Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial

BACKGROUND

Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking.

OBJECTIVE

Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed.

STUDY DESIGN

This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile.

RESULTS

The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years.

CONCLUSION

Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Evaluating the impact of a 'virtual clinic' on patient experience, personal and provider costs of care in urinary incontinence: A randomised controlled trial

OBJECTIVE

To evaluate the impact of using a 'virtual clinic' on patient experience and cost in the care of women with urinary incontinence.

MATERIALS AND METHODS

Women, aged > 18 years referred to a urogynaecology unit were randomised to either (1) A Standard Clinic or (2) A Virtual Clinic. Both groups completed a validated, web-based interactive, patient-reported outome measure (ePAQ-Pelvic Floor), in advance of their appointment followed by either a telephone consultation (Virtual Clinic) or face-to-face consultation (Standard Care). The primary outcome was the mean 'short-term outcome scale' score on the Patient Experience Questionnaire (PEQ). Secondary Outcome Measures included the other domains of the PEQ (Communications, Emotions and Barriers), Client Satisfaction Questionnaire (CSQ), Short-Form 12 (SF-12), personal, societal and NHS costs.

RESULTS

195 women were randomised: 98 received the intervention and 97 received standard care. The primary outcome showed a non-significant difference between the two study arms. No significant differences were also observed on the CSQ and SF-12. However, the intervention group showed significantly higher PEQ domain scores for Communications, Emotions and Barriers (including following adjustment for age and parity). Whilst standard care was overall more cost-effective, this was minimal (£38.04). The virtual clinic also significantly reduced consultation time (10.94 minutes, compared with a mean duration of 25.9 minutes respectively) and consultation costs compared to usual care (£31.75 versus £72.17 respectively), thus presenting potential cost-savings in out-patient management.

CONCLUSIONS

The virtual clinical had no impact on the short-term dimension of the PEQ and overall was not as cost-effective as standard care, due to greater clinic re-attendances in this group. In the virtual clinic group, consultation times were briefer, communication experience was enhanced and personal costs lower. For medical conditions of a sensitive or intimate nature, a virtual clinic has potential to support patients to communicate with health professionals about their condition.

[Incidence of incontinence after radical prostatectomy using claims-based data]

OBJECTIVE

To determine the effect of radical prostatectomy (RP) hospital volume on the probability of post-RP incontinence.

DESIGN

Retrospective research based on claims-based data of health insurers.

METHOD

For every patient with RP the probability of incontinence was determined, based on the definition of claims of one or more incontinence pads per day. Casemix corrections were made based on indicators available in claims-data: age, lymph node dissection, and radiotherapy. No casemix corrections could be made for tumour stage and surgical technique.

RESULTS

A total of 1590 patients were included in this study; for 26.0% of these patients, an average of one or more incontinence pads per day were claimed for. A significant relation between the volume of RP per hospital and the claims of incontinence material was observed. The probability of incontinence was significantly lower in hospitals with a volume of more than 100 RP patients per year when compared to hospitals with less than 100 RP patients per year.

CONCLUSION

The probability of post-RP incontinence decreases as hospitals conduct more RP procedures. The casemix factors included in the analysis only had a limited impact on this observation.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Objective

To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence.

Design

Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources.

Methods

Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken.

Results

Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties.

Conclusions

Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

[Economic importance of postoperative urinary incontinence]

In the 22,160 patients treated in Germany for prostate cancer by prostatectomy, the costs for direct and indirect sequelae as the result of postoperative urinary incontinence are estimated to be 71.8 million €. This greatly exceeds the costs of 69.8 million € for the operation itself. This additional economic burden can, however, be decisively influenced by using a surgical technique that preserves the integrity of the urethral sphincter.

Cost-effectiveness of a behavioral intervention for persistent urinary incontinence in prostate cancer patients

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of a behavioral intervention for urinary incontinence of prostate cancer patients. Study subjects were either participating in or eligible but declined (i.e., nonparticipating) the active intervention study.

METHODS

The intervention-participating subjects were randomized into three groups, including two intervention groups (support and telephone groups) and a usual care reference group. Intervention-nonparticipating subjects were concurrently enrolled. Intervention effectiveness was assessed on the EQ-5D measure. The costs included direct healthcare cost from medical billing data, patient out-of-pocket expense, caregiver expense, patient loss-of-work cost, and intervention cost. We calculated incremental cost-effectiveness ratios (ICERs) from societal, provider, and patient perspectives.

