Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis

Abstract

Purpose: We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings.

Materials and methods: Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates.

Results: The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol.

Conclusions: A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.

Keywords: DVIU; EPA; NIS; Nationwide Inpatient Sample; RUG; SP; VCUG; costs and cost analysis; direct vision internal urethrotomy; excision and primary anastomosis; retrograde urethrography; suprapubic; urethra; urethral stricture; voiding cystourethrography.