title: Routine perioperative chemotherapy instillation with initial bladder tumor resection: a reconsideration of economic benefits.
abstract: BACKGROUND
  Level-1 evidence has demonstrated decreased recurrence of low-grade bladder tumors when initial transurethral resection (TUR) is followed by perioperative instillation (PI) of chemotherapy. A meta-analysis determined that the number needed to treat (NNT) was 8.5 patients to prevent 1 recurrence. No benefit was demonstrated for tumors classified as T0, tumor in situ, or T2; thus, patients with those tumors were excluded from the analysis, which potentially may have resulted in underestimating the true NNT. Economic benefits were suggested, but cost calculations were not presented. The objectives of the current analysis were to recalculate the NNT considering patients who previously were excluded and to examine the economic implications based on various management alternatives for tumor recurrence.
  
  
  METHODS
  For each study that was included in the current meta-analysis, the number of patients excluded because of 'inappropriate' pathology results was determined. A potentially more accurate NNT was calculated, and pertinent Medicare reimbursements were obtained to estimate costs.
  
  
  RESULTS
  The added cost for 8.5 patients who underwent inpatient TUR to receive PI was $1711. Inpatient TUR ($7025) was extremely costly compared with hospital outpatient TUR ($2666), ambulatory surgery center TUR ($2113), and physician office fulguration ($1167). Although the inclusion of patients who previously were excluded resulted in a recalculated NNT of 9.6 patients, the authors used a more conservative NNT if 8.5 patients to estimate the economic impact of the 'best-case scenario.'
  
  
  CONCLUSIONS
  Routine PI significantly lowered the overall cost if recurrences were managed in the inpatient setting, but these benefits were offset mostly or completely by outpatient management in the United States. Thus, the authors concluded that the decision to use routine PI of chemotherapy should be based on clinical effects and not on presumed economic benefits.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, A100, Cleveland, OH 44195, USA.
authors.forename: Pravin K
authors.initials: PK
authors.lastname: Rao
authors.forename: J
authors.initials: J
authors.lastname: Stephen Jones
mesh_terms: D000283:Administration, Intravesical; D000553:Ambulatory Care / Q000191:economics; D017024:Chemotherapy, Adjuvant / Q000191:economics*; D003131:Combined Modality Therapy; D006801:Humans; D015201:Meta-Analysis as Topic; D009364:Neoplasm Recurrence, Local / Q000191:economics / Q000517:prevention & control; D019990:Perioperative Care; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000191:economics* / Q000601:surgery