Intermittent catheterization remains the ‘gold standard’ management strategy for neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI). More often, indwelling urinary catheter are initiated in the long-term management for NLUTD in patients where self-catheterization is difficult or impossible.  We sought to investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with NLUTD due to SCI from a Canadian publicly funded health care perspective.

A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Patients were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from published literature and expert opinion (Table 1). Costs were obtained from provincial health care system and hospital data in Canadian Dollars. The primary outcome was cost per QALY and life years gained (LYG). A standard discount rate of 1.5% was applied annually. Probabilistic and one-way deterministic sensitivity analyses were performed.

CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old patient with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496 (Table 2). A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities.

This cost-effectiveness study was modeled to reproduce the actual bladder care scenarios including potential catheter related events, genitourinary sequelae and quality of life indicators over life-time horizon. These treatment scenarios are guided by the values, utilities and Qol context inferred from RCTs when possible which serves as a reference against which a SCI individual can measure the different domains of bladder management across their personal life.

This economic analysis demonstrates that CIC is a dominant treatment strategy (offering increased benefits at lower cost) to manage SCI patients with NLUTD compared to indwelling urethral or suprapubic catheters over lifetime horizon, from a publicly funded health care perspective: single-use noncoated intermittent catheters (higher effectiveness and a higher ICUR) and single-use hydrophilic catheters (offering increased benefits at lower cost). While it may be cost feasible for some patients to use noncoated intermittent catheters, single-use hydrophilic coated catheters have the greatest opportunity of being cost-effective. Taking into account the marginal differences in overall costs across the three bladder management approaches, indwelling catheterization (SPC or UC) may appear as cost competitive technology with acceptable long-term efficacy. It is also important to note the markedly higher costs of complications-associated and device transition costs in the Canadian setting, which is a key driver of the overall bladder management associated costs throughout the lifetime simulation. Given these findings, we offer a new insights and broader evaluation of economic burden over the public health care system that, with further research, may be of value to health care decision making and government advocacy.

CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared to indwelling urethral or suprapubic catheters over lifetime horizon, from the public payer perspective.