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316 COST-EFFECTIVENESS ANALYSIS OF TREATMENT OF APICAL PROLAPSE REPAIR WITH EITHER SACROCOLPOPEXY OR SACROSPINOUS FIXATION
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THE JOURNAL OF UROLOGY姞
completed their evaluation in significantly shorter times with decreased time between the diagnosis of hematuria and completion of the CT scan (22.0 vs. 45.2 days, p⬍0.05) and completion of cystoscopy (35.8 vs. 70.6 days, p⬍0.05). Additionally, more patients in group A had their CT scan completed prior to their first urology visit (75.5% vs. 28.6%, p⬍0.05). Also, group A had more patients who completed their evaluation in one urology visit (56.6% vs. 21.9%, p⬍0.05). CONCLUSIONS: Incorporating a care coordination system into the referral process for hematuria decreased the time to complete evaluation. Timeliness, one of the Institute of Medicine’s quality metrics, is particularly important for this situation as 3.8% of patients had a new cancer diagnosis. Additionally, increasing the number of CT scans done prior to the first urology visit resulted in less total urology visits per evaluation. This finding should result in decreased cost to patients and payors, as well as increased access to care for others as more appointments will be open. It is estimated there are 500,000 to 1,000,000 hematuria evaluations per year in the U.S., so removing an initial visit with a cost of $100 could save the healthcare system approximately $50 to $100 million per year. Further analysis of the economic and quality ramifications of this care coordination system is under way. Source of Funding: Szollosi Healthcare Innovation Program, Grant Healthcare Foundation
315 COST COMPARISON OF NEPHRON-SPARING THERAPIES Joan Ko*, Jessica Hammett, Nora Byrd, Noah Schenkman, Tracey Krupski, Charlottesville, VA INTRODUCTION AND OBJECTIVES: In this era of high quality yet cost-conscious health care, patients and physicians are considering therapeutic cost. Ablative procedures, such as cryoablation and radiofrequency ablation, are particularly receiving more attention, in part because they are presumed to be cost-effective. We sought to determine, using Virginia claims data, 1) whether ablative therapies were increasing and 2) if these ablative procedures have a cost advantage over other surgical options. METHODS: All patients who underwent surgical treatment for renal mass in Virginia from 2000 to 2008 were identified using the Virginia Department of Health Patient Level Database System reported via the Thomson Reuters Polaris Suite. Data were refined using primary International Classification of Disease (9th revision; ICD-9) codes referencing renal mass worrisome for carcinoma (renal cell carcinoma 189.0 and renal mass unspecified 236.91) and ICD-9 procedure codes consistent with nephrectomy (55.51, 55.54), partial nephrectomy (55.4), and tumor ablation (55.32, 55.33, 55.34, 55.35, 55.39). The prevalence of these procedures was compared between academic centers and community hospitals during each year. The average cost of each procedure over the given time period was also calculated. Data analysis was performed using Microsoft Excel 2008. RESULTS: From 2000 to 2008, a total of 3608 nephrectomies, 936 partial nephrectomies, and 227 ablative procedures were performed in academic and community hospitals across the state of Virginia. Over this time period, the frequency of ablative procedures increased eight-fold in community hospitals and five-fold in academic hospitals while the number of nephrectomies experienced a sustained decrease. The average costs (procedure and hospitalization) for nephrectomy, partial nephrectomy, and ablative therapy in all Virginia hospitals were $38,744, $41,108 and $46,626, respectively. The cost difference between these procedures was not significant. CONCLUSIONS: In the state of Virginia, renal tumor ablation is on the rise as more academic and community physicians are incorporating these techniques. In an era of cost-conscious medicine, some may surmise that ablative procedures are less expensive when compared to nephrectomies and partial nephrectomies. However, according to the Virginia data, there is no significant difference in cost between
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
these procedures. Considering these results, patients with renal malignancy should be treated according to criteria that minimize cost considerations. Source of Funding: None
