THE TIME FOR LEGISLATIVE PARITY HAS COME: AN ECONOMIC ARGUMENT FOR INSURANCE REIMBURSEMENT FOR ERECTILE DYSFUNCTION THERAPY AFTER RADICAL PROSTATECTOMY

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DOES OBESITY IMPACT THE COSTS OF PARTIAL AND RADICAL NEPHRECTOMY? Karim Bensalah*, Jay D Raman, Aditya Bagrodia, Andrea Marvin, Yair Lotan. Dallas, TX. ,1752'8&7,21$1'2%-(&7,9(:HDQDO\]HGWKHLPSDFW of obesity on the costs of partial and radical nephrectomy. METHODS: The charts of 237 patients who underwent open radical nephrectomy (ORN, n=48), laparoscopic radical nephrectomy (LRN, n=67 patients), open partial nephrectomy (OPN, n=61) or laparoscopic partial nephrectomy (LPN, n=61) were retrospectively reviewed. Clinical data including age, American Society RI$QHVWKHVLRORJLVWV$6$ VFRUHERG\PDVVLQGH[%0, WXPRUVL]H occurrence of complications, and length of stay (LOS) was collected. Cost data was comprised of total direct costs and subcosts including anesthesia, laboratory, operating room service, radiology, room and board, pharmacy and surgical supplies. Obese and non obese patients ZHUHFRPSDUHGZLWKLQHDFKJURXSXVLQJ0DQQ8:KLWQH\DQGȤWHVWV for continuous and categorical variables, respectively. Univariate analysis was used to assess predictors of direct costs. RESULTS: LOS was longer in obese patients of the OPN group (p=0.04). There were no differences between obese and non obese patients in terms of complications and co-morbidities. Costs ZHUHKLJKHULQREHVHSDWLHQWVLQWKH231JURXSYV p=0.02). There were no other differences in cost between obese and non obese patients in the three other surgical groups. In univariate analysis, LOS robustly predicted the cost for each kind of operation (p<0.0001). 2EHVLW\ VWDWXV ZDV QHDUO\ D VLJQL¿FDQW SUHGLFWRU RI GLUHFW FRVW LQ WKH OPN group (p=0.056). CONCLUSIONS: BMI had an impact on costs only in the subset of OPN patients. LOS seems to be the main determinant of costs in renal surgery. Further studies are warranted.

COST COMPARISON OF OPEN VERSUS ROBOTIC CYSTECTOMY Casey K Ng, Richard K Lee*, Anna Borkina, Douglas S Scherr. New York, NY. INTRODUCTION AND OBJECTIVE: Robotic cystectomy offers the promise of less morbid surgery with preserved oncologic control for the treatment of bladder cancer although at the expense of higher materials cost. In this study, we attempt to elucidate the cost EHKDYLRURIURERWLFF\VWHFWRP\VSHFL¿FDOO\H[DPLQLQJZKHWKHUKLJKHU LQLWLDOPDWHULDOVFRVWPD\EHMXVWL¿HGLQWKHVHWWLQJRIDQRYHUDOOORZHUHG economic burden of disease. METHODS: Data was prospectively collected on patient demographics, American Society of Anesthesiologists (ASA) class, body mass index (BMI) as well as total anesthesia, operating room, recovery room, and length of stay (LOS) times from 62 and 41 consecutive patients undergoing OC and RC, respectively. A linear model was created to simulate treatment with open cystectomy (OC) versus robotic cystectomy (RC). OC and RC cohorts were then further subdivided by urinary diversion into ileal conduit (IC), Indiana pouch (IP), and ileal neobladder (IN) subgroups. Procedural costs were derived from the Medicare Resource-Based Relative Value Scale (RBRVS). Materials costs were queried from respective suppliers. Indirect costs of complications were considered. Sensitivity analyses were performed. RESULTS: Despite the increased materials cost, RC was less expensive than OC across all three urinary diversion groups. The FRVWVRI2&ZLWK,&,3DQG,1ZHUHDQG UHVSHFWLYHO\FRPSDUHGWRDQGIRUWKHLU5& counterparts. Mean age, ASA score, BMI and number of LN removed were not statistically different between the RC and OC cohorts. The largest cost driver in the study was hospital LOS, where RC patients systematically demonstrated shorter LOS compared to OC patients. Analysis of indirect costs showed that RC patients with IC had lower complication rates, while those with IP and IN had shorter complication related LOS. &21&/86,2165&DSSHDUVWREHPRUHFRVWHI¿FLHQWWKDQ OC as a treatment for muscle invasive bladder cancer at a high volume, tertiary care referral center despite an increased materials cost. The cost EHQH¿WREWDLQHGIURPUHGXFHG/26ZLWK5&LVVLJQL¿FDQW

Source of Funding: Assoiation Francaise d’Urologie.

