Surgical treatments for men with benign prostatic enlargement: cost effectiveness study.

OBJECTIVE: To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective. DESIGN: Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation. DATA SOURCES: Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources. METHODS: The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25,000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10,000 iterations. RESULTS: A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of pound20,000 (euro21,595, $28,686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses. CONCLUSION: The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.

Incidence, predictors, and associated outcomes of prostatism after kidney transplantation.

BACKGROUND AND OBJECTIVES: Renal transplantation is increasingly performed in elderly patients, and the incidence of benign prostatic hyperplasia (BPH) increases with age. Anuric males on dialysis may have occult BPH and not develop obstructive symptoms until urine flow is restored after transplantation. If left untreated, BPH poses a risk for numerous complications, including acute urinary retention (AUR), recurrent urinary tract infections (UTI), and renal failure. The authors hypothesized that incident BPH after renal transplantation would adversely affect allograft survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Medicare claims for BPH, AUR, UTI, and prostate resection procedures (transurethral resection of the prostate; TURP) were assessed in a retrospective cohort of 23,622 adult male Medicare primary renal transplant recipients in the United States Renal Data System database who received transplants from 1 January 2000 to 31 July 2005 and followed through 31 December 2005. RESULTS: The 3-yr incidence of BPH post-transplant was 9.7%. The incidences of AUR, UTI, and TURP after BPH diagnosis (up to 3 yr posttransplant) were 10.3%, 6.5%, and 7.3% respectively, and each was significantly associated with BPH. Cox regression analysis showed that recipient age per year, later year of transplant, and dialysis vintage were associated with incident BPH. Using Cox nonproportional hazards regression, BPH was significantly associated with renal allograft loss (including death). CONCLUSIONS: BPH is common in males after renal transplant and is independently associated with AUR, UTI, and graft loss. It is unknown whether treatment of BPH, either medical or surgical, attenuates these risks.

Differences in alpha blocker usage among enlarged prostate patients receiving combination therapy with 5 ARIs.

OBJECTIVE: The objective of this study was to directly assess the likelihood and timing of alpha blocker discontinuation in patients receiving combination therapy with dutasteride or finasteride plus an alpha blocker. METHODS: A retrospective analysis of the PharMetrics Integrated Medical and Pharmaceutical Database (Watertown, Mass) was conducted to assess differences in alpha blocker discontinuation rates for patients initiated on 5-alpha reductase inhibitor (5ARI) therapy. The database is nationally representative, encompassing more than 45 million patients from 85 managed healthcare plans. Male patients aged >50 years with a diagnosis of enlarged prostate (EP) who were receiving alpha blocker therapy and who began 5ARI treatment (dutasteride or finasteride) between January 1, 1999, and March 1, 2005, were included. Patients were studied for up to 12 months to evaluate the likelihood and timing of alpha blocker discontinuation. RESULTS: Overall, 56.7% of the patients remained on alpha blocker therapy for 6 months. At 1 year, more dutasteride patients had discontinued alpha blocker therapy (48.9% remained on alpha blocker) than finasteride patients (58.7% remained on alpha blocker). After controlling for background covariates, dutasteride patients were 19.9% more likely to discontinue alpha blocker therapy over 365 days. CONCLUSION: Patients with EP who are taking an alpha blocker and 5ARI in combination for urinary symptom relief discontinue their alpha blocker 19.9% earlier when taking dutasteride than when taking finasteride. The ability to discontinue alpha blocker therapy earlier could reduce the costs of pharmacotherapy while continuing to provide an adequate level of symptom control and disease modification, which may result in cost savings to healthcare plans.

[Medical-economic models of benign prostatic hypertrophy]. / Modèles médico-économiques pour l'hypertrophie bénigne de la prostate.

This article is designed to explain the importance of medico-economic models for evaluation of the impact of treatments of benign prostatic hyperplasia. The authors illustrate this approach by comparing two hypotheses: transurethral resection of the prostate versus watchful waiting using a Markov type of model. This model is able to simulate the probability of development of events such as transurethral resection of the prostate, acute urinary retention over a 40-year period by 3-month cycles. The model is also able to simulate the mean cost of management of a patient over this period. This type of model may appear slightly artificial and complicated, but it is the only model which could allow long-term simulations of the respective value of the various therapeutic strategies for BPH. This type of model is also evolutive, its performance is gradually improved as new data become available in the literature, allowing refinement of a number of hypotheses.

