Prevalence of leakage and its negative impact on quality of life in people living with a stoma in the UK

Cost-Effectiveness of a Digital Leakage Notification System (Heylo™) for People with Ileostomies or Colostomies in the United Kingdom

BACKGROUND

People with stomas report a substantial negative impact of stomal effluent leaking outside the ostomy baseplate and subsequent complications in their professional and social lives, causing immense worry. However, many patients are not able to recognize leakages in a timely manner. We conducted a cost-effectiveness study to evaluate the impact of a digital leakage notification system (DLNS) to reduce leakages outside the baseplate (LOB) and worry about leakage for people with intestinal stomas from a UK National Health Service and Personal Social Services perspective.

METHODS

A Markov model for ostomy care was used to compare health-related quality of life and costs for adults with ileostomies or colostomies using UK standard of care ostomy products with the DLNS (intervention) or without the DLNS (comparator). The base case model used a 3-year time horizon with 1-week cycles and an annual 3.5% discounting of utilities and costs. Patients in all health states experience LOB events and/or worry about leakage as events associated with one-time utility decrements and costs of additional healthcare provider visits and ostomy product use. Probabilities of LOB (DLNS, 46.5%; comparator, 78.6%) and worry about leakage (DLNS, 39.1%; comparator, 78.6%) were based on clinical trial results. Peristomal skin complications were included in the model with the same probabilities of occurrence in the intervention and comparator arms. Sensitivity and scenario analyses were performed to test the robustness of the base case model assumptions.

RESULTS

In the base case analysis, the DLNS arm had 49.81 fewer LOB events per person than the comparator arm, resulting in 0.309 incremental quality-adjusted life-years (QALYs) and cost savings of British Pound Sterling (GBP) £1703 per person over 3 years (2023/2024 costing year). The DLNS arm had 56.98 fewer worry about leakage events per person, resulting in cost savings of £403 per person. Total costs and QALYs were £18,600 and 1.818 for the intervention arm, respectively, and £18,566 and 1.509 for the comparator arm. Overall, the DLNS provided 0.309 incremental QALYs at an incremental cost of £34 versus the comparator arm for an incremental cost-effectiveness ratio of £110/QALY gained, well below a willingness-to-pay threshold of £20,000/QALY. Sensitivity analyses showed the DLNS was cost-effective in 97.6% of simulations.

CONCLUSIONS

This analysis suggests that the DLNS added to standard of care ostomy products is a cost-effective intervention to help prevent LOB events and reduce worry about leakage for people with stomas in the UK. Results of the present study suggest that timely awareness of leakage has a positive impact on the health-related quality of life of people with stomas and on the direct costs of stoma management in the UK.

Stoma Care Nurse Consultations Regarding Leakages and Peristomal Skin Complications During the First Year After Ostomy Creation: A Chart Review

In the first year after ostomy creation, affected persons require substantial support to manage potential complications and adjust to their new life situation. This study aimed to describe the number of visits to the stoma care nurse, the occurrence of leakage and peristomal skin complications, and the use of ostomy products to prevent these complications among persons consulting a stoma care nurse during the first year after surgery. A descriptive study was conducted using data from medical charts for 240 adults with ileostomy or colostomy. Persons with an ileostomy were more burdened by leakage and peristomal skin complications and visited the stoma care nurse more often than those with a colostomy. On average, across ostomy types, episodes of leakage and peristomal skin complications each elicited around one additional nurse visit and increased use of supporting ostomy products. Persons undergoing acute surgery, with a high ASA classification, and females experienced more episodes of leakage, peristomal skin complications and nurse visits. A patient-tailored approach based on risk factors, such as surgery type, ASA class and sex, could potentially reduce the occurrence of complications and the associated healthcare resource utilisation, including stoma care nurse visits. High variability in results further underscores the importance of personalised care.

The Prevalence of Leakage, Peristomal Skin Complications and Impact on Quality of Life in the First Year Following Stoma Surgery

