Water intake and recurrent urinary tract infections prevention: economic impact analysis in seven countries.

BACKGROUND: To estimate the economic impact of preventing urinary tract infections (UTI) by increasing water intake among women with recurrent UTI and low fluid intake across seven countries: France, United Kingdom, Spain, United States of America, Mexico, China and Australia. METHODS: A Markov model was developed to compare costs and outcomes of UTIs associated with low fluid intake in women versus a strategy of primary prevention by increasing water intake. Model inputs were based on randomized controlled trial data which found that increasing water intake by 1.5 L/day decreased the risk of developing cystitis by 48% in women with low fluid intake and recurrent UTI. A time horizon of 10 years was used; outcomes were from the payer perspective and included both direct and indirect costs, reported in 2019 United States dollars ($). Discounting rates varied by country. Scenarios of increasing levels of compliance to the increased water intake strategy were evaluated. RESULTS: The total cost of one UTI episode, including diagnostics, treatment and complications, ranged from $2164 (Mexico) to $7671 (Australia). Assuming 80% compliance with the increased water intake strategy over a 10-year time horizon, the number of UTIs prevented ranged from 435,845 (Australia) to 24150,272 (China), resulting in total savings of 286 million (Australia) to $4.4 billion (China). Across all countries, increased water intake resulted in lower cost and fewer UTIs compared with low water intake. CONCLUSION: Preventing recurrent UTIs by increasing water intake would reduce both the clinical and economic burden associated with UTI. Public, healthcare professionals and patients should be made aware about the preventive positive impact of appropriate water intake on UTIs.

Bladder EpiCheck urine test in the follow-up of NMIBC: a cost analysis.

PURPOSE: In the Netherlands yearly more than 5000 patients are diagnosed with non-muscle invasive bladder cancer (NMIBC). With a specificity of 88.0% and a negative predictive value (NPV) for high grade NMIBC of 99.3%, the Bladder EpiCheck (BE) urine test may be used in NMIBC to reduce the burden of follow-up cystoscopies. METHODS: In this study a cost analysis of the BE follow-up strategy in the Dutch healthcare system was performed. In half of the follow-up appointments, BE was used as a rule-in for cystoscopy. In addition, the possible delay in recurrence detection was estimated. A cost calculation tool was developed using Microsoft Excel. RESULTS: The BE strategy results in an estimated cost reduction of 8%, 4% and 9% in low, intermediate and high risk patients, respectively. In the Netherlands this may result in a cost reduction of approximately 1.6 million euro per year. The estimated delay in the detection of recurrent disease would be 3.9, 1.7 and 1.3 months in low, intermediate and high risk NMIBC patients respectively. CONCLUSION: To conclude, the BE can be used to reduce the costs of NMIBC follow-up, with a small delay in diagnosis of recurrent disease.

Predictive factors of diagnostic delay and effect on treatment patterns in testicular germ cell tumor patients.

BACKGROUND: Increased time from clinical symptom onset to diagnosis of testicular germ cell tumor (GCT), termed diagnostic delay (DD), is associated with an increased likelihood of metastatic disease at presentation. We assessed the association of patient factors on DD and subsequent treatment patterns. METHODS: The records for patients undergoing orchiectomy at a tertiary care hospital and safety net county hospital between 2006 and 2018 were obtained. Demographic variables, clinical symptoms, and post-diagnosis parameters were queried. Patient factors were assessed for association with DD by using both univariate and multivariable analyses. The effect of the Patient Protection and Affordable Care Act (PPACA) on DD was also studied. RESULTS: 201 patients received orchiectomy, and median DD was 38 days (IQR 14.5-122.5). Patients with metastatic disease had increased DD compared to those with localized disease (76 vs. 31 days, P < 0.001). Increased DD was associated with presentation to the safety net hospital (P = 0.001), non-white (P = 0.025), emergency department presentation (P = 0.025), uninsured (P = 0.01), testicular pain (P = 0.019), and presentation before 2014 (P = 0.047). DD was independently associated with presentation before 2014 (P = 0.004) on multivariate analysis. DD >38 days (i.e., above the median) was associated with increased receipt of adjuvant therapy (P = 0.001). CONCLUSION: PPACA implementation is associated with earlier detection of testicular cancer. Our findings highlight the impact of health care legislation on improving access of care to young men with cancer. Delay in diagnosis can lead to increased stage at presentation and need for adjuvant treatment. Further research to identify and overcome sociodemographic factors associated with diagnostic delay may lead to decreased treatment-related morbidity.

