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Costs of female urinary incontinence
IMPORTANCE OF INCONTINENCE
Costs of female urinary incontinence Eduardo Cortes Con Kelleher
Urinary incontinence is a common condition affecting between 10% and 30% of the adult population. The costs of treatment of urinary incontinence are substantial and are likely to escalate significantly in the next decade. The prevalence of urinary incontinence increases with age; for non-institutionalized people over 60 years of age, the prevalence ranges from 15% to 35%, with women having twice the prevalence of men.1 Survey data from caregivers of the elderly show that approximately 53% of the housebound elderly are incontinent of urine.2 As the prevalence of urinary incontinence has increased dramatically over the past few decades, so has the cost of managing it. Factors such as expectation of a longer and better quality of life, better accessibility of healthcare and better awareness of the problem of incontinence have contributed to the cost escalation. In 2001, the estimated total cost of managing urinary incontinence in the USA was $16.3 billion ($12.4 billion for women), representing a 60% increase since 1990.3 The healthcare costs of community and nursing homes contributed $11.2 and $5.2 billion respectively towards this estimate ($8.6 and $3.8 billion for women). The costs of treating urinary incontinence are greater than for many common medical conditions (Figure 1).
How are treatment costs estimated? The financial burden of treating urinary incontinence includes both direct and indirect costs. Direct costs Direct costs can be divided into diagnostic, treatment, routine care and consequence costs (Figure 2). Most patients will be treated as out-patients in the community, with only a small proportion requiring hospitalization. Estimates of hospitalization figures from 2002–3 in England (Hospital Episode Statistics, Department of Health), showed that there were 5838 hospital admissions for unspecified urinary incontinence, 70% of which were for women. The mean hospital stay was 6.1 days and 10% of admissions were emergencies. As the majority of patients with urinary incontinence
Eduardo Cortes is a Specialist Registrar in Obstetrics and Gynaecology at Guy’s and St Thomas’ NHS Foundation Trust, UK. Con Kelleher is a Consultant in Obstetrics and Gynaecology and Leading Consultant in Urogynaecology at Guy’s and St Thomas’ NHS Foundation Trust, UK.
WOMEN’S HEALTH MEDICINE 2:6
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© 2005 The Medicine Publishing Company Ltd
IMPORTANCE OF INCONTINENCE
Indirect costs Indirect costs of urinary incontinence, including costs such as those incurred from loss of productivity in the workplace, are more difficult to estimate. Poor work performance may be due to sleep deprivation resulting from nocturia, leading to fatigue at work, loss of concentration and interference with job performance. Urinary incontinence is also associated with absence from work due to care visits, depression, embarrassment or repeated change of containment devices. To date, no studies have objectively quantified the fiscal impact of this loss of productivity.
Comparison of direct costs of illness in the USA in 20013 Gynaecological and breast cancer
11.1
Osteoporosis
13.8
Pneumonia and influenza
15.8
Urinary incontinence
16.3
Arthritis
Cost-effectiveness of treatment
17.6 0
5
10
15
Unfortunately, healthcare funding is finite and cost constraints limit, to some extent, the care that we are able to provide for patients. Not only is it important to decide on the priorities for healthcare expenditure but, once the priorities are established, to assess which treatments offer the best value. A medical intervention that yields better outcomes for less cost than another is considered dominant, and different epidemiological models are available to analyse cost-effectiveness. It should be remembered that from
20
US$billion 1
are managed as out-patients, clearly the calculation of costs on the basis of hospitalization significantly underestimates total costs. Treatment of overactive bladder is a major contributor to the overall cost of managing urinary incontinence in the community. In a study conducted in the USA, the direct costs of overactive bladder management (estimated population prevalence 16.9%) were estimated at $9.14 billion in the community and $4.4 billion in nursing homes.4 These costs included personal care, drug treatment and other related costs.
Cost comparions Example 1: tension-free vaginal tape vs. Burch colposuspension Tension-free vaginal tape (see pages 36–37) is a relatively new, minimally invasive mid-urethral tape procedure for the primary surgical treatment of urodynamic stress incontinence. The procedure can be performed as a day-case or may require an overnight admission. It has significantly reduced morbidity and in-patient stay compared to older surgical procedures such as the Burch colposuspension. Both surgical procedures have similar symptom resolution rates at 5-year follow-up and therefore, where both procedures are interchangeable, it would be logical to prefer the least invasive and less costly.
