1
|
Brazzelli M, Javanbakht M, Imamura M, Hudson J, Moloney E, Becker F, Wallace S, Omar MI, Shimonovich M, MacLennan G, Ternent L, Vale L, Montgomery I, Mackie P, Saraswat L, Monga A, Craig D. Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation. Health Technol Assess 2020; 23:1-306. [PMID: 30929658 DOI: 10.3310/hta23140] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves. OBJECTIVE To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences. DESIGN An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken. RESULTS Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value. LIMITATIONS Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling. CONCLUSIONS To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates. STUDY REGISTRATION This study is registered as PROSPERO CRD42016049339. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Eoin Moloney
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Frauke Becker
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sheila Wallace
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Laura Ternent
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Luke Vale
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Phil Mackie
- Scottish Public Health Network, NHS Health Scotland, Edinburgh, UK
| | | | - Ash Monga
- University Hospital Southampton Foundation Trust, Southampton, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
2
|
Javanbakht M, Moloney E, Brazzelli M, Wallace S, Ternent L, Omar MI, Monga A, Saraswat L, Mackie P, Becker F, Imamura M, Hudson J, Shimonovich M, MacLennan G, Vale L, Craig D. Economic evaluation of surgical treatments for women with stress urinary incontinence: a cost-utility and value of information analysis. BMJ Open 2020; 10:e035555. [PMID: 32532771 PMCID: PMC7295417 DOI: 10.1136/bmjopen-2019-035555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/06/2020] [Accepted: 05/05/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (MUI) are common conditions that can have a negative impact on the quality of life of patients and serious cost implications for healthcare providers. The objective of this study was to assess the cost-effectiveness of nine different surgical interventions for treatment of SUI and stress-predominant MUI from a National Health Service and personal social services perspective in the UK. METHODS A Markov microsimulation model was developed to compare the costs and effectiveness of nine surgical interventions. The model was informed by undertaking a systematic review of clinical effectiveness and network meta-analysis. The main clinical parameters in the model were the cure and incidence rates of complications after different interventions. The outcomes from the model were expressed in terms of cost per quality-adjusted life-years (QALYs) gained. In addition, expected value of perfect information (EVPI) analyses were conducted to quantify the main uncertainties facing decision-makers. RESULTS The base-case results suggest that retropubic mid-urethral sling (retro-MUS) is the most cost-effective surgical intervention over a 10-year and lifetime time horizon. The probabilistic results show that retro-MUS and traditional sling are the interventions with the highest probability of being cost-effective across all willingness-to-pay thresholds over a lifetime time horizon. The value of information analysis results suggest that the largest value appears to be in removing uncertainty around the incidence rates of complications, the relative treatment effectiveness and health utility values. CONCLUSIONS Although retro-MUS appears, at this stage, to be a cost-effective intervention, research is needed on possible long-term complications of all surgical treatments to provide reassurance of safety, or earlier warning of unanticipated adverse effects. The value of information analysis supports the need, as a first step, for further research to improve our knowledge of the actual incidence of complications.
Collapse
Affiliation(s)
- Mehdi Javanbakht
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sheila Wallace
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Muhammad Imran Omar
- Academic Urology Unit/Cochrane Incontinence Group, University of Aberdeen, Aberdeen, UK
| | - Ash Monga
- Gynaecology, University Hospitals Southampton Foundation Trust, Southampton, UK
| | - Lucky Saraswat
- Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Phil Mackie
- Scottish Public Health Network, NHS Health Scotland, Glasgow, UK
| | - Frauke Becker
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
3
|