RESULTS

Two hundred and sixty-seven intervention-participating and 69 intervention-nonparticipating post-cancer treatment patients were included. The support and telephone groups, but not the usual care group, had significantly higher EQ-5D index scores (0.054, p = 0.033, and 0.057, p = 0.026, respectively) than the intervention-nonparticipating group at month 6. Within 6 months, intervention cost per subject was $252 and $484, respectively, for providers, and $564 and $203, respectively, for the support and phone group subjects. The final ICERs were $16,759 per quality-adjusted life year (QALY) and $12,561/QALY for support and telephone groups, compared with those of the intervention-nonparticipating group. These ICERs are much smaller than $50,000/QALY, the consensus threshold to determine cost-effectiveness for society.

CONCLUSIONS

The study interventions are cost-effective in consideration of eligible patients who declined the interventions. The interventions can provide meaningful outcome improvement on urinary continence at a low cost. This evidence provides critical information for future health policy decision-making of healthcare providers and payers.

Cost-effectiveness analysis of onabotulinumtoxinA (BOTOX(®)) for the management of urinary incontinence in adults with neurogenic detrusor overactivity: a UK perspective

OBJECTIVES

To evaluate the cost effectiveness of onabotulinumtoxinA (BOTOX(®), 200 units [200 U]) for the management of urinary incontinence (UI) in adults with neurogenic detrusor overactivity (NDO) due to subcervical spinal cord injury or multiple sclerosis that is not adequately managed with anticholinergic drugs (ACHDs).

PERSPECTIVE

UK National Health Service (NHS) perspective.

METHODS

A Markov state-transition model was developed, which compared onabotulinumtoxinA + best supportive care (BSC) with BSC alone (comprising behavioural therapy and pads, alone or in combination with clean intermittent catheterization and possibly with ACHDs). Non-responders were eligible for invasive procedures. Health states were defined according to the reduction in UI episodes. Efficacy data and estimates of resource utilization were pooled from 468 patients on onabotulinumtoxinA in two phase III clinical trials. Drug costs (2013) and administration costs (NHS Reference Costs 2011-2012) were obtained from published sources. The time horizon of the model was 5 years, and costs and benefits were discounted at 3.5%. Scenario, one-way and probabilistic sensitivity analyses (PSAs) were conducted to explore uncertainties around the assumptions.

RESULTS

In the base case, treatment with onabotulinumtoxinA + BSC over 5 years was associated with an increase in costs of £1,689 and an increase in quality-adjusted life-years (QALYs) of 0.4, compared with BSC alone, resulting in an incremental cost-effectiveness ratio of £3,850 per QALY gained. Sensitivity analyses showed that utility values had the greatest influence on model results. PSA suggests that onabotulinumtoxinA + BSC had a 100 % probability of being cost effective at a willingness to pay of <£20,000.

CONCLUSION

For adult patients with NDO who are not adequately managed with ACHDs, onabotulinumtoxinA + BSC appears to be a cost-effective use of resources in the UK NHS.

Cost-effectiveness analysis of solifenacin versus oxybutynin immediate-release in the treatment of patients with overactive bladder in the United Kingdom

OBJECTIVE

To carry out a cost-utility analysis comparing initial treatment with solifenacin 5 mg/day vs oxybutynin immediate-release (IR) 15 mg/day for the treatment of patients with overactive bladder (OAB) from the perspective of the U.K. National Health Service (NHS).

METHODS

A Markov model with six health states was developed to follow a cohort of OAB patients treated with either solifenacin or oxybutynin during a 1-year period. Costs and utilities were accumulated as patients transited through the health states in the model and a drop-out state. Some of the solifenacin patients were titrated from 5 mg to 10 mg/day at 8 weeks. A proportion of drop-out patients were assumed to continue treatment with tolterodine ER. Utility values were obtained from a Swedish study and pad use was based on a multinational clinical trial. Adherence rates for individual treatments were derived from a U.K. database study. For pad use and utility values, the drop-out state was split between those patients who were no longer receiving treatment and those on second-line therapy. Patients on second-line therapy who drop-out were referred for a specialist visit. Results were expressed in terms of incremental cost-utility ratios.

RESULTS

Total annual costs for solifenacin and oxybutynin were £504.30 and £364.19, respectively. First-line drug use represents 49% and 4% of costs and pad use represent 23% and 40% of costs for solifenacin and oxybutynin, respectively. Differences between cumulative utilities were small but were greater for solifenacin (0.7020 vs. 0.6907). The baseline incremental cost-effectiveness ratio was £12,309/QALY.

