A Markov model was constructed to estimate the cost-effectiveness of several types of catheters for intermittent self-catheterization in a hypothetical SCI population with a mean age of 40 years (Bermingham et al. 2013; United Kingdom). The model projected forward to a lifetime time horizon. The comparators included hydrophilic coated catheters, gel reservoir coated catheters, single-use sterile non-coated catheters, clean non-coated catheters changed daily and clean non-coated catheters changed weekly. The Markov model included 6 different health states related to an individual’s movement between no symptomatic urinary tract infection, different catheter associated urinary tract infection states and death. Results were presented as cost per QALY. In the base case result, gel reservoir catheters were calculated to cost £54,350 per QALY compared to non-coated catheters. The cost per QALY was even higher for hydrophilic catheters. Between the different options for non-coated catheters, catheters changed weekly were more effective and less expensive than catheters changed daily or single use catheters. In the scenario where non-coated catheters are not an option, the cost per QALY of gel reservoir catheters compared to hydrophilic catheters was £3,075 per QALY gained. The sensitivity analyses did little to change the results of the analysis suggesting that the model was robust even with uncertainty. The authors noted that there were concerns with the conclusions of this study expressed by the stakeholders of the guidelines for which this study was to inform (patient groups, manufacturers and National Health Service trusts). There were liability concerns from clinicians regarding catheter infections if single use non-coated catheters were recommended to patients. Also there were concerns regarding the off-label recommendation by a government organization for multiple uses of a single use catheter. The evidence regarding this recommendation was reported as low to very low quality. Thus, the recommendation was revised to allow patient choice of gel reservoir and hydrophilic catheters.
In one study, clean non-coated catheter (replaced weekly) was the most cost-effectiveness intervention compared to the same intervention replaced daily, one-time use sterile non-coated catheters, hydrophilic catheters and gel reservoir catheters. This is based on a decision-maker’s willingness to pay threshold of £20,000-30,000.