164 IMPACT OF POST-CYSTECTOMY INFECTIOUS COMPLICATIONS ON COST, LENGTH OF STAY, AND MORTALITY Benjamin J Davies*, Veerasathpurush Allareddy, Badrinath R Konety. San Francisco, CA. INTRODUCTION AND OBJECTIVE: The economic and clinical impact of infectious complications following radical cystectomy KDYHQRWEHHQDQDO\]HG:HXVHGWKH1DWLRQZLGH,QSDWLHQW6DPSOHV 1,6 RIWKH+HDOWKFDUH&RVWDQG8WLOL]DWLRQ3URMHFW+&83 WRDQDO\]H the impact of infectious complications after cystectomy METHODS: All 6,686 patients undergoing radical cystectomy for bladder cancer were identified from the NIS from 2000-2004. 6HSWLFHPLDEDFWHULDOLQIHFWLRQVDQGP\FRVHVFDVHVZHUHFDWHJRUL]HG XVLQJWKH&OLQLFDO&ODVVL¿FDWLRQ6RIWZDUH8VLQJPDWFKHGSDLUDQDO\VLV we compared the study group to patients who did not experience any SRVWRSHUDWLYHLQIHFWLRQ:HWKHQDQDO\]HGWKHHIIHFWRIVHSWLFHPLDRQ in-hospital mortality, length of stay, and total hospital charges. RESULTS: 241 patients (3.6%) were diagnosed with septicemia following cystectomy. The overall, in-hospital mortality rate ZDVQ  6HSWLFHPLDZDVDVLJQL¿FDQWSUHGLFWRURILQKRVSLWDO mortality (p<.001). The mean hospital charge for septicemia patients ZDVQHDUO\WLPHVWKHDPRXQWRIWKHFRQWUROSDWLHQWVYV  S  7KH OHQJWKRIVWD\ /26  ZDV  WLPHV ORQJHU IRU septicemia patients compared to controls (29 vs 10 days, p<.001). Hospital charges for bacterial infections (n=161) and mycoses infections Q ZHUHVLJQL¿FDQWO\JUHDWHUWKDQWKHLUPDWFKHGFRQWUROSRSXODWLRQ  DQG YV  DQG  YV  UHVSHFWLYHO\ p<.001- both). The mean LOS for both bacterial infections (19.4 days) DQGP\FRWLFLQIHFWLRQVGD\V ZHUHDOVRVLJQL¿FDQWO\JUHDWHUWKDQ their matched controls (19.4 days vs 10.8 days, and 18.9 days vs 10.8 days, respectively, p<.001- both). CONCLUSIONS: Septicemia following cystectomy predicts patient mortality. Septicemia, bacterial infections, and mycotic infections contribute to large increases in LOS and total hospital charges. Aggressive prevention and timely treatment of post-operative infections FRXOGVLJQL¿FDQWO\LPSURYHWKHFOLQLFDODQGHFRQRPLFLPSDFWRIWKHVH complications. Source of Funding: None

Direct and indirect costs of cystectomy Open Open cystectomy cystectomy with IC with IP Total direct   costs Total indirect   costs Total costs  

Open Robotic Robotic Robotic cystectomy cystectomy cystectomy cystectomy with IN with IC with IP with IN            

Source of Funding: None

166 THE TIME FOR LEGISLATIVE PARITY HAS COME: AN ECONOMIC ARGUMENT FOR INSURANCE REIMBURSEMENT FOR ERECTILE DYSFUNCTION THERAPY AFTER RADICAL PROSTATECTOMY Elias S Hyams*, Mary Ann Ficile, Andrew R McCullough. New York, NY. INTRODUCTION AND OBJECTIVE: In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA) requiring that third party payors (TPP) covering mastectomy for breast cancer also provide coverage for breast reconstruction. The goal of this mandate was to protect women’s self-esteem related to body image. There is no legislative parity for men after radical prostatectomy (RP). Virtually all men after RP experience some degree of erectile dysfunction (ED). The detrimental impact of ED on male self esteem and body image is no less than that experienced by women after mastectomy. Our paper contends that the overall cost of ED therapy post-RP is similar to the cost of reconstruction after mastectomy and that legislative parity is needed. METHODS: The projected number of RP in 2007 and the number of breast reconstruction procedures following mastectomy from