Diagnostic and Cost Implications of the 2020 AUA Microhematuria Guidelines: Modeling Impact in a Large Public Health Care System.

PURPOSE: We sought to model the diagnostic recommendations and associated costs of new hematuria guidelines regarding referral patterns, procedure utilization and urothelial cell carcinoma (UCC) detection. MATERIALS AND METHODS: Patients with microhematuria were identified retrospectively. Initial encounter data were collected from January 2017 to May 2018 from a large public health care system; followup was continued to December 2020. Risk stratification was performed based on the American Urological Association 2020 microhematuria guidelines, and disease outcomes were analyzed within this framework. The guideline-recommended workups and costs were modeled; cost data were sourced from the Centers for Medicare & Medicaid Services Medicare Physician Fee Schedule and Clinical Laboratory Fee Schedule for 2020. Modeled diagnostic volumes and costs were assessed for 2020 and 2012 microhematuria guidelines, respectively. RESULTS: Of the 3,789 patients included for analysis, 1,382 (36.5%), 1,026 (27.1%) and 1,381 (36.4%) were retroactively stratified as low risk, intermediate risk (InR) and high risk (HiR), respectively. A total of 19 cases of UCC (17 bladder, 2 upper tract) were diagnosed, of which 84% were HiR. For high-grade UCC, 92% of cases were HiR. The 2020 guidelines recommended renal ultrasound for 1,117 InR cases, computerized tomography urogram (CTU) for 1,476 HiR cases, and cystoscopy for 2,593 InR and HiR cases combined. Total costs were $1,905,236 (2012) versus $1,260,677 (2020), driven mainly by CTU costs. Per-cancer detected costs were $100,276 (2012) versus $61,760 (2020). CONCLUSIONS: In retrospect, the 2020 guidelines would have effectively risk-stratified microhematuria cases for detection of malignancies. As compared to the 2012 guidelines, application of the 2020 guidelines would result in significant changes to diagnostic and procedural volumes, while substantially reducing total and per-patient costs.

The early impact of medicaid expansion on urologic malignancies in the United States.

PURPOSE: To assess the effects of variable adoption of Medicaid Expansion (ME) of the Affordable Care Act among different states on urologic malignancies using a new variable that defines ME status of patient's residence in a nationwide cancer registry. BASIC PROCEDURES: The National Cancer Database was queried for urologic malignancies (bladder, prostate, kidney and testis) from 2011 to 2016, spanning the period surrounding the primary ME which took place in 2014. Trends in insurance status at time of diagnosis and effects on stage at presentation and survival after ME were evaluated using a difference-in-differences estimator and stratified Cox proportional hazards regression model. MAIN FINDINGS: The percentage of patients with Medicaid coverage at the time of diagnosis increased significantly after adoption of ME in ME states across all urologic malignancies. Concurrently, there was a significant decrease in percentage of uninsured patients diagnosed with testis cancer, but not other urologic malignancies, in ME states. A change in the stage at presentation was not observed across all urologic malignancies for patients in ME states after adoption of ME. No difference in overall survival was noted among patients living in a ME state compared to non-ME states with adoption of ME in 2014. PRINCIPAL CONCLUSIONS: Despite increases in the proportion of patients with Medicaid coverage after 2014 in states that enrolled in ME, there was not an associated change in stage at presentation or survival for patients with genitourinary malignancy.

The Economics of Cystoscopy: A Microcost Analysis.