The costs of urinary incontinence Diagnostic costs • Laboratory tests • Physicians’ consultations • Urodynamic evaluations Treatment costs • Medication • Surgery • Behavioural therapy • Devices
Example 2: choice of antimuscarinic therapy for overactive bladder A major obstacle to successful treatment of overactive bladder with antimuscarinic medications is the side effects experienced by users. Poor tolerability of medication leads to reduced persistency and, in some cases, discontinuation of treatment. In a study of 246 women taking generic immediate-release oxybutinin, only 18% remained on therapy 6 months after the initial diagnosis and prescription of treatment. In many cases this was due to intolerable side effects.6 Newer antimuscarinic agents (e.g. tolterodine, solifenacin) have improved tolerability, persistency and therefore efficacy, but are more expensive. Ultimately, it may be more effective to commence patients on a more expensive drug therapy, which they are likely to continue to use, than cheaper medication, which they are likely to discontinue. Effective treatment of overactive bladder can improve the quality of life of patients, improve their productivity, reduce the risk of falls and fractures, skin infections and urinary tract infections. The cost of treating these comorbidities alone is significant.
Routine care costs • Incontinence pads • Laundry • Odour control products • Nursing time • Disposable bed pads • Indwelling urinary catheters Consequence costs • Treatment of falls • Treatment of skin infections • Treatment of urinary infection • Lengthened hospital stay • Depression 2
WOMEN’S HEALTH MEDICINE 2:6
3
4
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
the perspective of patients, healthcare providers and society, the cost-effectiveness of the same treatments may be different. The Quality Adjusted Life Year (QALY) is a commonly used measure of the value of health outcomes. Since health is a function of both length and quality of life, the QALY was developed to integrate both of these into a single measure. The QALY calculation is simple: the change in utility value (a measure grading life from ‘death = 0’ to ‘perfect health = 1’) induced by a treatment, is multiplied by the duration of the treatment effect, to provide the number of QALYs gained. QALYs can then be incorporated with medical costs to arrive at a final common denominator of cost/QALY. 5 Financial decision-making in clinical practice is often far simpler and does not involve complicated health economics. The examples in Figure 3 reflect how estimation of cost-effectiveness might affect decision-making in a hospital or out-patient setting. Tension-free vaginal tape vs. Burch colposuspension is an obvious cost comparison, but costing the choice of antimuscarinic therapy for overactive bladder involves more subtle analysis.
Future costs There has been a persistent age-related increase in the costs of urinary incontinence over the past years and evidence suggests that these costs are likely to escalate in the future. Data from the US Census Bureau estimate that by the year 2030 there will be an increase of 1 million consultations for pelvic floor disorders, with an increase of 11% in women between 30 and 59 years and 81% among those from 60 to 89 years old. The costs of both containment and treatment of urinary incontinence are therefore likely to rise in coming years and economic assessment of the value of individual treatment strategies will play an increasingly important part in our ability to treat and improve the quality of life of our patients.
REFERENCES 1 Thomas P A, Plymat K R, Blannin J, Meade T W. Prevalence of urinary incontinence. Br Med J 1980; 281: 1243–5. 2 Noelker L S. Incontinence in elderly cared for by family. Gerontologist 1987; 27: 194–200. 3 Wilson L, Brown J S, Shin G P, Luc K O, Subak L L. Annual direct costs of urinary incontinence. Obstet Gynecol 2001; 98(3): 398–406. 4 Hu T, Wagner T, Bentkover J, Leblanc K, Piacentini A, Stewart W, Corey R, Zhou Z, Hunt T. Economic costs of overactive bladder. Presented at the 2nd International Consultation on Incontinence, 1–3 July, 2001, Paris. 5 Prieto L, Sacristán, J A. Problems and solutions in calculating quality-adjusted life years (QALYs). Health Qual Life Outcomes 2003; 1: 80. 6 Kelleher C J, Cardozo L, Khullar V, Salvatore S. A medium-term analysis of the subjective efficacy of treatment for women with detrusor instability and low bladder compliance. Br J Obstet Gynaecol 1997; 104: 988–93.
