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Comparing Direct Medical Costs of OnabotulinumtoxinA With Other Common Overactive Bladder Interventions

This cost analysis demonstrated that onabotulinumtoxinA is one of the least-costly treatment options for inadequately managed overactive bladder syndrome.
Published Online: Feb 02,2018
Alon Yehoshua, PharmD, MS; Brian P. Murray, MD; Sandip P. Vasavada, MD; and Peter K. Sand, MD
The cost of onabotulinumtoxinA included drug cost (100U) administered 1.72 times per year, based on the mean number of annual injections administered in a long-term extension study11; administration costs at the physician’s office ($310.58 per injection procedure, based on 2015 Current Procedural Terminology [CPT] code 52287); 1 bladder scan (CPT 51798; $18.99); 1 follow-up physician visit (CPT 99213; $73.08) after each treatment cycle; and costs associated with UTI (12% per cycle) and urinary retention (6% per cycle), based on the reported AE rates compared with placebo in a phase 3 clinical trial.12 The costs of a UTI were assumed to include the cost of 1 physician visit ($73.08) and 1 cycle of ciprofloxacin (500 mg, 10 tablets) at $3.00 per cycle.13,14 The cost of urinary retention included 1 physician visit and 63 days of intermittent catheterization,11 assuming the use of 4 catheters per day, at $1.85 per catheter.15 All administration is assumed to occur in a physician outpatient office setting for the base-case analysis; however, previous research has indicated that in Europe, the cost of onabotulinumtoxinA may be largely attributable to treatment setting.16 Thus, administration in an ambulatory surgical center (ASC) ($801 per injection procedure) or hospital outpatient setting ($1297 per injection procedure) was explored in a sensitivity analysis. In this analysis, it was assumed that 60% of procedures took place in a physician’s office, 25% in an ASC setting ($838.82), and 15% in a hospital outpatient setting ($1377.47). The cost of SNS included cost of the device, device eligibility testing by peripheral nerve evaluation (PNE) and/or staged implantation, cost of permanent implantation, device maintenance (assuming patients receive 2 reprogramming visits per year),17 and cost of battery replacement at Year 7 (Table 2).18,19

For the base case, it was assumed that SNS device implantation was conducted at an ASC with a bundled payment for procedure and device. Only a proportion of patients (51%) evaluated for SNS ultimately received a permanent implant. This proportion was calculated as the sum of patients with successful PNE who move directly to surgical lead and battery placement, patients who fail PNE but respond to a staged trial and proceed to implantation, and patients who directly enter a 2-stage procedure (Figure 1).20 Device replacement was assumed to occur at a rate of 3% per year.18

The cost of PTNS includes the cost of physician-office–based neurostimulation at a rate of $120.72 per visit (CPT 64566). Patients are assumed to receive weekly treatments for the first 12 weeks, with maintenance visits every 3.64 weeks thereafter, based on a median of 1.1 treatments per month reported among patients enrolled in the Sustained Therapeutic Effects of Percutaneous Tibial Nerve Stimulation study.21 All patients were assumed to have complete adherence to prescribed therapy. For the base-case analysis, patient cost-sharing was not considered.

In the analysis of onabotulinumtoxinA compared with pharmaceutical therapies, total cost of anticholinergics over 1 year ranged from $500 (oxybutynin chloride IR to $3472 (Detrol LA), and the cost of mirabegron was $3266. At years 5 and 10, respectively, the costs of anticholinergic treatment ranged from $2500 and $5000 (oxybutynin chloride IR), to $17,360 and $34,720 (Detrol LA), and the costs of mirabegron were $16,330 and $32,660. OnabotulinumtoxinA was associated with a total annual cost of $1892—a lower annual cost than all branded medications included in the analysis, but more costly than 3 of the 4 generic anticholinergics (tolterodine tartrate IR, trospium chloride IR, and oxybutynin chloride IR) included in the analysis. In the sensitivity analysis exploring the impact of onabotulinumtoxinA administration split between the physician office (60%), ASC (25%), and hospital outpatient (15%) settings, the total annual cost for onabotulinumtoxinA treatment was $2505, which was still less expensive than all branded medications except for Sanctura XR and Ditropan XL, and more costly than the 4 generic anticholinergics (Figure 2).

In the analysis that compared onabotulinumtoxinA 100U injection procedure with device treatments, year 1 costs were $1892 (onabotulinumtoxinA), $3395 (PTNS), and $19,443 (SNS). At years 5 and 10, respectively, the costs were as follows: $9458 and $18,916 (onabotulinumtoxinA); $11,849 and $21,316 (PTNS); and $21,316 and $33,801 (SNS) (Figure 3). The first-year cost of SNS was approximately 10 times higher than that of onabotulinumtoxinA due to the high initial cost of testing and device implantation. While costs for SNS were reduced in subsequent years, the total 5- and 10-year costs for SNS remained the highest of all the treatments evaluated.