Contemporary Patterns of Third-line Treatments for Privately Insured Individuals With Overactive Bladder in the United States.

OBJECTIVE: To evaluate utilization of third-line overactive bladder (OAB) treatments including percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and intradetrusor botulinum toxin A (BTX) among privately insured patients and examine factors associated with their use. MATERIALS AND METHODS: Using MarketScan claims (2015-2017), we identified patients who underwent third-line OAB treatments based on procedure codes. Factors of interest included location, age, health plan, among others. We fit multivariable logistic regression models to estimate associations between pertinent factors with receipt of PTNS and SNS relative to BTX and associations between provider type and practice location with each treatment modality. RESULTS: We identified 7383 patients (mean age 50.9) in our cohort. SNS was used most frequently (n = 3602, 48.8%), while PTNS was used least frequently (n = 955, 12.9%). PTNS patients were more likely to reside in metropolitan areas (vs BTX: OR 1.6, 95%CI 1.3-2.1; vs SNS: OR 2.2, 95%CI 1.7-2.8), be aged 55 years or older (vs BTX: 54% vs 47%, OR 1.6, 95%CI 1.2-2.1; vs SNS: 54% vs 45%, OR 1.6, 95%CI 1.2-2.0), and be covered under a health maintenance organization (vs BTX: 17% vs 10%; vs SNS: 17% vs 10%, P <.01). Urologists were most likely to perform SNS, and gynecologists were most likely to perform BTX. 91% of PTNS procedures were performed in office settings. CONCLUSION: Among patients receiving third-line OAB treatment, PTNS was used infrequently. PTNS utilization was concentrated within urban areas, and among older patients and those covered by cost-conscious health maintenance organizations.

Efficacy of Percutaneous Tibial Nerve Stimulation for Overactive Bladder in Women and Men at a Safety Net Hospital.

PURPOSE: We investigated efficacy and compliance related to percutaneous tibial nerve stimulation in patients treated for overactive bladder at a large, urban safety net hospital. MATERIALS AND METHODS: Consecutive patients who underwent percutaneous tibial nerve stimulation at Grady Memorial Hospital from May 2015 through January 2019 were included in our cohort and records were reviewed retrospectively. Primary outcomes of interest included self-reported urinary symptoms and episodes of urinary incontinence. Our secondary outcome of interest was patient compliance, defined as completion of 12 or more treatment sessions. Descriptive analysis and paired t-tests were performed. RESULTS: Of the 50 patients with a mean ± SD age of 59 ± 12 years 80% were black, 52% were male, 34% were uninsured and 54% subscribed to government insurance. Prior treatment included behavioral modification in 100% of cases, anticholinergics in 86% and mirabegron in 4%. Patients completed a mean of 10.7 ± 2.7 of the 12 planned weekly percutaneous tibial nerve stimulation treatments. Of the patients 70% completed all 12 weekly treatments and 77% of those who completed 12 treatments continued to maintenance treatment. After percutaneous tibial nerve stimulation treatment average symptoms improved across all metrics, including mean daytime frequency (from 11.0 to 6.6 episodes per day or -24.5%), nighttime frequency (from 4.8 to 2.5 episodes per night or -47.1%), urgency score (from 3.4 to 1.9 or -42.1%) and incontinence (from 1.6 to 0.4 episodes per day or -79.6%) (each p <0.001). A total of 43 patients (86%) reported symptom improvement. CONCLUSIONS: Percutaneous tibial nerve stimulation had favorable efficacy and compliance in a traditionally underserved patient population. This should be considered as a feasible modality to manage overactive bladder symptoms in patients in a similar demographic.

Initial patterns of care with oral targeted therapies for patients with renal cell carcinoma.

OBJECTIVES: To characterize the contemporary use of oral-targeted therapies (ie, sunitinib, sorafenib) among patients with renal cell carcinoma (RCC) and to assess the factors associated with short-term and sequential treatment. METHODS: We used an administrative claims database of privately insured patients to evaluate oral-targeted therapy use among patients with RCC from 2006 to 2007. After identifying patients with RCC who had received sunitinib and/or sorafenib, we determined the prevalence of patients treated with short-term and/or sequential therapy. We performed bivariate and multivariate analyses to estimate the associations between the patient characteristics and receipt of short-term and/or sequential treatment regimens. RESULTS: We identified 938 patients with RCC who had initially been treated with sunitinib (n = 554) or sorafenib (n = 384). In this group, 36% and 23% of patients had received short-term or sequential therapy, respectively. Most patients (61%) who had received sequential therapy had undergone short-term treatment with ≥1 drugs, with second-line sorafenib more likely to be given as short-term therapy than sunitinib (63% vs 34%, P < .001). Short-term therapy was more common in female patients (odds ratio 1.53, 95% confidence interval 1.12-2.09) and patients in the Southern United States (odds ratio 1.71, 95% confidence interval 1.05-2.80). Sequential therapy was more common among patients receiving sorafenib first (odds ratio 2.30, 95% confidence interval 1.64-3.21). CONCLUSIONS: Short-term and sequential oral targeted therapy use was relatively prevalent among patients with RCC. For patients treated with sunitinib and sorafenib, the patterns of short-term use varied by the sequence of medications, suggesting differences in the effectiveness or tolerability of each regimen. These findings highlight the need for future studies to characterize the "real-world" clinical outcomes and economic effect associated with these treatment courses.