Costs of urinary incontinence and overactive bladder in the United States: a comparative study

OBJECTIVES

To update the cost of urinary incontinence (UI) for year 2000 and compare it with the cost of overactive bladder (OAB).

METHODS

Using the cost-of-illness framework, disease epidemiologic data were combined with treatment rates, consequence probabilities, and average cost estimates. All costs reflect the costs during 2000.

RESULTS

The total cost of UI and OAB was 19.5 billion dollars and 12.6 billion dollars, respectively (year 2000 dollars). With UI, 14.2 billion dollars was borne by community residents and 5.3 billion dollars by institutional residents. With OAB, 9.1 and 3.5 billion dollars, respectively, was incurred by community and institutional residents.

CONCLUSIONS

OAB affected 34 million individuals compared with 17 million with UI. Despite the differences in epidemiology, the total and per-person costs of UI were higher than the OAB costs because OAB individuals without incontinent episodes incurred fewer costs, on average.

Economic and personal impact of fecal and urinary incontinence

Failure to control the elimination of urine or stool causes psychological stress, complicates medical illnesses and management, and has major economic consequences. Patients often describe the impact of both fecal and urinary incontinence in terms of shame and embarrassment and report that it causes them to isolate themselves from friends and family. Incontinence frequently results in an early decision to institutionalize elderly relatives because families have difficulty coping with incontinence at home. Not surprisingly, there is an increase in symptoms of depression and anxiety in patients with incontinence as well as degradation in quality of life that has been documented by standardized assessment instruments. The direct health care costs for urinary incontinence are estimated to be 16.3 billion dollars per year (1995 costs). Separate cost estimates for fecal incontinence are not available. There is an acute need for methodologically sound studies to document the economic and personal impact of incontinence to develop guidelines for the allocation of health care resources and research funding to this major public health problem. This need is especially great for fecal incontinence, for which there is much less health care economic data than for urinary incontinence.

Cost-effectiveness analysis of extended-release formulations of oxybutynin and tolterodine for the management of urge incontinence

INTRODUCTION

Oxybutynin and tolterodine are two drugs widely used for the management of overactive bladder and urge urinary incontinence. The once-daily, extended-release formulations benefit from being well tolerated and efficacious. However, their costs, compared with generic immediate-release (IR) oxybutynin, are significantly greater. This study compared the cost effectiveness of oxybutynin extended-release (Oxy-XL), tolterodine extended-release (Tol-ER), tolterodine immediate-release (Tol-IR) and oxybutynin immediate-release (Oxy-IR).

STUDY DESIGN

A cost-effectiveness model.

METHODS

A systematic review that identified appropriate randomised clinical trials provided evidence on efficacy. Empirical models of drug effects (number of incontinent-free weeks) and persistence (proportion of patients still on therapy) were constructed in order to determine clinical effectiveness which was combined with cost data (direct medical costs to the UK NHS, year 2001 values) to calculate the drugs' cost-effectiveness from the perspective of the NHS. Univariate sensitivity analyses were conducted to test the robustness of the results.

PATIENTS

Hypothetical cohort of patients with urge incontinence associated with overactive bladder.

MAIN OUTCOME MEASURES AND RESULTS

The incremental cost per incontinent-free week for Oxy-IR (versus no treatment) ranged from pound sterling 2.58 to pound sterling 16.59. Oxy-XL and Tol-ER were more effective than Oxy-IR but at additional costs per incontinent-free week. Tol-IR did not appear to be a cost-effective option as it was less effective and more costly than the extended-release formulations. Uncertainty surrounding the health and cost consequences of early discontinuation affected these results, although the model results were robust to parameter uncertainty.

CONCLUSION

Oxy-IR, Oxy-XL and Tol-ER appear to be cost-effective options for the management of urge incontinence from the NHS perspective. A decision among the treatments depends on the acceptable cost per additional incontinent-free week.