Transurethral resection of the prostate among Medicare beneficiaries in the United States: time trends and outcomes. Prostate Patient Outcomes Research Team (PORT).

OBJECTIVES: The purpose of this study was to examine the epidemiology of transurethral resection of the prostate (TURP) and associated risks among Medicare beneficiaries during the period of 1984 to 1990. METHODS: Medicare hospital claims for a 20% national sample of Medicare beneficiaries were used to identify TURPs performed during the study period. All reported rates were adjusted to the composition of the 1990 Medicare population. Risks of mortality and reoperation were evaluated using life-table methods. RESULTS: The age-adjusted rate of TURP reached a peak in 1987 and declined thereafter. Similar trends were observed for all age groups. In 1990, the rates of TURP (including all indications) were approximately 25, 19, and 13 per 1000 for men over the age of 75, 70 to 74, and 65 to 69, respectively. The 30-day mortality following TURP for the treatment of benign prostatic hyperplasia (BPH) decreased from 1.20% in 1984 to 0.77% in 1990 (linear trend, p = 0.0001). The cumulative incidence of a second TURP among men with BPH has likewise decreased steadily over time; in this study, the average was 7.2% over 7 years (5.5% when the indication for the second TURP was restricted to BPH only). CONCLUSIONS: The rate of TURP has been declining since 1987, conceivably due to increasing availability of alternative treatments or changes in treatment preferences of patients and physicians. Over the same period, the outcomes following TURPs have improved, perhaps due to improved surgical care and changes in patient selection.

Annual costs of benign prostatic hyperplasia in New Zealand.

Benign prostatic hyperplasia (BPH) has been regarded as part of the normal aging process in men and little attention has been focused on the cost of the disease in New Zealand. The purpose of this study was to estimate the direct and indirect costs of treating BPH in both the public and the private sectors in New Zealand. The costs of treatment were estimated from public and private hospital data on admissions for BPH, obtained from the New Zealand Department of Health, medical insurance reimbursement schedules, hospital ward costs at one centre, and urology and general practitioner consultation fees. The length of time spent off work, as a measure of indirect costs, during urological investigations or treatment was estimated from interviews with urologists. The annual 1991 total direct medical costs of treated BPH as primary diagnosis in New Zealand were estimated at $NZ16 million (the average of the end-month mid-point exchange rate for the first quarter of 1992 was $US0.5457 per $NZ1), and the costs of lost production plus loss of leisure time by patients was estimated at $NZ4 million (1992 dollars). Patients with a principal diagnosis of BPH stayed on average 8.9 days in a public hospital and 4.6 days in a private hospital. Based on the above costs, if the average length of stay of public hospital patients could be reduced to that of private hospital patients, then hospital ward costs for BPH could fall by 37% and the total direct medical costs by 21%. The most commonly performed surgical operation for BPH was transurethral prostatectomy (TURP). For operations performed in a public hospital, patients stayed on average 8.5 days, while patients whose operations were performed in private hospitals stayed 4.3 days. The mean age of these public hospital patients was 71 years compared with 67 years for those in private hospitals. A complication rate of 2.02% was recorded for TURP in public hospitals but audits (conducted by the researchers) in both public and private settings indicated that the complication rate was substantially under-recorded.

Mortality and reoperation following prostatectomy: outcomes in a Medicare population.

Data from a series of pilot projects undertaken by the Health Care Financing Administration and seven peer review organizations were used to evaluate the outcomes of prostatectomy. Outcomes in both the original random sample of 3,641 patients and subsample of 2,617 patients that had a diagnosis of benign prostatic hyperplasia and did not have a diagnosis of prostatic carcinoma were examined. Patients undergoing a transurethral resection had increased probabilities of reoperation and mortality. However, the increased risk associated with having a transurethral resection was not statistically significant after controlling for other variables associated with mortality.