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2004 were obtained from the American Cancer Society and American Society of Plastic Surgeons, respectively. The estimated cost of breast reconstruction was obtained from 50th % national charges, and the cost of ED therapy was calculated using standard costs from Red Book 2004. The cost of annual ED therapy was multiplied by average life span after prostate cancer diagnosis to obtain the lifetime cost of therapy. The total economic burden of these treatments was compared. RESULTS: Approximately 60,000 RP and 60,000 breast reconstruction procedures following mastectomy are performed annually. 50th % national surgeon and ancillary charges for breast reconstruction UDQJHIURP$YHUDJHGXUDWLRQRIOLIHDIWHUSURVWDWHFDQFHU diagnosis is 10 years. Costs of ED therapy over 10 years are shown in Table 1 and compared with costs of breast reconstruction and penile implant surgery. Table 1: Cost Comparison of ED Therapy vs. Breast Reconstruction Treatment Calculation 60,000 men x 72 pills/yr x 10 years 6LOGHQD¿O #WUHDWPHQW[RIPDUNHW 60,000 men x 72 rx/yr x 10 years IUA #WUHDWPHQW[RIPDUNHW Penile Rx 60,000 men x 72 rx/yr x 10 years ICI #WUHDWPHQW[RIPDUNHW VED PHQ#U[[RIPDUNHW Total

Cost     

Breast [  Reconstruction Penile Implant [  ,8$ LQWUDXUHWKUDODOSURVWDGLO,&, LQWUDFDYHUQRVDOLQMHFWLRQV9(' YDFXXPHUHFWLRQ device

CONCLUSIONS: The economic cost of breast reconstruction following mastectomy, appropriately covered by TPP per federal mandate, exceeds the potential economic burden of covering ED therapy DIWHU53$FWXDOXWLOL]DWLRQRI('EHQH¿WVZRXOGOLNHO\EHORZHUDVQRWDOO men seek treatment. There is compelling evidence that ED treatment leads to improved quality of life for the man and his partner. The time for legislative parity in this area has come. Source of Funding: None

167 MANAGING COSTS OF PROSTATE CANCER SCREENING PROGRAMS: IMPLICATIONS OF PSA LEVEL UPPER LIMIT Daher C Chade*, Alberto A Antunes, Fabio Vicentini, Affonso C Piovesan, Paulo Cordeiro, Renato T Yamada, Geraldo Freire, Miguel Srougi. Sao Paulo, Brazil. ,1752'8&7,21$1' 2%-(&7,9( :H DQDO\]HG LQ WKLV study, the impact on costs of a prostate cancer screening by changing WKHXSSHUOLPLWRIVHUXPWRWDOSURVWDWHVSHFL¿FDQWLJHQOHYHO36$ IURP 4.0 ng/mL to 2.5 ng/mL. Costs generated from extra biopsies were included in the analysis, and compared to a scenario with a higher PSA upper limit. METHODS: A total of 1052 men were included in a PSA-based screening program. They were submitted to digital rectal exam (DRE) and total PSA measured. Analysis was made considering PSA levels UDQJLQJIURP]HURWRQJP/WRQJP/DQG36$DERYH ng/mL. The screening program budget was not included in this analysis. Each biopsy necessary to investigate men with PSA above upper limit determined for each group described generated an average cost of 86IRUWKHKHDOWKV\VWHP RESULTS: The mean age was 61.2 years and mean PSA level, 4.3 ng/mL. There were 608 men (57.78%) with PSA levels ranging IURP]HURWRQJP/PHQ EHWZHHQDQGQJ mL, 206 men (19.58%) between 4.1 and 10.0 ng/mL, and 128 men (12.17%) above 10.0 ng/mL. While determining PSA upper limit, we YHUL¿HGRIPHQZLWK36$OHYHODERYHQJP/DQGRI men with PSA level above 2.5 ng/mL.The cost generated by the biopsies FRQVLGHULQJQJP/WKH36$XSSHUOLPLWOHYHOZDV867KH group of patients with PSA level ranging from 2.6 to 4.0 ng/mL generated DQH[WUDFRVWRI86LQWKLVVLQJOHLQVWLWXWLRQSURVWDWHFDQFHU screening program, which summed up a total cost for the biopsies RI 86 7KLV EXGJHW GLG QRW LQFOXGH H[SHQVHV ZLWK VWDII laboratory and costs of treatment derived from prostate cancer patients diagnosed in the screening program.

