Kevin Wymer: Thanks for having me.
Daniel Joyce: Really interesting study, an area where we have now a ton of treatments, a ton of surgical treatments for management of BPH. Tell us a little bit about what you did and why it's important.
Kevin Wymer: I think you touched on why I think modeling and decision analytics is a great addition to the BPH field. BPH, unlike a lot of other treatment areas, has a ton of different options. And we all know that patients come in and it can be overwhelming to the patient, it can be overwhelming to the provider to try and run through all of these different surgical modalities and the pros and the cons, and we are really lacking in head-to-head comparisons. And so the purpose of this cost-effectiveness model was to compare guideline-based treatment for [inaudible 00:01:02] AdCC prostates, including missed options like UroLift or Rezum or the newer options like Optilume, iTind, to TURP to enucleation, to aquablation, and really look at the effectiveness as far as clinical outcomes and patient satisfaction quality of life, and cost. And do that in a model that's able to compare all of these head-to-head and come up with a more robust way to present this really overwhelming decision.
Daniel Joyce: It's a model that you're using to compare these different treatments and how does that work and how does that differ from just what you as a clinician would talk to your patients about?
Kevin Wymer: It's a model that looks at a theoretical cohort of patients and the inputs include probabilities of different outcomes as far as improvement in symptoms, risk of complications, durability of any given surgery based on the literature, and then costs. And in this case, our costs are based on a Medicare perspective, so Medicare reimbursement. And the nice thing about these models is although we have a base case that we start with that represents a population average, we can then vary that based on either uncertainty or differences in patient preferences or physician priorities. And so it allows you a much more comprehensive dynamic approach where you can say, "On average from a societal level, this may be a more cost-effective option, but in this interaction with this patient or this physician, when we vary the priorities, it may change that." And so it gives you a much more comprehensive look at that.
Daniel Joyce: Yeah, I think that's a really interesting point. We have, it seems like in every space of urology now, all of these either single-arm trials or just retrospective data or prospective data of one treatment not compared head-to-head with another treatment. And so we're left with the data we have, which aren't always that great and there's uncertainty in that data. So how then do we talk to patients about, well, here's the data for this, here's the data for that, you decide what you want to do? And this, it sounds like, gives you the ability to assess that uncertainty and be able to explain that to patients a little bit better. Am I getting that right?
Kevin Wymer: Yeah. And as an oncologist, I would argue that you guys are ahead of us in the benign space where we're even further behind with good quality randomized or even prospective data. And it's probably going to get worse. The funding and resources for those types of trials is decreasing. And so relying on these modeling type approaches is probably going to be a more feasible option and you can account for some of that unknowingness or lack of evidence with the variability. And so it's a more realistic way to try and compare a lot of data that we can't do in this gold standard randomized controlled fashion.
Daniel Joyce: So in the cancer world, recurrence, survival, these things matter the most when we're talking about differences in treatment. But in the benign space, I would expect you're really talking about, one, functional outcomes, but also toxicities of those treatments and need for further treatment downstream. So what did you find in the comparison of these treatments? How did they stack up?
Kevin Wymer: I think analogous to recurrence-free survival on [inaudible 00:04:25] would be retreatment rates for BPH. And then I do think even more than some of these approaches, the quality of life metrics are huge with BPH. And BPH is often a quality of life disease where we're treating to improve quality of life, not necessarily overall prognosis. And so when comparing these treatments, the overall takeaway was that the cost-effectiveness was largely driven by durability. And with that HoLEP, which had the highest durability, meaning the lowest surgical retreatment rate over a patient's lifetime was the most cost-effective. The nuances come into play when you start to look at other specific factors as far as quality of life. So if you change, for example, how much a patient prioritizes antegrade ejaculation, which we know varies between these procedures, it may be that on a population level a HoLEP is cost-effective, but if you alter that and say ejaculatory preservation is a huge priority and the patient is going to take a bigger hit in quality of life if they lose that, not surprisingly, HoLEP may not be the most cost-effective.
Similarly, if you're looking at a shorter follow-up where durability may not matter as much, an older patient, for example, something less durable may be more cost-effective. So there's the societal big picture cost-effectiveness, but also as you look at specific priorities with quality of life or patient longevity, that changes the output.
Daniel Joyce: That's really fascinating. When I do cost-effectiveness work, the response I always get is who cares? Because we don't use ICERs in America. That's not driving decision-making. The American healthcare system doesn't seem to care about cost whatsoever. And so these value assessments, I think get written off as, yeah, okay, whatever, this doesn't impact my practice at all. But what you're saying is that there's a value assessment within those variables that you get. And so depending on how you value those outcomes, that might change the effectiveness for the patient. So let's say how would you translate this study then into your clinic office? How do you talk differently to that patient now who wants a BPH treatment based on what you found?
