Cost-effective Strategies for the Management and Treatment of Urethral Stricture Disease.

Following failed endoscopic intervention, the most cost-effective strategy for recurrent urethral stricture disease (USD) is urethroplasty. Inpatient hospital costs associated with urethroplasty are driven by patient comorbidities and postoperative complications. Symptom-based surveillance for USD recurrence will reduce unnecessary diagnostic procedures and cost.

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications.

OBJECTIVE: To determine which factors are associated with higher costs of urethroplasty procedure and whether these factors have been increasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality. MATERIALS AND METHODS: We conducted a retrospective analysis using the 2001-2010 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP cost-to-charge ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression, and expressed as odds ratios (OR). RESULTS: A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated cost was $7321 ($5677-$10,000). Patients with multiple comorbid conditions were associated with extreme costs [OR 1.56, 95% confidence interval (CI) 1.19-2.04, P = .02] compared with patients with no comorbid disease. Inpatient complications raised the odds of extreme costs (OR 3.2, CI 2.14-4.75, P <.001). Graft urethroplasties were associated with extreme costs (OR 1.78, 95% CI 1.2-2.64, P = .005). Variations in patient age, race, hospital region, bed size, teaching status, payor type, and volume of urethroplasty cases were not associated with extremes of cost. CONCLUSION: Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications, and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.

Healthcare Costs Associated with Hydrophilic-Coated And Non-Coated Urinary Catheters for Intermittent Use In the United States.

This health economic evaluation simulated a cohort to compare hydrophilic-coated to non-coated catheters for intermittent catheterization. By using a Markov model, lifetime costs and catheter-related complications were investigated. Results determined that the use of hydrophilic-coated catheters save money and reduce treatment-related complications.

Quality and length of life, money and urethral stricture disease.

PURPOSE OF REVIEW: This article walks through some of the ideas behind patient-reported outcome measurement and quality of life research against the backdrop of urethral stricture disease and conditions of the lower urinary tract more generally, why measurement matters at all, future areas for research and development and potential opportunities for misuse and manipulation. RECENT FINDINGS: It is the authors' opinion that only one published study has substantially advanced our understanding of the way men with urethral stricture disease manage this condition in the real world, and, in turn, the outcomes those men seek when they consent to surgery and its associated risks. There is, however, almost certainly greater acceptance now by reconstructive urologists of the utility of patient-reported outcome measures in audit; surgical performance evaluation; clinical research; and fair, logical and transparent healthcare resource allocation at a population level. This is evidenced by the recent proliferation of studies incorporating patient-reported outcomes, which appear today to be on parity at least with those that surgeons historically gave priority to. SUMMARY: The next frontier in urethral stricture disease outcomes research is a better understanding of the impact of this condition on men's daily lives. That level of insight is likely to be gained through a mixture of qualitative and quantitative research methods applied to collaborative research ventures with men with the condition who, as those that have the most to gain and lose, must be majority stakeholders in this process.

The cost of surveillance after urethroplasty.

OBJECTIVE: To determine variability in urethral stricture surveillance. Urethral strictures impact quality of life and exact a large economic burden. Although urethroplasty is the gold standard for durable treatment, strictures recur in 8%-18%. There are no universally accepted guidelines for posturethroplasty surveillance. We performed a literature search to evaluate variability in surveillance protocols, analyzed costs, and reviewed performance of each commonly used modality. METHODS: MEDLINE search was performed using the keywords "urethroplasty," "urethral stricture," and "stricture recurrence" to ascertain commonly used surveillance strategies for stricture recurrence. We included English language articles from the past 10 years with at least 10 patients, and age >18 years. Cost data were calculated based on standard 2013 Centers for Medicare and Medicaid Services physician's fees. RESULTS: Surveillance methods included retrograde urethrogram or voiding cystourethrogram, cystourethroscopy, urethral ultrasound, American Urological Association Symptom Score, and postvoid residual and urine flowmetry (UF) measurement. Most protocols call for a retrograde urethrogram or voiding cystourethrogram at the time of catheter removal. After this, UF or PVR, cystoscopy, urine culture, or a combination of UF and American Urological Association Symptom Score was performed at variable intervals. The first-year follow-up cost of anterior urethral surgery ranged from $205 to $1784. For posterior urethral surgery, follow-up cost for the first year ranged from $404 to $961. CONCLUSION: Practice variability for surveillance of urethral stricture recurrence after urethroplasty leads to significant differences in cost.

