Page 4 - CUAJ February 2019: Clean intermittent catheterization: Single use vs. reuse

CIC: Single use vs. reuse

the efficacy of different cleaning methods since then. Although old for the National Institute of Clinical Excellence (NICE)
a systematic review published in 2017 referred to two articles in the U.K. 32
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that recommended a sterile (aseptic) technique, neither this Using a modified version of the model developed in
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review nor the Cochrane review provided any statistically the previous study, cost-effectiveness of HC catheters
significant recommendation on cleaning standards. 13,15 was addressed in Canada. This model predicted that in a
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50-year-old patient with SCI, using HC catheters would lead
Cost to living 0.78 years longer and to the gain of an additional
0.72 QALYs compared to using UC. The incremental cost
The cost of single-use catheters has been one of their main and ICER for this gain was $48 016 CAD and $66 634 CAD/
drawbacks for a long time. From the perspective of the pub- QALY, respectively. Moreover, the lifetime risk of develop-
lic payer, the out-of-pocket cost for these catheters can only ing UTI in these patients was estimated to be 11% less with
be justified if it can offer good value regarding complica- HC catheters compared to UC types. The authors concluded
tions, expected life-years, and QoL. It should be empha- that reimbursement of HCIC catheters should be considered
sized that the QoL is affected by several health-related and in these settings.
non-health-related factors, such as UTI, pain, discomfort, A similar study was conducted in Brazil and results were
time spent on catheterization, and social factors associated presented as cost per LYG, cost per QALY, and cost per num-
with catheterization. As cost-effectiveness and cost-utility ber of avoided UTIs. The results revealed cost-effectiveness
are among the fundamental aspects of health economics, of HC catheters compared to UC PVC catheters per LYG
several authors have looked into this matter to assist both (57 432 Brazilian Reais [BRL] equal to $17 773 USD, at an
patients and policy-makers with their decisions. 27-33 exchange rate of 0.31) and per QALY (122 330 BRL, equal
A cost-comparison analysis by Neovius et al showed that to $37 857 USD). HC catheters showed the potential to
the catheter cost for single-use types was more than that of reduce the lifetime number of UTIs by 6% at the cost of 31
reusable types (€2188 vs. €817 per year and per patient). 240 BRL ($9817 USD). 30
However, the annual cost imposed by catheter complica- Cost-effectiveness of HC catheters has also been evalu-
tions was lower in the single-use group. With the single- ated from the perspective of Italian Healthcare Service sys-
use catheters, complications such as UTI, antibiotic-resistant tem. The base-case incremental cost-effectiveness and cost-
UTI, bacteremia, strictures, and bladder stones resulted in an utility ratios (ICER and ICUR) associated with HC catheters
annual cost of €1243, while the figures for reusable catheters were €20 761 and €24 405, respectively. This implies that
stood at €2067 per patient. In other words, 60% of the extra HC catheters are likely to be cost-effective in comparison
cost of single-use catheters was compensated. 33 to uncoated ones, as the proposed Italian threshold values
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Watanabe et al studied the cost-effectiveness of HC range is between €25 000 and €66 400. 31
catheters for bladder management in spinal cord injury (SCI)
patients in Japan. They used a modified Markov decision Discussion
model and addressed direct medical costs, quality‐adjusted
life years (QALYs) and life years gained (LYG). In contrast Reuse of catheters for the purpose of IC has been popu -
to UC catheters, HC catheters resulted in 0.334 QALYs and lar and widely used. Although this has been more com -
0.781 LYG at an incremental cost of ¥1 279 886 ($10 578 mon in developing countries, it has been reported to be
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USD at an exchange rate of $1 USD=¥121) for HC cath- practiced by more than 35% of patients in North America. 3
eters per SCI patient. The incremental cost‐effectiveness ratio Despite this common use, the evidence on the prevalence
(ICER) of HC catheters vs. UC catheters was $31 623 USD/ of UTIs associated with repeated use of a catheter is con-
QALY gained and $13550 USD/LYG. flicting. 9,10,12,34 Aside from questionable cleaning methods, it
Clark et al published a paper comparing the cost-effec- is unclear how long a multiple-use catheter can be reused.
tiveness of long-term IC with single-use HC catheters vs. With the level of variation observed across clinical trials, it
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single-use UC catheters. They developed a model based is likely that similar, if not more variation can be expected
on the results published regarding IC in adults with SCI. in public use. The lack of evidence-based recommendations
UTIs and renal function were considered model health is sure to confuse the general public and alter their adher-
states. Their model predicted the life expectancy of a ence to cleaning methods. 23,24 These facts suggest single use
36-year-old SCI patient who used HC catheters to be 1.4 of catheters as a potential remedy. It is also important to
years longer compared to those using UC single-use cath- consider the effects that cleaning and repetitive uses can
eters (on average, another 23.9 years with HC catheters have on catheters. 18,22-25
and 22.5 years with UC types). When the increased cost The American Urological Association (AUA) white paper
of HC catheters was factored in, the ICER was a gain of on catheter-associated UTIs provides no recommendation
£6100 for each QALY. This cost is well within the thresh- on cleaning the reusable catheters, stating that HC catheters

CUAJ • February 2019 • Volume 13, Issue 2 67