Background
Currently, there is controversy over who requires preoperative screening for bacteriuria
in the urogynecologic population and whether treating asymptomatic bacteriuria reduces
postoperative urinary tract infection rates.
Objective
To evaluate the cost-effectiveness of selective, universal, and no preoperative bacteriuria
screening protocols in women undergoing surgery for prolapse or stress urinary incontinence.
Study Design
A simple decision tree model was created from a societal perspective to evaluate cost
and effectiveness of 3 strategies to prevent postoperative urinary tract infection:
(1) a universal protocol where all women undergoing urogynecologic surgery are screened
for bacteriuria and receive preemptive treatment if bacteriuria is identified; (2)
a selective protocol, where only women with a history of recurrent urinary tract infection
are screened and treated for bacteriuria; and (3) a no-screening protocol, where no
women are screened for bacteriuria. Our primary outcome was the incremental cost-effectiveness
ratio, calculated in cost per quality-adjusted life-years. Secondary outcomes were
the number of urine cultures, postoperative urinary tract infections, and pyelonephritis
associated with each strategy. Costs were derived from the Centers for Medicare &
Medicaid Services, Healthcare Cost and Utilization Project, and Medical Expenditure
Panel Survey. Clinical estimates were derived from published literature and data from
a historic surgical cohort. Quality-of-life-associated utilities for urinary tract
infection (0.73), pyelonephritis (0.66), and antibiotic use (0.964) were derived from
the published literature using the HALex scale, reported directly by affected patients.
One-way sensitivity analyses were performed over the range of reported values.
Results
In the base case scenario, selective screening is more costly (no screen: $101.69,
selective: $101.98) and more effective (no screen: 0.096459 quality-adjusted-life-year,
selective: 0.096464 quality-adjusted-life-year) than no screening, and is cost-effective,
with an incremental cost-effectiveness ratio of $49,349 per quality-adjusted-life-year.
Both selective screening and no screening dominate universal screening in being less
costly (universal: $111.92) and more effective (universal: 0.096446 quality-adjusted-life-year),
with a slightly higher rate of postoperative urinary tract infection (no screen: 17.1%,
selective: 16.9%, universal: 16.6%). In 1-way sensitivity analyses, selective screening
is no longer cost-effective compared with no screening when the cost of a urine culture
exceeds $12, cost of a preoperative urinary tract infection exceeds $93, the cost
of a postoperative urinary tract infection is below $339, the specificity of a urine
culture is less than 96%, or preoperative bacteriuria rates in those without symptoms
but a history of recurrent urinary tract infection is <23%. Universal screening only
becomes cost-effective when the postoperative urinary tract infection rate increases
to >50% in those without risk factors and untreated preoperative bacteriuria. When
compared with no screening, selective screening costs an additional $104 per urinary
tract infection avoided and $2607 per pyelonephritis avoided. Compared with selective
screening, universal screening costs $4609 per urinary tract infection avoided and
$115,223 per pyelonephritis avoided.
Conclusion
Implementation of a selective preoperative bacteriuria protocol is cost-effective
in most scenarios and associated with only a <1% increase in the 30-day postoperative
urinary tract infection rate. No screening is cost-effective when cost of a preoperative
urinary tract infection is high and the rate of preoperative bacteriuria in those
without risk factors is low.
Key words
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Article Info
Publication History
Published online: December 16, 2021
Accepted:
November 25,
2021
Received in revised form:
November 17,
2021
Received:
September 4,
2021
Footnotes
This project was funded by Departmental Funds (Duke OBGYN).
N.S. reports funding from Medtronic Inc. All other authors report no conflict of interest.
Cite this article as: Hendrickson WK, Havrilesky L, Siddiqui NY. Cost-effectiveness of bacteriuria screening prior to urogynecologic surgery. Am J Obstet Gynecol 2022;226:831.e1-12.
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