Javanbakht M, Moloney E, Brazzelli M, Wallace S, Omar MI, Monga A, Saraswat L, Mackie P, Imamura M, Hudson J, Shimonovich M, MacLennan G, Vale L, Craig D. Surgical treatments for women with stress urinary incontinence: a systematic review of economic evidence. Syst Rev 2020; 9:85. [PMID: 32312310 PMCID: PMC7169003 DOI: 10.1186/s13643-020-01352-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/07/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Surgical interventions for the treatment of stress urinary incontinence (SUI) in women are commonly employed following the failure of minimally invasive therapies. Due to the limited information available on the relative cost-effectiveness of available surgeries for treating SUI, a de novo economic analysis was conducted to assess costs and effects of all relevant surgeries. To inform the economic analysis, the objective of this review was to identify and assess the quality of existing economic evaluation studies on different surgical interventions for the treatment of SUI in women. METHODS The following databases were searched during the review process: Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process, Excerpta Medica Database (Embase), National Health Service Economic Evaluation Database (NHS EED), and Health Management Information Consortium and Cost-Effectiveness Analysis Registry (CEA registry). The key criteria for inclusion were that the study population included women with SUI and that the surgical interventions considered were utilised as either a primary or a follow-up surgery. The review included only full economic evaluations. Studies were quality assessed using the Drummond checklist for economic evaluations. No quantitative synthesis of the results by meta-analysis was conducted due to the high methodological heterogeneity. RESULTS Twenty-six economic evaluations were included, of which 13 were model-based analyses. Surgical treatments assessed most frequently were mid-urethral slings and open and laparoscopic colposuspension. There were some differences in the methodological approaches taken, including differences in type of economic analysis, perspective, time horizon, types of resource use, and costs and outcomes that were included in the analysis. The majority of studies conducted a cost-utility analysis from a health system perspective and applied a time horizon of between 1 and 5 years. The cost-effectiveness results suggest that single-incision mini-sling and mid-urethral slings are among the most cost-effective options. CONCLUSIONS The review has shown that methods used for the economic evaluation of surgical treatments for SUI vary widely in terms of study design, analysis type, compared alternatives, time horizon, costing methodologies and effect outcomes. Future economic evaluation studies on surgical treatments for SUI may be improved by the application of available guidelines. SYSTEMATIC REVIEW REGISTRATION Registered in PROSPERO in 2016, CRD42016049339.
Collapse
Affiliation(s)
- Mehdi Javanbakht
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Eoin Moloney
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sheila Wallace
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Muhammad Imran Omar
- Guidelines Office Methodology Supervisor, European Association of Urology, Arnhem, Netherlands
| | - Ash Monga
- University Hospitals Southampton Foundation Trust, Southampton, UK
| | | | - Phil Mackie
- Scottish Public Health Network, NHS Health Scotland, Glasgow, UK
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Dawn Craig
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| |
Collapse
|
4
|
Villoro R, Merino M, Hidalgo-Vega A, Jiménez M, Martínez L, Aracil J. Women with urinary incontinence in Spain: Health-related quality of life and the use of healthcare resources. Maturitas 2016; 94:52-57. [PMID: 27823745 DOI: 10.1016/j.maturitas.2016.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/03/2016] [Accepted: 08/18/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe Health-Related Quality of Life (HRQOL) and healthcare resource utilization in women aged 60 and over in Spain. DESIGN Descriptive analysis of primary data from the Spanish National Health Survey, 2012. MAIN OUTCOME MEASURES Utility indices were obtained through the EQ5D5L questionnaire included in the survey, and utilization rates of consultations, hospitalizations, emergency services, and medication intake. HRQOL and utilization rates were systematically compared between women diagnosed with UI, women diagnosed with other chronic conditions (OCC) and healthy women of the same age. RESULTS Utility indices were 0.47 in UI women versus 0.78 and 0.96 in women diagnosed with OCC and healthy women, respectively. Each year 351,675 Quality Adjusted Life Years are lost in Spain due to UI in the population of women aged 60 and over. Resource utilization of these women was significantly higher than that of other women. CONCLUSIONS UI has a larger impact on both HRQOL and healthcare consumption in women who are aged 60 and over, than OCC. Appropriate treatment of UI might entail an important gain in terms of HRQOL and a significant reduction in healthcare consumption in Spain.
Collapse
Affiliation(s)
- Renata Villoro
- Instituto Max Weber, Calle Las Norias, 123, Majadahonda, 28221 Madrid, Spain.
| | - María Merino
- Instituto Max Weber, Calle Las Norias, 123, Majadahonda, 28221 Madrid, Spain
| | - Alvaro Hidalgo-Vega
- Department of Economics, Universidad de Castilla-La Mancha, Facultad de Ciencias Jurídicas y Sociales de Toledo, Cobertizo de San Pedro Mártir s/n., Toledo, 45071, Spain
| | - Margarita Jiménez
- Instituto Max Weber, Calle Las Norias, 123, Majadahonda, 28221 Madrid, Spain
| | - Lucía Martínez
- Instituto Max Weber, Calle Las Norias, 123, Majadahonda, 28221 Madrid, Spain
| | - Javier Aracil
- Allergan, International Market Access Area, 1st floor Marlow International Parkway, Marlow, Bucks SL7 1YL, United Kingdom
| |
Collapse
|