Open urethroplasty versus endoscopic urethrotomy--clarifying the management of men with recurrent urethral stricture (the OPEN trial): study protocol for a randomised controlled trial.

BACKGROUND: Urethral stricture is a common cause of difficulty passing urine in men with prevalence of 0.5 %; about 62,000 men in the UK. The stricture is usually sited in the bulbar part of the urethra causing symptoms such as reduced urine flow. Initial treatment is typically by endoscopic urethrotomy but recurrence occurs in about 60% of men within 2 years. The best treatment for men with recurrent bulbar stricture is uncertain. Repeat endoscopic urethrotomy opens the narrowing but it usually scars up again within 2 years requiring repeated procedures. The alternative of open urethroplasty involves surgically reconstructing the urethra, which may need an oral mucosal graft. It is a specialist procedure with a longer recovery period but may give lower risk of recurrence. In the absence of firm evidence as to which is best, individual men have to trade off the invasiveness and possible benefit of each option. Their preference will be influenced by individual social circumstances, availability of local expertise and clinician guidance. The open urethroplasty versus endoscopic urethrotomy (OPEN) trial aims to better guide the choice of treatment for men with recurrent urethral strictures by comparing benefit over 2 years in terms of symptom control and need for further treatment. METHODS/DESIGN: OPEN is a pragmatic, UK multicentre, randomised trial. Men with recurrent bulbar urethral strictures (at least one previous treatment) will be randomised to undergo endoscopic urethrotomy or open urethroplasty. Participants will be followed for 24 months after randomisation, measuring symptoms, flow rate, the need for re-intervention, health-related quality of life, and costs. The primary clinical outcome is the difference in symptom control over 24 months measured by the area under the curve (AUC) of a validated score. The trial has been powered at 90% with a type I error rate of 5% to detect a 0.1 difference in AUC measured on a 0-1 scale. The analysis will be based on all participants as randomised (intention-to-treat). The primary economic outcome is the incremental cost per quality-adjusted life year. A qualitative study will assess willingness to be randomised and hence ability to recruit to the trial. DISCUSSION: The OPEN Trial seeks to clarify relative benefit of the current options for surgical treatment of recurrent bulbar urethral stricture which differ in their invasiveness and resources required. Our feasibility study identified that participation would be limited by patient preference and differing recruitment styles of general and specialist urologists. We formulated and implemented effective strategies to address these issues in particular by inviting participation as close as possible to diagnosis. In addition re-calculation of sample size as recruitment progressed allowed more efficient design given the limited target population and funding constraints. Recruitment is now to target. TRIAL REGISTRATION: ISRCTN98009168 Date of registration: 29 November 2012.

Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis.

PURPOSE: We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings. MATERIALS AND METHODS: Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates. RESULTS: The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol. CONCLUSIONS: A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.

Office dilation of the female urethra: a quality of care problem in the field of urology.

PURPOSE: Historically dilation of the female urethra was thought to be of value in the treatment of a variety of lower urinary tract symptoms. Subsequent work has more accurately classified these complaints as parts of various diseases or syndromes in which scant data exist to support the use of dilation. Yet Medicare reimbursement for urethral dilation remains generous and we describe practice patterns regarding female urethral dilation to characterize a potential quality of care issue. MATERIALS AND METHODS: Health care use by females treated with urethral dilation was compiled using a complementary set of databases. Data sets were examined for relevant inpatient, outpatient and emergency room services for women of all ages. RESULTS: Female urethral dilation is common (929 per 100,000 patients) and is performed almost as much as treatment for male urethral stricture disease. Approximately 12% of these patients are subjected to costly studies such as retrograde urethrography. The overall national costs for treatment exceed $61 million per year and have increased 10% to 17% a year since 1994. A diagnosis of female urethral stricture increases health care expenditures by more than $1,800 per individual per year in insured populations. CONCLUSIONS: Urethral dilation is still common despite the fact that true female urethral stricture is an uncommon entity. This scenario is likely secondary to the persistence of the mostly discarded practice of dilating the unstrictured female urethra for a wide variety of complaints despite the lack of data suggesting that it improves lower urinary tract symptoms.

