Long-Term Cost Analysis of Third-Line Treatment Options for Overactive Bladder

INTRODUCTION

We aimed to analyze the long-term cost of overactive bladder third-line treatments.

METHODS

This insurance claims review analyzed the 2015 to 2020 MarketScan (MKS) claims data set subjects age ≥ 18, diagnosis of overactive bladder (OAB) using ICD-9/ICD-10 codes and receipt of treatment for percutaneous tibial nerve stimulation, sacral neuromodulation (SNM), or botulinum A. Age, gender, treatment types, and cost were extracted. Treatment costs were aggregated at the level of patient and treatment type for total payment and patient contribution by combining copay, coinsurance, and deductible. We used the Wilcoxon rank-sum test for continuous and chi-square test for categorical variables. SAS v9.4 was used for analyses. Significance was set at P < .05.

RESULTS

We identified 17,755 patients from the commercial claims MKS and 10,912 patients from the Medicare supplemental (MDC) database with mean age 50.7±11.1 and 75.5±7.6 years, respectively, who underwent ≥ 1 third-line OAB treatment. Patients receiving third-line treatment were predominantly female (84.9%, MKS, 74.8%, MDC). Long-term costs over a 15-year period were estimated. Percutaneous tibial nerve stimulation is the most expensive in terms of total net payment ($105,337.50 MKS, $94,102.50 MDC) and patient contribution ($9177.60 MKS, $3921.00 MDC). Total net payment for botulinum A was $67,968 (MSK), $54,261 (MDC), and patient contribution cost was $2850 (MSK), $1110 (MDC). The most cost-effective option was SNM in terms of both total net payment ($5179.10 MKS, $6099.00 MDC) and patient contribution ($59.10 MKS, $60.00 MDC).

CONCLUSIONS

SNM was the most cost-effective third-line treatment for OAB looking over a 15-year period in terms of both total net payment and patient contribution.

Microhematuria in Women: Prevalence of Malignancy and Risk Score Evaluation

OBJECTIVES

To (1) determine the prevalence of urologic malignancy in women evaluated for microhematuria (MH) in a large university-based urology practice, (2) describe clinical features shared by women with MH, and (3) evaluate a risk score for urologic malignancy in women with MH.

METHODS

A retrospective chart review identified women with MH evaluated by a large, university-based urology practice between 2010 and 2020. Clinical and demographic variables associated with their evaluation, referral pattern, appropriateness of referral and evaluation, workup completed, and resulting diagnoses were reported. Patterns of repeat evaluations were also described. Patients were stratified as low-, intermediate-, or high-risk according to AUA/SUFU recommended risk stratification.

RESULTS

4456 charts resulted from an initial query based on females with ICD-9 and ICD-10 codes for MH between 2010-2020. 1730 patients (95.5% referrals v. 4.5% established urology patients) met criteria for inclusion in the study, and 1350 underwent evaluation for MH at the practice. Over 30% of referrals were considered inappropriate. 13 patients were diagnosed with urologic malignancy, all of whom were classified as intermediate- or high-risk according to AUA/SUFU criteria. Over 10% of patients had at least 2 evaluations for MH, with only 1 malignancy discovered on repeat evaluation for persistent MH.

CONCLUSIONS

Inappropriate referrals for MH are common. Incidence of urologic malignancy is incredibly low among women evaluated for MH, but especially among those classified as low- and intermediate-risk by new guidelines. Repeat evaluations for persistent, stable MH appear low yield in detecting malignancy.

Vaginal cuff pyoderma gangrenosum with associated ureteral stricture: A case report

Pyoderma gangrenosum is a sterile inflammatory disease of unknown etiology characterized by recurrent cutaneous ulcers. It can occur in extracutaneous locations, especially at operative sites, and has been reported following gynecologic surgery. This report is the first case of pyoderma gangrenosum as a remote complication of pelvic surgery with associated ureteral stricture. It demonstrates the diagnostic challenge of this rare disease and the importance of broadening the differential diagnosis when apparent infections do not respond to treatment to minimize the morbidity of ineffective antibiotic and surgical interventions.

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries

Importance

Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries.

