title: A cost-effectiveness analysis of conservative versus surgical management for the initial treatment of stress urinary incontinence.
abstract: OBJECTIVE
  We sought to determine whether conservative or surgical therapy is more cost effective for the initial treatment of stress urinary incontinence (SUI).
  
  
  METHODS
  We created a decision tree model to compare costs and cost effectiveness of 3 strategies for the initial treatment of SUI: (1) continence pessary, (2) pelvic floor muscle therapy (PFMT), and (3) midurethral sling (MUS). We identified probabilities of SUI after 12 months of use of a pessary, PFMT, or MUS using published data. Parameter estimates included Health Utility Indices of no incontinence (.93) and persistent incontinence (0.7) after treatment. Morbidities associated with MUS included mesh erosion, retention, de novo urge incontinence, and recurrent SUI. Cost data were derived from Medicare in 2012 US dollars. One- and 2-way sensitivity analysis was used to examine the effect of varying rates of pursuing surgery if conservative management failed and rates of SUI cure with pessaries and PFMT. The primary outcome was an incremental cost-effectiveness ratio threshold <$50,000.
  
  
  RESULTS
  Compared to PFMT, initial treatment of SUI with MUS was the more cost-effective strategy with an incremental cost-effectiveness ratio of $32,132/quality-adjusted life year. Initial treatment with PFMT was also acceptable as long as subjective cure was >35%. In 3-way sensitivity analysis, subjective cure would need to be >40.5% for PFMT and 43.5% for a continence pessary for the MUS scenario to not be the preferred strategy.
  
  
  CONCLUSIONS
  At 1 year, MUS is more cost effective than a continence pessary or PFMT for the initial treatment for SUI.
authors.affiliation: Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA. Electronic address: Monicalucero@gmail.com.
authors.forename: Monica L
authors.initials: ML
authors.lastname: Richardson
authors.affiliation: Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA.
authors.forename: Eric R
authors.initials: ER
authors.lastname: Sokol
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D017773:Pelvic Floor; D010570:Pessaries / Q000191:economics*; D026741:Physical Therapy Modalities / Q000191:economics*; D011475:Prosthesis Failure; D019057:Quality-Adjusted Life Years; D053825:Suburethral Slings / Q000191:economics*; D016896:Treatment Outcome; D014481:United States; D014550:Urinary Incontinence, Stress / Q000628:therapy*
keywords: continence pessary; cost effectiveness; midurethral sling; pelvic floor muscle therapy; stress urinary incontinence