CONCLUSION

Under the baseline assumptions, solifenacin would appear to be cost-effective with an incremental cost-utility of less than £20,000/QALY. However, small differences in utility between the alternatives and the large number of drop-outs means that the results are sensitive to small adjustments in the values of utilities assigned to the drop-out state.

A randomized controlled trial to assess the efficacy and cost-effectiveness of urinary catheters with silver alloy coating in spinal cord injured patients: trial protocol

BACKGROUND

Patients with non-acute spinal cord injury that carry indwelling urinary catheters have an increased risk of urinary tract infection (UTIs). Antiseptic Silver Alloy-Coated Silicone Urinary Catheters seems to be a promising intervention to reduce UTIs; however, actual evidence cannot be extrapolated to spinal cord injured patients. The aim of this trial is to make a comparison between the use of antiseptic silver alloy-coated silicone urinary catheters and the use of standard urinary catheters in spinal cord injured patients to prevent UTIs.

METHODS/DESIGN

The study will consist in an open, randomized, multicentre, and parallel clinical trial with blinded assessment. The study will include 742 spinal cord injured patients who require at least seven days of urethral catheterization as a method of bladder voiding. Participants will be online centrally randomized and allocated to one of the two study arms (silver alloy-coated or standard catheters). Catheters will be used for a maximum period of 30 days or removed earlier if the clinician considers it necessary. The main outcome will be the incidence of UTIs by the time of catheter removal or at day 30 after catheterization, the event that occurs first. Intention-to-treat analysis will be performed, as well as a primary analysis of all patients.

DISCUSSION

The aim of this study is to assess whether silver alloy-coated silicone urinary catheters improve ITUs in spinal cord injured patients. ESCALE is intended to be the first study to evaluate the efficacy of the silver alloy-coated catheters in spinal cord injured patients.

TRIAL REGISTRATION

NCT01803919.

Violence against women with chronic maternal disabilities in rural Bangladesh

This study explored violence against women with chronic maternal disabilities in rural Bangladesh. During November 2006-July 2008, in-depth interviews were conducted with 17 rural Bangladeshi women suffering from uterine prolapse, stress incontinence, or fistula. Results of interviews showed that exposure to emotional abuse was almost universal, and most women were sexually abused. The common triggers for violence were the inability of the woman to perform household chores and to satisfy her husband's sexual demands. Misconceptions relating to the causes of these disabilities and the inability of the affected women to fulfill gender role expectations fostered stigma. Emotional and sexual violence increased their vulnerability, highlighting the lack of life options outside marriage and silencing most of them into accepting the violence. Initiatives need to be developed to address misperceptions regarding the causes of such disabilities and, in the long-term, create economic opportunities for reducing the dependence of women on marriage and men and transform the society to overcome rigid gender norms.

Urinary incontinence in adults: nurses' beliefs, education and role in continence promotion. A narrative review

INTRODUCTION

Urinary incontinence (UI) has a high prevalence worldwide, in both genders; the available data suggest that the number of incontinent people will dramatically increase in the next few years. The costs generated by UI are similar to those induced by HIV and breast cancer. We aimed to investigate nurses' beliefs, knowledge and educational situation in the field of urinary continence.

METHODS

We performed a narrative review of literature, by searching qualitative and qualitative studies (2006-11) in PubMed, CINAHL and the Cochrane Library. Papers investigating pharmacological and/or surgical intervention were excluded. Only studies referred to adults have been taken into consideration.

RESULTS

Prevalence ranges from 25 to 45% in women; in men, post-prostatectomy UI occurs in a median of 10-15% of the total cases. Benign prostatic hyperplasia, which affects 50% of men aged 50 to 60, is often associated with urge incontinence. The yearly individual expense for pads in Italy has been estimated to be as high as 913 euros in 2004. People often do not know about the possible solutions to UI; nurses seem to lack education in continence promotion, notwithstanding the proven effectiveness of the conservative interventions they could perform in autonomy. In Italy, few academic programs offer nursing education in this field.

CONCLUSIONS

Urinary incontinence seems to be an underestimated problem; nurses often lack proper education in continence promotion. Academic, structured courses would be a solution; however, since education itself is not sufficient to really improve clinical practice, organizational support would be required to effectively promote continence in the broadest possible population. This would be a long-term investment for both quality of care and costs. Further studies are needed, regarding conservative management of UI; research could lead to a strong integration between clinical and academic branches of nursing, resulting in good quality evidence for clinical practice.

