Costs of managing urinary and faecal incontinence in a sub-acute care facility: a "bottom-up" approach

Change in care hours, cost, and functional independence following continence and assistive technology intervention in an acquired brain injury population

PURPOSE

After acquired brain injury (ABI) dependence on intervention for continence management is common. This preliminary investigation aimed to (i) quantify toileting care hours and costs in a community-based ABI rehabilitation and disability setting, and (ii) measure change in care needs, costs, and functional independence after intervention with assistive technologies (ATs).

METHOD

Pragmatic pre-post intervention pilot study of 14 adults with ABI and toileting disability accessing community-based neurorehabilitation or disability support in Western Australia. Toileting and functional independence were assessed monthly from baseline (T₀) to 3-month follow-up (T₃). Basic and nursing care hours (Northwick Park Dependency Score), cost of care estimates (Northwick Park Care Needs Assessment), functional independence (Functional Independence and Assessment Measure), and cost of consumables were examined pre- and post-intervention with ATs. Multilevel mixed-effects models with bootstrap estimation were conducted.

RESULTS

Cost of consumables significantly declined (AU$69/week), and functional independence significantly improved following intervention (+23.5 points). There was a non-significant reduction in care needs for toileting (4 h/week) and in the cost of toileting care (AU$633/week).

CONCLUSION

Toileting disability substantially impacts care hours and costs. This study provides preliminary evidence that comprehensive continence management is beneficial in reducing costs and supporting people with an ABI to increase their independence.IMPLICATIONS FOR REHABILITATIONA comprehensive continence assessment and management plan reduces the number of care hours, cost of care, and cost of continence products in a neurorehabilitation and disability support sample for people with acquired brain injury (ABI).Assistive technologies for continence management are beneficial in supporting people with ABI to increase independence, and reduce costs.Providing comprehensive continence assessment and management plan reduces reliance on staff for continence care, and improves functional independence.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

A prospective "bottom up" study of the costs of faecal incontinence in ambulatory patients

BACKGROUND AND AIM

The few studies that have examined direct costs of faecal incontinence are limited in that they employed retrospective databases, postal surveys, and focused upon institutionalised patients or post partum women. The aim of the current study was to identify the direct pre-treatment costs of faecal incontinence expended by a range of home dwelling patients and identify relationships between costs and severity of incontinence.

METHODS

Consecutive patients attending an outpatient clinic for treatment of faecal incontinence were interviewed using a questionnaire, modeled on the Dowel Bryant Incontinence Cost Index. The information collected included costs of: (i) basic personal hygiene: pads, laundry, wipes, cleansers; (ii) medication: loperamide, creams and stool bulking agents; and (iii) diagnostic: medical attendance, anorectal physiology, colonoscopy. Costs were broken down into personal expenses, government costs, and costs to health funds. A St Mark's Faecal Incontinence Severity Score was recorded.

RESULTS

A total of 100 consecutive patients consented (15 males, 85 females) mean age 70.8 (SD12) years. Mean St Mark's score was 12 (SD4.5). The median total patient cost was $437.72 AUD (range 0-2807) per annum. Government costs were $537AUD (range 135-1657), and health fund median $0 AUD (0-1628). Incontinence severity correlated with personal expense only median $283.75AUD (range 0-2350). The aged were more incontinent but costs did not increase in relation to age.

CONCLUSION

Faecal incontinence results in a substantial financial burden for both patients and Government. Effective treatments which relieve the financial burden of faecal incontinence, are likely to be economically advantageous into the future for both patients and Government.

Evaluation of the structured bowel management program in inpatient rehabilitation: a prospective study

PURPOSE

The purpose of this study is to evaluate the impact of the structured bowel management program (SBMP) in an inpatient rehabilitation service.

METHOD

Prospective recruitment of consecutive patients admitted to the rehabilitation unit (n = 100). Each patient was assessed for bowel dysfunction on admission and an individualised SBMP was instituted based on the clinical needs. The assessments were at baseline (T1), and discharge from ward (T2) using validated questionnaires. Program evaluation was at 3-month (T3) post-discharge.

RESULTS

Participants were predominantly female (52%), mean age 68 ± 13 years. Almost one-half (43%) had neurological conditions and 41% musculoskeletal problems. At admission, 62% self-reported bowel dysfunction, mainly constipation (82%) and faecal incontinence (FI) (11%). At T2, participants showed significant improvement in bowel habit and stool consistency (Bristol stool chart, p < 0.001); severity of bowel symptoms such as FI (Wexner FI score, p < 0.05); and impact on quality of life (FI Quality of Life (QoL) subscales: "life style" and "coping/behavior", p < 0.05 for both). All functional independent measure "motor" and "cognition" subscales improved significantly (p < 0.01 for all), with moderate to large effect sizes (r = 0.5-0.7). No adverse effects were reported.

