Incontinence in women. Don't suffer it

BACKGROUND

Urinary incontinence is a distressing and embarrassing condition suffered by at least 1 in 10 women. Incontinence is not just a disease of the elderly: 40% of women aged 30 to 50 suffer from incontinence and a surprising 11% of young women who have never borne children may also experience it.

OBJECTIVE

Incontinence unlike other chronic diseases can be cured in up to 70% of patients.

DISCUSSION

The cost of incontinence is immense. Studies based on health care costs of urine incontinence in the USA indicate expenses as high as 2% of the national health care budget. Australia spends nearly 1 billion dollars per year on incontinence aids and this represents only a fraction of the total cost of incontinence.

Calculating the direct costs of urinary incontinence: a new test instrument

OBJECTIVES

To develop a universally applicable test instrument to measure the total direct costs of urinary incontinence, including personal costs and treatment costs, i.e. the Dowell-Bryant Incontinence Cost Index (DBICI), and to study the construct validity and test-retest reliability of the instrument.

PATIENTS AND METHODS

In a prospective observational study, 100 consecutive community-dwelling ambulatory women who presented with stress, urge or mixed incontinence were asked to complete the DBICI questionnaire on two occasions, 7 days apart, before any treatment. The construct validity of the DBICI was ascertained by correlation with other standard measures of urinary incontinence severity; (i) a visual analogue scale (VAS) to assess the impact of leakage upon lifestyle; (ii) frequency-volume charts (voids/24 h, leaks/week); (iii) urine loss during a standard 1 h pad test; and (iv) two disease-specific quality of life questionnaires. The test-retest reliability was measured by comparing the two test results and the construct validity of the individual subsets (personal and treatment) of the DBICI similarly assessed.

RESULTS

Ninety-seven women completed the baseline assessment and 84 completed the re-test. The median (interquartile range) total direct incontinence cost (in Au$) was 12. 89 (5.26-22.67) per week, which comprised the median personal costs of 5.61 (1.68-10.36) and the median treatment costs of 4.96 (1.22-13. 37). The total direct incontinence cost was significantly correlated with the severity of urinary leakage on a 1 h pad test (Kendall's rank correlation, P=0.01), with the VAS impact score (P<0.001) and with the number of leaks/week (P=0.005). The correlation between the personal cost subset and other quantitative measures was also highly significant. Test-retest analysis of the personal costs subset revealed that this subset was robust and satisfied the statistical criteria of repeatability.

CONCLUSIONS

The DBICI gives a detailed measure of the direct economic costs of urinary incontinence in ambulatory home-dwelling women, with the construct validity confirmed by the significant correlation with other quantitative measures of incontinence. By substituting local prices into the test format, the index should be useful in other countries. In the current climate of economic rationalization, such an index should be a part of future urinary incontinence research.

Addressing Medicare coverage for biofeedback in the treatment of urinary incontinence

Clinicians use biofeedback as a tool to assist in muscle re-education when treating patients with urinary incontinence. Although the literature on biofeedback suggests its effectiveness, it lacks consensus and data on the frequency and number of biofeedback sessions necessary. Patient selection for pelvic floor muscle exercise with and without biofeedback is also not clearly identified. Medicare carriers in 21 states have written policies that specifically recognize biofeedback in the treatment of urinary incontinence. In states with these policies, problematic issues include failure to recognize the appropriate biofeedback code, number of services recognized, and bundling other services with biofeedback. In states without a written policy, attention needs to focus on developing a local medical review policy. Clinicians can make a difference by understanding the factors hindering the process, including the inadequacy of the literature and confusion over muscle re-education and the role of biofeedback. There is a need to identify a standard that addresses the diversity of clinicians and their opinions. This article reviews urinary incontinence and the role of biofeedback, focusing on Medicare coverage and how clinicians can help develop local carrier policies to supplement the national policy.

