Comparative Cost Analysis: Teleurology vs Conventional Face-to-Face Clinics.

OBJECTIVE: To compare costs associated with teleurology vs face-to-face clinic visits for initial outpatient hematuria evaluation. MATERIALS AND METHODS: The analysis included 3 cost domains: transportation, clinic operations, and patient time. Transportation cost was based on standard government travel reimbursement. Clinic staff cost was based on hourly salary plus fringe benefits. For a face-to-face clinic encounter, patient time included time spent for travel, parking, walking to and from clinic, checking in and checking out, nursing evaluation, urologic evaluation, laboratory, and waiting. Patient time cost was based on the Federal minimum wage. Provider and laboratory times were excluded from the cost analysis as these were similar for both encounters. RESULTS: We included 400 hematuria evaluations: 300 teleurology and 100 face-to-face. Both groups had similar median age (63 vs 64 years, P = .48) and median travel distance/time (58 vs 54 miles, P = .19; 94 vs 82 minutes, P = .09, respectively). Average patient time was greater for face-to-face encounters (266 vs 70 minutes teleurology, P < .001). Transportation was the primary driver of overall costs ($83.47 per encounter), followed by patient time ($32.87/encounter) and clinic staff cost ($18.68/encounter). The average cost per encounter was $135.02 for face-to-face clinic vs $10.95 for teleurology (P < .001) exclusive of provider and laboratory times. Cost savings associated with each telehematuria encounter totaled $124.07. CONCLUSION: Teleurology offers considerable cost savings of $124 per encounter for the initial evaluation of hematuria compared to face-to-face clinic. With 1.5 million annual hematuria encounters nationally, implementation of teleurology for hematuria evaluation offers cost savings approaching $200 million per year.

Comparative analysis of alpha-blocker utilization in combination with 5-alpha reductase inhibitors for enlarged prostate in a managed care setting among Medicare-aged men.

OBJECTIVE: To evaluate the likelihood of alpha-adrenergic antagonist (alpha-blocker) discontinuation in combination with dutasteride or finasteride among patients aged > or =65 years with enlarged prostate. METHOD: This retrospective analysis used 2003-2006 data representing more than 30 million managed care members. Medical/pharmacy claims were used to select patients, matched 1:1 using propensity scoring. The proportion remaining on alpha-blocker therapy more than 12 months and time to discontinuation were compared between groups, controlling for covariates using survival analysis. RESULTS: The matched sample included 1674 patients. Alpha-blocker therapy discontinuation was observed at 90 days (86.9% dutasteride patients and 91.8% finasteride patients remained on alpha-blocker therapy). After 12 months, more dutasteride patients discontinued (38.1% remained) alpha-blocker therapy than finasteride patients (56.3% remained). CONCLUSIONS: Patients discontinued alpha-blocker therapy as early as 3 months. Those taking dutasteride were 64% more likely to discontinue alpha-blocker therapy than patients taking finasteride. Dutasteride's impact on discontinuation may have important implications and should be examined further.

Medical therapy for benign prostatic hyperplasia--present and future impact.

The purpose of this manuscript is to provide clinicians, health plan decision makers, and policy makers with highlights of key findings pertaining to our current understanding of the condition of enlarged prostate (EP) from a managed care perspective. This includes a brief discussion regarding the prevalence and economic burden of EP, followed by a review of clinical characteristics and pathophysiology, with the final section on treatment approaches with a focus on pharmacologic options. This supplement is not intended to be a comprehensive review of EP, because many review articles on this subject are available elsewhere. This manuscript does, however, serve to introduce 3 additional manuscripts contained within this supplement. The first article provides the readers with a real-world comparison of dutasteride and finasteride relative to acute urinary retention and surgery attenuation rates. The second article investigates differences in discontinuation rates of alpha blockers when used in combination with dutasteride or finasteride. The last article addresses the cost implications associated with dutasteride and finasteride therapy. All 3 articles represent data from a naturalistic, managed care population. This supplement is intended to assist managed care formulary decision makers in evaluating key clinical and economic data which could help to differentiate dutasteride and finasteride. Although the information presented does not prove superiority of either product, it will answer some important questions and raise some important issues beyond ingredient cost.

A large retrospective analysis of acute urinary retention and prostate-related surgery in BPH patients treated with 5-alpha reductase inhibitors: dutasteride versus finasteride.