CONCLUSIONS

Bowel management should be a priority within rehabilitative services. Evidence-based SBMP can improve bowel symptoms and enhance overall QoL in patients admitted to rehabilitation settings.

IMPLICATIONS FOR REHABILITATION

Bowel dysfunction is common in inpatient rehabilitation settings. A structured bowel management program can improve bowel symptoms and enhance overall QoL in patient. Bowel management should be a priority for patients admitted to rehabilitation settings.

Urinary incontinence in the elderly and in the oldest old: correlation with frailty and mortality

Urinary incontinence (UI) is very common in the elderly and has personal and social implications. Many authors have pointed out the necessity to analyze UI in correlation with the overall quality of aging, to better understand this syndrome and define measures for its prevention and treatment. In the present study, we addressed this problem by analyzing the UI correlation with frailty, which has emerged in the last decade as the geriatric syndrome correlated with individual homeostatic capacity and then as the basis of the age-related physical decline. In addition, the monitoring of our sample for a long period allowed us to estimate the prognostic significance of UI by analyzing the correlation between UI and mortality. The analysis was performed in a large sample that included numerous ultra-nonagenarians, a population segment that is still poorly known for UI and other geriatric parameters. We found a strict correlation between UI and frailty, suggesting that UI is correlated to the homeostatic and physiological decline leading to frailty. In addition, we found that UI is an independent mortality risk factor in ultra-nonagenarians, suggesting that the neurological sensitivity needed to be continent is lost very soon when the frailty associated physiological decline begins. On the whole, our study suggests that UI is a marker of frailty and that UI patients should be monitored and, in case, treated in a timely manner to avoid, or to limit, the effects of frailty such as malnutrition, falls, and the consequent accumulation of disabilities.

Health-related quality of life and economic impact of urinary incontinence due to detrusor overactivity associated with a neurologic condition: a systematic review

BACKGROUND

Patients with neurologic diseases often have neurogenic detrusor overactivity (NDO), which can result in a loss of voluntary bladder control and uncontrollable urinary incontinence (UI).The impact of UI due to NDO on patients' lives has not been well studied. The objective of this review was to assess the health-related quality of life (HRQoL) and economic burden in patients with urgency UI due to NDO in select countries in North America, the European Union, Asia, and Australia.

METHODS

Systematic literature searches and reviews of articles published in English (January 2000 to February 2011) were conducted using MEDLINE®, EMBASE®, and the Cochrane Library. Studies assessing the impact of UI on HRQoL of patients with an underlying neurologic condition of interest (i.e., multiple sclerosis, spinal cord injury, Parkinson's disease, stroke, or spina bifida) were included. Economic studies in urgency UI also were included.

RESULTS

Of 876 citations generated in the initial search, a total of 27 articles were deemed relevant: 16 articles presented HRQoL data and 11 articles presented information on the economic burden of UI. Humanistic studies used a range of HRQoL instruments to measure HRQoL burden, and the economic studies included different cost components to quantify the economic burden, making meaningful comparisons challenging. Despite this heterogeneity, the literature suggests that HRQoL in patients with UI due to NDO is worse than patients with UI in general or those with the same underlying neurologic condition without UI. In addition, urgency UI also results in substantial economic costs.

CONCLUSIONS

Incontinent patients with underlying neurologic conditions have impaired HRQoL as well as substantial economic burden attributable to UI due to NDO. There is a need for urgency UI treatments that improve HRQoL of these patients and alleviate the economic burden of this condition.

Sacral nerve stimulation in the elderly

AIM

Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years.

METHOD

Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively.

RESULTS

Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6).

CONCLUSION

SNS is an effective treatment for faecal incontinence in patients over 65 years.

The effects of a multi-intervention incontinence care program on clinical, economic, and environmental outcomes

PURPOSE

The aim of the study was to assess the effects of a multi-intervention program consisting of use of new absorbent products, a structured skin care regimen, and nursing advice on clinical (incontinence-associated dermatitis [IAD]), economic, and environmental outcomes.

SUBJECTS AND SETTING

The study setting was a nursing home in northern Italy. Sixty-three patients with urinary incontinence participated, including 46 women and 17 men. Their average was 84.0 ± 9.1 years (mean ± SD). Thirty-five participants were entirely dependent on others for activities of daily living, such as bathing or dressing.

DESIGN

Single-group, pre-/postintervention study.

