To stage or not to stage?—A cost minimization analysis of sacral neuromodulation placement strategies

Abstract

Aims Sacral neuromodulation (SNM) is a standard therapy for refractory overactive bladder (OAB). Traditionally, SNM placement involves placement of an S3 lead with 1–3 weeks of testing before considering a permanent implant. Given the potential risk of bacterial contamination during testing and high success rates published by some experts, we compared the costs of traditional 2‐stage against single‐stage SNM placement for OAB. Methods We performed a cost minimization analysis using published data on 2‐stage SNM success rates, SNM infection rates, and direct reimbursements from Medicare for 2017. We compared the costs associated with a 2‐stage vs single‐stage approach. We performed sensitivity analyses of the primary variables listed above to assess where threshold values occurred and used separate models for freestanding ambulatory surgery centers (ASC) and outpatient hospital departments (OHD). Results Based on published literature, our base case assumed a 69% SNM success rate, a 5% 2‐stage approach infection rate, a 1.7% single‐stage approach infection rate, and removal of 50% of non‐working single‐stage SNMs. In both ASC ($17 613 vs $18 194) and OHD ($19 832 vs $21 181) settings, single‐stage SNM placement was less costly than 2‐stage placement. The minimum SNM success rates to achieve savings with a single‐stage approach occur at 65.4% and 61.3% for ASC and OHD, respectively. Conclusions Using Medicare reimbursement, single‐stage SNM placement is likely to be less costly than 2‐stage placement for most practitioners. The savings are tied to SNM success rates and reimbursement rates, with reduced costs up to $5014 per case in centers of excellence (≥ 90% success).

Treatment of Fecal Incontinence With a Rechargeable Sacral Neuromodulation System: Efficacy, Clinical Outcome, and Ease of Use—Six-Month Follow-Up

“…If success rates are high, single nonstaged procedures may be more cost-effective. A recent cost minimization analysis in patients with overactive bladder showed a cut off of 65.4% success for nonstaged to become more costeffective compared to staged approach (14). Using this model, a success rate above 85% would certainly will be more costeffective.…”

One‐stage implant in sacral neuromodulation for faecal incontinence – short‐term outcome from a prospective study

“…To the best of our knowledge, no cost‐effectiveness analysis of one‐stage implantation for FI has so far been conducted. Based on the urological literature, a success rate of 61.3%–71% (≥50% improvement) in patients following a one‐stage implantation is considered cost effective [21, 23, 24]. A cost‐effectiveness analysis must be based on national cost and reimbursement rates and may not be directly transferable to the colorectal field and to the national level.…”

“…To the best of our knowledge, no costeffectiveness analysis of one-stage implantation for FI has so far been conducted. Based on the urological literature, a success rate of 61.3%-71% (≥50% improvement) in patients following a one-stage implantation is considered cost effective [21,23,24].…”

Neuromodulation in Urology: Current Trends and Future Applications

“…However, it is more uncomfortable to the patient since only local anesthesia is being used [57]. As a matter of fact, single-staged implantation after PNE could save US $1500-5000 depending on how high the success rate of the implantation is, an argument well utilized on part of advocates at both ends of the debate of whether to stage or not [58].…”