Optimizing Overactive Bladder Treatment: Phenazopyridine's Cost-Effective Approach - Anjali Kapur
August 7, 2024
Anjali Kapur discusses a cost analysis comparing oral Phenazopyridine (Pyridium) to intravesical lidocaine for pain control during Botox injections for overactive bladder. The study finds that using Pyridium is less costly, saving about $98 per visit and potentially $24 million annually if widely adopted. Dr. Kapur highlights the high prevalence of overactive bladder and the increasing use of Botox as a treatment. She explains that Pyridium offers advantages such as shorter office visits, no need for sterile preparation, and over-the-counter availability. The discussion covers the practical differences between the two methods in clinical settings, the derivation of costs in the analysis, and potential patient-facing costs. Dr. Kapur emphasizes that this small change in protocol could significantly improve office efficiency and reduce healthcare costs while maintaining patient satisfaction and pain control.
Biographies:
Anjali Kapur, MD, Fellow, Urogynecology and Reconstructive Pelvic Surgery, NYU Langone Health and Northport Veterans Affairs Medical Center, New York, NY
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Anjali Kapur, MD, Fellow, Urogynecology and Reconstructive Pelvic Surgery, NYU Langone Health and Northport Veterans Affairs Medical Center, New York, NY
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi everyone. Welcome back again to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist in Nashville, Tennessee. Today I'm excited to be joined by Dr. Anjali Kapur, who is a Female Pelvic Reconstructive Medicine Fellow at NYU Urology. Thanks for making time to chat with us today. We're really excited to hear more about your recent cost analysis of oral medications versus intravesical medications at the time of intradetrusor Botox injection.
Anjali Kapur: Thank you so much for having me and for that introduction, I'm excited to share my work. Botox is indicated for the treatment of idiopathic overactive bladder and is the most commonly used minimally invasive treatment modality for this condition. Compared to PTNS and sacral neuromodulation, it's both FDA-approved and in the SUFU and AUA guidelines for this condition. It's well known that overactive bladder affects one in six people in the US. In 2022, there were over 240,000 procedures performed for idiopathic overactive bladder alone. Because cystoscopy with intradetrusor Botox injection is done predominantly as an office procedure, pain control for patients is an essential component. Common agents used for pain control by urologists and urogynecologists who perform this procedure include intravesical lidocaine in the form of a 20-minute instillation of 50 cc of 2% lidocaine. The other method is oral Pyridium or phenazopyridine, which is a 200-milligram tablet that's taken one to two hours prior to the procedure.
A prior RCT that was published in 2022 found that oral Pyridium was non-inferior to intravesical lidocaine instillation when used for analgesia for Botox in females who were treated for idiopathic overactive bladder. It was also associated with shorter appointment times, so 44 minutes for the Pyridium group versus 57 minutes for the lidocaine group, and similar ease of performing the procedure by physicians in terms of visualization. With the volume of Botox procedures performed per year for idiopathic overactive bladder, we sought to understand the cost difference in the use of these two medications, and so we performed a healthcare sector perspective cost analysis. We created a model of total cost per use of intravesical lidocaine and total cost per use of oral Pyridium prior to Botox injection. The total base cost for use of each drug took into account the cost of the medication itself, the cost of the steps involved in administering the medication, the cost of the total office visit based on the length of time, and the cost and probability of adverse events to each medication.
I should mention here that the adverse reactions listed are the worst-case scenario outcomes of toxicity from long-term or excessive use of these drugs, and so their incidence and costs may be a bit overestimated when applied to this context. Through univariate sensitivity analysis, we found that Pyridium is less costly compared to lidocaine per office visit for Botox, with a difference of about $98 per visit. And if multiplied by the number of procedures performed for idiopathic overactive bladder in one year, this amounts to a cost saving of more than $24 million in one year. Per our threshold sensitivity analysis, we found that these are the circumstances under which Pyridium is no longer cost-saving. So one is the cost of a total office visit for Botox with lidocaine is below $360. Two is the cost of Botox with Pyridium is greater than $430.