OBJECTIVE: To evaluate the per-procedure cost of flexible cystoscopy in relation to reimbursement. MATERIALS AND METHODS: Capital, maintenance, reprocessing, labor, and disposable costs were calculated at a high-volume academic institution over the fiscal year 2019. Five-year amortized values were used to calculate reusable cystoscope and automated endoscopic reprocessor (AER) per-procedure cost. Twenty flexible cystoscope procedure cycles were timed and multiplied by prevailing medical office assistant wages to determine labor costs. Medicare and commercially insured reimbursements were queried to evaluate the cost and profitability of cystoscopy. RESULTS: In total, 3739 flexible cystoscopies were performed with 415 procedures per cystoscope. Total annual costs for capital and maintenance, reprocessing, labor, and disposable supplies was $202,494, $147,969, $128,117, and $121,904, respectively. The per-procedure cost for reusable cystoscopy with AER reprocessing, reusable cystoscopy with a high-level disinfectant (HLD), and theoretical costs of disposable cystoscopy were calculated to be $161, $133, and $222, respectively. The volume of procedures per scope had a significant impact on cost and profitability. The number of procedures per cystoscope performed to have equivalent cost as a disposable scope was, 196 and 145 cystoscopies per cystoscope per year, for AER and HLD-reprocessed cystoscopes, respectively. CONCLUSIONS: There is a considerable contribution of capital equipment, maintenance, labor, and supplies to the cost of cystoscopy with profitability highly depend on the volume of cystoscopies performed for each cystoscope. The use of AER results in higher cost than HLD. Cost-effectiveness of disposable scopes needs to be determined but will vary by clinic volume and site of practice.

Simple Nephrectomy in a Tertiary Care Safety Net Hospital-Patient Characteristics, Causes, Cost, and Renal Function Implications.

OBJECTIVE: To evaluate factors associated with simple nephrectomy at a safety net hospital with a diverse patient population and large catchment area. Simple nephrectomy is an underreported surgery. Performance of simple nephrectomy may represent a failure of management of underlying causes. METHODS: We performed a retrospective review of simple nephrectomies performed at a major urban safety net hospital from 2014 to 2019. Detailed demographic, surgical, and renal functional outcomes were abstracted. We assessed the medical and social factors leading to performance of simple nephrectomy and report contemporaneous perception of preventability of the simple nephrectomy by the surgeon. RESULTS: Eighty-five patients underwent simple nephrectomy during the study period; 55% were non-white, 77% were women, and the median age at time of surgery was 46 years. The most common medical factors contributing to simple nephrectomy were stone disease in 55.3%, followed by retained ureteral stent (30.6%) and stricture (30.6%). The most common social factors were lack of insurance (58.5%), substance abuse issues (32.3%), mental health issues (24.6%), and immigration status (18.5%). In 38.8% of cases, the provider felt the surgery was preventable if medical factors leading to simple nephrectomy were properly addressed. CONCLUSIONS: Simple nephrectomy is a common surgery in the safety net hospital setting. Both medical and sociologic factors can lead to simple nephrectomy, and awareness of these factors can lead efforts to mitigate them. This review has led to the implementation of strategies to minimize occurrences of retained stents in our patients.

Decision Analysis Model Comparing Cost of IsoPSA™ vs Repeat Biopsy for Detection of Clinically Significant Prostate Cancer in Men with Previous Negative Findings on Biopsy.

INTRODUCTION: We compared cost of IsoPSA™ vs repeat biopsy in detection of clinically significant prostate cancer in men with previous negative office based prostate biopsy. METHODS: A decision tree model compared cost of biopsy for all men with previous negative biopsy and rising prostate specific antigen (standard arm) vs initial IsoPSA with biopsies performed only in cases of abnormal IsoPSA. Study endpoints were cost, number of biopsies and cancers detected. Cost was based on Medicare reimbursement and peer reviewed literature. Cost of sepsis, complications and loss of work were incorporated into the analysis. Sensitivity analyses were performed varying model assumptions. A separate analysis incorporated cost of treatment for patients with cancer. RESULTS: Using the baseline model with 20.5% prostate cancer incidence yielded an overall cost for 100 men of $197,700 and $165,300 for the standard and IsoPSA arms, respectively, including the cost of the IsoPSA assay, herein assumed to be $350. The IsoPSA arm detected 0.8 fewer Gleason 7-10 prostate cancers (12.6 vs 13.4) but generated 34% fewer biopsies. The IsoPSA arm was less expensive if overall biopsy cost is more than $1,027, if IsoPSA cost is less than $674 or cancer rate was less than 70%. In the model incorporating treatment of men with a cancer diagnosis the IsoPSA arm was also less expensive, generating savings of $53,300 per 100 men. CONCLUSIONS: The use of IsoPSA to select patients for repeat biopsy reduced the number of biopsies needed by 34% and generated significant cost savings.