Objective: It is well established that having a stoma can negatively impact health-related quality of life (HRQoL), but there is a paucity of research describing the natural history of certain complications associated with living with a stoma, such as leakage and peristomal skin complications (PSCs), and whether these affect QoL within the first year of stoma surgery. The objective of this study was to investigate the pattern of such complications and impact on QoL in individuals who had stoma surgery within the preceding year. Methods: A cross-sectional study was conducted at three hospital sites in the United Kingdom to evaluate the burden of disease in those who had undergone intestinal stoma formation surgery within the preceding year. The study consisted of a one-to-one consultation with a study nurse and the completion of an online questionnaire by the patient (ISRCTN-registry: 23080097). The nurse-led interview directly evaluated peristomal skin health, whilst the online questionnaire evaluated the impact of leakage (using the Ostomy Leak Impact tool), generic mental well-being (by WHO-5) and wider HRQoL (by EQ-5D-5L). Results: A total of 114 individuals with an intestinal stoma completed the evaluations. The participants had a mean age of 55.8 years (range 18-87 years) and 58% were male. Forty-three percent of the participants had experienced leakage of stomal effluent outside the baseplate (e.g., onto clothes) in the preceding two weeks and 85% suffered from PSCs ranging from mild (35%), to moderate (18%), and severe (32%). Leakage and PSCs were associated with lower mental well-being and HRQoL (p < 0.05). Leakage events, HRQoL, mental well-being and peristomal skin health were similar for individuals across different timepoints from the time of surgery within the first year. Conclusions: This study reported a high disease burden in people with a new intestinal stoma. Experiencing frequent leakage incidents and/or living with severe PSCs were associated with reduced HRQoL and mental well-being.

Evaluating the Effect of a Novel Digital Ostomy Device on Leakage Incidents, Quality of Life, Mental Well-Being, and Patient Self-Care: An Interventional, Multicentre Clinical Trial

Background: Most people with a stoma worry about leakage, and a quarter experience leakage of stomal effluent outside the baseplate on a monthly basis. Leakage has additional physical and psychosocial consequences, for instance, peristomal skin complications, feeling unable to cope, and self-isolation. Method: An interventional, single-arm, multi-centre study was undertaken in the United Kingdom to evaluate a novel digital leakage notification system for ostomy care, including a support service (=test product) for 12 weeks in patients with a recent stoma formation (≤9 months). Patients completed questionnaires at baseline and after 4, 6, 8, 10, and 12 weeks, evaluating leakage episodes, Ostomy Leak Impact (tool containing three domains), and patient self-management (by PAM-13). Additionally, mental well-being (by WHO-5) and health-related quality of life (QoL) (by EQ-5D-5L) were assessed. Outcomes between baseline and final evaluation were compared by generalised linear and linear mixed models. Results: 92 patients (ITT population) with a mean age of 49.4 years (range 18-81 years) were recruited. Of these, 80% had an ileostomy, and 53% were female. After 12 weeks of using the test product, a significant decrease in mean episodes of leakage outside the baseplate (1.57 versus 0.93, p < 0.046) was observed. Ostomy Leak Impact scores improved across all three domains (p < 0.001), indicating less embarrassment, increased engagement in social activities, and increased control. Patient self-management also improved significantly (PAM-13 score: ∆6.6, p < 0.001), as did the WHO-5 well-being index (∆8.0, p < 0.001). Lastly, EQ-5D-5L profile scores tended to improve (p = 0.075). Conclusions: A new digital leakage notification system demonstrated strong improvements to patients' stoma self-care, mental well-being, and QoL. Registration number on ClinicalTrials.gov: NCT05135754.

Raising the voice of specialist stoma care nurses: a call for a national strategy in stoma care

Specialist stoma care nurses (SSCNs) are highly educated professionals who play a critical role in the care of people living with a stoma. However, they experience some unique challenges. Currently in the UK, stoma care has no national standards, targets or best practice pathway, resulting in significant variation and an undervalued service. As members of an evidence-based profession, SSCNs need to demonstrate their value. Specialist nurses in cancer care and inflammatory bowel disease are supported by nationally, with pathways, targets and standards of care, as well as career and education frameworks. This system could be used for SSCNs. A national approach is needed to develop an evidence-based best-practice pathway, commissioned and implemented across the UK for all stoma patients and with SSCNs at its heart. SSCNs need to demonstrate their value through data and evidence. Working with Getting it Right First Time, a taskforce aims to review the evidence and establish minimum standards of care for all stoma patients. SSCNs should be co-ordinators and drivers of change at the highest level of national innovation, policy and decision-making. The work of SSCNs should be is recognised and valued because what they do matters.

Quality of life in permanent ostomates - what really matters to them?

PURPOSE

The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their relationship with stoma satisfaction is unclear. This study aimed to identify which aspects of QoL were most associated with stoma satisfaction.

METHODOLOGY

A cross-sectional study of consecutive patients who had an APR for rectal cancer at an Australian tertiary hospital (2012-2021), identified from a prospectively maintained database, was conducted. The Stoma-QoL questionnaire was used. Overall patient satisfaction with stoma function, and whether healthcare advice was sought for stoma dysfunction, were explored. Linear regression assessed the association between individual issues examined in the Stoma-QoL questionnaire and overall patient satisfaction with stoma function.

