle training is a more cost-effective approach to treat urinary incontinence in older women: economic analysis of a randomised trial

QUESTION(S)

How cost-effective is group-based pelvic floor muscle training (PFMT) for treating urinary incontinence in older women?

DESIGN

Economic evaluation conducted alongside an assessor-blinded, multicentre randomised non-inferiority trial with 1-year follow-up.

PARTICIPANTS

A total of 362 women aged ≥ 60 years with stress or mixed urinary incontinence.

INTERVENTION

Twelve weekly 1-hour PFMT sessions delivered individually (one physiotherapist per woman) or in groups (one physiotherapist per eight women).

OUTCOME MEASURES

Urinary incontinence-related costs per woman were estimated from a participant and provider perspective over 1 year in Canadian dollars, 2019. Effectiveness was based on reduction in leakage episodes and quality-adjusted life years. Incremental cost-effectiveness ratios and net monetary benefit were calculated for each of the effectiveness outcomes and perspectives.

RESULTS

Both group-based and individual PFMT were effective in reducing leakage and promoting gains in quality-adjusted life years. Furthermore, group-based PFMT was ≥ 60% less costly than individual treatment, regardless of the perspective studied: -$914 (95% CI -970 to -863) from the participant's perspective and -$509 (95% CI -523 to -496) from the provider's perspective. Differences in effects between study arms were minor and negligible. Adherence to treatment was high, with low loss to follow-up and no between-group differences.

CONCLUSION

Compared with standard individual PFMT, group-based PFMT was less costly and as clinically effective and widely accepted. These results indicate that patients and healthcare decision-makers should consider group-based PFMT to be a cost-effective first-line treatment option for urinary incontinence.

TRIAL REGISTRATION

ClinicalTrials.govNCT02039830.