(017) COST-EFFECTIVENESS MODELING OF IMPLANTABLE PROSTHESIS AS A FIRST-LINE OPTION FOR ERECTILE DYSFUNCTION MANAGEMENT
Authors: Ranti D , Berman R , Misgano D , Kazal F , Alukal J , Joice G 
Published: December 2024

Abstract

Introduction
Erectile dysfunction (ED) rates in the United States have increased over the past several decades due to multiple factors, including an aging population and rising rates of diabetes and peripheral vascular disease. Implantable penile prostheses (IPP) are highly effective for refractory ED, however, insurance coverage is variable and often requires demonstration of both failed oral and injectable therapy. Delayed IPP placement in high-risk patients is likely to reduce quality of life metrics as well as increase costs associated with failed pharmacological trials.

Objective
We aimed to evaluate the quality associated life years (QALY) and the cost per QALY of direct IPP placement for PDE5 inhibitor-resistant ED.

Methods
A literature review was conducted to gather probability functions of success and complications associated with PDE5 inhibitors, intracavernosal injection (ICI), and IPP, as well as costs and QALYs associated with each therapy. TreeAge was used to generate a Markov model, which evaluated two separate strategies: 1) a standard pathway, in which all patients would be trialed on PDE5 inhibitors and ICI for 1 to 6 months each, and 2) a direct-to-IPP pathway, in which patients would immediately be offered an IPP. Each model was run for 10 000 iterations for 10 years per iteration. The standard pathway was run for 9 scenarios, in which each population would have a varying response rate to PDE5 inhibitors and ICI (10% to 90% response). Cumulative QALY, costs, and the incremental cost-effectiveness ratio (ICER) of each strategy were calculated.

Results
The standard pathway model considered 10% to 90% response rates to traditional medical management, resulting in average 10-year costs ranging between $22 914 and $44 187. In comparison, the direct-to-IPP group had average 10-year costs of $17 750 (Fig. 1). The ICERs for the standard pathway compared to the direct-to-IPP approach ranged linearly from -$34 221 to -$45 595 (from 10% to 90% medical management success). Average total QALY for a 10-year period ranged from 6.99 (90% medical management success) to 7.61 (direct-to-IPP).

Conclusions
In this analysis, we sought to quantify the cost-effectiveness of the prevailing management strategy for erectile dysfunction compared to an IPP-first strategy. We found that the ICER of medical management compared to a direct-to-IPP strategy ranged from -$34 K to -$46 K, indicating that medical management was both more costly and less effective in providing patients with ED quality of life. While it is unreasonable to suggest that IPP should be a first-line treatment for all patients with erectile dysfunction, these data are informative for counseling in populations particularly susceptible to high rates of erectile dysfunction, such as those with diabetic neuropathy, a history of radical prostatectomy, or peripheral vascular disease. In these populations, counseling directly on penile prosthesis before PDE5 inhibitors or ICI trials could be both cost-effective and fit within the current American Urological Association guideline statements.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Gregory Joice MD is a consultant for Boston Scientific.