WOMEN’S HEALTH MEDICINE 2:6
5
© 2005 The Medicine Publishing Company Ltd
Costs of female urinary incontinence Eduardo Cortes Con Kelleher
Urinary incontinence is a common condition affecting between 10% and 30% of the adult population. The costs of treatment of urinary incontinence are substantial and are likely to escalate significantly in the next decade. The prevalence of urinary incontinence increases with age; for non-institutionalized people over 60 years of age, the prevalence ranges from 15% to 35%, with women having twice the prevalence of men.1 Survey data from caregivers of the elderly show that approximately 53% of the housebound elderly are incontinent of urine.2 As the prevalence of urinary incontinence has increased dramatically over the past few decades, so has the cost of managing it. Factors such as expectation of a longer and better quality of life, better accessibility of healthcare and better awareness of the problem of incontinence have contributed to the cost escalation. In 2001, the estimated total cost of managing urinary incontinence in the USA was $16.3 billion ($12.4 billion for women), representing a 60% increase since 1990.3 The healthcare costs of community and nursing homes contributed $11.2 and $5.2 billion respectively towards this estimate ($8.6 and $3.8 billion for women). The costs of treating urinary incontinence are greater than for many common medical conditions (Figure 1).
How are treatment costs estimated? The financial burden of treating urinary incontinence includes both direct and indirect costs. Direct costs Direct costs can be divided into diagnostic, treatment, routine care and consequence costs (Figure 2). Most patients will be treated as out-patients in the community, with only a small proportion requiring hospitalization. Estimates of hospitalization figures from 2002–3 in England (Hospital Episode Statistics, Department of Health), showed that there were 5838 hospital admissions for unspecified urinary incontinence, 70% of which were for women. The mean hospital stay was 6.1 days and 10% of admissions were emergencies. As the majority of patients with urinary incontinence
Eduardo Cortes is a Specialist Registrar in Obstetrics and Gynaecology at Guy’s and St Thomas’ NHS Foundation Trust, UK. Con Kelleher is a Consultant in Obstetrics and Gynaecology and Leading Consultant in Urogynaecology at Guy’s and St Thomas’ NHS Foundation Trust, UK.
WOMEN’S HEALTH MEDICINE 2:6
3
© 2005 The Medicine Publishing Company Ltd
IMPORTANCE OF INCONTINENCE
Indirect costs Indirect costs of urinary incontinence, including costs such as those incurred from loss of productivity in the workplace, are more difficult to estimate. Poor work performance may be due to sleep deprivation resulting from nocturia, leading to fatigue at work, loss of concentration and interference with job performance. Urinary incontinence is also associated with absence from work due to care visits, depression, embarrassment or repeated change of containment devices. To date, no studies have objectively quantified the fiscal impact of this loss of productivity.
Comparison of direct costs of illness in the USA in 20013 Gynaecological and breast cancer
11.1
Osteoporosis
13.8
Pneumonia and influenza
15.8
Urinary incontinence
16.3
Arthritis
Cost-effectiveness of treatment
17.6 0
5
10
15
Unfortunately, healthcare funding is finite and cost constraints limit, to some extent, the care that we are able to provide for patients. Not only is it important to decide on the priorities for healthcare expenditure but, once the priorities are established, to assess which treatments offer the best value. A medical intervention that yields better outcomes for less cost than another is considered dominant, and different epidemiological models are available to analyse cost-effectiveness. It should be remembered that from
20
US$billion 1
are managed as out-patients, clearly the calculation of costs on the basis of hospitalization significantly underestimates total costs. Treatment of overactive bladder is a major contributor to the overall cost of managing urinary incontinence in the community. In a study conducted in the USA, the direct costs of overactive bladder management (estimated population prevalence 16.9%) were estimated at $9.14 billion in the community and $4.4 billion in nursing homes.4 These costs included personal care, drug treatment and other related costs.
Cost comparions Example 1: tension-free vaginal tape vs. Burch colposuspension Tension-free vaginal tape (see pages 36–37) is a relatively new, minimally invasive mid-urethral tape procedure for the primary surgical treatment of urodynamic stress incontinence. The procedure can be performed as a day-case or may require an overnight admission. It has significantly reduced morbidity and in-patient stay compared to older surgical procedures such as the Burch colposuspension. Both surgical procedures have similar symptom resolution rates at 5-year follow-up and therefore, where both procedures are interchangeable, it would be logical to prefer the least invasive and less costly.