Systematic review of the management of incontinence and promotion of continence in older people in care homes: descriptive studies with urinary incontinence as primary focus

AIM

This is a review of descriptive studies with incontinence as the primary focus in older people in care homes.

BACKGROUND

Incontinence is prevalent among residents of care home populations.

DATA SOURCES

MEDLINE and CINAHL were searched from 1996 to 2007 using the highly sensitive search strings of the Cochrane Incontinence Review Group for urinary and faecal incontinence including all research designs. Search strings were modified to enhance selectiveness for care homes and older people and exclude studies involving surgical or pharmacological interventions. Searching of reference sections from identified studies was also used to supplement electronic searches. The Cochrane Library was searched for relevant systematic reviews to locate relevant studies from those included or excluded from reviews. The search was limited to English-language publications.

METHODS

A systematic review of studies on the management of incontinence, promotion of continence or maintenance of continence in care homes was conducted in 2007-2009. This is a report of descriptive studies. Results. Ten studies were identified that reported on prevalence and incidence of incontinence (urinary with or without faecal), policies, assessment, documentation, management or economic evaluation of its management. Use of incontinence pads and toileting programmes comprised the most common management approaches used. No studies were identified that attempted to maintain continence of residents in care homes.

CONCLUSIONS

Studies on maintaining continence and identifying components of toileting programmes that are successful in managing or preventing incontinence and promoting continence in residents of care home populations along with their economic evaluation are warranted.

Redesigning a continence prescription service to improve patient safety and experience

A review of prescribing practice for continence related products revealed shortcomings in the service that patients were receiving. This led to it being radically redesigned, with the continence service being responsible for prescriptions. The new service model also includes telephone triage before prescriptions are issued. Patient feedback on the new model has been extremely positive. This project won the 2009 Nursing Times continence award.

Economic impact of tension-free vaginal tape surgery for urinary incontinence in an ambulatory regimen compared with hospital admission

OBJECTIVES

To determine the cost per patient of a tension-free vaginal tape procedure involving major ambulatory surgery (MAS) compared with inpatient surgery in 2002 and 2003, and to analyse the medical care given following each procedure in a public hospital in Spain.

MATERIAL AND METHODS

The method used was activity-based costing, which involves designing a protocol of processes of caring for the patient with the help of professionals and subsequently calculating the cost of each process; this system was applied retrospectively to patients cared for in 2002 and 2003. In addition, the clinical histories of these patients were reviewed in order to evaluate complementary care given by the emergency service and admissions to hospital immediately following surgery. The relation between these events and each sample group was analysed by means of a non-parametric test and CIs for a 95% level of significance were obtained in order to make the calculations more robust.

RESULTS

The mean cost for the patients in the ambulatory group was 42.43% lower than that for the hospitalized patients. Whereas 5.5% of the ambulatory patients subsequently required admission and a further 7.3% required complementary medical care, 19.2% of the patients who had been hospitalized for the surgery required complementary medical care and 1.4% were readmitted after intervention. In spite of these results, there was no dependence between these variables according to the chi(2) test.

CONCLUSION

MAS produced better results in terms of minimizing costs; under our conditions it was less costly but was of equal efficacy to the surgical intervention.

The cost of urinary incontinence

It has been estimated that 13 million Americans have suffered from urinary incontinence (UI). Costs associated with UI include not only those pertaining to direct treatment, but they include costs related to the indirect psychosocial effects of the condition as well. This article will review both direct and indirect costs of UI and how urologic nurses can assist patients with UI in their overall plan of care.

Solifenacin in the treatment of overactive bladder syndrome in Italian patients: pharmacoeconomic evaluation

OBJECTIVE

To investigate the pharmacoeconomic performance of treatment with solifenacin, a new antimuscarinic with selectivity for the bladder, when compared to tolterodine and placebo, in Italian patients with overactive bladder (OAB).

METHODS

The evaluation was performed using a Markov model. The time horizon of the simulation was 52 weeks, with 1-week cycles. The model simulated outcomes and costs of the treatment with solifenacin (5 mg/day), tolterodine ER (4 mg/day) and no treatment in a cohort representative of the Italian population with OAB. The analysis was conducted mainly from the perspective of the patient, since drugs for the treatment of OAB are not included in the Italian reimbursement list. A supplementary scenario explored the consequences of a hypothetical reimbursement decision by the Italian Health Service to reimburse half of the current retail price in incontinent and responding OAB patients only.