RESULTS

Overall, 64 patients (62.5% male, mean 68.1 years) participated. Stoma-QoL score was associated with stoma satisfaction (P < 0.05). QoL items impacting satisfaction were: needing to know nearest toilet location (P = 0.04), pouch smell concerns (P = 0.008), needing daytime rest (P = 0.02), clothing limitations (P = 0.02), sexual attractiveness concerns (P < 0.05), embarrassment (P < 0.05), difficulty hiding the pouch (P = 0.02), concerns about being burdensome (P = 0.04) and difficulty with interpersonal interaction (P = 0.03). Only 11 (17.2%) patients sought healthcare advice for stoma dysfunction.

CONCLUSION

While stoma-specific QoL is associated with stoma satisfaction, individual QoL aspects impact differently on satisfaction in permanent colostomy patients. These findings may help identify focus areas for peri-operative counselling for clinicians and stomal therapists, highlight the importance of tailored multidisciplinary care in ostomates and suggests that a stoma type-specific Stoma-QoL questionnaire is required.

Comparison of adjustment to a temporary or permanent ostomy using the OAI-23

AIM

The aim of this work was to compare adjustment between those with a new temporary or permanent ostomy in a cohort of Australian adults.

METHOD

This is a multicentre, longitudinal observational study. Ostomy adjustment was measured using the Ostomy Adjustment Inventory (OAI-23) at six possible time points ending at 9 months postsurgery or at the time of ostomy closure in those with a temporary stoma. The OAI-23 includes four domains: anger, acceptance, anxious preoccupation and social engagement.

RESULTS

Eligibility criteria were met by 1230 patients, with 849 (69%) recruited and consented. Of these, 108 were excluded as their surgery did not result in the formation of an ostomy and a further 41 were excluded due to there being no data on ostomy type (temporary or permanent). This left a study population of 700, of whom 397 had a temporary and 303 a permanent ostomy. Only small differences were observed between the temporary and permanent ostomy groups at most time points within the four OAI-23 domains. There were no statistically significant differences found beyond 2 weeks postdischarge and the differences were of small size. While no difference was found between the groups in the domain of anxious preoccupation, both groups demonstrated an increase in anxious preoccupation over time. Neither group regained their presurgery confidence to attend social engagements.

CONCLUSION

We found only minor differences in adjustment in those with a new temporary ostomy compared with a new permanent ostomy. Both groups demonstrated increasing anxious preoccupation and problems with social engagement. This suggests that access to education, training and support should be equitable between these two groups in clinical practice, and needs to incorporate a focus on psychological as well as physical outcomes.

Stoma care: an update

Each year an estimated 13 500 stoma surgeries are carried out in the UK (Kettle, 2019). Stoma surgery may involve the formation of a colostomy or an ileostomy. The person with a stoma may require help and support from the community nurse. This article aims to update readers on the indications for colostomy and ileostomy surgery and to enable them to support ostomates to reduce the risks of complications.

Development of a leakage impact assessment for patients with a stoma, who may be impacted by leakage

For people living with a stoma leakage is unpredictable. Despite advances in stoma products, leakage can lead to soiling and this, along with worrying about leakage, can significantly affect patients' everyday lives and impact their quality of life. It is also associated with excessive product use and increased healthcare resources. Leakage therefore remains a major unmet need for many people living with a stoma. To address this, Coloplast Ltd in collaboration with the authors and a broader group of stoma care nurses have worked together to develop a first version of the Leakage Impact Assessment. This assessment is intended to identify patients who struggle with leakage and leakage worry, and who might benefit from the reassurance that a new digital leakage notification system, Heylo™, can provide. This article reviews the evidence for leakage and its impact on people living with a stoma and outlines the development process for the assessment.

The economic burden of stomas in the UK: a retrospective observational study of health records and hospital encounters

BACKGROUND

Stomas divert waste from the small intestine (ileostomy), large intestine (colostomy) or ureters (urostomy), and complications are common.

AIMS

This study evaluated healthcare resource utilisation (HCRU) and costs of stomas from a UK perspective.

METHODS

This was a retrospective observational study of adults with new stomas (New Stoma Group) or new/existing stomas and >6 months of follow-up (Established Stoma Group) using health records linked with hospital encounters (January 2009-December 2018). Age- and sex-matched controls were identified for each stoma case (1:50).

FINDINGS

Both the New (n=8533) and Established (n=9397) stoma groups had significantly higher HCRU (all P<0.0001) and associated costs (all P<0.01), driven by inpatient admissions. New Stoma Group: colostomy versus controls, £3227 versus £99 per person; ileostomy, £2576 versus £78 per person; and urostomy, £2850 versus £110 per person (all P<0.0001). Findings were similar in the Established Stoma Group.

CONCLUSION

Stomas are associated with a substantial economic burden in the UK driven by hospital care. (Supplementary data tables can be obtained from the authors.).