Male urethral stricture disease.

PURPOSE: The incidence of urethral stricture disease in the United States is unknown. We estimated the impact of urethral stricture disease by determining its prevalence, costs and other measures of burden, including side effects and the need for surgical intervention. MATERIALS AND METHODS: Analyses of services for urethral stricture disease were performed in 10 public and private data sets by epidemiological, biostatistical and clinical experts. RESULTS: Male urethral stricture disease occurred at a rate as high as 0.6% in some susceptible populations and resulted in more than 5,000 inpatient visits yearly. Yearly office visits for urethral stricture numbered almost 1.5 million between 1992 and 2000. The total cost of urethral stricture diseases in 2000 was almost $200 million, not including medication costs. A diagnosis of urethral stricture increased health care expenditures by more than $6,000 per individual yearly in insured populations after controlling for comorbidities. Urethral stricture disease appeared to be more common in the elderly population and in black patients, as measured by health care use. In most data sets services provided for urethral stricture disease decreased with time. Patients with urethral stricture disease appeared to have a high rate of urinary tract infection (41%) and incontinence (11%). CONCLUSIONS: Despite decreasing rates of urethral strictures with time the burden of urethral stricture disease is still significant, resulting in hundreds of millions of dollars spent and hundreds of thousands of caregiver visits yearly.

Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture.

PURPOSE: Treatment for urethral stricture disease often requires a choice between readily available direct vision internal urethrotomy (DVIU) and highly efficacious but more technically complex open urethral reconstruction. Using the short segment bulbous urethral stricture as a model, we determined which strategy is less costly. MATERIALS AND METHODS: The costs of DVIU and open urethral reconstruction with stricture excision and primary anastomosis for a 2 cm bulbous urethral stricture were compared using a cost minimization decision analysis model. Clinical probability estimates for the DVIU treatment arm were the risk of bleeding, urinary tract infection and the risk of stricture recurrence. Estimates for the primary urethral reconstruction strategy were the risk of wound complications, complications of exaggerated lithotomy and the risk of treatment failure. Direct third party payer costs were determined in 2002 United States dollars. RESULTS: The model predicted that treatment with DVIU was more costly (17,747 dollars per patient) than immediate open urethral reconstruction (16,444 dollars per patient). This yielded an incremental cost savings of $1,304 per patient, favoring urethral reconstruction. Sensitivity analysis revealed that primary treatment with urethroplasty was economically advantageous within the range of clinically relevant events. Treatment with DVIU became more favorable when the long-term risk of stricture recurrence after DVIU was less than 60%. CONCLUSIONS: Treatment for short segment bulbous urethral strictures with primary reconstruction is less costly than treatment with DVIU. From a fiscal standpoint urethral reconstruction should be considered over DVIU in the majority of clinical circumstances.

Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective.

