(Poster 166) Timing of Postpartum Physical Therapy Referrals for Urinary Incontinence

Objectives: To perform a cost-effectiveness analysis of 4 strategies for timing of referral to postpartum pelvic floor physical therapy (PFPT) for urinary incontinence (UI):
1. Do nothing (no referral even if UI develops)
2. Universal referral for all patients upon hospital discharge
3. Referral at the 6 week postpartum visit for all patients who attend
4. Referral at the 6 week postpartum visit for symptomatic patients only

Methods: We created a cost-effectiveness analysis using TreeAge Pro with a 12-month time horizon following delivery. Board-certified urogynecologists developed the treatment pathways. We assumed postpartum visits occurred at 6 weeks, scheduling PFPT takes 12 weeks from time of referral, and patients complete 6 sessions of PFPT. For patients with UI, we assumed that they are twice as likely to attend postpartum visits or PFPT appointments. For patients with UI who choose not to undergo PFPT, they will experience UI for the modeled time period. Costs (2024 US$) included PFPT and the cost of living with UI. We measured effectiveness with quality-adjusted-life years (QALYs) which ranged from 0-1 over 1 year. The incremental cost-effectiveness ratio (ICER) was calculated for non-dominated treatment strategies (ΔCost/ΔQALY), with a willingness-to-pay (WTP) threshold of ICER < $100,000/QALY. Costs, probabilities, and utilities were gathered from Medicare reimbursement data, and published literature.

Results: Of the four options, universal referral at hospital discharge had the highest effectiveness (QALY 0.929) and referral at the postpartum visit only for symptomatic patients had the lowest cost ($1,324). The preferred treatment strategy is universal referral at hospital discharge, as it had the highest effectiveness with an ICER of $39,32/QALY. Universal referral at the postpartum visit and doing nothing were dominated by the other treatment options. This means that other treatment options were less costly with a higher quality of life, effectively eliminating these strategies from consideration.

Multiple one-way sensitivity analyses were performed. If the cost of UI became < $3375/year, do nothing becomes a less costly option; however, universal referral at hospital discharge remains the preferred strategy with the higher QALY. Thus, no reasonable thresholds would change our conclusion. To predict healthcare utilization, our modeling showed that with universal referral for PFPT at hospital discharge, 45% of women would undergo PFPT compared to 13% of women with the referral strategy for symptomatic women at 6 weeks postpartum.

Conclusions: The preferred strategy to address postpartum urinary incontinence is to refer patients to pelvic floor physical therapy universally at hospital discharge. These findings highlight the importance of addressing postpartum urinary incontinence at the earliest opportunity to optimize postpartum care.


Legend for Table 1:
Effectiveness is measured in Quality-Adjusted-Life-Years (QALY); ICER = Incremental cost/effectiveness ratio calculated as Δcost/ΔQALY

*ICER= incremental cost effectiveness ratio is only calculated for the non-dominated treatment strategies. Likewise, increased costs and increased effectiveness columns are only calculated for non-dominated strategies