Despite its high prevalence, overactive bladder (OAB) remains under-treated.  This failure to help patients remains multifactorial, but there is a confirmed high attrition rate with return visits, low penetration of third line therapies, and lack of appeal with current treatment options. Instituting a multimodal care pathway for OAB patients is known to help patients have goal directed care, increase patient compliance, and increase delivery of third line therapies. Herein, we describe a single provider’s third line penetration rate, and the effect of two new devices to treat OAB: a permanent tibial implant (eCoin) offered within the constraints of an investigational device exemption study, and a rechargeable sacral neuromodulation (SNM) device (Axonics) in conjunction with using a standardized care pathway consistently.

A retrospective chart review from January 1, 2016 to March 20, 2020 was completed from a single female urologist for unique OAB visits and therapy delivery within the timeframe. Penetration rates of third line therapies were evaluated. The impacts of the investigational use of the eCoin device and the use of a newly available, rechargeable SNM system were also evaluated.  A care pathway was implemented consistently near the end of 2017 and modified between October 1, 2018, and April 30, 2019, to include the use of eCoin as a therapy option within the constraints of an investigational device exemption study. The care pathway was modified again on November 18, 2019 to include the use of the rechargeable SNM system as an available third line therapy following its FDA approval.

A total of 2,984 unique patients were seen for OAB during the study period. Progressions to third line therapy before and after consistent care pathway use were 18.5% and 27.4%, respectively. Of those patients who progressed to third line therapies before and after consistent care pathway use, 7.1% and 18.7% received SNM therapy, respectively. Once eCoin was added as an available therapy option, the third line therapy penetration rate rose to 32.9%, with 18.2% receiving the eCoin device and 11.9% receiving SNM therapy. When eCoin was no longer an available therapy option, progressions to third line therapy before and after the availability of the rechargeable SNM system were 36.9%(5/1/2019 to 11/17/2019)  and 40.3%(11/18/2019 to 3/20/2020), respectively. Of those patients who progressed to third line therapies before and after the availability of the rechargeable SNM system, 11.2% and 10.1% received SNM therapy, respectively. The third line therapy penetration rates can be found in Figure 1 and the breakdown of third line therapy progressions can be found in Figure 2.

The consistent implementation of a care pathway increased the rates of third line therapies received by patients and the proportion of those patients that received SNM. The third line therapy penetration rate went even higher with the limited seven-month availability of the tibial implant eCoin, and, during this time, the proportion of patients that received SNM decreased. The two timeframes post-eCoin display significant growth in PTNS therapy, perhaps suggesting patients explored this option in anticipation of the approval of the eCoin tibial implant after discussions including it in the most recent care pathways. When the eCoin device was no longer available, the rate of third line therapies received by patients remained at a higher level and even increased over time, but the proportion of patients receiving SNM remained constant, even after the addition of a rechargeable SNM option. It should be noted that all patients chose the rechargeable SNM option when available even with both SNM options offered on the care pathway.

Care pathways can deliver more advanced therapy to patients, but we desperately need innovative offerings that are more appealing and distinctively different from current offerings so we can expand options for patients.