[Is it possible to optimize the use of economical and professional resources in the diagnosis and treatment of urinary incontinence?]

In 1996, the estimated costs in Sweden, owing to urinary incontinence, increased to $0.5 billion or 2-3% of the health budget. In Denmark, the cost of urinary incontinence is unknown, but probably much the same as that in Sweden. Growth of the elderly population, a rise in the costs of routine incontinence care (mostly pads), and an increasing ability to cure incontinence challenge the existing economic priorities. Economic analysis in this field is sparse. Treatment of urinary incontinence imposes a significant financial burden on society. Based on a review of the literature, the authors recommend increased focus on health economy and preventive possibilities, as well as a change in the diagnostic and treatment algorithm of urinary incontinence.

Annual direct cost of urinary incontinence

OBJECTIVE

To estimate the annual direct cost of urinary incontinence in 1995 US dollars.

METHODS

Epidemiologically based models using diagnostic and treatment algorithms from published clinical practice guidelines and current disease prevalence data were used to estimate direct costs of urinary incontinence. Prevalence and event probability estimates were obtained from literature sources, national data sets, small surveys, and expert opinion. Average national Medicare reimbursement was used to estimate costs, which were determined separately by gender, age group, and type of incontinence. Sensitivity analyses were performed on all variables.

RESULTS

The annual direct cost of urinary incontinence in the United States (in 1995 dollars) was estimated as $16.3 billion, including $12.4 billion (76%) for women and $3.8 billion (24%) for men. Costs for community-dwelling women ($8.6 billion, 69% of costs for women) were greater than for institutionalized women ($3.8 billion, 31%). Costs for women over 65 years of age were more than twice the costs for those under 65 years ($7.6 and $3.6 billion, respectively). The largest cost category was routine care (70% of costs for women), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and evaluations (1%). Costs were most sensitive to changes in incontinence prevalence, routine care costs, and institutionalization rates and costs.

CONCLUSION

Urinary incontinence is a very costly condition, with annual expenditures similar to other chronic diseases in women.

Economics of lower urinary tract symptoms (LUTS) in older people

Urinary incontinence is an area of clinical and social importance to older people and providers of care. This article provides an update on the 'symptom' of urinary incontinence and reviews the concept of lower urinary tract symptoms (LUTS). The challenges facing health services researchers working in this field are also discussed in terms of trying to quantify the size and extent of the underlying problem. Economic issues and work undertaken to evaluate the cost of LUTS are appraised and the common nonsurgical treatments for LUTS are described together with associated conditions and their cost implications. The cost to individuals and society of LUTS is generally underestimated and the importance of reducing its severity (if cure is not achievable) makes clinical and economic sense.

Costs and resources associated with the treatment of overactive bladder using retrospective medical care claims data

The objectives of this study were to determine age- and gender-specific drug treatment prevalence rates for overactive bladder (OAB), and to compare resource use and costs among MCO members receiving drug treatment for OAB. Administrative claims data from seven affiliated health plans were analyzed for 8,661 members with a diagnosis or treatment indicative of OAB during 1998. Resource use and associated costs were analyzed over a four-month follow-up. In 1998, the prevalence of OAB among plan members was 1.1%. Of the patients with OAB, 71% did not receive pharmacotherapy. After multivariate analysis, treatment with tolterodine, oxybutynin, or other OAB treatment did not significantly affect the percent change in total per patient per month (PPPM) costs compared with the group not receiving a pharmacologic agent. Although the adjusted percent change in PPPM pharmacy costs was significantly higher within the tolterodine group, medical and total PPPM costs were not.

Economic costs of urinary incontinence in community-dwelling Australian women

OBJECTIVE

To estimate the economic cost of urinary incontinence in community-dwelling Australian women aged 18 years and over for the year 1998.

DESIGN

Extrapolation of data from studies of women with incontinence to the Australian population of women aged 18 years and over in 1998.

MAIN OUTCOME MEASURES

Estimated prevalence of urinary incontinence in 1998, and estimated cost in Australian dollars of resource use and personal costs related to management of incontinence.