PURPOSE: We developed an algorithm for the management of urethral stricture based on cost-effectiveness. MATERIALS AND METHODS: United Kingdom medical and hospital costs associated with the current management of urethral stricture were calculated using private medical insurance schedules of reimbursement and clean intermittent self-catheterization supply costs. These costs were applied to 126 new patients treated endoscopically for urethral stricture in a general urological setting between January 1, 1991 and December 31, 1999. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention following initial intervention. Mean followup available was 25 months (range 1 to 132). RESULTS: The costs were urethrotomy/urethral dilation 2,250.00 pounds sterling (3,375.00 dollars, ratio 1.00), simple 1-stage urethroplasty 5,015.00 pounds sterling (7,522.50 dollars, ratio 2.23), complex 1-stage urethroplasty 5,335.00 pounds sterling (8,002.50 dollars, ratio 2.37) and 2-stage urethroplasty 10,370 pounds sterling (15,555.00 dollars, ratio 4.61). Of the 126 patients assessed 60 (47.6%) required more than 1 endoscopic retreatments (mean 3.13 each), 50 performed biweekly clean intermittent self-catheterization and 7 underwent urethroplasty during followup. The total cost per patient for all 126 patients for stricture treatment during followup was 6,113 pounds sterling (9,170 dollars). This cost was calculated by multiplying procedure cost by the number of procedures performed. A strategy of urethrotomy or urethral dilation as first line treatment, followed by urethroplasty for recurrence yielded a total cost per patient of 5,866 pounds sterling (8,799 dollars). CONCLUSIONS: A strategy of initial urethrotomy or urethral dilation followed by urethroplasty in patients with recurrent stricture proves to be the most cost-effective strategy. This financially based strategy concurs with evidence based best practice for urethral stricture management.

Managing many patients with a urethral stricture: a cost-benefit analysis of treatment options.

OBJECTIVES: To report a management method in a community where there are many patients with urethral stricture and where the short-term goal of providing some treatment to most may override the sometimes conflicting long-term aim of minimizing recurrence rates. PATIENTS AND METHODS: Over a 3-year period, using optical urethrotomy in 76 patients followed by intermittent self-dilatation (ISD) in 29, urethroplasty in 28 and dilatation in three, 92 of 134 patients with a urethral stricture were treated and the outcome compared. RESULTS: The overall recurrence rate was 22%; a combination of urethrotomy plus ISD had a recurrence rate of 17% and gave a mean duration of follow-up without recurrence similar to that after urethroplasty. ISD significantly increased both the time before recurrence and the duration of follow-up without recurrence after urethrotomy. In addition to providing lasting treatment to many patients, urethrotomy was also 10 times cheaper, 10 times faster to perform and offered the surgeon better protection from infection with human immunodeficiency virus than did urethroplasty. CONCLUSION: Because wrongly selecting urethrotomy (resulting in a failed procedure) wastes valuable operating time and resources, the pre-operative recognition of strictures unsuitable for urethrotomy and their treatment by urethroplasty is important for overall efficiency.

[Treatment of stenoses of the urethra. 2]. / Traitement des sténoses de l'urètre. Deuxième partie.

This is a comparative study in 183 patients of the treatment of urethral stenoses by two-stage urethroplasty, internal endoscopic urethrotomy and urethrotomy via the Olbert catheter. Urethroplasty (39 patients) was preferentially carried out in patients with moniliform stenosis greater than 2 cm long in the penile and penoscrotal urethra. There was no significant difference in the indications for the two forms of urethrotomy. Good results were obtained for the 3 techniques in about 80% of cases but there was significantly higher complication rate with surgical urethroplasty. The failure rate of the 3 techniques did not differ significantly. The cost of treatment, on the other hand, greatly differed depending on the technique. Surgical urethroplasty was 2.8 times more costly than internal endoscopic urethrotomy and 10.4 times more costly than Olbert catheter urethrotomy. Olbert catheter urethrothomy was 3.7 times cheaper than internal endoscopic urethrotomy.

[Treatment of urethral stenosis. 1]. / Traitement des sténoses de l'urètre. Première partie.

The treatment of urethral strictures has considerably developed over recent years: surgical urethroplasty has been perfected at the same time as internal urethrotomy has gained a new lease of life as a result of endoscopy. Urethral dilatation by means of probes used for arterial stenoses constitutes another interesting development in this field. We reviewed our case files with a double objective in mind: to determine the reasons for our changing therapeutic practices and the results of these three methods. Our study was also interesting because it was the first time that the incidence of this therapeutic development on the economic consequences of this disease, which generally affects professionally active adults, has been assessed. Several factors can be taken into consideration: however, as the length of time off work and the cost of concomitant drug treatments were unable to be determined with sufficient accuracy by our survey, we finally assessed the duration and the number of hospital admissions for each patient. Although only fragmentary, these data appear to reflect fairly accurately the economic impact of the treatments used.