An Economic Evaluation of a Web-Based Management Support System for Children With Urinary Incontinence: The eADVICE Trial.

PURPOSE: Children who require specialist outpatient care typically wait substantial periods during which their condition may progress, making treatment more difficult and costly. Timely and effective therapy during this period may reduce the need for lengthy specialist care. This study evaluated the cost-effectiveness of an individualized, evidence-informed, web-based program for children with urinary incontinence awaiting a specialist appointment (Electronic Advice and Diagnosis Via the Internet following Computerized Evaluation [eADVICE]) compared to usual care. eADVICE was supervised by a primary physician and delivered by an embodied conversational agent. MATERIALS AND METHODS: A trial-based cost-effectiveness analysis was performed from the perspective of the health care funder as a substudy of eADVICE, a multicenter, waitlist-controlled, randomized trial. Outcomes measures were incremental cost per incremental change in continence status and quality of life on an intention-to-treat basis. Uncertainty was examined using cost-effectiveness planes, scenarios, and 1-way sensitivity analyses. Costs were valued in 2021 Australian dollars. RESULTS: The use of eADVICE was found to be cost saving and beneficial (dominant) over usual care, with a higher proportion of children dry over 14 days at 6 months (risk difference 0.13; 95%CI 0.02-0.23, P = .03) and mean health care costs reduced by $188 (95%CI $61-$315) per participant. CONCLUSIONS: An individualized, evidence-informed, web-based program delivered by an embodied conversational agent is likely cost saving for children with urinary incontinence awaiting a specialist appointment. The potential economic impact of such a program is favorable and substantial, and may be transferable to outpatient clinic settings for other chronic health conditions.

Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial.

BACKGROUND: Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking. OBJECTIVE: Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed. STUDY DESIGN: This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile. RESULTS: The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years. CONCLUSION: Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

National Trends in Neuromodulation for Urinary Incontinence Among Insured Adult Women and Men, 2004-2013: The Urologic Diseases in America Project.

OBJECTIVE: To examine US trends in neuromodulation for urinary incontinence (UI) treatment from 2004 to 2013. METHODS: This study utilized 2 data sources: the Optum© de-identified Clinformatics® Data Mart Database for privately insured adults aged 18-64 years with a UI diagnosis (N≈40,000 women and men annually) and the Medicare 5% Sample for beneficiaries aged ≥65 years with a UI diagnosis (N≈65,000 women and men annually). We created annual cross-sectional cohorts and assessed prevalence of UI-related neuromodulation procedures among men and women separately from 2004 to 2013. Analyses were conducted overall and stratified by age, race/ethnicity, and geographic region. RESULTS: Nearly all neuromodulation procedures occurred in outpatient settings. Sacral neuromodulation (SNM) procedures for UI in both women and men grew steadily from 2004 to 2013, with more procedures performed in women than men. Among women with UI, SNM prevalence grew from 0.1%-0.2% in 2004 to 0.5%-0.6% in 2013. Posterior tibial nerve stimulation (PTNS) experienced growth from 2011 to 2013. Chemodenervation of the bladder with onabotulinumtoxinA (BTX) combined with other injectable procedures (including urethral bulking) remained stable over time. CONCLUSIONS: From 2004 to 2013, SNM procedures remained relatively uncommon but increased consistently. PTNS experienced growth starting in 2011 when PTNS-specific insurance claims became available. BTX trends remain unclear; future studies should assess it separately from other injectable procedures. Neuromodulation has a growing role in UI treatment, and ongoing trends will be important to examine.

A Cost Analysis of Icon Reusable Underwear Versus Disposable Pads for Mild to Moderate Urinary Incontinence.

OBJECTIVE: The objective of this study was to perform a cost analysis assessing the economic feasibility of reusable underwear as alternative for disposable pads for women with mild to moderate urinary incontinence. METHODS: A consumer-perspective cost analysis was performed with the following assumptions: (1) consumers have mild to moderate urinary incontinence and use 2 pads per day (PPD); (2) consumers have a 2-week supply of underwear; (3) there is no difference in laundering cost between 2 incontinence options; (4) there is no difference in use of labor/other accessories of care; (5) there is no difference in skin complaints/associated cost; (6) cost of products are nonfluctuant with time; and (7) all incontinence products were purchased online. Sensitivity analyses were performed varying the longevity of underwear, price of regular underwear, price of pads, pads used per day, and shipping and handling. RESULTS: The total cost of disposable pads with regular underwear was US $392.40, whereas the cost of Icon underwear was US $380.80 over the course of 2 years. Icon costs less than using regular underwear with disposable pads as long as the cost of the regular underwear is at least US $2.17. Icon is economically inferior if the cost per pad is US $0.15 when using 3 PPD or if the cost per pad is US $0.24 when using less than 2 PPD. CONCLUSIONS: Reusable incontinence underwear can be an economically feasible alternative to disposable pads for light to moderate urinary incontinence after 2 years of use assuming underwear has a 2-year longevity and the consumer is using 2 PPD with regular underwear.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial.

BACKGROUND: Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences. METHODS: This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers. DISCUSSION: TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Social position and geriatric syndromes among Swedish older people: a population-based study.

BACKGROUND: Older people with a low social position are at higher risk of poor health outcomes compared to those with a higher social position. Whether lower social position also increases the risk of geriatric syndromes (GSs) remains to be determined. This study investigates the association of social position with GSs among older community-dwellers. METHODS: Three consecutive population-based health surveys in 2006, 2010 and 2014 among older community-dwellers (age 65-84 years) in Stockholm County were combined (n = 17,612) and linked with Swedish administrative registry information. Social position was assessed using registry information (i.e. education, country of origin and civil status) and by self-reports (i.e. type of housing and financial stress). GSs were assessed by self-reports of the following conditions: insomnia, urinary incontinence, functional decline, falls, depressive disorder, hearing or vision problems. Binomial logistic regression analyses were used to estimate the association between social position and GSs after adjusting for age, sex, health status, health behavior and social stress. RESULTS: The prevalence of GSs was 70.0%, but varied across GSs and ranged from 1.9% for depression to 39.1% for insomnia. Living in rented accommodation, being born outside the Nordic countries, being widowed or divorced were associated with GS presence. Financial stress was most strongly associated with GSs (adjusted odds ratio, 2.59; 95% CI, 2.13-3.15). CONCLUSION: GSs are highly prevalent among older Swedish community-dwellers with wide variations across syndromes and strong association with all measures of social position, most strikingly that of experiencing financial stress.

[Absorbent products for urinary incontinence management]. / Place des protections dans la prise en charge de l'incontinence urinaire.

INTRODUCTION: Despite therapeutic strategies of female and male urinary incontinence (UI) are currently well defined, there is no precise indication of the real place or strategy use of absorbent products regardless of the etiology of the incontinence or the clinical context. METHODS: We performed a research from the PubMed database using the following keywords: (urinary incontinence [MESH Terms]) AND absorbent pad [MeSH Terms]; allowing us to isolate 362 articles. RESULTS: Many protections designs are available over-the-counter without prescription and without reimbursement in France. For "light UI", disposable insert pads are the design that seems to be the most suitable for women, compared to disposable menstrual pads, OR=0.27 [0.14, 0.52], washable pants with integral pad OR=0.12 [0.06, 0.26] or washable insert pads OR=0.05 [0.02, 0.26]. For moderate to severe UI, there is no "best universal product". There are differences between the gender and the use of a panel of protections seems the most appropriate. Both women and men prefer pull-ups to disposable insert pads, OR=0.41 [0.20, 0.87] and OR=0.39 [0.22, 0.68] respectively. In men, a preference in 70 % of subjects for urisheats is observed compared to the protections they usually use (P=0.02). The use of protections improves independence in daily OR activities=0.102 [0.046, 0.158] and quality of life related to UI OR=4.40 [1.74, 7.07] compared to patients not using protections. Despite this, their use must remain cautious because of the potential infectious urinary complications, more frequent in particular in institutional people, with 41 % of users developing at least one urinary infection over an evaluation period of 12 months vs. 11 % of non-users (P=0.001), or immuno-allergic with the "dermatitis associated incontinence" whose prevalence can reach a rate of 50 %. CONCLUSION: Comparative analyzes of risk-benefit, economic costs, patient satisfaction, protections vs. other measures are lacking. It is necessary to continue the development of these products and to compare more precisely their intrinsic characteristics, to best support patients choices.

From stigma to the spotlight: A need for patient-centred incontinence care.

Incontinence is not a single disorder but a family of related conditions with different etiologies and treatments; it is a chronic disability that carries an enormous stigma. In few disorder/treatment pairings, there is the need to reinvent care more urgent and clear than in the area of incontinence. Patient-centred care has been realized to improve outcomes, quality of care, and patient satisfaction while concurrently reducing healthcare costs. To improve continence care and move it away from "cleaning up accidents" to a patient-centred care model, in which the disorder is managed to best practice guidelines, does not require investigative or developmental prowess but a simple, concentrated effort to diffuse existing knowledge to close the knowledge gaps, both at the clinical language level for clinical nurses and family physicians, as the gatekeepers to specialist care, and in simplified layperson's language for the healthcare worker, family carer, and person living with incontinence.

[Incidence of incontinence after radical prostatectomy using claims-based data]. / Hoe vaak incontinentie na radicale prostatectomie?

OBJECTIVE: To determine the effect of radical prostatectomy (RP) hospital volume on the probability of post-RP incontinence. DESIGN: Retrospective research based on claims-based data of health insurers. METHOD: For every patient with RP the probability of incontinence was determined, based on the definition of claims of one or more incontinence pads per day. Casemix corrections were made based on indicators available in claims-data: age, lymph node dissection, and radiotherapy. No casemix corrections could be made for tumour stage and surgical technique. RESULTS: A total of 1590 patients were included in this study; for 26.0% of these patients, an average of one or more incontinence pads per day were claimed for. A significant relation between the volume of RP per hospital and the claims of incontinence material was observed. The probability of incontinence was significantly lower in hospitals with a volume of more than 100 RP patients per year when compared to hospitals with less than 100 RP patients per year. CONCLUSION: The probability of post-RP incontinence decreases as hospitals conduct more RP procedures. The casemix factors included in the analysis only had a limited impact on this observation.

The increasing importance of a continence nurse specialist to improve outcomes and save costs of urinary incontinence care: an analysis of future policy scenarios.

BACKGROUND: In an ageing population, it is inevitable to improve the management of care for community-dwelling elderly with incontinence. A previous study showed that implementation of the Optimum Continence Service Specification (OCSS) for urinary incontinence in community-dwelling elderly with four or more chronic diseases results in a reduction of urinary incontinence, an improved quality of life, and lower healthcare and lower societal costs. The aim of this study was to explore future consequences of the OCSS strategy of various healthcare policy scenarios in an ageing population. METHODS: We adapted a previously developed decision analytical model in which the OCSS new care strategy was operationalised as the appointment of a continence nurse specialist located within the general practice in The Netherlands. We used a societal perspective including healthcare costs (healthcare providers, treatment costs, insured containment products, insured home care), and societal costs (informal caregiving, containment products paid out-of-pocket, travelling expenses, home care paid out-of-pocket). All outcomes were computed over a three-year time period using two different base years (2014 and 2030). Settings for future policy scenarios were based on desk-research and expert opinion. RESULTS: Our results show that implementation of the OSCC new care strategy for urinary incontinence would yield large health gains in community dwelling elderly (2030: 2592-2618 QALYs gained) and large cost-savings in The Netherlands (2030: health care perspective: €32.4 Million - €72.5 Million; societal perspective: €182.0 Million - €250.6 Million). Savings can be generated in different categories which depends on healthcare policy. The uncertainty analyses and extreme case scenarios showed the robustness of the results. CONCLUSIONS: Implementation of the OCSS new care strategy for urinary incontinence results in an improvement in the quality of life of community-dwelling elderly, a reduction of the costs for payers and affected elderly, and a reduction in time invested by carers. Various realistic policy scenarios even forecast larger health gains and cost-savings in the future. More importantly, the longer the implementation is postponed the larger the savings foregone. The future organisation of healthcare affects the category in which the greatest savings will be generated.

The impact of a mobile application-based treatment for urinary incontinence in adult women: Design of a mixed-methods randomized controlled trial in a primary care setting.

