New England Section of the American Urological Association

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Cost-Effectiveness Analysis of Autologous versus Allograft Pubovaginal Slings
Michal Ursiny, MD, Ajay K. Singla, MD
Massachusetts General Hospital, Boston, MA

BACKGROUND: Pubovaginal slings are considered the gold standard in the treatment of stress urinary incontinence when considering clinical outcomes. When considering sling material, there are numerous options available to the surgeon and patient with notable differences in durability, success rates, and cost. Autologous fascial slings harvested either from the rectus fascia or the fascia lata have the best long-term outcomes, but with improvements in processing, allograft material may approach in efficacy. In the literature, the assumption has been that allograft slings are more costly, but no analysis has been done to support this assertion.
METHODS:A decision analysis model was constructed to compare the cost-effectiveness of cadaveric (allograft) and autologous pubovaginal slings. Clinical outcomes and complication data was obtained from published studies. Cost data was obtained from a conglomeration of healthcare claims data from health plans, plan administrators, and medicare using the FairHealth Consumer database. Expected value calculations with Markov modeling and sensitivity analysis was used to determine the superior sling material based on overall cost-effectiveness inclusive of equipment, time, secondary costs from complications, and re-interventions. The model was analyzed over a 5 year period and a perspective of cost to society was adopted.
RESULTS:Decision analysis modeling demonstrated that on a per-procedure basis, autologous and allograft pubovaginal slings incur an expected cost of $8635 and $9717, respectively. The primary driver of increased cost of allograft pubovaginal slings is the increased re-operation rates in comparison to autologous slings. However, varying costs of operating room time, regional cost discrepancies, and individual success rates are critical variables in altering cost-effectiveness.
CONCLUSIONS:Our decision analysis model demonstrates superior cost-effectiveness for autologous pubovaginal slings compared to allograft-based slings. The cost-savings are primarily due to superior clinical outcomes despite longer operative times. Based on this analytical modeling, surgeons can aim to utilize their own loco-regional outcomes and cost data to determine the most cost-effective approach in their specific practice.


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