And three is the cost of a nursing phone call to take Pyridium greater than $338. And I listed what the base costs for each scenario are below, just for comparison. So now why does this really matter? We can get into that. The prevalence of overactive bladder is considerably high and it represents a huge public health burden, as it has a significant social, physical, and emotional toll on patients. Overactive bladder medications are often not well tolerated or cost prohibitive, and with the recent change in the guidelines for the management of overactive bladder, which essentially eliminated stepwise therapy, Botox may be offered sooner to patients as a treatment option. So this scenario represents a huge opportunity to find a way to reduce healthcare costs associated with this procedure. One benefit of Pyridium is that it is commonly used and prescribed. If patients are unable to afford the medication or it's not covered by insurance, in rare circumstances, they can buy an over-the-counter alternative, which is Azo.
Additionally, with Pyridium, there's no sterile preparation or catheterization required by nursing staff, and there's no dwell time like there is with lidocaine. Therefore, the office visit time is significantly less. Potential disadvantages are that a patient has to be reminded to take Pyridium prior to the procedure or they may forget, and additionally, you may want to avoid giving Pyridium to an older patient with a reduced GFR or creatinine clearance, although a one-time dose is unlikely to have an adverse effect. In conclusion, per our cost analysis, using oral Pyridium for pre-Botox analgesia for idiopathic overactive bladder can provide a huge cost saving to the healthcare sector. Factors that play a role in this cost saving are the shorter visit time associated with Pyridium, and less cost of associated tasks by ancillary staff in administering the medication. If this practice is implemented widely, it has the potential to increase office efficiency while maintaining patient satisfaction and pain control. Thank you.
Ruchika Talwar: Thanks so much. I really enjoyed reading your study because I think it is just another example of how small changes in the way that we see patients and treat patients, small changes to various protocols, can actually result in a net large amount of savings for our healthcare system. And you alluded to that by giving us an idea of what the burden of overactive bladder is. So tell me, as somebody who sees these patients and performs these procedures yourself, from a practical perspective, what are the differences between using Pyridium versus using lidocaine?
Anjali Kapur: So I actually do have a good example because in one of our clinics in Brooklyn, we do tell patients to take Pyridium prior and don't do the instillation of lidocaine unless they forget. And in our clinic in Manhattan, everyone by pathway gets that lidocaine instillation. So doing the lidocaine instillation definitely requires a dedicated nursing or MA team to be able to run that procedure on their own. And it is generally more of a time-suck for everyone in the office, it is taking up an extra room for those additional 20 minutes. And so there can be sometimes delays in patient care and just more of a clogged schedule during the day compared to if the patient just comes in for the procedure, it's done in five minutes and they're able to go. So I have seen it definitely make a difference in terms of clinic workflow.
Ruchika Talwar: Absolutely. And efficiency matters because, in the end, efficiency translates to healthcare-related dollars and spend.
Anjali Kapur: Exactly.
Ruchika Talwar: So that's a really good point. Now, let's dig into the methods of your analysis just a little bit. Tell me how the cost for Pyridium was derived. Is that the cost that the patient pays to pay for the medication?
Anjali Kapur: Yes.
Ruchika Talwar: Is that the cost that the insurance company would pay? How does that work?
Anjali Kapur: Yeah, so that's the cost that the patient pays to get the medication. That was actually taken from GoodRx based on an average of the cost at various types of pharmacies in the US.
Ruchika Talwar: Got it, got it. So that may potentially vary a bit.
Anjali Kapur: Yeah. The difference was about, sorry, about $6 to $10.
Ruchika Talwar: Got it, got it. Now when we use lidocaine, is there any patient-facing cost associated with the lidocaine that's used in the office before their Botox procedure?
Anjali Kapur: Not directly to the patient. That would just affect the insurance coverage of the procedure total.
Ruchika Talwar: Got it. So it would add to the overall cost of care, but not necessarily patient-facing costs. Because I think that's an important thing to consider when patients perhaps are needing to pick up an extra medication and they may feel that burden of the $6, which could be a lot in some situations. But I think it's really interesting that you hammer home the point that we need to look at all associated costs because this is a big burden on the entire healthcare system.
Anjali Kapur: Right.
Ruchika Talwar: Absolutely. So as we wrap up here, tell me, what are your big takeaways for the urologic community from this study?
