DM Hynes, Hines VA Health Services Research & Development Programs & Cooperative Studies Program & Loyola University; DJ Reda, Hines VA Cooperative Studies Program; KT Stroupe, Hines VA Health Services Research & Development Programs and Cooperative Studies Program; JH Wasson, Dartmouth Medical School; RC Bruskewitz, University of Wisconsin Medical School; D Johnson, Dartmouth Medical School; M Abdellatif, Hines VA Cooperative Studies Program; WG Henderson, Hines VA Cooperative Studies Program

Objectives: Treatment options for benign prostatic hyperplasia (BPH) include transurethral resection (TURP), watchful waiting (WW) and pharmacotherapy. Treatment guidelines based on long-term cost and effectiveness comparisons are needed but lacking. In this study, we compare the costs of TURP and WW and use cost-effectiveness analysis to identify which men gain the most from TURP at the lowest cost. We also estimate the costs for treatments with medications (terazosin and finasteride) compared to TUPR and WW from patient’s and insurer’s perspectives.

Methods: A VA Cooperative Studies Program RCT was conducted at nine VA hospitals comparing outcomes for WW and TURP over three years of follow-up. Men 55 years or older were eligible if symptoms of BPH were moderate or somewhat severe. Outcomes were measured using standard questionnaires to determine patient’s bother by urinary difficulties (scores normalized to 100-point scale). Men were classified at baseline as more (score >= 55) or less (score <55) bothered. Utilization data on outpatient, drug, and inpatient services were collected for 547 patients for three years of follow-up, and costs for this utilization were estimated. To estimate the cost-effectiveness, we calculated the additional cost of TURP relative to WW per unit improvement in bother score. We calculated subgroup cost-effectiveness ratios for men classified at baseline as more or less bothered. To estimate long-term economic impacts, we used the three-year study costs to project costs for 15 years. To estimate costs of pharmacotherapy, we added terazosine and finasteride costs to those of WW. In cost projection scenarios, we varied the rate health care use increased and the cross-over rate from WW to TURP. For each scenario, we estimated costs from the insurer perspective (assuming 80% of inpatient and outpatient costs and no drug costs are coveraged) and patient with Medicare perspective (assuming patients pay 20% of inpatient and outpatient costs and 100% of drug costs).

Results: For men more bothered by their symptoms the cost-effectiveness of TURP versus WW was $109 per unit improvement in the urinary bother score compared to $254 for men less bothered. A 90% crossover rate from WW to TURP over five years would be necessary before WW became more expensive. Under certain scenarios, pharmacologic management of BPH was the most expensive treatment option. For example, from the perspective of a Medicare patient with no supplemental insurance for prescription benefits, cost of WW in combination with pharmacologic management exceed the cost of TURP after 3-4 years with terazosin and after the first year with finasteride.

Conclusions: Compared to WW, TURP is most cost-effective for men who are bothered by their symptoms. From a patient perspective pharmacologic treatment may not be a preferred option without insurance coverage for prescription drugs.

Impact: Treatment guidelines based on long-term cost and effectiveness comparisons are needed but lacking. This study illustrates that patients and insurers may face different incentives when pharmacy costs are the patient’s responsibility. Patients, providers and payers need direct, long-term comparisons of costs and effectiveness among all established treatments to make the best choices for managing BPH symptoms.