Implementing an incontinence management protocol in long-term care. Clinical outcomes and costs

This article describes clinical outcomes and costs of implementing an incontinence management protocol based on the recommendations contained in the Agency for Health Care Quality and Research clinical practice guidelines on incontinence and pressure ulcer prevention. Following implementation of the protocol, 63 nursing home residents were followed for 6 months and assessed for the presence of wetness or pressure ulcers. Facility costs for incontinence management were accumulated. Fifty-four percent of the residents (34 of 63) received treatments for incontinence and 60% (20 of 34) became dry. Pressure ulcer rates decreased from 16 participants developing 26 pressure ulcers to 3 participants developing 5 ulcers. Facility cost of incontinence management for 6 months was $86,436 with 46% attributed to direct labor costs. Toileting was the most expensive component, costing $36,755. Total daily cost of incontinence management was $573 ($9.09 +/- 10.52 per resident). Implementation of the incontinence protocol resulted in improved "dryness" of the participants and reduced pressure ulcer incidence.

Labor costs associated with incontinence in long-term care facilities

OBJECTIVES

To understand the labor resource consumption in caring activities of long-term care residents with versus without urinary incontinence (UI) and the variation in consumption patterns across shifts and facility types.

METHODS

This prospective study was conducted in three phases. Phase I of the study developed a taxonomy of the caring activities involved in the care of the incontinent patient and of the control group patient. In Phase II, the frequency of these activities was assessed. Phase III extrapolated the cost impacts of incontinence. The sample consisted of 37 long-term care facilities in the vicinity of Winston-Salem, North Carolina, along with a supplemental sample of 12 facilities in the vicinity of Chapel Hill, North Carolina. The study examined the costs of labor, supplies, and services. To our knowledge, this is the first study to apply microcosting approaches to UI.

RESULTS

All things being equal, the incremental labor costs (per shift) were 3.31 dollars (in 2002 dollars) for patients with occasional UI and 5.16 dollars for patients with frequent UI. Combining patients with frequent UI (more than 70% of all UI patients) and occasional UI, the weighted average incremental costs per shift were 4.52 dollars.

CONCLUSIONS

With incremental labor costs of 4.52 dollars per patient per shift, UI costs an additional 13.57 dollars to treat per day, or 4957 dollars annually. Our findings can be used to capture the "averted costs" in long-term care facilities from curing UI.

The impact of urinary incontinence on self-efficacy and quality of life

Urinary incontinence impacts 15 to 35% of the adult ambulatory population. Men after the removal of the prostate for cancer can experience incontinence for several weeks to years after the surgery. Women experience incontinence related to many factors including childbirth, menopause and surgery. It is important that incontinence be treated since it impacts not only the physiological, but also the psychological realms of a person's life. Depression and decreed quality of life have been found to co-occur in the person struggling with incontinence. Interventions include pharmacological, surgical as well as behavioral interventions. Effective treatment of incontinence should include the use of clinical guidelines and research to promote treatment efficacy.

Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up

OBJECTIVE

To compare the efficacy and labour costs of nurse continence advisors and urogynaecologists in conservative management of urinary incontinence.

DESIGN

Single centre randomised controlled trial of patients with mild or moderate leakage.

SETTING

Tertiary urogynaecology unit.

SAMPLE

One hundred and forty-five consecutive patients with stress and/or urge incontinence.

METHODS

Standardised conservative therapy regimens, provided by nurse continence advisors and urogynaecologists.

MAIN OUTCOME MEASURE

One-hour pad test, frequency volume charts, a 20-point incontinence score and two quality of life tests, staff treatment times and costs.

RESULTS

Of 110 women who completed 12-week treatments, 64% of the women in the nurse continence advisor group (n = 58) and 52% of women treated by urogynaecologists (n = 52) were asymptomatic (dry pad test; OR 1.63, 95% CI 0.71-3.75). There was no significant difference between clinician groups for change in pad test result (P = 0.71), voids/day (0.43), incontinence score (P = 0.57) or quality of life scores (urogenital distress inventory, P = 0.27; Incontinence Impact Questionnaire, P = 0.41). Despite the expected longer consultation times for the advisor group (median 160 min, interquartile range [IQR] 130-210) versus the urogynaecologist group (median 90 min, IQR 60-120), the per capita labour cost for advisor treatment (median AU$59.20, IQR 48.10-77.70) was lower than for treatment given by urogynaecologists (median cost AU$ 189.70, IQR 120.60-250.70, Mann-Whitney U test, P < 0.0001). At 2.5 years, 23/58 patients (40%) treated by advisor and 27/52 patients (52%) treated by urogynaecologist group, who had been cured and discharged, were available for contact. Of these, 29% of women in the nurse continence advisor group and 41% of those treated by urogynaecologists remained continent (on 20-point score). Quality of life improvement persisted equally in both groups. These data should be interpreted cautiously due to a 24% dropout rate.