AIMS: We aim to assess whether a purpose-developed mobile application (app) is non-inferior regarding effectiveness and cost-effective when used to treat women with urinary incontinence (UI), as compared to care as usual in Dutch primary care. Additionally, we will explore the expectations and experiences of patients and care providers regarding app usage. METHODS: A mixed-methods study will be performed, combining a pragmatic, randomized-controlled, non-inferiority trial with an extensive process evaluation. Women aged ≥18 years, suffering from UI ≥ 2 times per week and with access to a smartphone or tablet are eligible to participate. The primary outcome will be the change in UI symptom scores at 4 months after randomization, as assessed by the International Consultation on Incontinence Modular Questionnaire UI Short Form. Secondary outcomes will be the change in UI symptom scores at 12 months, as well as the patient-reported global impression of improvement, quality of life, change in sexual functioning, UI episodes per day, and costs at 4 and 12 months. In parallel, we will perform an extensive process evaluation to assess the expectations and experiences of patients and care providers regarding app usage, making use of interviews, focus group sessions, and log data analysis. CONCLUSION: This study will assess both the effectiveness and cost-effectiveness of app-based treatment for UI. The combination with the process evaluation, which will be performed in parallel, should also give valuable insights into the contextual factors that influence the effectiveness of such a treatment.

Evaluating the impact of a 'virtual clinic' on patient experience, personal and provider costs of care in urinary incontinence: A randomised controlled trial.

OBJECTIVE: To evaluate the impact of using a 'virtual clinic' on patient experience and cost in the care of women with urinary incontinence. MATERIALS AND METHODS: Women, aged > 18 years referred to a urogynaecology unit were randomised to either (1) A Standard Clinic or (2) A Virtual Clinic. Both groups completed a validated, web-based interactive, patient-reported outome measure (ePAQ-Pelvic Floor), in advance of their appointment followed by either a telephone consultation (Virtual Clinic) or face-to-face consultation (Standard Care). The primary outcome was the mean 'short-term outcome scale' score on the Patient Experience Questionnaire (PEQ). Secondary Outcome Measures included the other domains of the PEQ (Communications, Emotions and Barriers), Client Satisfaction Questionnaire (CSQ), Short-Form 12 (SF-12), personal, societal and NHS costs. RESULTS: 195 women were randomised: 98 received the intervention and 97 received standard care. The primary outcome showed a non-significant difference between the two study arms. No significant differences were also observed on the CSQ and SF-12. However, the intervention group showed significantly higher PEQ domain scores for Communications, Emotions and Barriers (including following adjustment for age and parity). Whilst standard care was overall more cost-effective, this was minimal (£38.04). The virtual clinic also significantly reduced consultation time (10.94 minutes, compared with a mean duration of 25.9 minutes respectively) and consultation costs compared to usual care (£31.75 versus £72.17 respectively), thus presenting potential cost-savings in out-patient management. CONCLUSIONS: The virtual clinical had no impact on the short-term dimension of the PEQ and overall was not as cost-effective as standard care, due to greater clinic re-attendances in this group. In the virtual clinic group, consultation times were briefer, communication experience was enhanced and personal costs lower. For medical conditions of a sensitive or intimate nature, a virtual clinic has potential to support patients to communicate with health professionals about their condition.

Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors.

BACKGROUND: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs. AIM: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS. METHODS: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission. OUTCOME: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions. RESULTS: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS. CLINICAL IMPLICATIONS: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy. STRENGTHS AND LIMITATIONS: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables. CONCLUSIONS: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065.

Trends in inpatient female urinary incontinence surgery and costs in Taiwan, 1997-2011.