316 COST-EFFECTIVENESS ANALYSIS OF TREATMENT OF APICAL PROLAPSE REPAIR WITH EITHER SACROCOLPOPEXY OR SACROSPINOUS FIXATION W. Stuart Reynolds*, Melissa Kaufman, Roger Dmochowski, David Penson, Nashville, TN INTRODUCTION AND OBJECTIVES: Little comparison data exist examining either effectiveness or cost of abdominal sacrocolpopexy (ASC) and sacrospinous ligament fixation (SSLF) for pelvic organ prolapse (POP). A cost-effectiveness analysis (CEA) was performed comparing ASC and SSLF for apical POP. METHODS: A CEA decision model was developed (with TreeAge Pro software) to compare direct costs (2010 US dollars) and effectiveness (quality-adjusted life years (QALYs)) of SSLF and ASC for the treatment of apical POP for 1 year from the health care system perspective. Two treatment strategies were modeled in the decision tree: ASC or SSLF. For each strategy, cure or failure are each associated with the possibility of no complication, major complications or mesh erosion. All failures additionally were modeled for retreatment or no retreatment. Variables are represented in the table. Variable estimates and ranges were either calculated or extrapolated from existing literature. Sensitivity analyses for all variables were performed. RESULTS: The expected costs of each strategy were $6836 and $3813 for ASC and SSLF and expected effectiveness at 1 year was 0.8405 and 0.8394 QALYs, respectively. The incremental costeffectiveness ratio (ICER) for ASC as compared to SSLF was $2,677,010/QALY, which is dramatically higher than the generally accepted threshold of $50,000/QALY. In 1-way sensitivity analyses, cost of ASC, cost of SSLF and probability of major complications after SSLF, had the most impact on ICER. Threshold values resulting in ICER ⬍ $50K and thus preferring ASC are minimum cost of SSLF of $6466, a maximum cost of $3034 for ASC and probability of major complication of SSLF of 22.1%. CONCLUSIONS: ASC was not cost-effective compared to SSLF for the treatment of apical POP. If the costs of PVS decreased and of TVT increased, and the complication rate after SSLF increased, then PVS would be cost effective. Table. Variables and ranges used in CEA and sensitivity analyses Point estimate Variable (% or $) Range (% of $) Probability of SSLF failure 18 0–80 Probability of major perioperative complication SSLF*
1.9
Probability of Mesh Erosion SSLF
0
Probability of POP retreatment SSLF Probability of Failure ASC
3.9 10
0–50 0 0–50 0–80
Probability of major perioperative complication ASC
3.7
0–50
Probability of Mesh erosion ASC
3.4
0–50
Probability of POP retreatment ASC
2.3
0–50
Cost of SSLF*
3380
2500–5000
Cost of ASC*
5000
2500–16000
Cost of Retreatment POP
3840
2500–16000
Cost of mesh excision
3380
2500–5000
Cost of major perioperative complication 13000 10000–15000 *Variables with significant impact on incremental cost effectiveness ratio on sensitivity analyses.
Source of Funding: None
THE JOURNAL OF UROLOGY姞
completed their evaluation in significantly shorter times with decreased time between the diagnosis of hematuria and completion of the CT scan (22.0 vs. 45.2 days, p⬍0.05) and completion of cystoscopy (35.8 vs. 70.6 days, p⬍0.05). Additionally, more patients in group A had their CT scan completed prior to their first urology visit (75.5% vs. 28.6%, p⬍0.05). Also, group A had more patients who completed their evaluation in one urology visit (56.6% vs. 21.9%, p⬍0.05). CONCLUSIONS: Incorporating a care coordination system into the referral process for hematuria decreased the time to complete evaluation. Timeliness, one of the Institute of Medicine’s quality metrics, is particularly important for this situation as 3.8% of patients had a new cancer diagnosis. Additionally, increasing the number of CT scans done prior to the first urology visit resulted in less total urology visits per evaluation. This finding should result in decreased cost to patients and payors, as well as increased access to care for others as more appointments will be open. It is estimated there are 500,000 to 1,000,000 hematuria evaluations per year in the U.S., so removing an initial visit with a cost of $100 could save the healthcare system approximately $50 to $100 million per year. Further analysis of the economic and quality ramifications of this care coordination system is under way. Source of Funding: Szollosi Healthcare Innovation Program, Grant Healthcare Foundation
315 COST COMPARISON OF NEPHRON-SPARING THERAPIES Joan Ko*, Jessica Hammett, Nora Byrd, Noah Schenkman, Tracey Krupski, Charlottesville, VA INTRODUCTION AND OBJECTIVES: In this era of high quality yet cost-conscious health care, patients and physicians are considering therapeutic cost. Ablative procedures, such as cryoablation and radiofrequency ablation, are particularly receiving more attention, in part because they are presumed to be cost-effective. We sought to determine, using Virginia claims data, 1) whether ablative therapies were increasing and 2) if these ablative procedures have a cost advantage over other surgical options. METHODS: All patients who underwent surgical treatment for renal mass in Virginia from 2000 to 2008 were identified using the Virginia Department of Health Patient Level Database System