CONCLUSIONS

The reduction in urine leakage and improvement in quality of life observed in patients treated by nurse continence advisors and urogynaecologists were similar at 12 weeks and 2 years, but lower costs arose from treatment provided by nurse advisors. We suggest that conservative treatment by the nurse continence advisor could be used more widely in mild to moderate incontinence.

Urinary incontinence in subacute care--a retrospective analysis of clinical outcomes and costs

OBJECTIVE

To investigate the effect of incontinence on clinical outcomes and costs for patients in subacute care.

DESIGN

Retrospective analysis of data collected over a 3-month period in 1996.

SETTING

54 medical facilities in Australia and New Zealand providing subacute care in an inpatient setting.

PATIENTS

6773 episodes of care provided to 6455 rehabilitation and geriatric evaluation and management patients.

MAIN OUTCOME MEASURES

Urinary continence status, treatment outcomes, length of stay, discharge destination, and nursing and allied healthcare costs.

RESULTS

Discharge destination differed between incontinent and continent patients (57% compared with 82%, respectively, discharged home, and 29% compared with 12%, respectively, discharged to a nursing home or to further care). There was a difference in cost between patients who were continent and those who were incontinent throughout their episode of care (rehabilitation: $185.60 [95% CI, $181-$190] per day for incontinent and $156.82 [95% CI, $153-$160] for continent patients; and geriatric evaluation and management: $164.62 [95% CI, $157-$172] for incontinent and $121.40 [95% CI, $114-$129] for continent patients). However, multilevel analyses showed that, after allowing for age and level of functional independence, the contribution of continence status to the cost of care depended on the functional independence of the patient (cognitive function for orthopaedic patients [P < 0.01] and motor function for stroke patients [P = 0.04]).

CONCLUSION

The relationship between continence status and cost of care is complex. However, the cost differences found in our study need to be considered in payment systems, allocation of staff levels on wards and in development of casemix classifications.

Estimated economic costs of overactive bladder in the United States

OBJECTIVES

To estimate the economic costs of overactive bladder (OAB), including community and nursing home residents, and to compare the costs in male versus female and older versus younger populations.

METHODS

The National Overactive Bladder Evaluation Program included a representative telephone survey of 5204 community-dwelling adults 18 years and older in the United States and a follow-up postal survey of all individuals with OAB identified and age and sex-matched controls. The postal survey asked respondents about bladder symptoms, self-care use, treatment use, work loss, and OAB-related health consequences. Survey data estimates were combined with year 2000 average cost data to calculate the cost of OAB in the community. Institutional costs were estimated from the costs of urinary incontinence in nursing homes, limited to only those with urge incontinence or mixed incontinence (urge and stress).

RESULTS

The estimated total economic cost of OAB was 12.02 billion dollars in 2000, with 9.17 and 2.85 billion dollars incurred in the community and institutions, respectively. Community female and male OAB costs totaled 7.37 and 1.79 billion dollars, respectively. The estimated total cost was sensitive to the estimated prevalence of OAB; therefore, we calculated the average cost per community-dwelling person with OAB, which was 267 dollars per year.

CONCLUSIONS

By quantifying the total economic costs of OAB, this study-the first obtained from national survey data-provides an important perspective of this condition in society. The conservative estimates of the total cost of OAB were comparable to those of osteoporosis and gynecologic and breast cancer. Although this provides information on the direct and indirect costs of OAB, quality-of-life issues must be taken into account to gain a better understanding of this condition.

Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases International Symposium on Epidemiologic Issues in Urinary Incontinence in Women

The Epidemiologic Issues in Urinary Incontinence: Current Databases and Future Collaborations Symposium included an international group of 29 investigators from 10 countries. The purpose of the symposium was to discuss the current understanding and knowledge gaps of prevalence, incidence, associated risk factors, and treatment outcomes for incontinence in women. During the symposium, investigators identified existing large databases and ongoing studies that provide substantive information on specific incontinence research questions. The investigators were able to form an international collaborative research working group and identify potential collaborative projects to further research on the epidemiology of urinary incontinence and bladder dysfunction.

