286 ”NEVER EVENTS” CMS COMPLICATIONS AFTER RADICAL CYSTECTOMY

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groups (0 % and 4.4%, respectively). The patient charges associated with a full course of alvimopan were $5712.20 while the mean charge for a hospital day was $10275.30. The mean savings based on LOS were $9803.50 per patient. CONCLUSIONS: Use of alvimopan in the routine perioperative care of our cystectomy and urinary diversion patients has decreased LOS by 1.5 days for a savings of $9803.50 per patient treated. While our results are promising, they may underestimate the effect of alvimopan due to the regimented cystectomy pathway that we practice. This is reflected by our low rate of readmission for ileus, even in the control group. A forthcoming multicenter, placebo-controlled double-blinded study (NCT00708201) should help clarify the role for alvimopan in cystectomy. Source of Funding: None

285 INCREASED EXPENDITURES ON FOLLOW-UP CARE AFTER DEFINITIVE SURGERY FOR BLADDER CANCER Gurdarshan S. Sandhu*, Kenneth G. Nepple, Robert L. Grubb 3rd, Liu Yang, Seth A. Strope, St. Louis, MO INTRODUCTION AND OBJECTIVES: Despite aggressive therapy with cystectomy, urothelial cancer recurrence is common. However, an optimal follow-up regimen following definitive surgery for bladder cancer has not been defined. We describe temporal changes in expenditures on outpatient postoperative care, and evaluate which aspects of care contribute most to increased expenditures. Temporal changes in survival were correlated to changes in expenditures. METHODS: Using Surveillance, Epidemiology, End Results data linked to Medicare records, we identified 2302 patients aged ⱖ66 years with bladder carcinoma treated with definitive surgery between 1992 and 2005. Geography and time (2011) standardized outpatient Medicare expenditures on urine, laboratory, imaging investigations, and physician visits were evaluated for two years after surgery. Expenditure trends were assessed with linear regression. Multivariable Cox proportional hazard regression models were used to estimate mortality hazard ratios by surgical year. RESULTS: The average per patient expenditures during 2 years of follow-up after surgery increased from $1352 in 1992/3 to $2865 for patients in 2004/5 (p⬍ 0.0001). Expenditures on physician visits ($84 to $232), urine ($19 to $49) and imaging investigations ($1213 to $2538) increased significantly (pⱕ0.0001 for all), with no significant change in laboratory expenditures. Advanced imaging investigations appeared to drive the increased expenditures on follow up care (Figure), with increased utilization also seen in these investigations (p⬍0.05 for all). After adjusting for demographic, socioeconomic, comorbid conditions, treatment and pathologic factors, improved mortality outcomes were seen from 2000-2005 (table). CONCLUSIONS: The increased utilization and associated costs of MRI and CT are largely driving the increased expense of follow-up care after surgery for bladder cancer. Increases in survival were seen in more recent years; whether this is the result of improved patient selection, treatment, or follow-up remains to be elucidated.

Multivariable Survival Outcomes by Surgical Year Bladder Cancer Specific Mortality Surgery Year (reference 1992/3) HR 95% CI 1994/5 0.97 0.76-1.23

p value 0.78

1996/7

0.97

0.76-1.24

0.80

1998/9

0.89

0.69-1.15

0.38

2000/1

0.64

0.49-0.84

0.001

2002/3

0.73

0.57-0.95

0.02

0.67 Overall Mortality Surgery Year (reference 1992/3) HR 1994/5 0.87

0.50-0.89

0.006

95% CI 0.72-1.04

p value 0.13

1996/7

0.94

0.78-1.13

0.51

1998/9

0.89

0.74-1.08

0.25

2000/1

0.70

0.58-0.86

0.004

2002/3

0.72

0.59-0.88

0.001

2004/5

0.74

0.59-0.92

0.007

2004/5

Source of Funding: Clinical and Translational Science Award (CTSA)program of the National Center for Research Resources (NCRR)at the National Institutes of Health (NIH)Grant Numbers UL1 RR024992, KL2 RR024994, the Barnes Jewish Hospital Foundation, and the American Cancer Society Internal Review Grant from Washington University