RESULTS

An estimated 1835628 community-dwelling women over the age of 18 years had urinary incontinence in 1998. The total annual cost of this urinary incontinence is estimated at $710.44 million, or $387 per incontinent woman, comprising $338.47 million in treatment costs and $371.97 million in personal costs. An estimated 60% of women with incontinence in 1998 were aged 40 years or over. Assuming the prevalence of incontinence remains constant and, allowing for inflation, we project that the total annual cost in 20 years' time will be $1267.85 million, 93% ($1.18 billion) of which will constitute costs associated with women aged over 40 years.

CONCLUSIONS

Urinary incontinence imposes a considerable drain on Australian healthcare resources. More research is needed to understand the magnitude of the problem and potential gains from continence promotion.

The management and prevention of incontinence dermatitis

Incontinence dermatitis (ID) is rising in incidence along with the increasing elderly population. Its management must therefore take on a greater level of importance. The focus of care must be on finding the causes of incontinence; in many cases it can be cured or the symptoms greatly improved and the development of ID prevented. Where it does occur, effective intervention is necessary. However, a survey into the knowledge base of nurses in caring for skin, carried out by the Royal College of Nursing Continence Care Forum in 1995, showed that care was based on customs and practice rather than evidence. This often causes incorrect treatment to be given, resulting in extra cost for the National Health Service (NHS). This article examines the aetiology and presentation of ID, and supports the need for greater dissemination of guidelines for incontinence professionals and the need for evidence-based literature.

Cost effectiveness and quality of life considerations in the treatment of patients with overactive bladder

This article summarizes the quality of life (QOL), cost of illness, and cost-effectiveness considerations in the treatment and management of patients with overactive bladder (OAB). Most cost studies have focused primarily on urinary incontinence, which is only one possible symptom of OAB. Prevalence rates of urge and mixed incontinence in the United States ranged from 3% to 8% and 5% to 37%, respectively. The highest prevalence was found in geriatric and psychogeriatric populations, where 40% and 90%, respectively, were classified as incontinent. In patients with OAB, all aspects of QOL can be compromised including physical, social, occupational, domestic, and sexual activities, and associated costs can be substantial. Oxybutynin has been the mainstay of pharmacotherapy for OAB but its more frequent side effects (including dry mouth) may deter patients from full compliance with treatment. Tolterodine, a newer antimuscarinic drug, has proven safe and effective in the treatment of OAB, with fewer side effects and better tolerability than existing agents. Cost effectiveness reports are reviewed. Further research on OAB is needed to characterize the disease process and identify risk factors.

The prevalence of urinary incontinence

Urinary incontinence is one of the most important health problems confronting modern society. More than 50 million men and women throughout the world are afflicted. Population studies have demonstrated that approximately 10% of all women suffer from urinary incontinence. Prevalence figures increase with increasing age and in women aged > or = 70 years more than 20% of the female population are affected. Urinary incontinence not only causes considerable personal suffering for the individual afflicted but is also of immense economic importance for the health service. The annual cost of urinary incontinence in Sweden in 1990 accounted for 2% of the total health care costs.

Reduction of costs of disability using neuroprostheses

The lifetime costs associated with spinal cord injury are substantial. Assistive technology that reduces complications, increases independence, or decreases the need for attendant services can provide economic as well as medical or functional benefit. This study describes two approaches for estimating the economic consequences of implanted neuroprostheses utilizing functional electrical stimulation. Life care plan analysis was used to estimate the costs of bladder and bowel care with and without a device restoring bladder and bowel function and to compare these with the costs of implementing the device. For a neuroprosthesis restoring hand grasp, the costs of implementation were compared to the potential savings in attendant care costs that could be achieved by the use of the device. The results indicate that the costs of implementing the bladder and bowel system would be recovered in 5 years, primarily from reduced costs of supplies, medications, and procedures. The costs of the hand grasp neuroprosthesis would be recovered over the lifetime of the user if attendant time was reduced only 2 hours per day and in a shorter time if attendant care was further reduced. Neither analysis includes valuation of the quality of life, which is further enhanced by the neuroprostheses through restoration of greater independence and dignity. Our results demonstrate that implantable neuroprosthetic systems provide good health care value in addition to improved independence for the disabled individual.

Don't ask, don't tell: the incontinence conspiracy

Don't ask, don't tell is the attitude of both patients and doctors toward symptoms of urinary incontinence (UI). This has serious fiscal implications for managed care, because the consequences of not treating the condition increase the annual cost of care by an estimated $3,941 per individual. Behavioral treatments have clinical efficacy of 87 percent, and should be tried first, according to the clinical practice guidelines published by the Agency for Health Care Policy and Research. Attitudes about the condition, and historical and current interventions, are discussed.

