Cost-effectiveness analysis of tension-free vaginal tape vs burch colposuspension for female stress urinary incontinence in the USA

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence

OBJECTIVE

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m²), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

Prevalence and cost of surgical treatment for female stress urinary incontinence in Brazil: A comparison between abdominal and vaginal approaches

OBJECTIVE

Report the progress of the treatment of female stress urinary incontinence (SUI) in Brazil through vaginal and abdominal approaches and the direct costs by hospitalisation, using DATASUS-a public entity of the Strategic and Participative Management Secretary of Health Ministry, with the responsibility of collecting, processing, and disseminating public health information.

DESIGN

Epidemiological study using the Brazilian Public Health Data Center System (DATASUS).

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

Data were collected on all hospital admissions associated with treatment from 2008 to 2019 from the DATASUS. We analysed the records of hospitalisations associated with an abdominal or vaginal surgical SUI treatment.

RESULTS

The total number of procedures for the treatment of female SUI performed from 2008 to 2019 was 84.378, of which 70 238 were vaginal and 14 140 abdominal. There was an overall decrease in the number of SUI procedures in Brazil over the years analysed (F = 52.72; P < .0001); only exception was the South region (F = 1.38; P = .267). A declining trend was identified for the abdominal approach, with an increased trend of the vaginal approach (F = 170.11; P < .0001). A declining number of hospitalisation days was noted in the vaginal procedures (P = .002). Despite the fact that no differences were noted between abdominal and vaginal expenses (P = .054), hospital expenditure increased over the years for both vaginal and abdominal approaches, with no significant differences between either approaches. However, a statistically significant professional expenditure was observed in the abdominal approach (P < .001). Analysing hospitalisation and professional expenses, the total mean in the period was statistically higher for the abdominal approach (P < .0001).

CONCLUSIONS

The number of procedures to treat female SUI in Brazil has decreased from 2008 to 2019. Total financial expenditure per procedure and length of hospital stay were both higher for the abdominal approach (Burch colposuspension). A preference for a vaginal approach (pubovaginal sling or midurethral sling) has increased significantly since 2008, and our study favours this approach.

Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation

BACKGROUND

Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.

OBJECTIVE

To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences.

DESIGN

An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken.

RESULTS

Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value.

LIMITATIONS

Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling.

CONCLUSIONS

To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016049339.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Surgical treatments for women with stress urinary incontinence: a systematic review of economic evidence

BACKGROUND

Surgical interventions for the treatment of stress urinary incontinence (SUI) in women are commonly employed following the failure of minimally invasive therapies. Due to the limited information available on the relative cost-effectiveness of available surgeries for treating SUI, a de novo economic analysis was conducted to assess costs and effects of all relevant surgeries. To inform the economic analysis, the objective of this review was to identify and assess the quality of existing economic evaluation studies on different surgical interventions for the treatment of SUI in women.

METHODS

The following databases were searched during the review process: Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process, Excerpta Medica Database (Embase), National Health Service Economic Evaluation Database (NHS EED), and Health Management Information Consortium and Cost-Effectiveness Analysis Registry (CEA registry). The key criteria for inclusion were that the study population included women with SUI and that the surgical interventions considered were utilised as either a primary or a follow-up surgery. The review included only full economic evaluations. Studies were quality assessed using the Drummond checklist for economic evaluations. No quantitative synthesis of the results by meta-analysis was conducted due to the high methodological heterogeneity.

RESULTS

Twenty-six economic evaluations were included, of which 13 were model-based analyses. Surgical treatments assessed most frequently were mid-urethral slings and open and laparoscopic colposuspension. There were some differences in the methodological approaches taken, including differences in type of economic analysis, perspective, time horizon, types of resource use, and costs and outcomes that were included in the analysis. The majority of studies conducted a cost-utility analysis from a health system perspective and applied a time horizon of between 1 and 5 years. The cost-effectiveness results suggest that single-incision mini-sling and mid-urethral slings are among the most cost-effective options.

CONCLUSIONS

The review has shown that methods used for the economic evaluation of surgical treatments for SUI vary widely in terms of study design, analysis type, compared alternatives, time horizon, costing methodologies and effect outcomes. Future economic evaluation studies on surgical treatments for SUI may be improved by the application of available guidelines.

