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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. And today I'm joined by both Dr. Charlotte Houston and Dr. Rachael Sussman from Georgetown University's Department of Urology. They'll be discussing some recent work that they published in Urology Practice exploring a cost-savings analysis of topical estrogen therapy to prevent UTIs in post-menopausal women. Thank you both for joining us today.

Rachael Sussman: Thank you so much for having us. We're very excited to share our research. So Dr. Houston, I'll let you share our slides and give a review.

Charlotte Houston: So, this was the paper that we recently published in Urology Practice looking at cost savings of topical estrogen therapies among postmenopausal women who are having recurrent infections. We know that these therapies are effective; studies have been going back to the nineties, showing that there's an improvement in the number of infections, antibiotic load, pH, and all of these things, but we really looked to see what the cost benefit would be given how significant the cost of UTIs is in the Medicare population. We looked at the cost of previously published studies of uncomplicated, complicated UTI-resistant infections and weighted these based on the prevalence of these infections to come up with a cost of about $1,200 per beneficiary per infection.

Then we looked at the reported improvement with estrogen therapy to come up with a cost with and without estrogen therapy based on our systematic literature review. And what we saw was there is a significant cost savings associated with these therapies between $3,600 and $5,400, excluding the cost of the therapy. And then we reviewed what the cost of the therapies were, both in Medicare Part D spending, as well as GoodRx discount pharmacy pricing, and what the cost was looking like to the patient. And what we saw is there's considerable variability for these therapies, both between types of therapies, tablets, rings versus creams, and even within just the generic estradiol cream, patients can be paying anywhere from $60 a year to a thousand dollars a year to $2,800 a year. The average Medicare spending was about a thousand dollars per beneficiary. When we deducted the cost of the medication itself, we found that there was still a benefit of somewhere between $1,200 to $4,800 per patient per year within that range of 0.5 to two infections based on the reported literature.

So, just demonstrating what an immense impact this is, this is based on the low end of the spectrum. So two infections a year, 0.5 using a generic estradiol cream at either $510 or $60, and $60 is the discount pharmacy pricing, just demonstrating what a significant reduction in cost this is. And so what we found was that we know that these therapies are effective, that's long been proven, but they're also cost-conscious, and we should really be prioritizing making these therapies available for patients, making sure patient adherence is good, as there's potential for billions of dollars in savings, just giving the number of women who are on these therapies in the Medicare system.

Ruchika Talwar: Thanks so much, Dr. Houston. Really, really interesting study. Obviously, the figures that you have quoted in your results and in your conclusion are staggering. That's a large amount of potential cost savings. I'm curious, from a clinical standpoint, Dr. Sussman, how do we disseminate this sort of information to other specialties? Because urologists are not the only ones treating UTIs. The majority of these patients, particularly in the Medicare population, may not even make it to a urologist. So, what are your thoughts on partnerships there and what we can do?

Rachael Sussman: Yeah, I think probably the most useful people to understand this information are primary care doctors. They're the ones seeing these patients with recurrent UTIs. I personally speak a lot to our family medicine department, our internal medicine. I've given grand rounds to try and educate them that for these peri- and postmenopausal women, vaginal estrogen is really first-line for UTI prevention and just the dramatic impact it has. This paper is really just kind of like back-of-the-napkin math. We know UTIs go down from five a year to less than one a year, and we know that they cost a lot of money. So it is actually so simple. I was not surprised by these findings whatsoever because I see this every single day.

And I think it really is about education. I think perhaps trying to get more studies along these lines published in journals focused on family medicine, internal medicine, and just really for us as providers to be really good about communicating with our own referring doctors about the utility of these therapies and that they are safe to prescribe. A lot of doctors are just not educated on how to prescribe vaginal estrogen, how to counsel patients about the minimal systemic absorption and minimal risk of these therapies. So I have so many primary care doctors who, they're just afraid to prescribe them and they really just need more information and education.

Ruchika Talwar: Yeah. Dr. Houston, you quoted a range of costs for topical estrogen therapies, and a lot of it, I think you alluded to, depends on the form of the therapy. But tell me a little bit about where patients get these therapies from. You also alluded to the fact that some of these are like GoodRx, some might be direct-to-consumer online pharmacies. Some patients go through the traditional model of going to their physician, getting a prescription, taking it to their local mom-and-pop pharmacy. How can we bring this information to our patients when we see them having these recurrent UTIs, and what is the range that they'll generally pay for these kinds of medications?

Charlotte Houston: So one of the things that I've been doing over at the VA with my patients, I'll just pull up GoodRx a lot of the times with these patients. And it's different for the VA population, but just plugging it in and saying, "Hey, look, this is the therapy that we're looking at. Here's all of the places you can go get it, and this is what you can expect to pay depending." And you'll see, I mean, if you put estradiol cream into GoodRx, you'll see that it ranges from $20 to a hundred dollars for a single vial of cream. And so I think having that transparency with patients upfront so they know where to look for it, and so they're not surprised if they go to their CVS that maybe it's expensive, and to know that they don't need to just stop there and be like, "Oh, well, I guess I can't get this therapy. It's a hundred dollars."

And I think that some of the direct-to-consumer pharmacies and compounding pharmacies have been really helpful. I know that I don't get any money back from Mark Cuban, but Cost Plus Drugs, it's $20 or $22, I think now, for estradiol cream. So I think that being able to just be very transparent with patients and help them understand why that pricing is, and doing everything in our power to drive down those costs so that patients, I mean, patients shouldn't have to sort through this, it's crazy.

Rachael Sussman: The other thing too, which I will often tell my patients is, "I'm going to send this prescription in. I have no idea what your copay is, but if your copay is more than $20 to $30, don't get it with your insurance." Because there are some patients that, with their insurance, they're paying $150 per tube. And sometimes that's a really hard concept for patients to wrap their head around, "I have insurance. Why would I get this without insurance?" And it's like, "Well, our healthcare system is broken, and this is how it works, but you should get the cheapest price that's available."

And just another thought on GoodRx, you can get Viagra for about 5 cents. I mean, that's a huge disparity in the way that our healthcare system prioritizes men's issues versus women's issues. And I think this is something that more nationally, pharmaceutical companies, insurance companies need to provide better coverage for. Because not only does it improve patients' quality of life, the number of infections they're having, but it's also just financially dumb as an insurance company because you're going to have to pay all this money for copays and cultures and ER visits. It makes no sense.

Ruchika Talwar: Yeah, I mean, I couldn't agree more with all of those points. I think I'm optimistic to see the electronic medical record companies now implementing these real-time benefit tools that'll allow us to put in a medication and it'll flag it for us. And it'll say, "Well, the patient's actually going to pay a hundred dollars, but if you switch to perhaps this version of the same drug, they'll pay less." And you can't be expected to know that as a clinician, but hopefully, we'll see technology help us. But to your point, I mean, it is a broken system, and it's crazy that this is even happening. I definitely commend you both on this study.

I'm really excited to be able to share the findings with our viewers and hope that we can continue to work with all healthcare providers who see recurrent UTI patients in this population, because we clearly have the ability to improve many, many, many patients' quality of life, but also improve overall cost savings for everyone since a lot of the Medicare patients are taxpayer-funded. So thank you both for joining us. Really looking forward to what else you have in the pipeline looking at this kind of work, and we appreciate it.

Rachael Sussman: Thanks so much for having us.

Ruchika Talwar: And to our audience, thanks again for tuning in. We'll see you next time.