The Role of Health Insurance in Patient Reported Satisfaction with Bladder Management in Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury.

PURPOSE: Neurogenic lower urinary tract dysfunction is a significant source of morbidity for individuals with spinal cord injury and is managed with a range of treatment options that differ in efficacy, tolerability and cost. The effect of insurance coverage on bladder management, symptoms and quality of life is not known. We hypothesized that private insurance is associated with fewer bladder symptoms and better quality of life. MATERIALS AND METHODS: This is a cross-sectional, retrospective analysis of 1,226 surveys collected as part of the prospective Neurogenic Bladder Research Group SCI Registry. We included patients with complete insurance information, which was classified as private or public insurance. The relationship between insurance and bladder management, bladder symptoms and quality of life was modeled using multinomial logistic regression analysis. Spinal cord injury quality of life was measured by the Neurogenic Bladder Symptom Score. RESULTS: We identified 654 privately insured and 572 publicly insured individuals. The demographics of these groups differed by race, education, prevalence of chronic pain and bladder management. Publicly insured patients were more likely to be treated with indwelling catheters or spontaneous voiding and less likely to take bladder medication compared to those with private insurance. On multivariate analysis insurance type was not associated with differences in bladder symptoms (total Neurogenic Bladder Symptom Score) or in urinary quality of life. CONCLUSIONS: There is an association between insurance coverage and the type of bladder management used following spinal cord injury, as publicly insured patients are more likely to be treated with indwelling catheters. However, insurance status, controlling for bladder management, did not impact bladder symptoms or quality of life.

Long-term compliance with bladder management in patients with spinal cord injury: A Saudi-Arabian perspective.

Objective: To examine long-term compliance with bladder management in patients with spinal cord injury (SCI) at a tertiary care rehabilitation facility in Saudi Arabia.Design: Cross-sectional survey.Setting: Tertiary care rehabilitation facility in Saudi Arabia.Participants: A self-administered questionnaire was distributed to patients with SCI during their clinic visits. 50 patients (41 males and nine females) participated in the survey. Data documentation included demographic characteristics, type and level of injury, compliance with bladder management and barriers in compliance.Main outcome measures: The type of bladder management employed at first follow-up visit was compared with that employed at discharge.Results: Eleven out of 41 patients who were discharged on clean intermittent catheterization (CIC) stopped it within 3 months of discharge, mainly due to lack of accessibility and financial support to buy catheters. Of the total sample, 23% reported that they did not know the difference between catheter types and their advantages, and 49% stated that they did not receive proper health education regarding bladder management.Conclusion: CIC was the most commonly used bladder management technique in patients with SCI following up at a tertiary care rehabilitation facility in Saudi Arabia. Compliance with CIC may be improved by ensuring access to catheters post-discharge and by providing appropriate education about bladder management during inpatient rehabilitation.

Drug utilization patterns and healthcare resource use and costs in patients with neurogenic bladder in the United Kingdom: A retrospective primary care database study.

AIM: To characterize patients with neurogenic bladder (NGB), their treatment patterns, healthcare resource utilization, and associated costs based on records from a primary care database in the United Kingdom. METHODS: This was a retrospective, descriptive, observational study of anonymized data from the Clinical Practice Research Datalink and Hospital Episode Statistics databases (selection period, 1 January 2004 to 31 December 2016). Adults with a definitive or probable diagnosis of NGB and ≥1 referral to a urologist were included. RESULTS: The study cohort included 3913 patients with definitive (n = 363) or probable (n = 3550) NGB. Patients had a mean of 8.6 (standard deviation [SD], 7.6) comorbidities, and mean Anticholinergic Cognitive Burden Scale score of 6.6 (SD, 5.9). During 12 months' follow-up, urinary tract infection (UTI) and urinary incontinence were the most common complications. Most patients (92.2%) received ≥1 prescription for an antimuscarinic agent or mirabegron, and 53.9% of patients received prescriptions for UTI-specific antibiotics. The mean number of visits to a general practitioner for any cause was 67.7 (SD, 42.6) per individual. Almost half (46.7%) of the study cohort visited a specialist during the 12-month follow-up period, and 11.0% had ≥1 hospital admission. Total mean per patient costs for healthcare resource utilization was £2395. CONCLUSIONS: The burden of illness, healthcare resource needs, and associated costs among patients with NGB are considerable. Drug prescribing patterns are consistent with the symptoms and complications of NGB, although increased awareness of drugs with anticholinergic activity among prescribers may help to reduce the cumulative anticholinergic burden in this vulnerable population.