SYSTEMATIC REVIEW REGISTRATION

Registered in PROSPERO in 2016, CRD42016049339.

The health and economic burden of pertussis in Canada: A microsimulation study

BACKGROUND

Despite excellent vaccine coverage, pertussis persists in Canada, with high incidence during recent outbreaks and non-negligible incidence in non-outbreak years. While Canadian pertussis incidence is well-characterized, the full health and economic impact of pertussis have not been examined in Canada. We estimated age-specific life years (LYs) and quality-adjusted life years (QALYs) lost, and costs due to pertussis in Ontario, Canada, using a model-based approach.

METHODS

We developed a microsimulation model to simulate pertussis natural history. Daily probabilities of pertussis complications, hospitalizations, and disease sequelae as well as utilities and costs for health states were literature-derived. A healthcare payer perspective was used with a lifetime time horizon. Model outcomes were compared to those from a model with no pertussis health states. Probabilistic sensitivity analyses were used to generate distributions for estimates. Economic burden was estimated by multiplying case cost estimates by annual age-specific incidence.

RESULTS

Overall, LYs lost per pertussis case was low, with negligible LYs lost in those aged >4 years. Infants (<6 months) had the greatest mean QALY loss per case (0.58), while adults lost only 0.05 QALYs per case. Infants experienced the greatest mean cost per case of $22,768 (95% CI: 21,144-23,406). Case costs generally declined with age, but increased in seniors (aged 65+) with mean cost of $1920 (95% CI: 1800-2033). Based on historic age-specific incidence, pertussis costs the Ontario healthcare system approximately $7.6-$21.5 M annually. In total economic cost estimates with QALYs valued at 1xGDP (3xGDP) per capita, the net impact of pertussis in Ontario was estimated at $21.7-$66.5 M annually ($50.0-$156.3 M). For all of Canada, total economic costs were estimated at $79.6-$241.3 M ($187.5-$580.5 M) annually.

CONCLUSION

The health and economic consequences of pertussis persistence are substantial and highlight the need for improved control strategies.

Costs analysis of surgical treatment of stress urinary incontinence in a brazilian public hospital, comparing burch and synthetic sling techniques

Introduction

Surgical treatment of urinary incontinence progressed significantly with the introduction of synthetic slings. However, in some public Brazilian hospitals, the costs of these materials prevent their routine use.

Objective

To compare the costs of ambulatory synthetic sling surgery with an historical series of patients submitted to Burch surgery in a Brazilian public hospital.

Materials and Methods

Twenty nine incontinent patients were selected to synthetic sling surgery. Demographic data were prospectively collected and also the costs of the procedure, including drugs and materials, use of surgical and recovery wards, medical staff and hospitalization. These data were compared to the costs of 29 Burch surgeries performed before the introduction of synthetic slings.

Results

Demographic data were similar, although median age was lower in the group submitted to Burch surgery (46.3±8.6 versus 56.2±11.3 (p<0.001)). Cost was significantly lower in patients submitted to sling in all items, except for time spent in recovery ward. Total value of 29 Burch surgeries was R$ 217.766.12, and of R$ 68.049.92 of 29 patients submitted to sling surgery (p<0.001).

Conclusion

Burch surgery was more expensive than ambulatory synthetic transobturator sling surgery, even when the cost of the synthetic sling was considered.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Stress urinary, incontinence as the most common type of incontinence, imposes significant health and economic burdens on society and the women affected. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure to correct stress urinary incontinence.