Economic considerations in overactive bladder

Many costs are associated with overactive bladder (OAB). They include direct costs, such as those associated with treatment, diagnosis, routine care, and the consequences of the disease; indirect costs of lost wages and productivity; and intangible costs associated with pain, suffering, and decreased quality of life. Quantification of all these costs is essential for establishing the total economic burden of a disease on society. Currently, the total economic burden of OAB is unknown. However, various studies have determined that the economic burden of urinary incontinence, one of the symptoms of OAB, is substantial. It is also important to establish the economic impact of various interventions for OAB. Cost-minimization, cost-outcome, cost-utility, and cost-benefit models can be used for these analyses. The most difficult aspect of evaluating the economic impact of a treatment is estimating the intangible costs.

Findings of a three-year retrospective study to investigate prevalence and incidence of urinary incontinence and overactive bladder in a typical managed care setting

This study was conducted in a large, integrated HMO to determine the prevalence and incidence of urinary incontinence, identify a demographic profile of patients having the UI subgroup condition of overactive bladder, and collect data to create an economic cost of illness description regarding current diagnosis and treatment practices. Using ICD-9 and CPT codes and prescription drug claims data as markers for the disease, subjects were selected for inclusion in the study. Resource use cost data was collected from this cohort over a three-year period and analyzed for total and mean monthly costs.

A pharmacoeconomic evaluation of two new products for the treatment of overactive bladder

The objective of this study is to evaluate the cost effectiveness of two new treatments for overactive bladder: once-daily controlled-release oxybutynin, and twice-daily tolterodine, with a comparison with oxybutynin immediate release. Also estimated are the potential cost savings to a health plan budget resulting from increased utilization of the most cost-effective treatment. The design is a decision-tree model based on clinical trial data and expert panel estimates with a six-month time horizon conducted from a payer perspective. The primary outcome measure used in the analysis was treatment success, with success defined as zero incontinence episodes per week. A secondary outcome measure was the expected number of continent days. As first-line therapy, controlled-release oxybutynin is the most cost-effective treatment as measured by expected cost per success and expected cost per continent days. Controlled-release, once-daily oxybutynin yielded the highest expected success rate and the highest number of expected continent days. The expected cost of treatment with controlled-release oxybutynin was lower than tolterodine and equivalent to immediate-release oxybutynin. Increased utilization of controlled-release oxybutynin results in an estimated saving of $0.007 to $0.026 per member per month for a hypothetical HMO. The model was robust, incorporating all assumptions based on univariate and multivariate sensitivity analysis. Initiating treatment with controlled-release oxybutynin is the most cost-effective approach to treatment for overactive bladder.

The cost of urinary incontinence in Italian women. A cross-sectional study. Gruppo di Studio Incontinenza

OBJECTIVE

To offer cost estimates of urinary incontinence (UI) in the general population based on prospectively collected data.

DESIGN

We analyzed individual costs in a sample of women with UI who were identified in the framework of a cross-sectional study on the prevalence of UI in women aged > 40 years.

SETTING

Six areas in Italy.

INTERVENTION

Home interview.

PATIENTS AND PARTICIPANTS

Women were identified among the patients registered with a network of general practitioners operating in each area using computer-generated random number lists.

RESULTS

A total of 2767 women were identified. Of these, 408 (14.7%) reported UI during the year before the interview and 229 underwent a detailed interview on UI-related costs. On the basis of this information, we estimated the direct costs associated with UI from the perspective of the Italian National Health Service (INHS). The lifetime cost per patient of diagnosis was 80,131 Italian lire (L) (exchange rate: $US1 = L1618). Consultations accounted for only 20% of the diagnostic cost, diagnostic tests for 36% and hospital admissions for diagnostic procedures accounted for 44%. The diagnosis cost estimate seems low, partly because several women did not request either consultations or diagnostic tests (the overall rate per patient was 0.76 for consultations and 0.39 for diagnostic tests). The only appreciable treatment cost, according to the INHS perspective, was for diapers. The annual cost per patient for diapers was L255,519. The prevalence of UI in women aged > 40 years in Italy is estimated in the study at 9.3%. Thus, combining this information with the cost estimates, the annual treatment cost of UI in Italian women aged > 40 years is L351,800 billion, considering diapers and drugs only.