59

CONCLUSIONS: In a PSA-based prostate cancer screening program, the determination of PSA level upper limit may not only LQÀXHQFH WKH UDWH RI HDUO\ GLDJQRVLV EXW DOVR VLJQL¿FDQWO\ LPSDFW RQ extra costs. The well known PSA trend towards lower upper limit, in this screening program described, has increased in 24.77% the expenses with biopsies alone. Consequences from this decision are shown HOVHZKHUHWREHQH¿WRUJDQFRQ¿QHGSURVWDWHFDQFHUGLDJQRVLVKRZHYHU unnecessary biopsies, overdiagnosis, and negative impact on quality of life should be considered when cost analyses are discussed. Source of Funding: None

168 TOTAL COST IN THE 1ST YEAR FOLLOWING DIAGNOSIS OF PROSTATE CANCER: ESTIMATES FROM US SEER-MEDICARE DATA Claus G Roehrborn*, Michael E Stokes, Agnes Benedict, Peter C Albertsen, Libby K Black. Dallas, TX, Montreal, QC, Canada, Budapest, Hungary, Farmington, CT, and Research Triangle Park, NC. INTRODUCTION AND OBJECTIVE: This study estimates the mean total per patient costs, by initial cancer stage and among cohorts UHFHLYLQJVSHFL¿FW\SHVRIWKHUDS\WKDWDFFUXHGXULQJWKHst year following a diagnosis of prostate cancer (PCa). METHODS: We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Patients aged 65 years or older and diagnosed with PCa during 1991-2002 were selected from SEER. Total direct medical costs in the 1st year following PCa diagnosis were calculated by stage and initial treatment type using the Medicare claims. Treatment was FODVVL¿HGDVLQLWLDOLIJLYHQZLWKLQPRQWKV02 IROORZLQJ3&DGLDJQRVLV 0DOH0HGLFDUHEHQH¿FLDULHVZKRZHUHQRWUHSRUWHGDVKDYLQJFDQFHU were matched to PCA patients on 5 year age groups in order to estimate routine healthcare costs unrelated to cancer. 5(68/76 :H LGHQWL¿HG  PHQ ZLWK 3&D ZKR PHW inclusion criteria. Mean age at diagnosis was 74.1 years (SD = 6.1). Over half were diagnosed at Stage I (51.2%). The remainder were evenly distributed between Stages II, III, and IV. Many patients had no record of a medical intervention within the 1st 6 MO following diagnosis (31.6%). The majority received initial treatment with either an LHRH analogue (30.8%), prostatectomy (18.9%), external beam radiation (16.0%), or brachytherapy (8.8%). Mean total per patient costs (2004 86 LQWKHst year following diagnosis for Stages I, II, III, and IV were   &,     &,   &, DQG&,  respectively. Mean costs among patients receiving only one type of WUHDWPHQWUDQJHGIURPIRUEUDFK\WKHUDS\WRIRUH[WHUQDO beam radiation. CONCLUSIONS: This analysis demonstrates a high rate of active surveillance (31.6% with no record of PCa treatment) as initial therapy. This is not surprising given the large proportion of patients diagnosed at Stage I and mean age of 74. Although many men were initially managed with active surveillance, the total costs among PCa SDWLHQWVLVVLJQL¿FDQW:LWKDPHDQSHUSDWLHQWFRVWRILQWKH 1st\HDUIROORZLQJGLDJQRVLVDQGDQLQFUHPHQWDOFRVWRIKLJKHU YHUVXV0HGLFDUHEHQH¿FLDULHVZLWKRXWFDQFHU3&DSUHYHQWLRQVWUDWHJLHV have the potential to reduce treatment costs which could result in VLJQL¿FDQWVDYLQJVWRWKHKHDOWKFDUHV\VWHP Source of Funding: Glaxo Smith Kline.