The role of neuromodulation in the management of urinary urge incontinence

OBJECTIVE

To examine the benefit-risk profile of neuromodulation in treating refractory urinary urge incontinence and other voiding disorders.

PATIENTS AND METHODS

The outcome measures from all patients in pivotal clinical trials who had undergone sacral nerve stimulation were analysed retrospectively.

RESULTS

Neuromodulation was effective in several clinical studies; the response is durable and the benefit-risk profile good.

CONCLUSION

Sacral nerve stimulation is becoming the standard of care for refractory overactive bladder and retention problems. The potential benefit of neuromodulation should be included in female urology and gynaecology training programmes.

Restorative Nursing Bladder Training program: recommending a strategy

This article describes a Restorative Nursing Bladder Training program, a performance improvement initiative aimed at helping patients regain bladder control by postponing voiding, and then urinating according to a specific, individualized timetable. Data were collected on 14 patients who participated in the program from April 1999 through January 2001. Eight patients achieved a 100% reduction in incontinent episodes; 1 patient documented a 90% reduction; another patient attained an 85% reduction; 3 patients showed a 50% reduction; and 1 patient showed a 30% reduction.

Clinical and cost effectiveness of a cleanser protectant lotion for treatment of perineal skin breakdown in low-risk patients with incontinence

Perineal dermatitis due to urinary and/or fecal incontinence is a common problem. A multicenter, open label, phase II product evaluation was conducted to determine the effectiveness of a new cleanser protectant lotion in reducing perineal erythema and pain in patients at low-risk for perineal dermatitis and to compare the cost of this product to standard protocols of care. Nineteen elderly patients (14 male, 5 female, mean age 73.1 years) participated in the study. Average baseline scores for erythema and pain were 2.3 (+/- 0.5) and 1.5 (+/- 1.0), respectively (scale 0 to 4). After 7 days, both scores were significantly lower (mean scores 0.6 +/- 0.8 and 0.3 +/- 0.8, respectively; P < 0.01). Based on an average of 2.6 perineal episodes per day, the one-step product evaluated would cost $136 per patient/year less than standard protocols of care while reducing caregiver time (average 23 seconds per episode of care). Optimal perineal care may reduce the incidence of complications; studies to ascertain the safety and effectiveness of commonly used products and procedures are needed.

Informal caregiving time and costs for urinary incontinence in older individuals in the United States

OBJECTIVES

To obtain nationally representative estimates of the additional time, and related cost, of informal caregiving associated with urinary incontinence in older individuals.

DESIGN

Multivariate regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people aged 70 and older (N = 7,443).

SETTING

Community-dwelling older people.

PARTICIPANTS

National population-based sample of community-dwelling older people.

MEASUREMENTS

Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling older people who reported (1) no unintended urine loss, (2) incontinence that did not require the use of absorbent pads, and (3) incontinence that required the use of absorbent pads.

RESULTS

Thirteen percent of men and 24% of women reported incontinence. After adjusting for sociodemographics, living situation, and comorbidities, continent men received 7.4 hours per week of care, incontinent men who did not use pads received 11.3 hours, and incontinent men who used pads received 16.6 hours (P <.001). Women in these groups received 5.9, 7.6, and 10.7 hours (P <.001), respectively. The additional yearly cost of informal care associated with incontinence was $1,700 and $4,000 for incontinent men who did not and did use pads, respectively, whereas, for women in these groups, the additional yearly cost was $700 and $2,000. Overall, this represents a national annual cost of more than $6 billion for incontinence-related informal care.

CONCLUSIONS

The quantity of informal caregiving for older people with incontinence and its associated economic cost are substantial. Future analyses of the costs of incontinence, and the cost-effectiveness of interventions to prevent or treat incontinence, should consider the significant informal caregiving costs associated with this condition.

Urinary incontinence in women and men

Urinary incontinence is one of the top 10 chronic health conditions in the United States and affects the lives of 13 million Americans. Although common in both men and women, it is a gender-specific condition whose lifetime distribution, incidence, and etiology differ between the two sexes. Recent advances in health care, along with the increasing aging of the population, create a demand for the treatment of urinary incontinence. This article reviews the currently available treatment options, many of which vary inter- and intra-gender.