286 “NEVER EVENTS”: CMS COMPLICATIONS AFTER RADICAL CYSTECTOMY Greg Joice*, Christopher Deibert, Max Kates, Benjamin A. Spencer, James M McKiernan, New York, NY INTRODUCTION AND OBJECTIVES: In 2008, the Center for Medicare and Medicaid Services (CMS) established ten hospital-acquired conditions that decrease hospital reimbursements if they occur. These ‘never events’ are ‘reasonably preventable’ through evidence based medicine, yet they do not consider preexisting risk factors that make patients more susceptible to these events. Radical cystectomy is a highly complex urologic intervention often necessary in a patient population with extensive comorbidities. The application of an unmodified system to track the rate of ‘never event’ outcomes may have a significant effect on healthcare delivery. We hypothesized that measurable patient and hospital characteristics may predict the occurrence of ‘never event’ complications after radical cystectomy. METHODS: Using the weighted Nationwide Inpatient Sample, we identified 54,429 patients with radical cystectomy for bladder cancer from 2002-2008. Incidence rates for each ‘never event’ were calculated (Table). Using multivariate regression analysis, the relationship of

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patient and hospital characteristics to ‘never events’, and then the impact that ‘never events’ had on mortality, length of stay (LOS), and total hospital charges was determined. RESULTS: The overall rate for ‘never event’ was 8.2%. Most common were SSI (3.7%), DVT/PE (2.7%), and vascular-catheter infection (1.3%). Demographics that predicted ‘never events’ included black race (OR 1.5, 95% CI 1.3 – 1.8), increasing age (OR 1.01, 95% CI 1.00 – 1.01), comorbidities (OR 1.3, 95% CI 1.1 – 1.5), Medicare insurance (OR 1.3, 95% CI 1.2 – 1.4). ‘Never event’ rate was decreased in females (OR 0.8, 95% CI 0.7 – 0.9), urban nonteaching hospitals (OR 0.7, 95% CI 0.6 – 0.8) and high cystectomy volume hospitals (OR 0.8, 95% CI 0.7 – 0.9). ‘Never events’ increased average LOS (by 13 days), total charges (by $80,000), and odds of in-hospital mortality (9.7% vs. 1.8%). CONCLUSIONS: ‘Never events’ are more likely in older patients with more comorbidities. Developing a ‘never event’ strongly predicts negative patient outcomes including higher LOS, charges, in-hospital mortality. High-risk populations may benefit from a case risk adjustment process prior to implementing a significant alteration in hospital or physician reimbursement policies. CMS ’Never Events’ after Radical Cystectomy ’Never Event’ Surgical Site Infection

Rate 3.69%

DVT/PE

2.65%

Vascular-Catheter Infection

1.34%

Pressure Ulcers

0.99%

Falls and Trauma

0.09%

Poor Glycemic Control

0.07%

Catheter Associated UTI

0.07%

Retained Foreign Object after Surgery

0.05%

Air Embolism

0.01%

Blood Incompatibility

0.0%

Source of Funding: None

287 COST-UTILITY RATIOS (CURS) AND DIFFERENT LEVELS OF EFFECTIVENESS IN URINARY INCONTINENCE (UI) MANAGEMENT Elisabetta Costantini*, Massimo Lazzeri, Vittorio Bini, Eleonora Salvini, Amelia Pietropaolo, Emanuele Scarponi, Emanuela Frumenzio, Massimo Porena, Perugia, Italy INTRODUCTION AND OBJECTIVES: In order to study the different levels of effectiveness and associated costs of urinary incontinence (UI) management, we have carried out a cost-utility analysis (CUA) by comparing the various treatments of stress urinary incontinence (SUI) and urgency incontinence (UUI), adopted in our health district. METHODS: A prospective analysis of 137 consecutive patients attending the outpatient service of our tertiary urological Institution were enrolled and stratified according the UI type and severity. Group A: grade II-III /Ingelman Sunderberg classification SUI 43 pts; all the patients underwent mid-urethral sling (MUS). Group B: grade I-II /Ingelman Sunderberg classification SUI 57 pts; they underwent pelvic floor muscle exercise. Group C: 37 pts. with UUI who underwent antimuscarinic treatment. A cost-utility analysis (cost per quality-adjusted life-year QALY) was conducted. To assess the well-being status the EQ-5D VAS, UDI and IIQ questionnaires were used. The direct and indirect costs including those for diagnosis, treatment and the first post-operative follow-up were also considered. RESULTS: The cost-utility ratios (CURs) in Euros, ie the cost per QALY gained for each of the three types of treatment compared to a no treatment strategy, subdivided according to the sections of EQ-5D questionnaire are reported in Table. They include all direct and indirect costs of interventions and consumption and disposal of pads. They show a considerable saving per QALY gained for both surgery and