A critical appraisal of the principal guidelines for neurogenic lower urinary tract dysfunction using the AGREE II instrument.

AIMS: The process of identifying research questions, synthesizing and interpreting evidence, and weight given to health economics differs between the clinical guidelines (CGs) for neurogenic lower urinary tract dysfunction (NLUTD). Consequently, the quality also varies which can have implications for clinical practice. METHODS: We used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to assess the quality of the National Institute for Health and Care Excellent (NICE), European Association of Urology (EAU), and the International Consultations on Incontinence (ICI) CGs on neurogenic bladder. RESULTS: The NICE CGs were deemed to be of the highest quality (overall score of 92%). NICE were the only guidelines to systematically incorporate cost-effectiveness research into their recommendations. The EAU CGs received an overall score of 83% and the ICI CGs achieved the lowest overall score (75%). The highest scoring domain among all the CGs was scope purpose (86%) and the lowest scoring domain was applicability (69%). All guidelines were recommended for use (mostly with some modifications). CONCLUSIONS: All CGs had their inherent advantages and disadvantages, though all were still deemed to be of high quality. Incorporating cost-effectiveness research would be near impossible for guidelines with a broad-country remit. Incorporating the AGREE II instrument in the development of CGs and better collaboration between the ICI, NICE, and EAU could improve the quality, and consistency between NLUTD CGs and ultimately improve health outcomes for this important patient group.

Understanding the Economic Impact of Neurogenic Lower Urinary Tract Dysfunction.

Neurogenic bladder is a chronic and disabling condition associated with multiple comorbidities and a widespread economic impact. Literature on cost of care and resource utilization is sparse and heterogeneous. Nonstandardized approaches, impact perspectives, and types of costs are used to describe the economic implications of neurogenic bladder. The financial toll is difficult to ascertain due to indirect and intangible costs exacerbated by the underlying disability. Health resource utilization based on clinical manifestations of neurogenic bladder may serve as an alternative measure. Understanding the multifold economic implications and health resource utilization patterns of neurogenic bladder may guide improvement of treatment strategies.

Emergency Department Utilization in Patients With Neurogenic Bladder: Contemporary Burden and National Trends in Prevalence, Inpatient Admission, and Associated Charges, 2006-2011.

OBJECTIVE: To quantify the national burden of neurogenic bladder disease, a chronic debilitating condition associated with frequent hospital visits, in the contemporary emergency care setting. METHODS: Relying on the Nationwide Emergency Department Sample, 2006-2011, we abstracted patients presenting to the emergency department (ED) with neurogenic bladder utilizing International Classification of Diseases, Ninth Revision (ICD-9) codes. National trends in ED presentation, subsequent inpatient admission vs discharge, and associated charges were examined using the estimated annual percent change methodology. RESULTS: Over the study period, a total of 875,066 patients with neurogenic bladder were seen in the ED, of which 538,532 (61.5%) were admitted. Total and median ED charges increased at an annual rate of 36.66% (P <.001) and 13.24% (P <.001), respectively, with total ED charges amounting to 87.48 million USD in the year 2011. Annual ED utilization also increased, although at a slower rate, 1.89% (P = .017). Inpatient admissions decreased at an annual rate of 3.67% (P <.001), whereas the use of long-term care facilities increased at 11.82% (P = .005). CONCLUSION: Total ED charges are increasing at a dramatic rate, driven by the increasing utilization of the ED as an entry point to health care as well as the increasing per-visit charges. Encouragingly, the rates of inpatient admission are decreasing, likely secondary to improved triaging in the ED and increased utilization of long-term care facilities. It remains to be seen, however, whether the increased spending in the ED for better triaging and investment in long-term care facilities will translate into an overall economic benefit by reducing inpatient charges or not.

[Medico-economic evaluation of urological cares of spinal cord injured patients: A review]. / Évaluation médico-économique des traitements urologiques chez les patients blessés médullaires : revue de la littérature.