Perioperative outcomes and cost of robotic vs open simple prostatectomy in the modern robotic era: results from the National Inpatient Sample.

OBJECTIVES: To perform a comparative analysis of perioperative outcomes and hospitalisation cost between open (OSP) and robot-assisted simple prostatectomy (RASP) for treatment of benign prostatic hyperplasia (BPH) using the National Inpatient Sample (NIS) in the contemporary robotic era. MATERIALS AND METHODS: The NIS was queried for cases of OSP and RASP for the treatment of BPH between 2013 and 2016. Perioperative complications, unadjusted hospital cost and length of stay (LOS) were compared between RASP and OSP. Smoothed linear regression curves comparing hospitalisation cost by increasing LOS was stratified by surgical approach to identify point of cost equivalency between RASP and OSP. Multivariable linear regression analysis was used to construct a hospitalisation cost model to examine the contribution of the robotic approach and LOS to hospitalisation cost. RESULTS: The total analytical cohort included 2551 OSP and 704 RASP procedures. Patients undergoing RASP were younger, at a median (interquartile range [IQR]) age of 68 (63-73) vs 71 (65-77) years, and with less comorbidity (76.8% vs 86.5%, P < 0.01). RASP was associated with fewer total complications (11.1% vs 29.2%, P < 0.01) and a greater likelihood of routine discharge to home rather than another facility (88.9% vs 76.7%, P < 0.01). While LOS was shorter with RASP (median [IQR], 2 [1-3] vs 4 [3-6] days, P < 0.01), total unadjusted hospitalisation cost (in United States dollars) was greater (median [IQR], $10 855 [$7965-$15 675] vs $13 467 [$10 572-$17 722], P < 0.01). Presence of any complication increased both LOS and hospitalisation cost (P < 0.01). Linear regression modelling determined the point of cost equivalence between RASP staying a median of 2 days was an OSP case staying between 5 and 6 days. On multivariable regression analysis, the robotic approach contributed an additional $6175 (P < 0.01) to the cost model, whereas each additional day of hospitalisation contributed $1687 (P < 0.01), suggesting LOS would need to be 3-4 days shorter with RASP to offset surgical costs of the robot. CONCLUSIONS: While RASP appears to have significantly better perioperative complication rates with shorter LOS and likely discharge to home, total hospitalisation cost remained greater, likely related to upfront operative costs. While this retrospective study is limited by selection bias for patients undergoing RASP, the benefits of improved convalescence, discharge to home, and lower rate of perioperative complications appear to justify performance of RASP in an experienced pelvic robotic centre despite relatively greater hospitalisation cost if referral to an experienced holmium laser enucleation of the prostate centre is not feasible.

Impact of circulating microRNA test (miRNA-371a-3p) on appropriateness of treatment and cost outcomes in patients with Stage I non-seminomatous germ cell tumours.

