COST-EFFECTIVENESS ANALYSIS OF THE TREATMENT OF CLASSIC BLADDER EXSTROPHY BY PRIMARY CLOSURE FOLLOWED BY KELLY OPERATION
Navroop S. Johal, MB Bch FRCS PhD, Naser Al Soudan Al Anazi, MD, Kevin Cao, MBBS MRCS MSc, Peter Cuckow, MBBS FRCS Phd.
Great Ormond Street Hospital, London, United Kingdom.
BACKGROUND There are many ways in which Bladder Exstrophy is treated around the World. As one of two UK NHS designated Exstrophy Centres, over 22 years, we have chosen a staged surgical approach comprising neonatal bladder closure without osteotomies and a Kelly soft tissue reconstruction in the second year of life, aiming for the goal of urethral voiding continence. If unfulfilled, dryness is achieved with a bladder neck reconstruction, ileocystoplasty and intermittent catheterisation via Mitrofanoff. In a group of young adults treated with this approach, we performed a cost-effectiveness analysis for those with and without a "successful' Kelly repair. By considering the quality of life (QoL) or happiness metrics in these patients, we have assessed the long-term value of our approach. METHODS Institutional costs for infant closure, Kelly repair and ileocystoplasty for the exstrophy diagnosis were extracted for 2017 to 2022 with 8% yearly inflation applied to bring costs to the current 2022 figures. QoL figures were generated through the EQ-5D-5L questionnaire administered via telephone interview with former patients aged 17-25. Thirty-five patients were called, and 17 responded. Domain scores were summated into a single index score of happiness using UK conversion value sets ranging from 0 (extreme unhappiness) to 1.0 (perfect happiness) . Index scores were compared against UK population norms and used to generate quality-adjusted life-years (QALYs) based on an 80-year life horizon. QALYs were measured against costs to generate the overall cost-effectiveness of our surgical approach. Finally, respondents were asked to comment on their scoring for thematic analysis of patient concerns. RESULTS The cost to the National Health Service of primary closure and Kelly soft tissue reconstruction came to £38,585, with additional ileocystoplasty being another £26,147. 10 ‘successful' adults (8M, 2F) reported a median index QoL score of 0.97 (range 0.59-1.0), generating 57.5 QALYs. Five patients who required ileocystoplasty for continence (3M, 2F) reported a median of 0.88, generating 56.05 QALYs. To compare against average UK population happiness scores, all EQ-5D-5L results were crosswalked to EQ-5D-3L equivalents: urethral-continent (0.94), augment-continent (0.77) vs. UK average 10-19 year-olds (0.913), 20-29 year-old (0.905) . The Cost-effectiveness of our approach came to £671 per QALY for infant closure and Kelly repair and £1,155 per QALY for additional ileocystoplasty to achieve continence. When judged against our long-term success rate for urethral continence of approximately 70%, the cost-effectiveness of the infant closure-Kelly repair approach with rescue ileocystoplasty as contingency is £816 per QALY. In thematic analysis, non-perfect scores in the urethral continent revolved around concerns about sex and relationships, whilst in patients with ileocystoplasty, comments tended to focus on bladder spasms, UTI, and pain from catheterisation. CONCLUSION Our strategy to treat classic bladder exstrophy has proven clinically effective and highly cost-effective. This approach may serve to compare different strategies and optimise them for the future. REFERENCES (1) Devlin NJ, et al. Health Economics. 2018 Jan;27(1):7-22 (2) Sullivan PW et al. Med Decis Making. 2011 Nov;31(6):800-4
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