SUFU Winter Meeting 2013 - Neurostimulation treatment for overactive bladder (OAB): An evaluation of cost effectiveness data - Session Highlights

LAS VEGAS, NV USA (UroToday.com) - Dr. Scott MacDiarmid started by mentioning the new guidelines for diagnosis and treatment of OAB (non-neurogenic) in adults.  He quickly went over first-line treatment which includes behavioral therapies for all patients, and this may be combined with antimuscarinics that are listed under second-line treatment.

The antimuscarinics can be given either as oral or transdermal treatment. Dr. MacDiarmid also mentioned a new medication that would fall under second-line treatment but was not approved by the FDA by the time the OAB guidelines were written and that is the new β3 agonist – mirabegron. But the focus of his presentation would be two of the therapies listed under third-line treatments, which he refers to as refractory or neuromodulation therapies: Sacral Neuromodulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS).

sufuBefore he went into the details about SNS and PTNS, Dr. MacDiarmid had some comments for the audience where he strongly expressed that he feels the therapies listed under third-line treatments (SNS, PTNS, and onabotulinumtoxinA) all are being underutilized and could be used in many more patients with OAB. In his opinion, all clinicians should consider being more liberal in offering and using all three of these therapies if they want to elevate the care of OAB patients. He also told the audience that he is a little disappointed with the new OAB guidelines as the “fine print” regarding the third-line treatments says that these options should “only be considered in carefully selected patients and not be combined.” Dr. MacDiarmid expressed his concern with this and said he does not agree; he thinks many more OAB patients would benefit from all three of these therapies and they may also be combined.

He went on to compare the therapies in order to find out which one is better but stated that this question has not really been answered yet. There have not been any head-to-head clinical trials to compare them so it is really up to the patient, with the help of the physician, to decide which of the therapies they prefer. None of them is a panacea or perfect, but as Dr. MacDiarmid emphasized, the fatal flaw is really to only offer or use one of these treatments; all clinicians should be offering and use all three treatments for their refractory OAB patients.

He continued to discuss whether cost matters when choosing between these therapies and he referred to himself being somewhat of a dinosaur in this case as he is from Canada and practices in the US, and he feels that medicine in the US is not practiced in a cost-effective way. At the same time he acknowledges that the world has changed and there is a new paradigm where cost really matters. He mentioned that for third-party payers, healthcare systems, and the government etc., cost effectiveness is really important and cost-effectiveness analysis is here to stay.

In the study that Dr. MacDiarmid was part of, where they wanted to look at cost effectiveness, the objective was to estimate the cost and cost effectiveness of initial and on-going therapy with PTNS and SNS in patients with OAB. They used a Markov model and looked at data from three years as there is published PTNS data available from three years now. They looked at it from a third-party payer perspective to see what it would cost now and used average national Medicare payments. Literature was used to find effectiveness, adherence rates, long-term effectiveness, and adverse-event rates (AEs).

The results are outlined in the table below:

sufu macdiarmid thumb

Dr. MacDiarmid pointed out that the initial cost for PTNS was $1,773 vs $24,438 for SNS, and the initial success rate was 67% vs 55% (PTNS vs SNS). After 3 years, the cumulative cost was $4,416 for PTNS patients and $14,544 for SNS patients, and 40% of patients were still on therapy in the PTNS group vs 47% in the SNS group.

He continued by saying that he really likes the next set of data where they only looked at the initially successful patients, i.e., initial success 100% for both PTNS and SNS. Obviously the initial costs for both treatments are the same as in the first case that looked at all patients. The cumulative cost differs at three years when they looked only at successful patients compared to all patients, it was $5,721 for PTNS patients vs $25,031 for SNS patients. At 3 years, 59% of patients in the PTNS group remained on treatment vs 85% in the SNS group.

Third-party payers like to look at Incremental Cost Effectiveness Ratio (ICER) and there is a formula to calculate this: ICER = (C1-C2/E1-E2). This translates into the cost per each additional patient remaining on therapy. In this study, the ICER in the first case, when they looked at cost for all treated patients, was $130,000/additional SNS patient remaining on treatment compared to PTNS. When considering only positive responders to SNS test stimulation, the ICER was $74 300/additional SNS patient remaining on treatment compared to PTNS.

In conclusion, Dr. MacDiarmid stated that both PTNS and SNS are safe and effective neuromodulation therapies, and when using a Markov model, PTNS is associated with lower initial and on-going costs compared to SNS. 

Presented by Scott MacDiarmid, MD at the Society for Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) 2013 Winter Meeting - February 26 - March 2, 2013 - Caesars Palace - Las Vegas, NV USA

Alliance Urology Specialists, Greensboro, NC, USA 

Written by Anna Forsberg, medical reporter for UroToday.com


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