(Poster 103) Cost-Minimization Analysis of Stress Urinary Incontinence Treatment Strategies

Objectives: Stress urinary incontinence (SUI) can be managed using various treatment strategies, yet comparative cost analyses remain limited. Our objective was to compare the one-year costs of three treatment options—pelvic floor muscle therapy (PFMT), vaginal pessary, and sling surgery (mid-urethral or pubovaginal)—using a cost-minimization approach.

Methods: Using 5% Medicare Limited Data Set claims data from 2008 to 2016, we identified women aged 66 and older with incident SUI. Patients were grouped by initial treatment strategy. Costs associated with each index treatment were calculated over a defined episode of care: 180 days prior to treatment and 90 days following treatment (180 days post-treatment for sling surgery). We included costs from inpatient procedures, outpatient visits, laboratory testing, and in-office diagnostics. All costs were adjusted to 2016 U.S. dollars and presented as median, mean, minimum, maximum, and interquartile range (25th and 75th percentiles).

Results: Among 16,695 patients, pessary was the most common treatment (46%, n=7,679), followed by PFMT (33.3%, n=5,559) and sling surgery (20.5%, n=3,422). Of patients initially treated with PFMT, 5.6% underwent subsequent sling surgery, compared to 4.2% after pessary and 3.1% undergoing repeat sling surgery.
The one-year median costs were: PFMT $2,346.79, pessary $2,539.48, and sling surgery $5,517.16. The mean costs were: PFMT $3,358.43, pessary $3,171.94, and sling surgery $6,581.74.
If minimum costs were applied to all variables, PFMT cost $293.61, pessary $239.11, and sling surgery $463.07. Conversely, maximum costs were: PFMT $35,033.24, pessary $27,509.85, and sling surgery $99,552.73.
Applying assumptions consistent with the American Urological Association (AUA) guidelines, one-year costs were: PFMT $1,391.76, pessary $1,430.48, and sling surgery $4,753.81 (Table 1).
Tornado plot analyses identified primary cost drivers for each strategy (Figure 1). For PFMT, these included the cost of complications, urodynamics, follow-up visits, and the probability of needing a sling. For pessary, key drivers were complications, follow-up visits, urodynamics, and downstream sling surgery. For sling surgery, cost drivers included the index procedure, pre- and post-operative visits, complications, urodynamics, cystoscopy, labs, and repeat surgery.

Conclusions: When treatment follows AUA guidelines, sling surgery is the most costly intervention for SUI, followed by pessary and PFMT. These findings can guide clinicians and policymakers in selecting cost-effective, evidence-based care pathways to reduce healthcare spending in SUI management.