title: Continence in the cloacal exstrophy patient: What does it cost?
abstract: BACKGROUND
  Surgical advancements have made cloacal exstrophy (CE) a survivable condition, though management remains complex. Urologic, orthopedic, colorectal and gynecologic interventions are not standardized, and the cost of this care is high. While the importance of a successful primary closure in terms of outcomes is known, the economic consequences of failure remain uncharacterized.
  
  
  METHODS
  A prospectively maintained institutional database of epispadias-exstrophy complex patients was reviewed for continent CE patients. Hospital charges for all inpatient admissions prior to achieving urinary continence were inflation-adjusted to year 2013 values using Consumer Price Index for medical care published by the United States Bureau of Labor Statistics. Records for which charge data were incomplete were completed by using single mean imputation, also inflation-adjusted. Descriptive data are presented as mean±standard deviation (SD).
  
  
  RESULTS
  Of 102 CE patients, 35 had available hospital charge data: 15 who underwent successful primary closure at the authors' institution and 20 who presented after previously failed primary closures at referring institutions. The mean±SD hospital charges for primary closure in the success group were $136,201±$48,920. These patients then underwent subsequent additional surgeries that accrued charges of $59,549±$25,189 in order to achieve continence. Overall, successful primary closures accumulated hospital charges of $200,366±$40,071. In comparison, patients referred after prior failure required significantly more hospital admissions and additional charges of $207,674±$65,820 were required to achieve continence (p<0.001). Patients who failed primary closure are estimated to accumulate 70% more total health care charges compared to the group following successful primary closure.
  
  
  CONCLUSIONS
  The cost of CE management until urinary continence is high, averaging more than $200,000 in inpatient hospital charges alone. Initial success is desirable from both an outcomes and economic perspective, as the cost of salvaging a failed primary closure at our institution is similar to the overall costs of a successful closure; this is in addition to the cost of any previous failed closures. Further studies will be required to determine the optimal timing of surgical management in terms of both patient outcomes and financial consequences.
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005. Electronic address: sgoldstein@jhmi.edu.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Goldstein
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Inouye
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Sunil
authors.initials: S
authors.lastname: Reddy
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Kathy
authors.initials: K
authors.lastname: Lue
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Ezekiel E
authors.initials: EE
authors.lastname: Young
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Abdelwahab
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Mehnaj
authors.initials: M
authors.lastname: Grewal
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005.
authors.forename: Spencer
authors.initials: S
authors.lastname: Wildonger
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Stec
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287. Electronic address: jgearha2@jhmi.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D017722:Hospital Charges / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007297:Inpatients; D008297:Male; D012086:Reoperation / Q000191:economics; D016879:Salvage Therapy / Q000191:economics*; D017211:Treatment Failure; D014481:United States; D014549:Urinary Incontinence / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D014564:Urogenital Abnormalities / Q000150:complications / Q000191:economics* / Q000601:surgery*
keywords: Cloacal exstrophy; Continence; Cost analysis