INTRODUCTION: To provide an overview of the urological management of spinal cord injured patients based on an economic analysis. MATERIALS AND METHODS: A literature search from January 1994 to December 2014 was performed using Medline and Embase database using the following keywords: cost-effectiveness; cost-benefit; cost-utility; spinal cord injury; neurogenic bladder; intermittent catheterization; antimuscarinics; botulinum toxin; sacral neuromodulation; tibial nerve; Brindley; sphincterotomy. The tool used for comparison was the QALY ("quality adjusted life years"); an indicator between 0 and 1 allowing the comparison between two medical treatments using cost per QALY. RESULTS: Solifenacin (5 to 10mg) is the most cost-effective treatment with an incremental cost-effectiveness ratio (ICER) of 19,893 €/QALY compared to trospium 40mg, of 16,657 €/QALY compared to trospium 60mg, of 12,309 £/QALY compared to oxybutinin. Botulinum toxin A is also cost-effective with an ICER of 24,720 $/QALY compared to best supportive cares for anticholinergic-refractory neurogenic detrusor overactivity. CONCLUSION: Solifenacin and botulinum toxin A appears to be the most cost-effective treatments for spinal injured urological cares. There is a pressing need to both increase and improve data collection and research on spinal cord injury.

Cost-effectiveness analysis of onabotulinumtoxinA (BOTOX(®)) for the management of urinary incontinence in adults with neurogenic detrusor overactivity: a UK perspective.

OBJECTIVES: To evaluate the cost effectiveness of onabotulinumtoxinA (BOTOX(®), 200 units [200 U]) for the management of urinary incontinence (UI) in adults with neurogenic detrusor overactivity (NDO) due to subcervical spinal cord injury or multiple sclerosis that is not adequately managed with anticholinergic drugs (ACHDs). PERSPECTIVE: UK National Health Service (NHS) perspective. METHODS: A Markov state-transition model was developed, which compared onabotulinumtoxinA + best supportive care (BSC) with BSC alone (comprising behavioural therapy and pads, alone or in combination with clean intermittent catheterization and possibly with ACHDs). Non-responders were eligible for invasive procedures. Health states were defined according to the reduction in UI episodes. Efficacy data and estimates of resource utilization were pooled from 468 patients on onabotulinumtoxinA in two phase III clinical trials. Drug costs (2013) and administration costs (NHS Reference Costs 2011-2012) were obtained from published sources. The time horizon of the model was 5 years, and costs and benefits were discounted at 3.5%. Scenario, one-way and probabilistic sensitivity analyses (PSAs) were conducted to explore uncertainties around the assumptions. RESULTS: In the base case, treatment with onabotulinumtoxinA + BSC over 5 years was associated with an increase in costs of £1,689 and an increase in quality-adjusted life-years (QALYs) of 0.4, compared with BSC alone, resulting in an incremental cost-effectiveness ratio of £3,850 per QALY gained. Sensitivity analyses showed that utility values had the greatest influence on model results. PSA suggests that onabotulinumtoxinA + BSC had a 100 % probability of being cost effective at a willingness to pay of <£20,000. CONCLUSION: For adult patients with NDO who are not adequately managed with ACHDs, onabotulinumtoxinA + BSC appears to be a cost-effective use of resources in the UK NHS.

Managed care aspects of managing neurogenic bladder/neurogenic detrusor overactivity.

Neurogenic bladder (NGB) and neurogenic detrusor overactivity (NDO) manifesting in urinary incontinence (UI) can present substantial treatment challenges to clinicians managing patients with underlying neurologic disorders such as multiple sclerosis, Parkinson's disease, spinal cord injury, spina bifida, and stroke. Although the clinical disease burden alone is difficult for patients and those managing their disorders, the significant negative impact that NGB/NDO and UI can have on health-related quality of life and the economic costs surrounding these disorders can be devastating for patients already burdened with neurologic disorders. Careful clinician assessment of these quality-of-life issues and the economic impact of NGB/NDO with UI is needed to appropriately assess the burden these disorders place on patients and their management and to assist clinicians to design the most clinically, socially, and economically effective individualized management plans to optimize patient outcomes.

Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis.