OBJECTIVES: To determine whether utilisation of a serum microRNA (miRNA) test could improve treatment appropriateness and cost-effectiveness for patients with Stage I non-seminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: A decision tree model was built to investigate treatment course, clinical and cost outcomes for patients with Stage IA (T1N0M0S0) and IB (T2-4N0M0S0) NSGCT. The model compared outcomes and cost of standard approach using histopathology, conventional serum tumour markers and radiographic staging (standard model) to a miRNA-based approach using the standard model + post-orchidectomy serum miR-371a-3p (marker model). Probabilities of expected treatment and outcomes were based on presence/absence of cancer upon entering into the model. Overtreatment was defined as adjuvant chemotherapy or primary retroperitoneal lymph node dissection in a patient without cancer. Undertreatment was defined as initial surveillance for a patient with cancer. RESULTS: Utilising the miRNA marker-based approach, 26% of patients avoid overtreatment and 8% avoid undertreatment in Stage IA NSGCT; 27% avoid overtreatment and 23% avoid undertreatment in Stage IB disease. Appropriate treatment decision-making increased from 65% to 94% and 50% to 92% for Stage IA and IB, respectively. The miRNA-based approach remained cost-effective over a wide range of performance characteristics with savings of ~$1400 (American dollars)/patient for both Stage IA and IB disease. CONCLUSION: A miRNA-based approach may potentially select patients with Stage I NSGCT for correct treatment in a cost-effective manner. Identification of residual teratoma-only remains an issue. Prospective studies are necessary to validate these findings.

Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors.

PURPOSE: To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using a national all-payer inpatient care database. METHODS: Nationwide Inpatient Sample (NIS) was queried between 2013-2016 for primary RPLND and germ cell tumor. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Linear regression plots identified point of cost equivalence between R-RPLND and O-RPLND. A multivariable linear regression model was generated to analyze predictors of cost. RESULTS: 44 cases of R-RPLND and 319 cases of O-RPLND were identified. R-RPLND was associated with lower rate of complications (0% vs. 16.6%, p < 0.01) and shorter LOS [Median (IQR): 1.5 (1-3) days vs. 4 (3-6) days, p < 0.01]. Rates of ileus, genitourinary complications, and transfusions were lower with R-RPLND, but did not reach significance. On multivariable analysis, robotic approach independently contributed $4457, while each day of hospitalization contributed to an additional $2,431 to the overall model of cost. Linear regression plots determined point of cost equivalence between an R-RPLND staying a mean of 2 days was 4-5 days for O-RPLND, supporting the multivariable analysis. Total hospitalization cost was equivalent between R-RPLND and O-RPLND [Median (IQR): $15,681($12,735-$21,596) vs $16,718($11,799-$24,403), p = 0.48]-suggesting that the cost equivalency of R-RPLND is, at least in part, attributable to shorter LOS. CONCLUSION: While O-RPLND remains the gold standard and this study is limited by selection bias of a robotic approach to RPLND, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased hospital LOS in select cases.

Molecular Predictors of Complete Response Following Neoadjuvant Chemotherapy in Urothelial Carcinoma of the Bladder and Upper Tracts.

Urothelial carcinoma of the bladder (UCB) and upper tracts (UTUC) is often regarded as one entity and is managed generally with similar principles. While neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is an established standard of care in UCB, strong evidence for a similar approach is lacking in UTUC. The longest survival is seen in patients with complete response (pT0) on pathological examination of the RC specimen, but impact of delayed RC in nonresponders may be detrimental. The rate of pT0 following NAC in UTUC is considerably lower than that in UCB due to differences in access and instrumentation. Molecular markers have been evaluated to try to predict response to chemotherapy to reduce unnecessary treatment and expedite different treatment for nonresponders. A variety of potential biomarkers have been evaluated to predict response to cisplatin based chemotherapy including DNA repair genes (ATM, RB1, FANCC, ERCC2, BRCA1, and ERCC1), regulators of apoptosis (survivin, Bcl-xL, and emmprin), receptor tyrosine kinases (EGFR and erbB2), genes involved in cellular efflux (MDR1 and CTR1), in addition to molecular subtypes (Basal, luminal, and p53-like). The current state of the literature on the prediction of response to NAC based on the presence of these biomarkers is discussed in this review.

Validating the predictors of outcomes after radical cystectomy for bladder cancer.