The national coverage decision for reimbursement for biofeedback and pelvic floor electrical stimulation for treatment of urinary incontinence

On October 6, 2000, the Centers for Medicare & Medicaid Services (CMS) (formerly the Health Care Financing Administration) issued a national coverage decision for the use of biofeedback and pelvic floor electrical stimulation in the treatment of urinary incontinence. This decision was the first major health care coverage decision made using CMS's new "open" process. The new process included the use of a panel of physicians to evaluate adequacy of evidence to support the utilization of the modalities. From the very beginning, there were indications that CMS was not favorably disposed toward the use of these modalities, and there was a real threat that coverage could be withdrawn or that no decision would be made. The organized and cohesive response of the health care community influenced CMS to make a positive coverage decision. Through the diligent and tenacious work of a group of nurses called the SUNA/WOCN Continence Coalition, professional organizations and prominent individuals were brought together to approach CMS with one message and one voice.

Cost-Effectiveness of tolterodine for patients with urge incontinence who discontinue initial therapy with oxybutynin: a Canadian perspective

BACKGROUND

Tolterodine is a novel muscarinic receptor antagonist for the treatment of overactive bladder.

OBJECTIVE

The purpose of this study was to examine the cost-effectiveness of tolterodine for patients with urge incontinence (UI) who discontinue initial therapy with oxybutynin in a Canadian setting.

METHODS

We compared 2 treatment strategies for the management of adult patients with UI: (1) generic oxybutynin with no further treatment for patients who discontinue and (2) generic oxybutynin with switch to tolterodine (2 mg BID) for patients who discontinue. We developed a 1-year Markov model (4-week cycle length) with transitions between disease states of normal, mild, moderate, and severe. Transition probabilities over 12 weeks were obtained from randomized trial data, and drug discontinuation rates were obtained from Quebec prescription claims data. Outcome measures were time in "normal" health state and quality-adjusted life-years (QALYs) using EuroQol-5D utility scores from a survey of Swedish patients with overactive bladder. Costs to the health care payer and patient out-of-pocket costs (in Canadian dollars) were included.

RESULTS

For patients who discontinue oxybutynin, the use of tolterodine is associated with approximately 6 months per year in a normal health or mild disease state, compared with approximately 3 months for those who do not receive further drug therapy after discontinuation. Tolterodine use resulted in an annual additional cost per patient of Can $163. The incremental cost per QALY was Can $9,982 and appeared to be robust to alternative model parameter assumptions.

CONCLUSION

Use of tolterodine in patients with UI who discontinue initial therapy with generic oxybutynin lies within currently accepted benchmarks for cost-effectiveness.

Incontinence aids in Sweden: users and costs

OBJECTIVE

To study age- and sex-specific use and costs of incontinence aids distributed free of charge in Sweden.

SUBJECTS AND METHODS

The study was conducted in the county of Jämtland, Sweden (132,000 inhabitants). The use and cost of incontinence aids for people living in their homes and the total cost of incontinence aids for residents of special accommodation (e.g. nursing homes, homes for the elderly and sheltered housing) was obtained from a central database constructed for the purpose. Individual usage of incontinence aids by those in special accommodation was studied in two districts of Jämtland, representing 18% of the population.

RESULTS

Free incontinence products were used by 6.4% of all women and 2.4% of all men in the county. There was a sharp increase in usage from the age of 75 years. Of the users, 21% lived in special accommodation. If the data from Jämtland are extrapolated nationally, then 274,000 women and 93,000 men in Sweden (total population 8.8 million) are using free incontinence products. The total cost of incontinence aids for Jämtland during 1999 was 15.4 million Swedish krona (SK), and those in special accommodation accounted for 46% of these costs. This corresponds to an estimated total cost in Sweden of approximately 925 million SK. Although 75% of the users were women, women only contributed 61% of the total costs. The mean annual cost of incontinence aids for an incontinent man was twice that of an incontinent woman. More than half of the costs were attributable to those aged >or=80 years.

CONCLUSIONS

The estimated national costs of free incontinence aids accounts for 0.5% of the total costs of Swedish healthcare, including the care and nursing of older and disabled people, and for 0.05% of the gross national product.

Integrated continence services

Nurses have an important role in continence promotion. Deborah Rigby argues that effective continence care should be multidisciplinary and seamless, from the patient's home through primary care and local community services to secondary hospital services.