Anjali Kapur: I think it's definitely worth a try to use this over-the-counter medication that can be available or easily prescribed when using it. Even for patients who are just undergoing cystoscopy for any other reason. Plenty of urologists do office cystoscopy just for, say, bladder biopsies or surveillance, and they may want some form of pain control during those procedures. So I think it is worth a shot in terms of trying to see if it helps people's individual office efficiency if patients are satisfied when they undergo the procedure and have less pain afterward and can tolerate it more. And I think it's definitely a good alternative.
Ruchika Talwar: Great. Yeah, I think so too. Thank you so much for sharing your insights with the UroToday community. We really appreciate your time and having you on the show.
Anjali Kapur: Thank you so much.
Ruchika Talwar: And to our audience, thanks again for joining. We'll see you next time.
Ruchika Talwar: Hi everyone. Welcome back again to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist in Nashville, Tennessee. Today I'm excited to be joined by Dr. Anjali Kapur, who is a Female Pelvic Reconstructive Medicine Fellow at NYU Urology. Thanks for making time to chat with us today. We're really excited to hear more about your recent cost analysis of oral medications versus intravesical medications at the time of intradetrusor Botox injection.
Anjali Kapur: Thank you so much for having me and for that introduction, I'm excited to share my work. Botox is indicated for the treatment of idiopathic overactive bladder and is the most commonly used minimally invasive treatment modality for this condition. Compared to PTNS and sacral neuromodulation, it's both FDA-approved and in the SUFU and AUA guidelines for this condition. It's well known that overactive bladder affects one in six people in the US. In 2022, there were over 240,000 procedures performed for idiopathic overactive bladder alone. Because cystoscopy with intradetrusor Botox injection is done predominantly as an office procedure, pain control for patients is an essential component. Common agents used for pain control by urologists and urogynecologists who perform this procedure include intravesical lidocaine in the form of a 20-minute instillation of 50 cc of 2% lidocaine. The other method is oral Pyridium or phenazopyridine, which is a 200-milligram tablet that's taken one to two hours prior to the procedure.
A prior RCT that was published in 2022 found that oral Pyridium was non-inferior to intravesical lidocaine instillation when used for analgesia for Botox in females who were treated for idiopathic overactive bladder. It was also associated with shorter appointment times, so 44 minutes for the Pyridium group versus 57 minutes for the lidocaine group, and similar ease of performing the procedure by physicians in terms of visualization. With the volume of Botox procedures performed per year for idiopathic overactive bladder, we sought to understand the cost difference in the use of these two medications, and so we performed a healthcare sector perspective cost analysis. We created a model of total cost per use of intravesical lidocaine and total cost per use of oral Pyridium prior to Botox injection. The total base cost for use of each drug took into account the cost of the medication itself, the cost of the steps involved in administering the medication, the cost of the total office visit based on the length of time, and the cost and probability of adverse events to each medication.
I should mention here that the adverse reactions listed are the worst-case scenario outcomes of toxicity from long-term or excessive use of these drugs, and so their incidence and costs may be a bit overestimated when applied to this context. Through univariate sensitivity analysis, we found that Pyridium is less costly compared to lidocaine per office visit for Botox, with a difference of about $98 per visit. And if multiplied by the number of procedures performed for idiopathic overactive bladder in one year, this amounts to a cost saving of more than $24 million in one year. Per our threshold sensitivity analysis, we found that these are the circumstances under which Pyridium is no longer cost-saving. So one is the cost of a total office visit for Botox with lidocaine is below $360. Two is the cost of Botox with Pyridium is greater than $430.
And three is the cost of a nursing phone call to take Pyridium greater than $338. And I listed what the base costs for each scenario are below, just for comparison. So now why does this really matter? We can get into that. The prevalence of overactive bladder is considerably high and it represents a huge public health burden, as it has a significant social, physical, and emotional toll on patients. Overactive bladder medications are often not well tolerated or cost prohibitive, and with the recent change in the guidelines for the management of overactive bladder, which essentially eliminated stepwise therapy, Botox may be offered sooner to patients as a treatment option. So this scenario represents a huge opportunity to find a way to reduce healthcare costs associated with this procedure. One benefit of Pyridium is that it is commonly used and prescribed. If patients are unable to afford the medication or it's not covered by insurance, in rare circumstances, they can buy an over-the-counter alternative, which is Azo.