METHODS

The multi-intervention program was implemented in 3 phases: (1) initial assessment of incontinence care (phase 0, baseline measurement), (2) introduction of new absorbent products for incontinence and a structured skin care regimen (phase 1), and (3) introduction of advice provided by continence nurses (phase 2).

RESULTS

All 63 subjects were found to have IAD at baseline.When compared to baseline measurement, the relative risk of IAD following implementation of phase 1 (new absorbent products and structured skin care regimen) was 0.24 (95% confidence interval [CI], 0.16-0.35). Adding advice from continence nurses during this final phase (2) of the study further diminished the relative risk of IAD to 0.15 (95% CI, 0.04-0.59). In addition,the relative risk of IAD was 0.03 (95% CI 0.01-0.12) when the complete intervention (new absorbent products, structured skin care regimen, and continence nurse advice) was compared to baseline measurement. Baseline evaluation revealed that incontinent residents used an average of 5.19 absorbent products,at a mean cost of € 1.79 per day. Following introduction of the multi-intervention program, the mean number of absorbent products consumed per day was 2.02 per incontinent patient, at a mean cost of € 0.97 per day. In addition to these clinical and economic outcomes, implementation of the multi-intervention program reduced the daily production of waste generated by the nursing home from 33 to 11 kg/d.

CONCLUSIONS

Results of this study suggest that a multi-intervention program, including introduction of new absorbent products, a structured skin hygiene program, and advice from continence nurses, reduce the relative risk of IAD, absorbent product use, and generation of waste materials.

Effective management of acute faecal incontinence in hospital: review of continence management systems

This paper reviews the scientific literature regarding current systems available for the management of acute faecal incontinence (FI) in hospital patients. The review searched Medline from 1950 to October 2009 using the adapted search strategy, as devised by the Cochrane Incontinence Group, in order to identify studies relevant to this review, yielding 197 records. Ten studies fitted the inclusion criteria with none of the studies being randomised control trials. Characteristics identified from the studies included: duration of the management devices, cost implications, length of patient stay, contraindications and patient assessment. The management of acute FI in acute settings is a relatively ignored problem, with little available evidence to support a standardised approach to its management. The review highlights the need for early identification of contraindications when FI management systems are being used, particularly in patients administered antithrombotic drugs such as aspirin.

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization

OBJECTIVE

We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI.

STUDY DESIGN

Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data.

RESULTS

FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients.

CONCLUSION

Increased screening of FI is needed.

Obstetric-induced incontinence: A black hole of preventable morbidity

There is a detailed literature comprising clinical and anorectal physiological studies linking faecal incontinence to vaginal delivery. Specific risk factors are high infant birthweight, forceps delivery and prolonged second stage of labour. The onset of symptoms may be delayed for many years. Faecal incontinence occurs in more than 10% of adult females and urinary incontinence in about a third of multiparous women. This places a very large economic burden on the Australian health system. A conservative estimate for overall management of incontinence would be in excess of $A700 million but the actual amount is unknown. Preventative measures for avoiding pelvic floor injuries need to be established, and safe obstetric practice needs to be redefined in the light of current knowledge about incontinence. Outcome measures for safe birthing should not only include infant and maternal mortality and infant morbidity, but should also include the long-term effects of vaginal delivery on the pelvic floor, particularly urinary and faecal incontinence. Several state reports and one federal senate report on safe birthing have been lacking in this area. The safety of birthing centres and home birthing needs to be examined to provide birthing mothers with complete and appropriate information about safety in order that they may consider their options. Appropriate Caesarean section rates for optimal birthing safety are unknown and need to be re-examined. Calls for overall reduction in Caesarean section rates in Australia are inappropriate and cannot be justified until the effects of pelvic floor injury are added to the overall assessment.

A Clinical Nursing Leadership Model for Enhancing Continence Care for Older Adults in a Subacute Inpatient Care Setting

This article describes the application and evaluation of a clinical nursing leadership model to enhance continence care in an inpatient rehabilitation setting for older adults. Multiple strategies were employed to optimize the uptake and sustainability of 3 practice initiatives: (1) establishment of an enhanced role for ward-based nurses to provide clinical support to patients and other staff for the management of incontinence, (2) a new method for nursing assessment and management of bowel elimination, and (3) a framework for improved discharge care of patients with incontinence. Evaluation data indicated a high level of acceptance of the role of the ward-based continence resource nurses, improved assessment and management of bowel elimination, and enhanced discharge care for patients with incontinence. These initiatives were sustainable during a 2-year period after their introduction, despite the gradual withdrawal of the clinical leader.