The costs of urinary incontinence Diagnostic costs • Laboratory tests • Physicians’ consultations • Urodynamic evaluations Treatment costs • Medication • Surgery • Behavioural therapy • Devices
Example 2: choice of antimuscarinic therapy for overactive bladder A major obstacle to successful treatment of overactive bladder with antimuscarinic medications is the side effects experienced by users. Poor tolerability of medication leads to reduced persistency and, in some cases, discontinuation of treatment. In a study of 246 women taking generic immediate-release oxybutinin, only 18% remained on therapy 6 months after the initial diagnosis and prescription of treatment. In many cases this was due to intolerable side effects.6 Newer antimuscarinic agents (e.g. tolterodine, solifenacin) have improved tolerability, persistency and therefore efficacy, but are more expensive. Ultimately, it may be more effective to commence patients on a more expensive drug therapy, which they are likely to continue to use, than cheaper medication, which they are likely to discontinue. Effective treatment of overactive bladder can improve the quality of life of patients, improve their productivity, reduce the risk of falls and fractures, skin infections and urinary tract infections. The cost of treating these comorbidities alone is significant.
Routine care costs • Incontinence pads • Laundry • Odour control products • Nursing time • Disposable bed pads • Indwelling urinary catheters Consequence costs • Treatment of falls • Treatment of skin infections • Treatment of urinary infection • Lengthened hospital stay • Depression 2
WOMEN’S HEALTH MEDICINE 2:6
3
4
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
the perspective of patients, healthcare providers and society, the cost-effectiveness of the same treatments may be different. The Quality Adjusted Life Year (QALY) is a commonly used measure of the value of health outcomes. Since health is a function of both length and quality of life, the QALY was developed to integrate both of these into a single measure. The QALY calculation is simple: the change in utility value (a measure grading life from ‘death = 0’ to ‘perfect health = 1’) induced by a treatment, is multiplied by the duration of the treatment effect, to provide the number of QALYs gained. QALYs can then be incorporated with medical costs to arrive at a final common denominator of cost/QALY. 5 Financial decision-making in clinical practice is often far simpler and does not involve complicated health economics. The examples in Figure 3 reflect how estimation of cost-effectiveness might affect decision-making in a hospital or out-patient setting. Tension-free vaginal tape vs. Burch colposuspension is an obvious cost comparison, but costing the choice of antimuscarinic therapy for overactive bladder involves more subtle analysis.
Future costs There has been a persistent age-related increase in the costs of urinary incontinence over the past years and evidence suggests that these costs are likely to escalate in the future. Data from the US Census Bureau estimate that by the year 2030 there will be an increase of 1 million consultations for pelvic floor disorders, with an increase of 11% in women between 30 and 59 years and 81% among those from 60 to 89 years old. The costs of both containment and treatment of urinary incontinence are therefore likely to rise in coming years and economic assessment of the value of individual treatment strategies will play an increasingly important part in our ability to treat and improve the quality of life of our patients.
REFERENCES 1 Thomas P A, Plymat K R, Blannin J, Meade T W. Prevalence of urinary incontinence. Br Med J 1980; 281: 1243–5. 2 Noelker L S. Incontinence in elderly cared for by family. Gerontologist 1987; 27: 194–200. 3 Wilson L, Brown J S, Shin G P, Luc K O, Subak L L. Annual direct costs of urinary incontinence. Obstet Gynecol 2001; 98(3): 398–406. 4 Hu T, Wagner T, Bentkover J, Leblanc K, Piacentini A, Stewart W, Corey R, Zhou Z, Hunt T. Economic costs of overactive bladder. Presented at the 2nd International Consultation on Incontinence, 1–3 July, 2001, Paris. 5 Prieto L, Sacristán, J A. Problems and solutions in calculating quality-adjusted life years (QALYs). Health Qual Life Outcomes 2003; 1: 80. 6 Kelleher C J, Cardozo L, Khullar V, Salvatore S. A medium-term analysis of the subjective efficacy of treatment for women with detrusor instability and low bladder compliance. Br J Obstet Gynaecol 1997; 104: 988–93.
WOMEN’S HEALTH MEDICINE 2:6
5
© 2005 The Medicine Publishing Company Ltd