An Examination of Treatment Patterns and Costs of Care Among Patients With Benign Prostatic Hyperplasia

Published Online: March 01, 2006
Libby Black, PharmD; Michael James Naslund, MD, MBA; Thomas D. Gilbert, Jr, MS; E. Anne Davis, PharmD, MS; and Daniel A. Ollendorf, MPH

Objective: To examine utilization and costs of care for benign prostatic hyperplasia (BPH)-related services in a large cohort of commercially insured persons.

Methods: Pharmacy and medical claims data were obtained from 61 US healthcare plans. Men aged =45 years who were newly diagnosed with BPH between January 2000 and March 2001 were identified. Each patient was followed for 12 months after diagnosis; utilization and costs were calculated for common procedures and disease-related events. Costs were estimated based on health plan payments. Univariate statistics were provided for relevant measures.

Results: A total of 77 040 patients were selected (mean age, 58.1 years). Thirty-six percent of patients had 1 or more urologist visits in the year after diagnosis. Two thirds of patients had a prostate-specific antigen test, whereas 7% had a prostate biopsy. A total of 14 392 patients (18.7%) received an alpha blocker during follow-up; 1860 patients (2.4%) received a 5-alpha reductase inhibitor. Approximately 2% of patients had a surgical procedure (either invasive or minimally invasive); transurethral prostatectomy costs averaged approximately $5600, consisting of mean (standard deviation) costs of $794 ($470) for the procedure and $4810 ($8487) in associated inpatient costs. Re-treatment was common (18.7%) among patients with a surgical procedure, at a mean cost of $1888 ($1636).

Conclusion: Most patients newly diagnosed with BPH appear to undergo watchful waiting in the year after diagnosis. Although rates of surgical intervention and adverse events at 1 year are low, these events are costly. Strategies to prevent or delay the need for surgery, such as regular examinations, testing, and use of pharmacotherapy where indicated, may further reduce the need for surgical intervention.

(Am J Manag Care. 2006;12:S99-S110)


Benign prostatic hyperplasia (BPH) is a noncancerous prostate enlargement which can lead to bothersome lower urinary tract symptoms (LUTS). It has been estimated that more than 50% of men older than 50 years of age and approximately 90% of men older than 80 years of age have BPH.1-3 There are several treatment options available for this condition, including watchful waiting, pharmacotherapy, phytotherapy (ie, use of medicinal plants and herbs), and surgical intervention.4

Watchful waiting is recommended for patients without bothersome LUTS and typically involves patient education, lifestyle changes (eg, reductions in fluid intake, avoidance of caffeine or alcohol), and periodic monitoring.4 These examinations are critical to rule out further complications of BPH progression as well as the development of prostate cancer. Patients whose symptomatology affects activities of daily living may receive pharmacotherapy, typically with 5- alpha reductase inhibitors or alpha blockers. Early treatment, particularly for patients receiving 5-alpha reductase inhibitors, may slow the rate of BPH progression and prevent or delay the need for surgical interventions and/or the incidence of complications.5,6

In 1993, BPH-related medical expenses were estimated to exceed $4 billion annually in the United States; other estimates that have taken into consideration the aging of the population and increasing use of medical and surgical intervention have suggested that these expenses may currently be much higher—estimates as high as $26 billion annually have been reported.7 Future treatment costs are likely to rise as the prevalence of BPH in the United States increases as a result of the aging population. In the United States, approximately 36.5 million men are between the ages of 50 and 89. By the year 2020, the number of men in this age range is expected to increase to 52.5 million.8

Despite awareness of the prevalence of BPH, patterns of care, and overall economic burden, detailed examinations of the resources consumed and their corresponding cost has only been performed in countries other than the United States.9,10 A study was therefore conducted to assess levels of medical resource utilization and costs after BPH diagnosis in the United States based on information from a large, national healthcare claims database.

METHODS

Data Source

Data were obtained from the PharMetrics Patient-Centric Database and spanned the period from July 1999 to June 2002. At the time of this study, the database contained fully adjudicated claims from 61 health plans across the United States. Inpatient and outpatient diagnoses (in International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] format) and procedures (in Current Procedural Terminology, Fourth Revision [CPT-4], ICD- 9-CM, and Healthcare Common Procedure Coding System [HCPCS] formats) as well as standard and mail order prescription records are included in the data set. Reimbursed payments and charged amounts are available for all services rendered as well as dates of service for all claims. Additional data elements include demographic variables (eg, age, sex, geographic region), health plan type (ie, health maintenance organization [HMO], preferred provider organization [PPO], point-of-service [POS], indemnity, other), payer type (eg, commercial, Medicare Risk, managed Medicaid), provider specialty, and start and stop dates for plan enrollment. All patients who met the sample selection criteria specified below were included in the analyses.