Kevin Wymer: You're right. You and I both know it is a continual challenge to say cost-effectiveness, yeah, it's a nice academic exercise, but what's the reality and are we ever going to change anything? And we can highlight high value care, but will it actually change policy? But I think the challenges of changing healthcare policy doesn't give us a ticket to ignore healthcare policy issues as providers. And the fact remains that there is no value component to reimbursement. And just because the CEA isn't going to lead to a law, it doesn't mean that we shouldn't acknowledge that and shouldn't support that idea with evidence and highlight what high value care actually is and highlight some of the discrepancies between reimbursement amounts and clinical outcomes. And so from... I guess it's more of a theoretical moral approach, I think we as physicians have a duty to be aware of that and acknowledge that.
On the practical side, I do think there is growing practicality with these. And I think you agree with this, that's going to be more on the patient level. And even from a cost standpoint, healthcare costs are rising not just on a larger scale, but that is trickling down to patients more and more and more. And so it may not be a conversation we have a lot now as far as patient costs, but unfortunately I think it will be moving forward and these models can incorporate patient level costs too. And so if you end up needing to have that conversation of this will be your out-of-pocket cost for this procedure, balance that with your personalized effectiveness, that could change a clinical decision. Currently, that is not the conversation I have with patients.
Currently, the way I incorporate these models is to say, "We don't have head-to-head comparisons, but as a whole, when you put this together, if your priority is durability or antegrade ejaculation is not a huge priority for you, we have good data supporting HoLEP. However, if antegrade ejaculation is a priority, we should look at these other options." And yes, you have all that data from the primary literature, but I think a more comprehensive analysis is still helpful to really drive that message home.
Daniel Joyce: Yeah, really well said. It really does provide you a more holistic and yet concise way of comparing these options for patients. And I totally agree with you, I think the days of clinicians burying their head in the sand about cost have to come to an end, whether we like it or not. And I know there's a lot of data out there to suggest physicians don't want to talk about these things because we feel totally ill-equipped, right?
Kevin Wymer: Can't do anything.
Daniel Joyce: We don't know what the costs are, we don't understand insurance benefit structures. But I do think what you're doing is actually empowering those clinicians to have that at their disposal, very easily translate all the data through a health-economics lens so that they can then bring that to their patients.
Kevin Wymer: Yeah. If anything, we should at least be proactive with this and not wait until it's an issue that we have no knowledge and no control over, because right now it's heading in that direction where costs are going to become bigger and bigger for patients.
Daniel Joyce: So where do we go next with this? What's the next step?
Kevin Wymer: I think another weakness of these models is the input data. They are dependent upon the data we put in. And I mentioned some of the limitations with clinical outcomes, but I think a more notable limitation from my standpoint is truly understanding patient priorities. We use these effectiveness measurements based on quality of life metrics that we won't get into, but then the high takeaway from that is they're not very good. They're not very validated. They're not very robust. And so can we do a better job at truly understanding patient priorities, patient-reported outcomes, what impacts patient quality of life, and in this case in the BPH disease space. From my standpoint, that's where I'm looking next is to do a better job at truly understanding what patients care about, how these different outcomes stack up relative to one another, and how they change before and after surgery.
It may be a man thinks he really cares about short-term incontinence and then after the fact realizes the urinary catheter was the biggest impact on his quality of life, and it's hard to prepare patients for things they haven't been through. And so having a better database or understanding of how patient priorities change, what they are would be really helpful counseling in this space.
Daniel Joyce: How do you foresee that then taking root in clinical practice? Are you talking about informing decision aids? Are you talking about some other platform to educate patients? How do you envision that going?
Kevin Wymer: Again, another challenge that I know you're aware of, decision aids I think in theory are excellent and that's what we should be using is evidence-based decision aids to supplement conversations that we're having in clinic. The reality is uptake on decision aids is very low. They're hard to incorporate. I also think though that will change, whether it be with AI or just more data available, we can make these types of, call them, decision supplements easier for patients. It could be a self-triage type thing where they're going online now and looking at ChatGPT, you could imagine a scenario where you could have these types of decision aids with cost linked into their EMR where a patient says, "I have BPH," and it asks you five questions about ejaculatory preservation, are you in retention, what type of insurance you have, and spits out essentially cost-effectiveness individualized to that patient. I think that's a ways down the road, but I honestly don't think it's a long ways down the road.
Daniel Joyce: That's a very, very exciting future and I think it really highlights the excitement of your work and how important it is. And I hope... First of all, thank you for sharing it with us and for talking to us about it. I hope the people watching this take one thing away and that's even though your study, first word is cost-effectiveness, don't write it off. There's value here beyond just the healthcare system side of things. It really is going to impact how we discuss treatments with our patients, and it's really, really valuable data to empower physicians to start incorporating costs in those discussions. Thanks again, Kevin. Really exciting one.
Kevin Wymer: Yeah, appreciate it. Thanks for having me.