Cost-effectiveness of Resonance® metallic ureteral stent compared with standard polyurethane ureteral stents in malignant ureteric obstruction: A cost-utility analysis

Abstract

Background: Malignant ureteral obstruction (MUO) is a frequent challenge for urologists. Patients have poor prognoses, treatment aims to improve quality-of-life while optimising renal function. Standard practice in the United Kingdom is to use polyurethane stents, which require frequent surgical replacements for blockages and encrustation. More durable metallic stents are available, although these incur an increased initial purchase price.

Aims: We aim to assess whether the use of polyurethane double-J (JJ) or metallic stent, Resonance® is more cost-effective for managing MUO in the UK healthcare setting.

Methods: A Markov model was parameterised to 5 years with costs and health-related quality-of-life consequences for treating MUO with Resonance metallic stent (Cook Medical), versus standard JJ stents, from the UK care system perspective, with 3.5% discounting. Deterministic and probabilistic sensitivity analyses were undertaken to assess the effect of uncertainty.

Results: Over 5 years, approximately four fewer repeat surgical interventions were estimated in the metallic stent arm compared with the JJ stent, driving a 23.4% reduction in costs. The mean estimates of costs and benefits indicate that treatment of MUO with Resonance for 5 years is dominant over JJ stents. Over 5 years a cost-saving of £2164.74 and a health gain of +0.046 quality-adjusted life years (QALYs) per patient is estimated. With a maximum willingness to pay of £20 k per QALY, a net monetary benefit (NMB) of £3077.83 is estimated. Probabilistic sensitivity analysis at a willingness to pay threshold of £20 000 indicates an 89.3% probability of Resonance being cost-effective over JJ stents. Within 1-year savings of £726.53 are estimated driven by a reduction of two fewer repeat surgical interventions when using the metallic stent.

Conclusions: Resonance metallic stents for the treatment of MUO reduce the number of repeat procedures and could be a cost-effective option for the treatment, potentially offering efficiencies to the healthcare system.

Keywords: cost‐effectiveness; double‐J stents; malignant ureteric obstruction; metallic stents.

FIGURE 1

Markov model to assess the cost‐effectiveness of Resonance for malignant ureteric obstruction. UTI, urinary tract infection.

FIGURE 2

PRISMA diagram of systematic search.

FIGURE 3

Incremental costs per patient for treatment with Resonance compared with JJ over a 5‐year. Time horizon. y‐axis reports the incremental differences in cost between Resonance use and JJ use (negative indicates a cost saving); x‐axis is time in months.

FIGURE 4

Tornado showing the influence of increasing or decreasing the top 15 key variables on Incremental costs. y‐axis lists the variables in order from highest impact to lowest impact on cost; x‐axis reports changes in incremental cost from the base case as each variable is varied to the lower and upper limit.

FIGURE 5

Tornado shows the influence of increasing or decreasing the top 15 key variables on net monetary benefit (NMB) at a willingness to pay threshold of £20 000 per QALY (quality adjusted life year). y‐axis lists the variables in order from highest impact to lowest impact on cost; x‐axis reports changes in incremental net monetary benefit from the base case as each variable is varied to the lower and upper limit.

FIGURE 6

Cost‐effectiveness plane, demonstrating 1000 Monte Carlo simulations (dots) deterministic result (square) the probabilistic results (triangle) and willingness to pay threshold (dashed line).

FIGURE 7

Cost‐effectiveness acceptability curve for Resonance and JJ stents for the treatment of MUO.