Objective

To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists.

Design, Setting, and Participants

This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019.

Main Outcomes and Measures

Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified.

Results

Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist.

Conclusions and Relevance

Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Female pelvic medicine and reconstructive surgery practice patterns: IUGA member survey

INTRODUCTION AND HYPOTHESIS

The purpose of this study is to describe the current practice patterns of the International Urogynecological Association (IUGA) members regarding the diagnosis, evaluation, and surgical management of stress urinary incontinence (SUI) and pelvic organ prolapse (POP).

METHODS

A 30-item internet-based survey was sent to IUGA members. Response to the survey was voluntary, and subjects answered questions regarding demographics, the evaluation of POP and SUI, including urodynamics (UDS) testing, preferred management of POP and SUI, and the application of mesh in reconstructive surgery.

RESULTS

Three hundred and thirty-four IUGA members responded to the survey; most of the responses were from Europe (40 %) and North America (23 %). After the FDA safety communication regarding serious complications of using transvaginal mesh, 45 % of responders reported decreased use of mesh, while 31 % reported that it had no effect or that they did not use mesh for transvaginal prolapse (23.6 %). Regarding the evaluation and treatment of SUI, 51 % of responders would perform urodynamics (UDS) before surgical correction of uncomplicated SUI and 78.5 % of responders would perform UDS if no urine leakage was demonstrated on examination. The preferred method of treatment for SUI is midurethral sling (MUS), regardless of prior treatments (65.1 %), concomitant surgeries (74.5 %), or examination findings (50.8-92.6 %). Regarding POP repair, the preferred approach for apical (61 %) and posterior (99.4 %) prolapse repair is vaginal.

CONCLUSIONS

Most respondents use a vaginal approach for POP surgery. The FDA safety communication regarding serious complications related to the use of transvaginal mesh for prolapse surgery led to a global decrease in the employment of mesh for POP. Synthetic midurethral slings are predominant in the current treatment of SUI. Despite new recommendations, many responders still perform UDS for uncomplicated SUI.

Patterns of care for renal surgery: Underutilization of nephron-sparing procedures

BACKGROUND

Nephron-sparing procedures are well-described, provide similar oncologic outcomes to nephrectomy, and potentially decrease morbidity as compared to nephrectomy.

METHODS

We analyzed academic and community health system data from Virginia and Kentucky to evaluate the utilization and cost of nephron-sparing procedures. Primary International Classification of Disease (ICD-9) diagnosis and procedure codes were employed to target subjects of interest.

RESULTS

In total, we analyzed 3809 subjects from Virginia and 3163 subjects from Kentucky between 2004 and 2009 who underwent treatment of a malignant renal mass. There has been a 6.1% and 14.8% decrease in nephrectomy utilization in Virginia and Kentucky, respectively, since 2004. In 2009, 71.4% and 68.8% of all procedures for the treatment of renal masses were radical nephrectomies. The proportion of nephron-sparing procedures has increased in academic (20%) and community (15%) health systems since 2004. The difference in cost between nephrectomy, partial nephrectomy and ablative therapy in Virginia and Kentucky hospitals was negligible (p > 0.05).

CONCLUSIONS

Nephron-sparing procedures have been increasingly employed over the last 6 years, but are still underutilized. There does not appear to be a significant cost difference in the treatment of renal masses with nephrectomy, partial nephrectomy or ablative therapies.

Patterns of care for renal surgery: Underutilization of nephron-sparing procedures

Background: Nephron-sparing procedures are well-described, provide similar oncologic outcomes to nephrectomy, and potentially decrease morbidity as compared to nephrectomy.Methods: We analyzed academic and community health system data from Virginia and Kentucky to evaluate the utilization and cost of nephron-sparing procedures. Primary International Classification of Disease (ICD-9) diagnosis and procedure codes were employed to target subjects of interest.Results: In total, we analyzed 3809 subjects from Virginia and 3163 subjects from Kentucky between 2004 and 2009 who underwent treatment of a malignant renal mass. There has been a 6.1% and 14.8% decrease in nephrectomy utilization in Virginia and Kentucky, respectively, since 2004. In 2009, 71.4% and 68.8% of all procedures for the treatment of renal masses were radical nephrectomies. The proportion of nephron-sparing procedures has increased in academic (20%) and community (15%) health systems since 2004. The difference in cost between nephrectomy, partial nephrectomy and ablative therapy in Virginia and Kentucky hospitals was negligible (p > 0.05).Conclusions: Nephron-sparing procedures have been increasingly employed over the last 6 years, but are still underutilized. There does not appear to be a significant cost difference in the treatment of renal masses with nephrectomy, partial nephrectomy or ablative therapies.

