Economic evaluation of sacral neuromodulation in overactive bladder: A Canadian perspective

Abstract

Introduction: Refractory overactive bladder (OAB) with urge incontinence is an underdiagnosed condition with substantial burden on the healthcare system and diminished patient's quality-of-life. Many 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). The goal of this study was to estimate the costefectiveness of SNM vs. OMT and BonT-A as important parameters from coverage and access to a therapy. Methods: A Markov model with Monte-Carlo simulation was used to assess the incremental cost effectiveness ratio (ICER) of SNM vs. BonT-A and OMT both in deterministic and probabilistic analysis from a provincial payer 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 surgeons. Cost data (2014-Dollars) were derived from provincial health insurance policy, drug benefit formulary, and hospital data. All cost and outcomes were discounted at a 3% rate. Results: The annual (year 1-10) incremental quality-adjusted life years for SNM vs. BonT-A was 0.05 to 0.51 and SNM vs. OMT was 0.19 to 1.76. The annual incremental cost of SNM vs. BonT-A was $7237 in year 1 and -$9402 in year 10 and was between $8878 and -$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 therapy, and SNM was dominant in consequent years. In the basecase analysis the probability of ICER being below the acceptability curve (willingness-to-pay $50 000) was >99% for SNM vs. BonT-A at year 3 and >95% for OMT at year 2. Conclusion: SNM is a cost-effective treatment option to manage patients with refractory OAB when compared to either BonT-A or OMT. From a Canadian payers' perspective, SNM may be considered a first-line treatment option in management of patients with OAB with superior long-term outcomes. Similar to all economic analysis, this study has limitations which are based on the assumptions of the used model.

Three month clinical results with a rechargeable sacral neuromodulation system for the treatment of overactive bladder

“…The rechargeable Axonics r‐SNM System is designed to have a 15‐year life. This rechargeable SNM system may further enhance the cost‐superiority of SNM compared to Botox and percutaneous tibial nerve stimulation . The long‐term follow‐up of this study will provide data to assess the cost implications of the system and validate the longevity of the device as well as provide insights into patient preference for a rechargeable system.…”

“…The rechargeable SNM device, modeled with a 10‐year life, was projected to save the United States healthcare system $12 billion over a 15‐year period . Non‐rechargeable SNM therapy has been shown to be a cost‐effective long‐term treatment of OAB in Europe and Canada, including studies showing that SNM is more cost‐effective than other third line OAB therapies . The rechargeable Axonics r‐SNM System is designed to have a 15‐year life.…”

Can we create a valid treatment algorithm for patients with drug resistant overactive bladder (OAB) syndrome or detrusor overactivity (DO)? Results from a think tank (ICI‐RS 2015)

“…By contrast, in the Canadian, Italian, and the UK healthcare systems, SNM was estimated to be more cost‐effective in the long term . Furthermore, the use of different models based on a great variance of clinical parameters could also contribute to the conflicting results of comparative cost‐effectiveness studies. A stark example is a study based on the Dutch healthcare system whereupon SNM was found to be more cost‐effective than Botox® after 4 years of treatment but with a model using general anesthesia for both procedures.…”

Overactive bladder

“…The implant is expensive, and the battery pack has to be replaced once it has discharged. However, if viewed in the longer term, the cost may be comparable to that of other treatments 54 . Incontinence episodes and voiding frequency are both reduced while receiving sacral nerve stimulation, and this is associated with improved quality of life 55 , 56 .…”