Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands

AIM: Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM-) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms. METHOD: A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years. RESULTS: The former treatment protocol cost euro22,651 per patient and the latter, after the introduction of SNM, cost euro16,473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs. CONCLUSION: The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence

存貨之估價及其會計上之處理

INTRODUCTION: Osteoporosis (OP) is one of the most prevalent metabolic bone disorders worldwide and it is associated with a higher incidence of fractures. The aim of this study was to identify OP as a risk factor for the development of nonunion. METHODS: In a prospective database all patients aged >50 years with an acute fracture were screened for osteoporosis from September 13, 2004 till February 9, 2009. Bone mineral density measurements (T-scores, Z-scores and absolute values in g/cm(2)) were performed. The selected patients were matched (1:2 ratio) to control patients based on gender, age (+/-5 years) and type of fracture according to the AO-criteria. Other parameters including diabetes mellitus, corticosteroid use, rheumatoid arthritis, smoking, alcohol use, and body mass index were recorded. Follow-up for the patients in the matched group was at least one year. RESULTS: This study included a total of 1498 patients who were screened for the presence of osteoporosis. In total 40 patients were treated for nonunion. After 1:2 matching this resulted in a total number of 120 patients for analysis. Logistic regression analysis including all covariates in the model demonstrated no correlation between the standardised regression coefficients and the development of nonunion (r(2)=0.10, p=0.6). The patients that developed an atrophic nonunion, according to radiographic results, were analysed separately and compared to matched patients. The presence of osteoporosis, osteopenia and normal bone density and the related independent BMD measurements did not differ significantly between the atrophic nonunion group and the matched controls. CONCLUSION: We conclude that although bone quality may be diminished in the elderly this does not influence the occurrence of nonunion. These results indicate that the use of BMD measurements preoperatively to identify osteoporosis as a possible risk factor of nonunion has no clinical value

Patient experience and satisfaction with sacral neuromodulation: results of a single-center sample survey

PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns