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Campeau et al

psychological well-being. Single-use HC catheters appear highest probability of being cost-effective against all other
to be preferred by most patients. comparators. This stems from marginal differences in QALYs
found between catheter types and high HC catheter costs.
4. Economic perspective
Impact of catheterization technique on economic perspective
A total of eight health economic analysis comparing different
types of IC were identified. All of them were cost utility anal- Clean vs. aseptic
yses (CUAs) assessing the cost-effectiveness in the U.K., 56,57
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Japan, the U.S., Italy, , Brazil, and Canada. 62,63 Each Randomized controlled trials have compared aseptic to
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uses local input variables where possible. For the purpose clean IC in different settings, such as perioperative patients,
of this best practice report, we will focus on the Canadian veterans in long-term care homes, and patients with SCI. 66-68
studies, as they are more relevant to our healthcare system. A review of the literature specifically relevant to neurogenic
bladder patients found the aseptic technique was associated
Impact of catheter type and material on economic perspective with 277% higher costs compared to the clean technique.
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None of these studies demonstrated a significant difference
Hydrophilic vs. uncoated catheters in UTIs.
HC catheters have an estimated cost of $7.02 in Canada. Catheter practices (single-use vs. reuse)
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The Canadian analyses compared the cost-effectiveness
of HC catheters to uncoated single-use catheters (UC), 62,63 Various techniques have been employed to clean and store
while Health Quality Ontario also included re-use of UC the catheter between uses, and generally a new catheter is
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catheters. They both use a Markov decision model and the used either each day or each week. Estimates from Health
index patient was a person with SCI. One study simulated Quality Ontario suggest that a year’s supply of uncoated
a lifetime horizon, while Health Quality Ontario selected intermittent catheters that were reused throughout the day
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a five-year horizon. Both models factor in antibiotic resist- and then discarded costs approximately $558, while using
ance, but there are some differences in which catheter-relat- a new catheter for each catheterization costs approximately
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ed outcomes are modelled. The studies model long-term $2232. The primary variable influencing cost-effectiveness
sequelae of UTIs and catheterization, which include various was the significant cost differences of the catheters used
renal complications, bladder stones, and urethral damage. in the two different scenarios. While there are conflicting
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However, Health Quality Ontario only include short-term opinions on whether catheter reuse results in a different UTI
consequences of symptomatic UTIs, with the latter suggest- risk, this has little effect on the model, as UTI is generally
ing a more conservative estimate. In terms of number of considered to be a brief, time-limited condition. Limitations
catherization per day, Welk et al base their analysis on four of this economic analysis include a lack of prior research
catheters used per day, while Health Quality Ontario addressing catheter reuse and the fact that this analysis did
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assumed five per day. not consider patient acceptability/satisfaction.
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Health Quality Ontario only takes the perspective of the
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healthcare system, while Welk et al also included a soci- Summary
etal perspective. They included health-related QOL (HRQOL)
gains that capture indirect health-related factors associated In summary, the use of HC catheters for IC is cost-effective
with IC (i.e., pain related to IC, steps and time needed for the over a lifetime horizon. Aseptic technique was associated
IC process). These values are based on the study by Averbeck with higher costs compared to the clean technique. Reuse
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et al that generates health state utilities using an internet-based of catheters appears to be a cost-effective approach; how-
time tradeoff (TTO) survey in a U.K. and Canadian popula- ever, these results should be interpreted with caution, given
tion. This allows the inclusion of utilities for user prefer- the limited availability of data and the large difference in
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ences in the incremental cost-effectiveness ratio calculation. resource use.
IC with HC becomes more economically attractive in these
scenarios, as increased patient satisfaction leads to a lower 5. Conclusions
cost per quality-adjusted life-year (QALY). When comparing
IC with HC vs. UC, they found HC catheters likely to be cost- Our summary recommendations are shown in Table 3.
effective. They predicted a gain of 0.72 QALYs at an additional IC is the gold standard for the management of failure to
cost of $48 016, leading to an ICER of $66 634/QALY. empty the bladder. When necessary, an indwelling catheter
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Health Quality Ontario found that the lowest cost inter- may be considered, and in most cases, a SPC is preferable
vention, reusing single-use UC catheters (one/week), had the to a long-term indwelling urethral catheter. Optimal catheter

E286 CUAJ • July 2020 • Volume 14, Issue 7