OBJECTIVE: The purpose of this study was to examine the rates of acute urinary retention (AUR) and surgery after initiating 5-alpha reductase inhibitor (5ARI) therapy and to compare the 2 currently available 5ARIs, dutasteride and finasteride, in a real-world, managed care setting. This study constitutes the first direct comparison of therapeutic outcome between a mono 5ARI (finasteride) and a dual 5ARI (dutasteride). METHODS: This is a retrospective descriptive and comparative analysis of the rates of AUR and prostate surgery in patients with benign prostatic hyperplasia (BPH) treated with 5ARI therapy, either dutasteride or finasteride. Data were obtained from the PharMetrics Integrated Medical and Pharmaceutical Database (PIMPD) (Watertown, Mass) during a 6-year period. The PIMPD is a large national healthcare database that represents a total of 85 managed health plans and covers more than 45 million patients. The data analysis included all patients aged 50 years or older diagnosed with BPH who were treated with 5ARIs (dutasteride 0.5 mg/day or finasteride 5 mg/day) for up to 12 months during the 6-year period of January 1, 1999, to March 1, 2005. Patients meeting the selection criteria were evaluated for a total of 12 months with regard to the likelihood of experiencing AUR or prostate-related surgery. RESULTS: After 5 months of 5ARI therapy, the rate of AUR during months 5 to 12 was found to be significantly lower in the dutasteride group compared with the finasteride group (5.3% vs 8.3%). After controlling for background covariates, dutasteride-treated patients were 49.1% less likely to experience AUR than patients treated with finasteride (P = .0207). Patients treated with dutasteride were also less likely to undergo prostate-related surgery, with 1.4% of dutasteride treated patients and 3.4% of patients receiving finasteride undergoing surgery; differences in surgery rates, however, were not statistically significant (P = .0745), even after controlling for background covariates. CONCLUSTION: Although the 2 drugs, dutasteride and finasteride, belong to the same category of 5ARIs, this large retrospective multivariate analysis potentially indicates differences in therapeutic outcomes. In this study, patients treated with dutasteride were less likely to experience AUR and demonstrated a trend toward being less likely to experience surgery than patients treated with finasteride.

Clinical and economic outcomes in patients treated for enlarged prostate.

BACKGROUND: Benign prostatic hyperplasia (BPH), also referred to as enlarged prostate, is a highly prevalent condition in men aged 50 years or older. It is a progressive disease with significant morbidity from complications. OBJECTIVE: The purpose of this study was to assess the likelihood of having acute urinary retention (AUR) and prostate surgery after initiating therapy with an alpha blocker or 5-alpha reductase inhibitor in a real-world setting. STUDY DESIGN: This was a retrospective study of patients who were treated for BPH between January 1, 2003, and November 30, 2003, in a large, national managed care claims database. Outcomes measures of interest included rate of AUR, prostate surgery, and surgical complications. RESULTS: There were 2959 patient records with a diagnosis of BPH who were taking prostate medications in the database. Eighty-nine percent of patients were receiving alpha blocker therapy, whereas 11% of patients were receiving 5-alpha reductase inhibitors. Overall, the 1-year AUR rate was 12.1%, and the prostate surgery rate was 5.8%. Patients who initiated 5-alpha reductase inhibitor therapy only were less likely to have AUR or surgery compared with patients taking alpha blockers, although surgical differences did not reach statistical significance (P = .0576). Overall, the surgical complication rate was 49.4%, and the rate of AUR within 180 days of prostate surgery was 30.6%. Rates of prostate surgery, AUR, and surgical complications all increased with age. CONCLUSION: Patients receiving 5-alpha reductase inhibitor therapy alone were less likely to have AUR compared with patients receiving alpha blockers and tended to be less likely to have surgery (P = .054).

An assessment of the diagnosed prevalence of diseases in men 50 years of age or older.

OBJECTIVE: A lack of focus on certain men's health problems has led to significant morbidity and mortality in aging men. Managed care must begin to focus on the conditions that are most prevalent in this fast-growing population in an effort to improve the quality of care. To assist in achieving this goal, a naturalistic retrospective study assessing the prevalence of the 10 leading disorders in men older than the age of 50 was conducted, with an additional focus on men eligible for Medicare. METHODS: Claims data were obtained from the Integrated Health Care Information Solutions National Managed Care Benchmark database (Waltham, Mass), that includes data from 30 health plans covering more than 25 million lives, and from the Centers for Medicare & Medicaid Services, representing men from a 5% random sample of Medicare-eligible patients. Men older than 50 years of age were included in the study. The prevalence of all diseases was determined in the 2003 calendar year for each population. Prevalence was calculated by dividing the number of diagnosed cases of a disease by the total person-time observations within the 2003 period. RESULTS: The results indicate that cardiovascular (ie, coronary artery disease [CAD], hypertension, and arrhythmias), urological (ie, enlarged prostate and prostate cancer), and musculoskeletal disorders (ie, osteoarthritis and bursitis) comprise 70% of the 10 leading diseases. CAD and hypertension ranked first and second across all age categories, whereas enlarged prostate ranked fourth. In men older than 50, diabetes ranked third, whereas cataracts ranked third in Medicare-eligible men. CONCLUSION: The diseases identified in this study have the potential to cause significant clinical and economic implications when poorly treated or undertreated. Therefore, there is a need to institute early treatment for these conditions before they progress and require more extensive and costly interventions.