CONTEXT: There is a lack of evidence about the efficacy and safety of anticholinergic drugs and about the optimal anticholinergic drug, if any, for the treatment of adult neurogenic detrusor overactivity (NDO). OBJECTIVE: Review the current evidence on the efficacy, safety, and tolerability of anticholinergic drugs in the treatment of adult NDO. EVIDENCE ACQUISITION: A literature search was conducted from 1966 to May 2011. Meta-analysis of all published randomised controlled trials (RCTs) comparing anticholinergic drugs with placebo and comparing different types, doses, and routes of administration of anticholinergic drugs, in adults with NDO, was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. The primary outcome was patient-reported cure/improvement of overactive bladder symptoms. Secondary outcomes were quality of life (QoL) changes, bladder diary events, urodynamic outcomes, adverse events, and costs to health services. EVIDENCE SYNTHESIS: A total of 960 patients from 16 RCTs with mean follow-up of 3.8 wk were included. Anticholinergic drugs were associated with statistically significantly better patient-reported cure/improvement (risk ratio: 2.80; 95% confidence interval [CI], 1.64 to 4.77), higher maximum cystometric capacity (weighted mean difference [WMD]: 49.49; 95% CI, 15.38 to 84.20), higher volume at first contraction (WMD: 49.92; 95% CI, 20.06 to 79.78), and lower maximum detrusor pressure (WMD: -38.30; 95% CI, -53.17 to -23.43) when compared with placebo. The dry-mouth rates were statistically significantly higher with anticholinergics, with no difference in withdrawals because of adverse events. There was no statistically significant difference in any of the outcomes between oxybutynin and other anticholinergics or among different doses and preparations of anticholinergic drugs. No study reported QoL changes or costs to health services. CONCLUSIONS: Compared with placebo, anticholinergic treatment in patients with NDO is associated with better patient-reported cure/improvement and significant reduction of maximum detrusor pressure; however, there is a higher incidence of adverse events. None of the anticholinergic drugs or different dosages assessed in this review was superior to another.

Five-year cost analysis of intra-detrusor injection of botulinum toxin type A and augmentation cystoplasty for refractory neurogenic detrusor overactivity.

PURPOSE: Treatment options for antimuscarinic refractory neurogenic detrusor overactivity (NDO) are botulinum toxin type A injections (BTX-A) and augmentation cystoplasty (AC). We estimated initial and cumulative 5-year costs of these treatments. MATERIALS AND METHODS: Base case is an individual with antimuscarinic refractory NDO and decreased bladder compliance. Primary analysis is from the health care payor perspective. Model probabilities and ranges were derived from literature and chart review. Reimbursements were derived from the average of insurance carriers. Complication cost calculations were based on standard practice. Decision-analysis model was made with TreeAge Pro Healthcare 2009 Software, Inc. and rolled back for cost calculation. One-way sensitivity analysis was performed on all variables, and two-way sensitivity analyses were based on these results. RESULTS: Average reimbursement for one BTX-A injection and AC was $2,946.83 and $25,041.53, respectively. BTX-A treatment was less expensive over 5 years, costing $28,065. The model was only sensitive within a reasonable clinical range for Botox durability. BTX-A was more cost-effective over 5 years if the effect lasted for >5.1 months. The model was based on an AC complication rate of 40%. If the PAC complication rate<14%, AC was cheaper over 5 years. The model was sensitive to surgeons costs of BTX-A ($3,027) and facility costs of BTX-A ($1,004) and AC ($17,100). CONCLUSIONS: This is the first cost analysis of BTX-A and AC. BTX-A is cheaper at durations>5.1 months and AC was cheaper when the cost of BTX-A increases or the AC complication rate dropped below 14%.

Treatment outcomes and resource use of patients with neurogenic detrusor overactivity receiving botulinum toxin A (BOTOX) therapy in Germany.

PURPOSE: To evaluate treatment outcomes and resource consumption of patients with neurogenic detrusor overactivity (NDO) before and after botulinum toxin A (Botox) therapy in Germany. METHODS: In a multi-center, cross-sectional, retrospective cohort study, data of patients with NDO 12 months before and after the first Botox therapy were analyzed. RESULTS: 214 patients (mean age 38 +/- 14.8 years, 145 male, 69 female) with NDO due to spinal cord injury (81%); myelomeningocele (14%), or Multiple Sclerosis (5%) from seven hospitals were included. Mean interval between treatments was 8 months. Following treatment, mean maximum detrusor pressure, maximum cystometric capacity and detrusor compliance improved significantly. Prior to Botox therapy, 68% reported urinary tract infections (UTI), 63% had incontinence episodes, and 58% used incontinence aids. These numbers decreased significantly (p < 0.05) after treatment to 28, 33, and 28%, respectively. In patients using incontinence aids, mean costs per patient decreased from 2euro to 1euro per day, whereas the mean cost of drugs to treat UTIs per patient decreased from 163euro to 80euro per year, respectively. CONCLUSION: This is the first study demonstrating the clinical usefulness of Botox therapy in clinical practice. Successful treatment resulted in lower costs for NDO associated morbidity due to less need for incontinence aids and UTI medication.