OBJECTIVE: To explore the factors influencing the trends in incidence and cost for female inpatient urinary incontinence (UI) surgery from 1997 to 2011. MATERIALS AND METHODS: A dataset of one million individuals was randomly drawn from the nationwide National Health Insurance claim database covering Taiwan's population from 1997 to 2011. The participants consisted of women aged ≥20 years who underwent UI surgery. We evaluated the trends of inpatient UI incidence, the medical cost of UI surgery, and the number of UI surgeries performed from 1997 to 2011. RESULTS: A total of 1517 women underwent inpatient UI surgery from 1997 to 2011. Among these patients, the age-standardized incidence of UI surgery gradually trended upward from 1997 to 2010 but decreased in 2011. The trends were similar for medical costs, including annual inpatient cost, total medical service cost, and surgery fees. The annual inpatient cost had doubled in 2011 compared with that in 1997. However, physician visit fees, ward fees, and anesthesia fees started decreasing from 2005. The length of hospital stay and medication fees decreased during the 15-year study period. Surgeries by doctor specialty, hospital accreditation level, and patient age were stable for the study period. CONCLUSION: The trends of age-standardized incidence of UI surgery, annual inpatient cost, total inpatient cost, and surgery fees increased significantly from 1997 to 2009, and abruptly decreased from 2010 to 2011. Long-term observation evaluating the impact of Diagnosis-Related Group payment system in Taiwan is warranted to verify in the future.

Análisis de coste efectividad de fesoterodina comparado con mirabegron en el marco de tratamiento de primera línea para vejiga hiperactiva con incontinencia urinaria de urgencia, desde la perspectiva del Sistema Nacional de Salud español / Cost effectiveness analysis of fesoterodine compared to mirabegron in first-line therapy setting for overactive bladder with urge urinary incontinence, from the Spanish National Health System perspective

Objetivos: Evaluar el coste-efectividad del tratamiento de primera línea de la vejiga hiperactiva (VH) con fesoterodina en relación con mirabegron, desde la perspectiva del Sistema Nacional de Salud (SNS) español. Métodos: Se desarrolló un modelo de árbol de decisión para representar un proceso clínico típico de tratamiento de 52 semanas para un paciente con VH con incontinencia urinaria de urgencia (IUU) iniciando el tratamiento de primera línea con fesoterodina 4 mg, incluyendo valoración opcional a 8 mg frente a mirabegron 50 mg. Los datos de eficacia se obtuvieron de un metaanálisis de tratamiento indirecto bayesiano. Los pacientes con IUU de menos de un episodio/día fueron definidos como respondedor al tratamiento, y la persistencia se evaluó en las semanas 4, 12 y 24. En la semana 12 los no respondedores interrumpieron el tratamiento de forma permanente. Los años de vida ajustados por calidad (AVAC) se calcularon sobre la base de tiempo de permanencia en estados de respondedores y no respondedores. Los costes de la medicina relacionada con la VH y atención médica, incluyendo visitas médicas, pruebas de laboratorio, compresas para la incontinencia y comorbilidades (fractura, infección de la piel, infecciones del tracto urinario y depresión) se modelaron y expresaron en 2015 Euros. Resultados: En la semana 52 el porcentaje de respondedores fue de 20,8% para los pacientes que comienzan con 4mg de fesoterodina, que opcionalmente valoró a 8 mg, y de 19,4% para los pacientes tratados con mirabegron. Los AVAC fueron ligeramente superiores con fesoterodina que con mirabegron (0,7703 vs. 0,7668, diferencia = 0,0035). El tratamiento con fesoterodina también tenía costes totales ligeramente mayores que mirabegron (3.296€ vs. 3.217, diferencia = 79€), lo que resulta en un coste de 22.523/AVAC€ ganado para la fesoterodina frente al mirabegron. El análisis de sensibilidad probabilístico confirmó la ligera ventaja de la fesoterodina, con un 61,1% de probabilidad de ser rentable en la disposición a pagar de 30.000€ para un umbral de AVAC. Conclusiones: Dada la relativamente pequeña diferencia de coste de un año entre los 2 tratamientos, la fesoterodina puede considerarse una opción rentable en relación con mirabegron para el manejo de primera línea de la VH con IUU en España