BACKGROUND: An assessment of surgical risk is essential for patient counseling and decision making, and it can provide rationale adjustment for patient populations as health care moves from a fee-for-service to a value-based reimbursement model. The modified Frailty Index (mFI) has been proposed as a risk-stratification tool for radical cystectomy (RC), and the objective of the current study was to validate this potential use of the mFI using an institutional cohort. METHODS: A retrospective review of all patients who underwent RC for bladder cancer was conducted at the authors' institution from 2012 to 2016. In addition to detailed clinicopathologic and treatment parameters, patients were categorized according to the mFI, the Charlson Comorbidity Index (CCI), and the American Society of Anesthesiologists (ASA) classification. Covariates were analyzed to determine associations with 1-month complication rates (according to the Clavien-Dindo system), 3-month readmission rates, hospitalization length, and hospitalization costs. RESULTS: In total, 346 patients were included in the analysis. The overall complication rate was 56.6%, the major (Clavien grade ≥3) complication rate was 19.4%, and the readmission rate was 27.9%. Receiver operating curve analysis demonstrated a weak association of all indices with major complications after RC: the area under the curve was 0.535 (95% confidence interval [CI], 0.460-0.611) for the ASA classification; 0.565 (95% CI, 0.485-0.645) for the CCI score; and 0.551 (95% CI, 0.471-0.631) for the mFI. There were no significant differences in the rate of major complications when stratifying the results according to the mFI, CCI, or ASA class. Length of hospitalization and associated costs were correlated with mFI. CONCLUSIONS: Frailty was not associated with postoperative complications and provided little additional predictive ability over the ASA classification and the CCI score. Further research is required to identify patients who are likely to suffer significant complications after RC.

Patient-reported outcomes of blue-light flexible cystoscopy with hexaminolevulinate in the surveillance of bladder cancer: results from a prospective multicentre study.

OBJECTIVE: To evaluate blue-light flexible cystoscopy (BLFC) with hexaminolevulinate in the office surveillance of patients with non-muscle-invasive bladder cancer with a high risk of recurrence by assessing its impact on pain, anxiety, subjective value of the test and patient willingness to pay. MATERIALS AND METHODS: A prospective, multicentre, phase III study was conducted during which the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Pain and 'Was It Worth It' questionnaires were administered at baseline, after surveillance with BLFC and after resection for those referred to the operating room. Comparisons of scores were performed between groups. RESULTS: A total of 304 patients were enrolled, of whom 103 were referred for surgical examination. Of these, 63 were found to have histologically confirmed malignancy. Pain levels were low throughout the study. Anxiety levels decreased after BLFC (∆ = -2.6), with a greater decrease among those with negative pathology results (P = 0.051). No differences in anxiety were noted based on gender, BLFC results, or test performance (true-positive/false-positive). Most patients found BLFC 'worthwhile' (94%), would 'do it again' (94%) and 'would recommend it to others' (91%), with no differences based on BLFC results or test performance. Most patients undergoing BLFC (76%) were willing to pay out of pocket. CONCLUSIONS: Anxiety decreased after BLFC in patients with negative pathology, including patients with false-positive results. Most of the patients undergoing BLFC were willing to pay out of pocket, found the procedure worthwhile and would recommend it to others, irrespective of whether they had a positive BLFC result or whether this was false-positive after surgery.

The use of blue light flexible cystoscopy with hexaminolevulinate & the diagnosis of bladder cancer.

Blue light cystoscopy improves the detection of bladder cancer at time of transurethral resection of bladder tumor for nonmuscle-invasive bladder cancer. This has translated to decreased tumor recurrence. Given this improvement in rigid cystoscopy, the question remains whether the use of blue light flexible cystoscopy (BLFC) in the surveillance setting provides the same benefits. This review aims to evaluate the recently reported Phase III prospective multicenter study of BLFC which evaluated the detection of bladder cancer during surveillance, which in its earliest reporting demonstrated improved detection of bladder cancer. This study evaluated 304 patients with findings of 63 confirmed malignancies, with 13 (20.6%) only identified by BLFC (p < 0.0001). The question still remains whether the improved detection rate will translate to improved clinical outcomes. Further, studies will be necessary to determine which patients will benefit from BLFC, optimal ways to incorporate into surveillance strategies and cost-effectiveness.

