Utilization of Rectal Examinations Before Magnetic Resonance Defecography Studies.

IMPORTANCE: More information is needed to guide referring subspecialists on the appropriate patient evaluation before magnetic resonance defecography (MRD). OBJECTIVES: This study aimed to evaluate how often health care providers perform digital rectal examination (DRE) before ordering MRD to investigate causes of bowel and pelvic floor complaints. STUDY DESIGN: We conducted a retrospective cohort review, including MRD performed on female patients at an integrated health care system from 2016 through 2020. The primary outcome was the presence or absence of documented rectal examination in the year before defecography by the referring provider or 6 months prior by a primary care physician or pelvic floor physical therapist. We hypothesized that the overall rate of rectal examination would be high and unaffected by the referring provider's subspecialty. RESULTS: Three hundred-four defecography tests were performed, with 209 patients (68.8%) referred by gastroenterology providers and 95 (31.2%) from other specialties. Gastroenterologists performed DRE in 32.8% of patients, in contrast to 84.4% of patients referred by other specialties ( P < 0.001). When comparing subspecialties that most commonly refer patients for MRD (gastroenterology, colorectal surgery and urogynecology), there was a statistically significant difference between gastroenterologists and colorectal surgeons ( P < 0.001) as well as urogynecologists ( P < 0.001) but no difference in the rate of rectal examination between colorectal surgeons and urogynecologists ( P = 1.00). CONCLUSIONS: At our single integrated health system, the rate of DRE before MRD testing varied significantly by specialty. Our findings highlight the need for better understanding of DRE utility in the algorithms for evaluation of bowel and pelvic floor disorders.

Cost-Effectiveness Analysis Between Sacral Neuromodulation and OnabotulinumtoxinA for the Treatment of Refractory Overactive Bladder in Women: A Systematic Review.

OBJECTIVE: We summarized the evidence evaluating the cost-effectiveness of sacral neuromodulation (SNM) versus onabotulinumtoxinA (BONT/A) in the treatment of refractory overactive bladder (OAB) among women. METHODS: We searched PubMed Medline (1946-2019), EMBASE (1947-2019), Web of Science (1900-2019), Clinical Trials.gov, reviewed references of included studies, and Cochrane subsets of CDSR, DARE, CENTRAL, and NHSEED. We included cost-utility and cost-effectiveness analyses or decision analysis comparing SNM versus BONT/A in women with nonneurogenic refractory OAB. Primary outcomes included incremental cost-effectiveness ratios (ICERs), reported as cost per quality-adjusted life year (QALY), which were abstracted or calculated. RESULTS: Five studies met the inclusion criteria. Three studies were industry supported. Two studies of high quality found BONT/A to be dominant over SNM (ICER range of $415,571/QALY at 5 years and $236,370/QALY at 10 years). This trend was further supported by a third study of high quality that favored BONT/A because SNM was not cost-effective (ICER, $116,427/QALY at 2 years). In contrast, 2 other studies of lower quality found that SNM was cost-effective or dominant in comparison to BONT/A (ICER range, $3,717/QALY to €15,226/QALY at 10 years). In general, models were sensitive to treatment duration, intervention setting, and lacked robust data on long-term outcomes. CONCLUSIONS: OnabotulinumtoxinA is more cost-effective for managing refractory OAB when compared with SNM. However, it remains unclear whether this finding holds true long term for what is considered a lifelong condition.