OBJECTIVES

The review aimed to determine the effects of open retropubic colposuspension for the treatment of urinary incontinence in women. A secondary aim was to assess the safety of open retropubic colposuspension in terms of adverse events caused by the procedure.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 5 May 2015), and the reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality or susceptibility to bias and appropriateness for inclusion and data extracted by two of the review authors. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 55 trials involving a total of 5417 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggested lower incontinence rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggested lower incontinence rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower incontinence rate after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (risk ratio (RR) for incontinence 0.46; 95% CI 0.30 to 0.72 before the first year, RR 0.37; 95% CI 0.27 to 0.51 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond five years).Evidence from 22 trials in comparison with suburethral slings (traditional slings or trans-vaginal tape or transobturator tape) found no overall significant difference in incontinence rates in all time periods evaluated (as assessed subjectively RR 0.90; 95% CI 0.69 to 1.18, within one year of treatment, RR 1.18; 95%CI 1.01 to 1.39 between one and five years, RR 1.11; 95% CI 0.97 to 1.27 at five years and more, and as assessed objectively RR 1.24; 95% CI 0.93 to 1.67 within one year of treatment, RR 1.12; 95% CI 0.82 to 1.54 for one to five years follow up, RR 0.70; 95% CI 0.30 to 1.64 at more than five years). However, subgroup analysis of studies comparing traditional slings and open colposuspension showed better effectiveness with traditional slings in the medium and long term (RR 1.35; 95% CI 1.11 to 1.64 from one to five years follow up, RR 1.19; 95% CI 1.03 to 1.37).In comparison with needle suspension, there was a lower incontinence rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.56; 95% CI 0.39 to 0.81), and beyond five years (RR 0.32; 95% CI 15 to 0.71).Patient-reported incontinence rates at short, medium and long-term follow-up showed no significant differences between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials incontinence was less common after the Burch (RR 0.38; 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up times.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. Voiding problems are also more common after sling procedures compared to open colposuspension.

AUTHORS' CONCLUSIONS

Open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85% to 90%. After five years, approximately 70% of women can expect to be dry. Newer minimal access sling procedures look promising in comparison with open colposuspension but their long-term performance is limited and closer monitoring of their adverse event profile must be carried out. Open colposuspension is associated with a higher risk of pelvic organ prolapse compared to sling operations and anterior colporrhaphy, but with a lower risk of voiding dysfunction compared to traditional sling surgery. Laparoscopic colposuspension should allow speedier recovery but its relative safety and long-term effectiveness is not yet known. A Brief Economic Commentary (BEC) identified five studies suggesting that tension-free vaginal tape (TVT) and laparoscopic colposuspension may be more cost-effective compared with open retropubic colposuspension.

Economic analyses of stress urinary incontinence surgical procedures in women

INTRODUCTION

To evaluate the quality of economic analysis (EA) of surgical procedures for stress urinary incontinence (SUI) in women.

METHODS

A MEDLINE search on EA for SUI surgical procedures for the years 2000-2014 included the MeSH terms "tension-free vaginal tape," "TVT," "trans-obturator tape," "TOT," "Burch colposuspension" (BC), "stress urinary incontinence," "economic analysis," and "cost-effectiveness analysis." Important criteria for evaluating articles were selected from panels that set out criteria to evaluate EA [Scales CD, Jr., Christopher SS, American Urological Association 32:121-128, 2013], [Hsieh MH, Maxwell MV, J Urol 178 1867-1874, 2007], [Wu JM, Catherine CM, Conover MM, et al., Obstet Gynecol 123 1201-1206, 2014].

RESULTS

Thirteen articles were identified: TVT compared to BC (6), to other surgical procedures for SUI (1), to TOT (3) and to the mini-sling (1); open BC compared to laparoscopic BC (1), and analysis of various slings and meshes for various types of incontinence (1). Articles originated from: United States (3), Europe (4), United Kingdom (4), and Canada (2). Eight described cost-effectiveness analysis (CEA), two cost-utility analysis, and three cost comparison. Follow-up time for patients ranged from 6 to 24 months in eight articles, with four having a minimum of 24 months follow-up. Studies mostly adhered to the criteria, however indirect costs, sensitivity analysis, and efficacy parameters varied. Long-term synthetic sling-related complications were not included.

CONCLUSION

Although CEA for SUI surgery is a burgeoning field, study comparisons remain difficult due to some variability, including health care delivery systems. As women live longer, long-term data will become critical as complications and reoperations can affect the real cost of SUI corrective procedures. Neurourol. Urodynam. 35:1040-1045, 2016. © 2015 Wiley Periodicals, Inc.