reported via the Thomson Reuters Polaris Suite. Data were refined using primary International Classification of Disease (9th revision; ICD-9) codes referencing renal mass worrisome for carcinoma (renal cell carcinoma 189.0 and renal mass unspecified 236.91) and ICD-9 procedure codes consistent with nephrectomy (55.51, 55.54), partial nephrectomy (55.4), and tumor ablation (55.32, 55.33, 55.34, 55.35, 55.39). The prevalence of these procedures was compared between academic centers and community hospitals during each year. The average cost of each procedure over the given time period was also calculated. Data analysis was performed using Microsoft Excel 2008. RESULTS: From 2000 to 2008, a total of 3608 nephrectomies, 936 partial nephrectomies, and 227 ablative procedures were performed in academic and community hospitals across the state of Virginia. Over this time period, the frequency of ablative procedures increased eight-fold in community hospitals and five-fold in academic hospitals while the number of nephrectomies experienced a sustained decrease. The average costs (procedure and hospitalization) for nephrectomy, partial nephrectomy, and ablative therapy in all Virginia hospitals were $38,744, $41,108 and $46,626, respectively. The cost difference between these procedures was not significant. CONCLUSIONS: In the state of Virginia, renal tumor ablation is on the rise as more academic and community physicians are incorporating these techniques. In an era of cost-conscious medicine, some may surmise that ablative procedures are less expensive when compared to nephrectomies and partial nephrectomies. However, according to the Virginia data, there is no significant difference in cost between
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
these procedures. Considering these results, patients with renal malignancy should be treated according to criteria that minimize cost considerations. Source of Funding: None
316 COST-EFFECTIVENESS ANALYSIS OF TREATMENT OF APICAL PROLAPSE REPAIR WITH EITHER SACROCOLPOPEXY OR SACROSPINOUS FIXATION W. Stuart Reynolds*, Melissa Kaufman, Roger Dmochowski, David Penson, Nashville, TN INTRODUCTION AND OBJECTIVES: Little comparison data exist examining either effectiveness or cost of abdominal sacrocolpopexy (ASC) and sacrospinous ligament fixation (SSLF) for pelvic organ prolapse (POP). A cost-effectiveness analysis (CEA) was performed comparing ASC and SSLF for apical POP. METHODS: A CEA decision model was developed (with TreeAge Pro software) to compare direct costs (2010 US dollars) and effectiveness (quality-adjusted life years (QALYs)) of SSLF and ASC for the treatment of apical POP for 1 year from the health care system perspective. Two treatment strategies were modeled in the decision tree: ASC or SSLF. For each strategy, cure or failure are each associated with the possibility of no complication, major complications or mesh erosion. All failures additionally were modeled for retreatment or no retreatment. Variables are represented in the table. Variable estimates and ranges were either calculated or extrapolated from existing literature. Sensitivity analyses for all variables were performed. RESULTS: The expected costs of each strategy were $6836 and $3813 for ASC and SSLF and expected effectiveness at 1 year was 0.8405 and 0.8394 QALYs, respectively. The incremental costeffectiveness ratio (ICER) for ASC as compared to SSLF was $2,677,010/QALY, which is dramatically higher than the generally accepted threshold of $50,000/QALY. In 1-way sensitivity analyses, cost of ASC, cost of SSLF and probability of major complications after SSLF, had the most impact on ICER. Threshold values resulting in ICER ⬍ $50K and thus preferring ASC are minimum cost of SSLF of $6466, a maximum cost of $3034 for ASC and probability of major complication of SSLF of 22.1%. CONCLUSIONS: ASC was not cost-effective compared to SSLF for the treatment of apical POP. If the costs of PVS decreased and of TVT increased, and the complication rate after SSLF increased, then PVS would be cost effective. Table. Variables and ranges used in CEA and sensitivity analyses Point estimate Variable (% or $) Range (% of $) Probability of SSLF failure 18 0–80 Probability of major perioperative complication SSLF*
1.9
Probability of Mesh Erosion SSLF
0
Probability of POP retreatment SSLF Probability of Failure ASC
3.9 10
0–50 0 0–50 0–80
Probability of major perioperative complication ASC
3.7
0–50
Probability of Mesh erosion ASC
3.4
0–50
Probability of POP retreatment ASC
2.3
0–50
Cost of SSLF*
3380
2500–5000
Cost of ASC*
5000
2500–16000
Cost of Retreatment POP
3840
2500–16000
Cost of mesh excision
3380
2500–5000
Cost of major perioperative complication 13000 10000–15000 *Variables with significant impact on incremental cost effectiveness ratio on sensitivity analyses.
Source of Funding: None