[Analysis of subjective effect, acceptance and costs of conservative treatment of prolapse and incontinence in women]

A renaissance of conservative treatment for urinary incontinence and descensus is taking place presently in the German speaking area for pre-surgical improvement of tissue quality as well as for long-term-treatment replacing or postponing surgery. Modern pessaries (shape and material), a more intense and pathophysiological well-founded physiotherapy as well as the support of treatment by electrostimulation and its completion by adequate hormone substitution lead to a successful conservative treatment. "Gesundheitsstrukturreform" (reformatory measures of the German Public Health System), "Fallpauschalen" (flat-rate tariff of treatment by the case) and "Praxisbudgets" (budgets for out-clinic-treatment by the case, also a form of flat-rate tariff) lead to a restriction in prescribing necessary conservative treatment or preventive measures. Assigning the patient to surgical treatment is therefore in large parts favoured (treatment costs are then charged to clinic budgets). On the basis of the presented exemplary cost analysis completed by data on subjective effectiveness, acceptance and evaluation of efforts for patient and doctor we want to show that it is not either method that has to be considered in the treatment but both. Besides we have to treat the patient sequentially-conservative treatment in most cases first, especially in younger women. Conservative treatment thereby offers the possibility to delay or postpone surgery, a very meaningful option offered regarding the relatively poor results of surgery especially in cases of recurrent disease.

Economic costs of urinary incontinence in 1995

Urinary incontinence imposes a significant financial burden on individuals, their families, and healthcare organizations. For individuals 65 years of age and older these costs are substantial, increasing from $8.2 billion (1984 dollars) to $16.4 billion (1993 dollars). Both of these cost-of-illness estimates, however, relied on data and factors that have changed over time. This study updates these cost estimates. The 1995 societal cost of incontinence for individuals aged 65 years and older was $26.3 billion, or $3565 per individual with urinary incontinence. Limitations, implications, and directions for future research are also discussed.

Economic considerations and outcome measurement in urge incontinence

OBJECTIVES

Urge incontinence exacts a physical, psychological, and economic toll on affected individuals. This article examines different approaches to estimate the burden of urge incontinence on patients and discusses how costs and consequences of treatments can be evaluated and compared to other interventions.

METHODS

Willingness-to-pay methodology was used in Sweden to illustrate patients' distress. Incontinence symptoms were compared to willingness-to-pay amounts and to health-related quality of life (QOL) as measured with a generic profile (SF-36) and a preference-based instrument (EuroQol). These measures were also tested using data from a clinical trial in the United States. A single effectiveness measure ("normal days") that would be meaningful to patients, physicians, and payers and could be used in cost-effectiveness analysis was tested in a multinational clinical trial.

RESULTS

Willingness to pay was significantly correlated with the expected health improvement, incontinence symptoms, and income. SF-36 scores were significantly lower than for the general Swedish population and were correlated with the severity of symptoms. Utility values obtained with EuroQol were also correlated with symptoms. Similar results were obtained in the clinical trial. The composite effectiveness measure was able to discriminate between treatment and placebo, despite a high placebo effect.

CONCLUSIONS

Patients with urge incontinence experience a number of different symptoms that affect activities of daily living and QOL. However, for cost-effectiveness analysis these symptoms should be expressed as a single outcome in order to allow for comparison within the same indication and to other diseases. We tested a disease-specific measure for incontinence and several generic measures to be used in cost-effectiveness analysis.

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.

The 'costs' of urinary incontinence

Urinary incontinence is a prevalent and costly health condition. This paper discusses the 'costs' of untreated urinary incontinence. Costs are broadly conceptualised within a framework which includes physical, psychosocial, and economical components. Limited data is available documenting the different costs of incontinence. Further research is needed to better quantify these costs to aid clinicians, payers, and public policy-makers in decision-making related to incontinence management.

Prospective development of a cost-efficient program for the pubovaginal sling

OBJECTIVES

We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care.

METHODS

A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test.

RESULTS

Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program (P < 0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P < 0.0001), operating room charges (11% decrease; P < 0.01), and medications (35% decrease; P < 0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 (P < 0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program.

CONCLUSIONS

With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

The value of clinical examination of the female incontinent patient

The role of different instruments in evaluation of disturbance in the lower urinary tract has been discussed briefly, emphasizing simplicity and the power of the contact between the physician and the patient. A good history based on clear and descriptive language is still the milestone in making the correct diagnosis. Combined with a proper physical examination and simple inexpensive and time-saving clinical examination this may leave only few patients requiring sophisticated multichannel urodynamic equipment before the adequate treatment can be offered. One should bear in mind that the world is facing diminishing medical resources at the same time as there are more and more women seeking help for their incontinence. Therefore the measurements must be cost effective and patient friendly.