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The Long-Term Cost Effectiveness of Treatments for Benign Prostatic Hyperplasia

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Abstract

Introduction

Excellent treatment outcomes with long-term durability and few adverse effects are expectations of treatments for chronic conditions. The long-term cost effectiveness of newer treatments for benign prostatic hyperplasia (BPH), including high-energy transurethral microwave thermotherapy (TUMT) and combination pharmaceutical therapy, has not been sufficiently studied against existing alternatives. The objective of this study was to estimate the incremental cost effectiveness of BPH treatment alternatives.

Methods

We employed a Markov model over a 20-year time horizon and the payer’s perspective to evaluate the cost effectiveness of watchful waiting (WW), pharmaceuticals (α-adrenoceptor antagonists [α-blockers], 5-α-reductase inhibitors [5-ARIs], combination therapy), TUMT and transurethral resection of the prostate (TURP) in treating BPH. Markov states included improvement in symptoms, no improvement in symptoms, adverse effects and death.

We used data from the published literature for outcomes, including systematic reviews whenever possible. Costs were estimated using a managed-care claims database and Medicare fee schedules, and were reported in $US, 2004 values. Costs and effectiveness outcomes were discounted at a rate of 3% per year. Men (aged ≥45 years) with moderate to severe lower urinary tract symptoms and uncomplicated BPH were included in the analysis, and results were stratified by age and BPH symptom levels.

Outcomes included costs, QALYs, incremental cost-utility ratios and cost-effectiveness acceptability curves. Sensitivity analysis was performed on important parameters, with an emphasis on probabilistic sensitivity analysis.

Results

α-Blockers and TUMT were cost effective for treating moderate symptoms using the threshold of $US50 000 per QALY. For example, at 65 years of age, the cost per QALY was $US16 018 for α-blockers compared with WW and $US30 204 for TUMT versus α-blockers. TURP was the most cost-effective treatment for severe symptoms ($US5824 per QALY) versus WW. Model results were robust to changes in costs and sensitive to the assumed probabilities, utility weights, extent of improvement and life expectancy. Nevertheless, acceptability curves consistently demonstrated the same alternatives as most likely to be cost effective.

Conclusions

Our model suggests that α-blockers and TURP appear to be the most cost-effective alternatives, from a US payer perspective, for BPH patients with moderate and severe symptoms, respectively. TUMT was promising for patients with moderate symptoms and the oldest patients with severe symptoms, but otherwise was dominated. Value of information analysis could be used to determine the net benefit of additional research.

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Acknowledgements

This manuscript was written as part of Dr DiSantostefano’s dissertation. Financial support was provided by a National Research Service Award Institutional Training Grant from the Institute on Aging (5-T32-AG00272), Chapel Hill, NC, USA and by grant number 1 R36 HS014719 from the Agency for Healthcare Research and Quality.

Dr DiSantostefano conducted research on a BPH pharmaceutical while on a graduate fellowship at GlaxoSmithKline. However, the results of this study were not favourable to the corresponding pharmaceutical.

We gratefully acknowledge additional members of Rachael DiSantostefano’s dissertation committee for providing comments on the draft manuscript, including Dale B. Christensen, Harry A. Guess, Kerry E. Kilpatrick and Josephine A. Mauskopf.

Rachael DiSantostefano was responsible for creating the model, calculating the results and writing the manuscript as part of her dissertation. Andrea Biddle provided the economic and technical expertise, reviewing the model and its assumptions, providing edits to the manuscript and serving as the dissertation chair. John Lavelle provided the clinical expertise, reviewed the model and its assumptions and edited the manuscript. The additional dissertation committee members were responsible for reviewing the manuscript and providing comments.

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Authors and Affiliations

  1. Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill, CB#7411, Chapel Hill, North Carolina, 27599-7411, USA

    Rachael L. DiSantostefano & Andrea K. Biddle

  2. Carolina Program in Healthcare and Aging Research, Institute on Aging, University of North Carolina, Chapel Hill, North Carolina, USA

    Rachael L. DiSantostefano

  3. Division of Urology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA

    John P. Lavelle

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  1. Rachael L. DiSantostefano
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Correspondence to Andrea K. Biddle.

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DiSantostefano, R.L., Biddle, A.K. & Lavelle, J.P. The Long-Term Cost Effectiveness of Treatments for Benign Prostatic Hyperplasia. Pharmacoeconomics 24, 171–191 (2006). https://doi.org/10.2165/00019053-200624020-00006

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