Adolescent pelvic pain: interstitial cystitis

Interstitial cystitis (IC) is a syndrome characterized by urinary urgency and frequency, dysuria, nocturia, and suprapubic pain. Patients are often difficult to treat due to the phenotypic heterogeneity of the disease and the limited efficacy of the treatment options. Treatment regimens must be individualized and tailored through a process of trial and error. There is a paucity of information regarding the treatment of adolescent IC. Here we report a case of a 13-year-old girl with IC who required multiple management strategies prior to obtaining symptomatic relief. We outline our treatment protocols based on the American Urologic Association IC treatment algorithm.

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience

OBJECTIVES

To evaluate the overall survival (OS) and disease-specific survival (DSS) in men receiving primary androgen-deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer.

PATIENTS AND METHODS

After Institutional Review Board approval, we retrospectively reviewed patients receiving ADT for prostate cancer between July 1987 and June 2007. Variables included age at diagnosis and ADT induction, race, PSA level before ADT, ADT schedule (continuous/intermittent), clinical/pathological stage, hormone-refractory prostate cancer (HRCP) status, PADT or SADT, and deaths.

RESULTS

In all, 548 men were analysed. The mean age at diagnosis and ADT induction were 70.1 and 72.3 years, respectively, and 321 (58.6%) were African-American. The median PSA level before ADT was 16.3 ng/mL. ADT was administered continuously in 497 (90.7%) patients; 342 (62.4%) received PADT while 206 (37.6%) received SADT. At mean (range) follow-up of 81.8 (2.1-445) months, 98 (17.9%) deaths occurred; 31 (31.6%) were cancer-specific. The OS and DSS in the PADT and SADT groups were not significantly different (P = 0.36 and P = 0.81, respectively). Mortality rates/distributions were similar between groups (P = 0.68). Multivariate predictors of OS and DSS included age at diagnosis (P = 0.03) and ADT induction (P = 0.009), tumour stage (P < 0.001), and PSA level at ADT induction (P = 0.01). Progression to HRPC worsened OS and DSS (both P < 0.001).

CONCLUSION

PADT and SADT prolong survival in men with prostate cancer. HRPC portends a poor DSS. Age at diagnosis and ADT induction, PSA level before ADT, and disease stage predict both OS and DSS in this population. However, most men died from causes unrelated to prostate cancer, thus questioning the true value of ADT in prolonging patient survival.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer

OBJECTIVE

Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer.

MATERIALS AND METHODS

We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant.

RESULTS

Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups.

CONCLUSIONS

De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.

Postinversion responses to inversion in normal subjects

The purpose of this study was to determine cardiac output and related cardiovascular responses during postinversion by comparing preinversion (baseline data) to postinversion data in healthy, normal subjects. Each of 20 subjects (means = 22 years) was inverted for five minutes. Cardiac output was measured noninvasively with the Beckman MMC and CO2 rebreathing program. ANOVA with repeated measures was used to determine significance of change between preinversion and postinversion values. The alpha level was set at 0.05 for statistical significance. During postinversion stand, there were (a) significant decreases in oxygen uptake (p less than 0.0008), cardiac output (p less than 0.0005), and stroke volume (p less than 0.0018); (b) significant increases in arteriovenous oxygen difference (p less than 0.0281), peripheral vascular resistance (p less than 0.0001), and diastolic blood pressure (p less than 0.0087); and (c) nonsignificant changes in heart rate, systolic blood pressure, and double product from the preinversion baseline standing position. The results demonstrate little if any need for concern for a subject's return to the upright position.