Sample Selection

Men with at least 1 medical claim with a listed diagnosis of BPH (ICD-9-CM 600.xx) were initially selected for inclusion in the study sample. An index date for each patient was established based on the first occurrence of a diagnosis. The study sample was restricted to those patients deemed to be newly diagnosed with BPH; patients with no claims activity containing a BPH diagnosis or relevant pharmacy claims for 6 months before the index date were therefore included. A follow-up period of 12 months was then created in relation to the index date.

Those patients not continuously enrolled during the 6-month pretreatment and 12- month follow-up periods were excluded from all analyses. Patients with a diagnosis of prostate cancer (ICD-9-CM 185.xx, 233.4x, 236.5x) at any point during the pretreatment or follow-up periods were also excluded. Additionally, patients had to be at least 45 years of age as of their index date. All claims spanning the period January 1, 1999, to June 30, 2002, were then extracted for eligible patients in the data set.

Measures and Analyses

The primary measures of interest for this study included the demographic and clinical characteristics of the newly-diagnosed BPH population (including type and duration of BPH pharmacotherapy) as well as the utilization and costs of the most frequently occurring BPH-related medical services over 12 months of follow-up. The rate of adverse events was also examined for patients undergoing a BPH-related surgical procedure during the 12-month follow-up period. BPH-related utilization was selected based on review of the available literature regarding common procedures,4,11,12 assumptions regarding those procedures likely to result in a healthcare encounter, and review of the reported frequency on the initial data distribution. Similarly, the adverse events selected for analysis—surgical re-treatment, acute urinary retention (AUR), serious urinary tract infection (UTI), erectile dysfunction, and permanent bladder dysfunction—were selected based on review of the literature regarding common postsurgical events4,11,12 as well as a review of the initial data distribution.

BPH-related procedure and laboratory costs were reported on an overall basis and stratified by type of plan or payer (ie, HMO, PPO, POS, Medicare Risk, and other; other included patients enrolled in mixed or hybrid products as well as those with an unknown plan or payer type). In addition, adverse event costs were only reported on an overall basis alone, because their frequency was expected to be too low for stratification by payer type. Duration of therapy with medications over the 12-month follow-up period was calculated based on the total number of recorded days on dispensed pharmacy claims.

During follow-up, patients utilizing each of the selected medical or surgical interventions, as well as those experiencing adverse events, were tracked. Costs were estimated based on health plan expenditures for services rendered and net of patient responsibility (ie, copayment, coinsurance, and/or deductible). Costs were reported during the year in which they were incurred; because the study was intended to reflect payments for services rendered during a period of observation, no special inflationary factors were applied.

The number of patients with each of the selected procedures at 1 year after their initial diagnosis was reported on an annual basis; the number of procedures performed was also tallied. Procedure costs (reimbursed amounts paid by health plans) were calculated on a per visit/procedure basis by dividing the total amount paid by the total number of visits or procedures. Univariate statistics were provided for each of the cost estimates (ie, mean, median, standard deviation [SD], 25th and 75th percentile). Total costs for each procedure were calculated as the product of the number of procedures performed multiplied by the average cost per procedure. Medication costs were analyzed based on levels of drug utilization and health plan reimbursed amounts; these costs were examined over the 12-month follow-up period, regardless of when medication was initiated, to simulate truly prevalent costs in a 1-year snapshot. Costs were summed to produce a total annual cost of BPH within the first year of diagnosis for this commercially insured population and adjusted to the national level using US Census data.13

Adverse events were examined for the subgroup of patients who had 1 of the reported surgical procedures during the follow-up period. For the event to be considered surgery related, only events that occurred within 6 months after the first surgical procedure were considered procedure related; only infections occurring within 30 days of the last surgical procedure were considered procedure related. Re-treatment was defined as the presence of any subsequent surgical procedure on the urinary system within 6 months of the first, based on the assumption that 2 procedures separated by a longer period of time would likely be unrelated. For example, a patient with a transurethral resection of the prostate (TURP) procedure and a subsequent TURP or catheterization within 6 months would be considered to be re-treated. Costs associated with the treatment of each adverse event were also calculated based on the presence of a relevant diagnosis on inpatient or outpatient claims. Similar to the procedure analysis described above, univariate statistics were provided for each of the cost estimates.

Although the focus of this analysis was the utilization and costs of selected procedures and tests only, information on less common and less costly services is also provided.

RESULTS

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