Cost-effectiveness of antimicrobial prophylaxis for children in the RIVUR trial.

PURPOSE: We evaluated the cost-effectiveness of antimicrobial prophylaxis to prevent recurrent UTIs in children with vesicoureteral reflux based on the RIVUR trial. MATERIALS AND METHODS: A decision tree model compared strategies of antimicrobial prophylaxis vs. placebo in children with reflux using results from the RIVUR trial. Risk reduction was 50% based on intention to treat analysis. Costs were based on Medicare reimbursement and data in literature. The model incorporated costs of medications, imaging and complications such as pyelonephritis, likelihood of surgery and loss of work. One- and two-way sensitivity analyses were performed evaluating the effect of changing variables on the cost-effectiveness of antibiotic prophylaxis in preventing recurrent UTIs. RESULTS: Mean costs were higher for treatment vs. placebo at $3092 and $2932, respectively, with 12.7 fewer infections per 100 children. One-way sensitivity analyses showed that antibiotics would be cost equivalent if the yearly medical cost was $386, rate of recurrent UTI increased to 32%, antibiotic risk reduction was 63%, or rate of pyelonephritis in the placebo group was 48%. Two-way analyses modifying antibiotic cost, risk reduction of antibiotics and probability of infection showed areas where antibiotics could be more cost-effective than placebo. CONCLUSIONS: Antibiotic prophylaxis is associated with marginally higher costs compared with placebo, but significantly fewer infections. A slight decrease in antibiotic cost or increase in recurrent UTIs on placebo may result in prophylaxis being more cost-effective. We recognize that the marginal overall cost in antibiotics may have a substantial impact on the quality of life for the individual patient and family.

Modelling cost-effectiveness of a biomarker-based approach to neoadjuvant chemotherapy for muscle-invasive bladder cancer.

OBJECTIVES: To model the cost-effectiveness of a biomarker-based approach to select patients for neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in muscle-invasive bladder cancer (MIBC). PATIENTS AND METHODS: We obtained data from the most recent clinical studies on patients with locally advanced MIBC treated by RC, including stage distributions, overall survival (OS) estimates, associated costs, and utilisation/response to NAC. Additionally, we estimated the putative efficacy of three biomarkers to select patients for NAC: DNA-repair gene panel [ataxia telangiectasia mutated (ATM), retinoblastoma 1 (RB1), and Fanconi anaemia complementation group C (FANCC)], excision repair cross-complementation group 2 (ERCC2), and ribonucleic acid (RNA) subtypes. A decision analysis model was developed to evaluate the cost-effectiveness of biomarker-based approaches to select patients with MIBC for NAC. Comparison of cost-effectiveness included RC alone, unselected NAC plus RC, and NAC based on the three aforementioned biomarkers. RESULTS: The DNA-repair gene panel-based approach to NAC was the most cost-effective strategy (mean OS of 3.14 years, $31 482/life year). Under this approach, 38% would undergo NAC, about twice the number of patients who are currently receiving NAC for MIBC. Such an approach would improve mean OS by 5.2, 1.6, and 4.4 months compared to RC alone, a hypothetical scenario where all patients received NAC, and compared to current estimates of NAC utilisation, respectively. CONCLUSIONS: A biomarker-based strategy to identify patients with MIBC who should undergo NAC was more cost-effective than unselected use of NAC or RC alone. As further data becomes available, such a model may serve as a basis for incorporating biomarkers into clinical decision making.

Cost consideration in utilization of multiparametric magnetic resonance imaging in prostate cancer.