CONCLUSION

This study has estimated the individual cost of UI in the general population. These figures may be useful when designing economic evaluations of UI.

Incontinence and PPS: a new era

Urinary incontinence (UI) is a prevalent and costly problem in nursing homes. Assessing residents with incontinence is necessary to determine the pathophysiologic causes and associated factors that can interfere with self-toileting. Nurses can perform this assessment at the bedside. Guideline tools have been developed to assist nursing home staff through the evaluation of UI and intervention. Treatment techniques, specifically behavioral interventions and toileting assistance programs, can be readily incorporated into nursing practice. Most nursing home staffs can easily implement interventions such as bowel and nighttime voiding management and dietary modifications. Nursing home research has demonstrated the effectiveness of toileting assistance programs; however, very little of this research and documented techniques has been used by nursing home staff. Scheduled toileting and bladder training programs can be successfully implemented in nursing home residents. The key to the success of these programs is identifying residents who should be targeted for each specific program. Staff education remains an ongoing issue, as caregivers must be aware of attitudes and beliefs about the aging process and its impact on the genitourinary system in order to provide effective care. Under the Prospective Payment System, nursing homes need to change business as usual and remain abreast of new innovations and research in different behavioral interventions and continence technology.

Continence assessment in long-term care

Many continence problems are curable. Elderly people living in long-term care should have their continence assessed. Inappropriately managed incontinence can be unnecessarily costly.

Promoting seniors' health--confronting the issue of incontinence

Incontinence is a demoralizing and costly problem that severely affects the quality of seniors' lives. With the aging Canadian population expected to double within the next 15 years, the elderly are at the highest risk of developing incontinence. It is now recognised that incontinence can be successfully managed, and in many cases, resolved. A survey was conducted with seniors experiencing problems with incontinence who were receiving home care services. Results showed that incontinence has a significant impact on their lives. Seniors tend to mistakenly see the problem as an inevitable factor in the aging process; consequently many hesitate to seek information. In addition, they face barriers to receiving incontinence care that includes knowledge and access to services and resources. Nurses have the potential to take a leading role in reducing the problem of incontinence and in reducing the impact on the lives of seniors. In order to realize this potential, nurses need to be more aware of their attitudes towards incontinence and more informed about conservative treatment options. Some thought needs to be given to the role of the general nurse, and the role of a specialized nurse such as the nurse continence advisor.

Use and costs of incontinence pads in female study volunteers. Continence Program for Women Research Group

OBJECTIVES

We examined the use and cost of incontinence pads and the relationship to factors such as age, duration of incontinence, diurnal frequency, incontinence severity indices, urodynamic diagnosis, and quality of life.

SUBJECTS AND SETTING

Three hundred fifteen women with urinary incontinence who volunteered to participate in 1 of 3 incontinence studies (behavioral intervention, estrogen supplementation, or surgery) were analyzed. Subjects were community-dwelling women aged 45 years and older living in 3 cities in the southeastern United States.

METHODS

Pad use was recorded on a daily diary. The type of pads used was reported on the history. Average price of pad types was assessed at local stores and reported in 1995 dollars. Statistical comparisons used nonparametric methods.

MAIN OUTCOME MEASURES

The number of pads used per week and annual cost of pads in 1995 dollars.

RESULTS

Seventy-seven percent of subjects used pads at baseline. Median cost per year for the entire cohort was $46 (interquartile range $3-$138). For pad users, median annual cost was $76 (interquartile range $36-$177), with costs being greater for women with detrusor instability than those with pure genuine stress incontinence (median $135-$138 versus $63). This increased cost was likely associated with the greater use of special incontinence products among women with detrusor instability. For the entire cohort, cost and usage did not differ by urodynamic diagnosis. Cost and pad usage were significantly associated with number of incontinent episodes and quality of life, but not with age, pad weight, or duration of incontinence.

CONCLUSIONS

The majority of incontinent women who sought treatment used absorbent pads at least once per week, with menstrual pads being the most common type of pad. The annual cost of pad usage was not as high as in previous estimates.