Additionally, with Pyridium, there's no sterile preparation or catheterization required by nursing staff, and there's no dwell time like there is with lidocaine. Therefore, the office visit time is significantly less. Potential disadvantages are that a patient has to be reminded to take Pyridium prior to the procedure or they may forget, and additionally, you may want to avoid giving Pyridium to an older patient with a reduced GFR or creatinine clearance, although a one-time dose is unlikely to have an adverse effect. In conclusion, per our cost analysis, using oral Pyridium for pre-Botox analgesia for idiopathic overactive bladder can provide a huge cost saving to the healthcare sector. Factors that play a role in this cost saving are the shorter visit time associated with Pyridium, and less cost of associated tasks by ancillary staff in administering the medication. If this practice is implemented widely, it has the potential to increase office efficiency while maintaining patient satisfaction and pain control. Thank you.
Ruchika Talwar: Thanks so much. I really enjoyed reading your study because I think it is just another example of how small changes in the way that we see patients and treat patients, small changes to various protocols, can actually result in a net large amount of savings for our healthcare system. And you alluded to that by giving us an idea of what the burden of overactive bladder is. So tell me, as somebody who sees these patients and performs these procedures yourself, from a practical perspective, what are the differences between using Pyridium versus using lidocaine?
Anjali Kapur: So I actually do have a good example because in one of our clinics in Brooklyn, we do tell patients to take Pyridium prior and don't do the instillation of lidocaine unless they forget. And in our clinic in Manhattan, everyone by pathway gets that lidocaine instillation. So doing the lidocaine instillation definitely requires a dedicated nursing or MA team to be able to run that procedure on their own. And it is generally more of a time-suck for everyone in the office, it is taking up an extra room for those additional 20 minutes. And so there can be sometimes delays in patient care and just more of a clogged schedule during the day compared to if the patient just comes in for the procedure, it's done in five minutes and they're able to go. So I have seen it definitely make a difference in terms of clinic workflow.
Ruchika Talwar: Absolutely. And efficiency matters because, in the end, efficiency translates to healthcare-related dollars and spend.
Anjali Kapur: Exactly.
Ruchika Talwar: So that's a really good point. Now, let's dig into the methods of your analysis just a little bit. Tell me how the cost for Pyridium was derived. Is that the cost that the patient pays to pay for the medication?
Anjali Kapur: Yes.
Ruchika Talwar: Is that the cost that the insurance company would pay? How does that work?
Anjali Kapur: Yeah, so that's the cost that the patient pays to get the medication. That was actually taken from GoodRx based on an average of the cost at various types of pharmacies in the US.
Ruchika Talwar: Got it, got it. So that may potentially vary a bit.
Anjali Kapur: Yeah. The difference was about, sorry, about $6 to $10.
Ruchika Talwar: Got it, got it. Now when we use lidocaine, is there any patient-facing cost associated with the lidocaine that's used in the office before their Botox procedure?
Anjali Kapur: Not directly to the patient. That would just affect the insurance coverage of the procedure total.
Ruchika Talwar: Got it. So it would add to the overall cost of care, but not necessarily patient-facing costs. Because I think that's an important thing to consider when patients perhaps are needing to pick up an extra medication and they may feel that burden of the $6, which could be a lot in some situations. But I think it's really interesting that you hammer home the point that we need to look at all associated costs because this is a big burden on the entire healthcare system.
Anjali Kapur: Right.
Ruchika Talwar: Absolutely. So as we wrap up here, tell me, what are your big takeaways for the urologic community from this study?
Anjali Kapur: I think it's definitely worth a try to use this over-the-counter medication that can be available or easily prescribed when using it. Even for patients who are just undergoing cystoscopy for any other reason. Plenty of urologists do office cystoscopy just for, say, bladder biopsies or surveillance, and they may want some form of pain control during those procedures. So I think it is worth a shot in terms of trying to see if it helps people's individual office efficiency if patients are satisfied when they undergo the procedure and have less pain afterward and can tolerate it more. And I think it's definitely a good alternative.
Ruchika Talwar: Great. Yeah, I think so too. Thank you so much for sharing your insights with the UroToday community. We really appreciate your time and having you on the show.
Anjali Kapur: Thank you so much.
Ruchika Talwar: And to our audience, thanks again for joining. We'll see you next time.