The screening, evaluation and management of prostate cancer changed significantly in the last decade. The recommendations regarding prostate cancer screening continue to evolve with new revelations about existing data sets and longer followup of landmark trials. Robotics has gained the vast majority of the marketplace for surgically managed prostate cancer in rapid fashion. The need for intervention in low risk prostate cancer has been closely examined and more men are being expectantly managed than ever before. Amidst all these changes, prostate magnetic resonance imaging (MRI) has emerged as a disruptive technology. Through the use of dynamic contrast-enhanced and diffusion weighted series, prostate tumors that were previously not visible have become identifiable and quantifiable. The ability of MRI to improve staging and identification of clinically significant disease has resulted in increased utilization for different aspects of prostate cancer care. The best studied use is in men with a prior negative transrectal ultrasound guided (TRUS) prostate biopsy and the performance characteristics in this role match well with the clinical question raised. The role for MRI in initial biopsy, in pre-surgical planning before prostatectomy and in men on active surveillance is less well defined. A primary concern in the use of MRI is that of cost. MRI units are expensive, both in initial outlay and ongoing use. The availability of MRI varies widely between countries and even within regions of the same country. Different healthcare models have different approaches for allocating the use of expensive resources, including MRI, in times when they are scarce. Prostate MRI can be used at multiple points in the management algorithm of prostate cancer and each implies different cost concerns. In this review we present an overview of current research in cost and cost efficacy for the use of MRI in the management of prostate cancer. By examining what is known and highlighting areas of ongoing research we hope to provide the reader with a solid foundation for understanding these complex, ever-changing issues.

Association Between Combined TMPRSS2:ERG and PCA3 RNA Urinary Testing and Detection of Aggressive Prostate Cancer.

IMPORTANCE: Potential survival benefits from treating aggressive (Gleason score, ≥7) early-stage prostate cancer are undermined by harms from unnecessary prostate biopsy and overdiagnosis of indolent disease. OBJECTIVE: To evaluate the a priori primary hypothesis that combined measurement of PCA3 and TMPRSS2:ERG (T2:ERG) RNA in the urine after digital rectal examination would improve specificity over measurement of prostate-specific antigen alone for detecting cancer with Gleason score of 7 or higher. As a secondary objective, to evaluate the potential effect of such urine RNA testing on health care costs. DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter diagnostic evaluation and validation in academic and community-based ambulatory urology clinics. Participants were a referred sample of men presenting for first-time prostate biopsy without preexisting prostate cancer: 516 eligible participants from among 748 prospective cohort participants in the developmental cohort and 561 eligible participants from 928 in the validation cohort. INTERVENTIONS/EXPOSURES: Urinary PCA3 and T2:ERG RNA measurement before prostate biopsy. MAIN OUTCOMES AND MEASURES: Presence of prostate cancer having Gleason score of 7 or higher on prostate biopsy. Pathology testing was blinded to urine assay results. In the developmental cohort, a multiplex decision algorithm was constructed using urine RNA assays to optimize specificity while maintaining 95% sensitivity for predicting aggressive prostate cancer at initial biopsy. Findings were validated in a separate multicenter cohort via prespecified analysis, blinded per prospective-specimen-collection, retrospective-blinded-evaluation (PRoBE) criteria. Cost effects of the urinary testing strategy were evaluated by modeling observed biopsy results and previously reported treatment outcomes. RESULTS: Among the 516 men in the developmental cohort (mean age, 62 years; range, 33-85 years) combining testing of urinary T2:ERG and PCA3 at thresholds that preserved 95% sensitivity for detecting aggressive prostate cancer improved specificity from 18% to 39%. Among the 561 men in the validation cohort (mean age, 62 years; range, 27-86 years), analysis confirmed improvement in specificity (from 17% to 33%; lower bound of 1-sided 95% CI, 0.73%; prespecified 1-sided P = .04), while high sensitivity (93%) was preserved for aggressive prostate cancer detection. Forty-two percent of unnecessary prostate biopsies would have been averted by using the urine assay results to select men for biopsy. Cost analysis suggested that this urinary testing algorithm to restrict prostate biopsy has greater potential cost-benefit in younger men. CONCLUSIONS AND RELEVANCE: Combined urinary testing for T2:ERG and PCA3 can avert unnecessary biopsy while retaining robust sensitivity for detecting aggressive prostate cancer with consequent potential health care cost savings.