Chay Junxing, Tung Joshua Yi Min, Su Rebecca Jade, Aslim Edwin Jonathan, Wong Callix, Swan Georgia, Chua Wei Jin, Ho Henry Sun Sien, Finkelstein Eric Andrew
Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.
Department of Urology, Singapore General Hospital, Singapore, Singapore.
J Med Econ. 2023 Jan-Dec;26(1):1269-1277. doi: 10.1080/13696998.2023.2266958. Epub 2023 Oct 14.
Minimally invasive surgical therapies, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically second-line options for patients in whom medical management (MM) failed but who are unwilling or unsuitable to undergo invasive transurethral resection of the prostate (TURP). However, the incremental cost-effectiveness of WVTT or PUL as first- or second-line therapy is unknown. We evaluated the incremental cost-effectiveness of alternative first- and second-line treatments for patients with moderate-to-severe benign prostatic hyperplasia (BPH) in Singapore to help policymakers make subsidy decisions based on value for money.
We considered six stepped-up treatment strategies, beginning with MM, WVTT, PUL or TURP. In each strategy, patients requiring retreatment advance to a more invasive treatment until TURP, which may be undergone twice. A Markov cohort model was used to simulate transitions between BPH severity states and retreatment, accruing costs and quality-adjusted life-years (QALYs) over a lifetime horizon.
In moderate patients, strategies beginning with MM had similar cost and effectiveness, and first-line WVTT was incrementally cost-effective to first-line MM (33,307 SGD/QALY). First-line TURP was not incrementally cost-effective to first-line WVTT (159,361 SGD/QALY). For severe patients, WVTT was incrementally cost-effective to MM as a first-line treatment (30,133 SGD/QALY) and to TURP as a second-line treatment following MM (6877 SGD/QALY). TURP was incrementally cost-effective to WVTT as a first-line treatment (48,209 SGD/QALY) in severe patients only. All pathways involving PUL were dominated (higher costs and lower QALYs).
Based on the common willingness-to-pay threshold of SGD 50,000/QALY, this study demonstrates the cost-effectiveness of WVTT over MM as first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL is not cost-effective as a first- nor second-line treatment. For patients with severe BPH, TURP as first-line is also cost-effective.
微创外科治疗，如水蒸气热疗（WVTT）和前列腺尿道悬吊术（PUL），通常是药物治疗（MM）失败但不愿或不适合接受侵入性经尿道前列腺切除术（TURP）患者的二线选择。然而，WVTT或PUL作为一线或二线治疗的增量成本效益尚不清楚。我们评估了新加坡中重度良性前列腺增生（BPH）患者替代一线和二线治疗的增量成本效益，以帮助政策制定者基于性价比做出补贴决策。
我们考虑了六种逐步升级的治疗策略，从MM、WVTT、PUL或TURP开始。在每种策略中，需要再次治疗的患者会升级到更具侵入性的治疗，直至TURP，TURP可能会进行两次。使用马尔可夫队列模型来模拟BPH严重程度状态和再次治疗之间的转变，在整个生命周期内累积成本和质量调整生命年（QALY）。
在中度患者中，以MM开始的策略具有相似的成本和效果，一线WVTT相对于一线MM具有增量成本效益（33,307新元/QALY）。一线TURP相对于一线WVTT不具有增量成本效益（159,361新元/QALY）。对于重度患者，WVTT作为一线治疗相对于MM具有增量成本效益（30,133新元/QALY），作为MM后的二线治疗相对于TURP具有增量成本效益（6877新元/QALY）。仅在重度患者中，TURP作为一线治疗相对于WVTT具有增量成本效益（48,209新元/QALY）。所有涉及PUL的治疗路径均占劣势（成本更高且QALY更低）。
基于每QALY 50,000新元的常见支付意愿阈值，本研究证明了WVTT作为中重度BPH患者一线治疗相对于MM的成本效益，表明其性价比高，应考虑给予补贴。PUL作为一线或二线治疗均不具有成本效益。对于重度BPH患者，TURP作为一线治疗也具有成本效益。
