Cost of Neuromodulation Therapies for Overactive Bladder: Percutaneous Tibial Nerve Stimulation Versus Sacral Nerve Stimulation

Purpose: Conservative therapy and antimuscarinic agents are first line therapies for overactive bladder. Patients refractory to treatment are candidates for neuromodulation therapy. We estimated the costs and cost-effectiveness of percutaneous tibial nerve stimulation and sacral nerve stimulation. Materials and Methods: A Markov model was constructed to simulate the total costs and effectiveness of percutaneous tibial and sacral nerve stimulation during 2 years. Cost data used average Medicare national physician payments, and ambulatory payment classification and diagnosis related group payments for hospital based care and office visits. Clinical effectiveness, and the rates of patient adherence to treatment and adverse events were estimated by a review of the literature. Results: The costs of initial therapy were $1,773 for 12 weekly percutaneous tibial nerve stimulation treatments and $1,857 for test sacral nerve stimulation. For ongoing therapy the cost of the sacral nerve stimulation surgical implant was $22,970. Cumulative discounted 2-year costs were $3,850 for percutaneous tibial nerve stimulation and $14,160 for sacral nerve stimulation, including those who discontinued therapy. Of the patients 48% and 49%, respectively, remained on therapy. The incremental cost-effectiveness ratio was $573,000 per additional patient on sacral nerve stimulation. When considering only patients who completed initial stimulation successfully, the costs were $4,867 and $24,342 for percutaneous tibial and sacral nerve stimulation with 71% and 90%, respectively, remaining on therapy for an incremental cost-effectiveness ratio of $99,872. Conclusions: Percutaneous tibial nerve stimulation and sacral nerve stimulation are safe, effective neuromodulation therapies for overactive bladder. In this economic model percutaneous tibial nerve stimulation had substantially lower cost. An additional 1% of patients would remain on therapy at 2 years if sacral nerve stimulation were used rather than percutaneous tibial nerve stimulation but the average cost per additional patient would be more than $500,000.