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physiotherapy, and a CUR for drug therapy, which is much lower than the cost-useful threshold that the National Institute for health and Clinical Excellence (NICE), in UK, has adopted per QALY gained (range from 23.000 to 35.000 €). CONCLUSIONS: This study showed that in an Italian district, the treatment of UI regardless the type of intervention has a favorable cost/benefit ratio. Drug reimbursement by national health system might improve CUR. Cost-utility Ratio Index EQ-5D VAS EQ-5D

Surgery -1189

Physiotherapy -776

Drug therapy 842

-963

-626

669

Source of Funding: None

288 COST-EFFECTIVENESS OF SACRAL NEUROMODULATION IN REFRACTORY OVERACTIVE BLADDER: A CANADIAN PERSPECTIVE Magdy Hassouna, Toronto, Canada; Jacques Corcos, Montreal, Canada; Neil Dwyer, Moncton, Canada; Jerzy Gajewski, Dalhousie, Canada; gary Gray, Magali Robert, Calgary, Canada; Le-mai Tu*, Sherbrooke, Canada; Hamid Sadri, Toronto, Canada INTRODUCTION AND OBJECTIVES: Refractory overactive bladder (OAB) with urgency incontinence is an underdiagnosed condition with substantial burden on the healthcare system and diminished patient’s quality of life. A significant number of patients will fail conservative treatment with optimized medical therapy (OMT) and may benefit from minimally invasive procedures including sacral neuromodulation (SNM) or botulinum toxin (BonT-A) injection. The goal of this study was to estimate the cost-effectiveness of SNM vs. OMT and BonT-A. METHODS: An economic Markov model with Monte Carlo simulation was used to assess the incremental cost-effectiveness ratio (ICER) of SNM vs. BonT-A and OMT. The model calculated the ICER in deterministic (base-case) and probabilistic (sensitivity) analysis from a Canadian provincial payer’s perspective over a 10-year time horizon with 9-month Markov cycles. Clinical data, healthcare resource utilization and utility scores were acquired from recent publications and an expert panel of 7 Canadian surgeons. Cost data (2011-Dollars) were derived from provincial health insurance policy, drug benefit formulary, and hospital data. All cost and outcomes were discounted at 3% rate. RESULTS: The annual (year 1-10) incremental Quality-Adjusted Life Years (QALY) for SNM vs. BonT-A was 0.05-0.51 and SNM vs. OMT was 0.19-1.76. The annual incremental cost of SNM vs. BonT-A was $7,237 in year-1 and -$9,402 in year-10 and was between $8,878 to -$11,447 vs. OMT. In the base-case deterministic analysis, the ICER for SNM vs. BonT-A and OMT were within the acceptable range ($44,837 and $15,130 respectively) at the second year of treatment, with SNM being dominant in the consequent years. In the base-case analysis the probability of ICER being below the acceptability curve (Willingness-To-Pay ⫽ $50,000) in Canada was ⬎99% for SNM vs. BonT-A at year 3 and ⬎95% for OMT at year 2. CONCLUSIONS: Sacral neuromodulation is a cost-effective treatment option for the management of patients with refractory overactive bladder when compared to either botolinum toxin or optimal medical therapy. From a Canadian payers’ perspective, sacral neuromodulation should be considered as first line treatment option in patients with overactive bladder. Source of Funding: Medtronics Inc

289 MEDICATION VS. MICROWAVE: A COMPARISON OF NOCTURIA, VOIDING SYMPTOM IMPROVEMENT AND COST Stephen Eyre*, Aaron Brafman, Ralph Orlando, Boston, MA; Lori Lerner, Hingham, MA INTRODUCTION AND OBJECTIVES: Nocturia is the most bothersome symptom associated with benign prostatic hyperplasia