Objectives: To evaluate the cost-effectiveness of first-line treatment of Overactive Bladder (OAB) with fesoterodine relative to mirabegron, from the Spanish National Health System (NHS) perspective. Methods: A decision tree model was developed to represent a typical clinical process of 52-week of treatment for an OAB patient with urge urinary incontinence (UUI) initiating first-line therapy with fesoterodine 4 mg, including optional titration to 8mg, vs.mirabegron 50 mg. Efficacy data were obtained from a Bayesian indirect treatment meta-analysis. Patients with UUI of less than one episode/day were defined as treatment responder and persistence was assessed at weeks 4, 12 and 24. At week 12, non-responders discontinued treatment permanently. Quality-adjusted life years (QALYs) were calculated based on time spent in responder and non-responder states. OAB-related drug and medical care costs including physician visits, laboratory tests, incontinence pads, and comorbidities (fracture, skin infection, urinary tract infections and depression) were modeled and expressed in Euros 2015. Results: At week 52, the percentage of responders was 20.8% for patients starting on fesoterodine 4 mg who optionally titrated to 8 mg and 19.4% for patients treated with mirabegron. QALYs were slightly higher with fesoterodine than mirabegron (0.7703 vs. 0.7668, difference = 0.0035). Fesoterodine treatment also had slightly higher total costs than mirabegron (3,296 € vs. 3,217, difference = 79 €), resulting in a cost of 22,523/QALYEuros gained for fesoterodine versus mirabegron. Probabilistic sensitivity analysis confirmed the slight advantage of fesoterodine with a 61.1% probability of being cost-effective at the 30,000€ willingness-to-pay for 1QALY threshold. Conclusions: Given the relatively small 1-year cost difference between the two treatments, fesoterodine can be considered a cost-effective option relative to mirabegron for the first-line management of OAB with UUI in Spain

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study.

OBJECTIVE: To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence. DESIGN: Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources. METHODS: Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken. RESULTS: Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties. CONCLUSIONS: Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Health Resource Utilization and Cost for Patients with Incontinent Overactive Bladder Treated with Anticholinergics.

BACKGROUND: Overactive bladder (OAB) is a common medical condition with significant economic and humanistic burden. Inadequately managed OAB may exacerbate or result in comorbidities such as depression, falls, and urinary tract infections, which can further increase the burden to the health care system. Anticholinergics are often prescribed for management of OAB with urinary incontinence ("wet" OAB). However, research has shown that patient adherence and persistence to anticholinergic therapy is poor, with approximately 80% of patients ultimately failing their first prescribed anticholinergic medication within the first year. While there has been a fair amount of research on the economic burden of OAB, the real-world impact of initiating anticholinergic therapy in patients with wet OAB has not been well studied. OBJECTIVE: To compare falls/fractures, anxiety/depression, health care resource utilization, and health care costs between a cohort of patients with wet OAB who initiated anticholinergic therapy and a matched cohort of patients without OAB. METHODS: This study was a retrospective medical and pharmacy claims analysis. Cases were members of a primary care-based, multispecialty physician medical group located in California. Cases were eligible for inclusion if they were prescribed anticholinergic therapy between January 2008 and May 2012 based on pharmacy claims, had a diagnosis of OAB, and reported having ≥ 1 urinary incontinence episode per day. Wet OAB cases were matched to non-OAB controls in a 1:3 ratio based on sex, age, and observation time. Medical and pharmacy claims data were used to analyze patient comorbidities, as well as track health care resource utilization (HRU) and direct payer costs. RESULTS: After initiating anticholinergic therapy, wet OAB patients had a 46% higher adjusted risk of experiencing falls/fractures (P < 0.001) and a 33% higher adjusted risk of experiencing depression/anxiety (P = 0.022) than non-OAB patients. Wet OAB was significantly associated with increased HRU rates of hospital admissions, outpatient visits, prescriptions filled, and diagnostic tests performed. After adjustment for covariates, total health care cost was 33% higher for wet OAB patients than non-OAB patients, resulting in an increased cost of $1,746 per member per year. CONCLUSIONS: The findings of this research suggest OAB patients who initiate anticholinergic therapy and still experience incontinence are at a greater risk for comorbidities such as falls/fractures and depression/anxiety, and use significantly more health care resources, than patients without OAB. Programs to improve patient monitoring and referrals, the appropriate use of alternative treatments within guidelines, and adherence to evidence-based practice parameters may improve clinical outcomes and decrease HRU for these patients. DISCLOSURES: This study was sponsored by Allergan, Irvine, California, which reviewed and approved the final manuscript. At the time of the study, Yehoshua had received a fellowship at the University of Arizona, which was funded by Allergan. Yehoshua, Joshi, and Campbell are employees of Allergan. Vasaveda has received consulting fees from Allergan, Medtronic, and Boston Scientific. Chancelor has received consulting fees from Allergan and Medtronic. All authors met the ICMJE authorship criteria. Neither honoraria nor payments were made for authorship. Study design was created by Yehoshua, Pulicharam, Malone, and Armstrong. Pulicharam took the lead in data collection, along with Chancellor and Campbell, and data interpretation was performed by Chancellor, Vasavada, Malone, and Armstrong. The manuscript was written by Yehoshua and revised by Joshi and Yehoshua, with assistance from the other authors.