Disparities in the management of multiple sclerosis-related bladder symptoms.

BACKGROUND: Participants enrolled in the North American Research Committee on Multiple Sclerosis (NARCOMS) registry report disability status using Performance Scales (PS), a self-report measure. The bladder/bowel subscale (PSB) of PS has not been validated. It is also unknown whether ethnic or socioeconomic disparities exist in bladder care. OBJECTIVE: We aimed to validate the bladder/bowel subscale used by the NARCOMS registry and to describe urologic symptoms, investigations, and treatments received by registry participants. METHODS: In the Fall 2005 update questionnaire, we collected the Bowel Control Scale (BWCS) and Urogenital Distress Inventory-6 (UDI-6) as criterion measures and urologic investigations and treatments. We measured associations between investigations, treatments, and symptoms with clinical and sociodemographic variables using chi(2) tests for categorical variables and Kruskal-Wallis tests for continuous variables, followed by multivariable logistic regression. RESULTS: Nine thousand six hundred eighty-eight participants completed the survey. For the UDI-6, the median (interquartile range) score was 33.3 (16.7 to 50.0), for the BWCS 3 (1 to 6), and for the PSB 1 (1 to 3). The correlation between the PSB and the UDI-6 was r = 0.67 and between the PSB and the BWCS r = 0.53 (both p < 0.0001). Participants had increased odds of receiving medication for bladder symptoms if they had health insurance (odds ratio [OR] 1.90; 1.07 to 3.35). Participants who were white (OR 1.5; 1.16 to 1.94) and had health insurance (OR 2.0; 1.3 to 3.07) had increased odds of undergoing urologic investigations. CONCLUSION: The Performance Scales bladder question has adequate criterion and construct validity in multiple sclerosis (MS). There are ethnic and socioeconomic disparities in bladder management in MS.

Clinical and economic consequences of volume- or time-dependent intermittent catheterization in patients with spinal cord lesions and neuropathic bladder.

STUDY DESIGN: Open comparative study. OBJECTIVE: To compare the impact of volume-dependent intermittent catheterization (VDIC) and time-dependent intermittent catheterization (TDIC) on financial burden and clinical outcomes in patients with spinal cord lesions (SCL). SETTING: Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Israel. METHOD: Economic and clinical outcomes were examined in 13 SCL patients treated with VDIC following bladder volume measurement by a portable ultrasound device (the study group), and in 11 patients treated with TDIC (the control group). Patients were followed for 12-30 days. Costs were calculated according to December 2003 prices at Loewenstein Hospital. The t-test and the Fisher's Exact Test were employed for comparisons between the groups. RESULTS: The number of catheterizations per patient per day, the time required to perform volume measurements and catheterizations, and their total cost, were approximately 44, 49, and 46% lower in the study group than in the control group. SCIMU (representing bladder management functioning) increased during the study in both groups, and the increase was 31% higher in the study group than in the control group. Urinary infection was found in three patients in the control group and in none in the study group. CONCLUSION: VDIC has economic and probably also clinical advantages over TDIC.

Economic considerations in overactive bladder.

Many costs are associated with overactive bladder (OAB). They include direct costs, such as those associated with treatment, diagnosis, routine care, and the consequences of the disease; indirect costs of lost wages and productivity; and intangible costs associated with pain, suffering, and decreased quality of life. Quantification of all these costs is essential for establishing the total economic burden of a disease on society. Currently, the total economic burden of OAB is unknown. However, various studies have determined that the economic burden of urinary incontinence, one of the symptoms of OAB, is substantial. It is also important to establish the economic impact of various interventions for OAB. Cost-minimization, cost-outcome, cost-utility, and cost-benefit models can be used for these analyses. The most difficult aspect of evaluating the economic impact of a treatment is estimating the intangible costs.