Cost-effectiveness of a pro-active approach of urinary incontinence in women.

OBJECTIVE: To estimate the cost-effectiveness and cost-utility of actively encouraging older community-dwelling women with urinary incontinence to be diagnosed and treated. DESIGN: The study was designed as cost-effectiveness and cost-utility analyses alongside a cluster randomised controlled trial. Analyses were performed from a societal perspective. Direct medical and nonmedical costs were taken into account and valued according to the standard Dutch guidelines for economic evaluations. SETTING: Primary care. POPULATION: Study participants were 350 community-dwelling women 55 years or older with urinary incontinence. METHODS: Women in the intervention group were invited for diagnostic testing and treatment. The control group received usual care according to the Dutch guideline on urinary incontinence. Follow-up period was 12 months. MAIN OUTCOME MEASURES: Incontinence Impact Adjusted Life Years (IIALY), Quality Adjusted Life Years (QALY) and incremental costs calculated per IIALY and per QALY gained. RESULTS: Costs per extra life year without impact on daily life from urinary incontinence amounted to €5179 (95% CI -17 323 to 36 260). Costs per QALY amounted to €23 907 (95% CI -124 849 to 121 849). Assuming a ceiling ratio of €20 000, the probability that the intervention was cost-effective based on IIALYs was 91% and 46% based on QALYs. CONCLUSIONS: Improvements in severity of incontinence in older community-dwelling women can be achieved against reasonable costs, with an improvement of symptom-specific QALYs. Findings support an active role of primary care physicians towards women who hesitate to ask for help for urinary incontinence. TWEETABLE ABSTRACT: Encouraging women with urinary incontinence to be treated, improves symptoms and QOL against reasonable costs.

Continence in the cloacal exstrophy patient: What does it cost?

BACKGROUND: Surgical advancements have made cloacal exstrophy (CE) a survivable condition, though management remains complex. Urologic, orthopedic, colorectal and gynecologic interventions are not standardized, and the cost of this care is high. While the importance of a successful primary closure in terms of outcomes is known, the economic consequences of failure remain uncharacterized. METHODS: A prospectively maintained institutional database of epispadias-exstrophy complex patients was reviewed for continent CE patients. Hospital charges for all inpatient admissions prior to achieving urinary continence were inflation-adjusted to year 2013 values using Consumer Price Index for medical care published by the United States Bureau of Labor Statistics. Records for which charge data were incomplete were completed by using single mean imputation, also inflation-adjusted. Descriptive data are presented as mean±standard deviation (SD). RESULTS: Of 102 CE patients, 35 had available hospital charge data: 15 who underwent successful primary closure at the authors' institution and 20 who presented after previously failed primary closures at referring institutions. The mean±SD hospital charges for primary closure in the success group were $136,201±$48,920. These patients then underwent subsequent additional surgeries that accrued charges of $59,549±$25,189 in order to achieve continence. Overall, successful primary closures accumulated hospital charges of $200,366±$40,071. In comparison, patients referred after prior failure required significantly more hospital admissions and additional charges of $207,674±$65,820 were required to achieve continence (p<0.001). Patients who failed primary closure are estimated to accumulate 70% more total health care charges compared to the group following successful primary closure. CONCLUSION: The cost of CE management until urinary continence is high, averaging more than $200,000 in inpatient hospital charges alone. Initial success is desirable from both an outcomes and economic perspective, as the cost of salvaging a failed primary closure at our institution is similar to the overall costs of a successful closure; this is in addition to the cost of any previous failed closures. Further studies will be required to determine the optimal timing of surgical management in terms of both patient outcomes and financial consequences.