RESULTS

Both treatments produced a reduction in symptoms and improvement in patients' quality of life, with an cost increase of about euro 540-640/patient/year with solifenacin and euro 680-780/patient/year with tolterodine. In a cost/utility analysis, solifenacin dominated tolterodine as it resulted in both more effective and less costly treatment; the cost/utility ratio with respect to no treatment was in the range euro 7,600-18,600/Quality-adjusted life year. The overall expenditure of the hypothesised reimbursement decision was estimated to be about 23 million euros, with a cost/utility ratio of about euro 600-2,400/Quality-adjusted life year, indicating an efficient allocation of health resources.

CONCLUSIONS

While both tolterodine and solifenacin appear to be cost/effective in Italy, the latter has proven to be superior.

NIH state-of-the-science conference statement on prevention of fecal and urinary incontinence in adults

OBJECTIVE

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on prevention of fecal and urinary incontinence in adults.

PARTICIPANTS

A non-DHHS, nonadvocate 15-member panel representing the fields of geriatrics, nursing, gastroenterology, obstetrics and gynecology, internal medicine, urology, general surgery, oncology, neurosurgery, epidemiology, biostatistics, psychiatry, rehabilitation medicine, environmental health sciences, and healthcare financing. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.

EVIDENCE

Presentations by experts and a systematic review of the literature prepared by the Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.

CONFERENCE PROCESS

The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

(1) Fecal incontinence and urinary incontinence will affect more than one fourth of all U.S. adults during their lives. The natural history of fecal incontinence is unknown, and the natural history of urinary incontinence over several years is not well described. (2) Fecal incontinence and urinary incontinence often have serious effects on the lives of the many individuals who suffer physical discomfort, embarrassment, stigma, and social isolation, and on family members, caregivers, and society. Financial costs are substantial and may be underestimated because of underreporting. (3) Routine episiotomy is the most easily preventable risk factor for fecal incontinence. Risk factors for both fecal and urinary incontinence include female sex, older age, and neurologic disease (including stroke). Increased body mass, decreased physical activity, depression, and diabetes may also increase risk. (4) Pelvic floor muscle training and biofeedback are effective in preventing and reversing fecal and urinary incontinence in women for the first year after giving birth, and these approaches may also prevent or reduce urinary incontinence in older women and in men undergoing prostate surgery. Fecal and urinary incontinence may be prevented by lifestyle changes, such as weight loss and exercise. (5) Efforts to raise public awareness of incontinence and the benefits of prevention and management should aim to eliminate stigma, promote disclosure and care-seeking, and reduce suffering. Organized approaches to improving clinical detection of fecal and urinary incontinence are needed and require rigorous evaluation. (6) To reduce the suffering and burden of fecal and urinary incontinence, research is needed to establish underlying mechanisms, describe a classification system, determine natural history, classify persons according to their future risk for fecal or urinary incontinence, design interventions targeted to specific population groups, determine the effects of these interventions, and guide public policy.

Urinary incontinence in women: Direct costs of routine care

OBJECTIVE

The purpose of this study was to estimate the direct costs of routine care for urinary incontinence (UI) in community-dwelling, racially diverse women.

STUDY DESIGN

In the Reproductive Risks for Incontinence Study at Kaiser population-based study, 528 women with UI weekly or more quantified resources that were used for UI. Routine care costs were calculated with the use of national resource costs ($2005). Potential predictors of these outcomes were examined by multivariable linear regression.

RESULTS

Mean age was 55 +/- 9 (SD) years. Among women with weekly UI, 69% reported incontinence-related costs. Median weekly cost was $1.83 (25%-75% interquartile range [IQR], $0.50, $5.23), increasing from $0.93 (IQR, $0, $3) for moderate to $7.82 (IQR, $5, $37) for very severe incontinence. Costs that increased with incontinence severity (P < .001) and body mass index (P < .001) were 2.2-fold higher for African American versus white women (P < .0001) and 42% higher for women with mixed versus stress incontinence (P < .05).

CONCLUSION

Women pay a mean of >$250 per year out-of-pocket for UI routine care. Effective incontinence treatment may decrease costs.

Incontinence in the aged: contact dermatitis and other cutaneous consequences

Urinary and faecal incontinence affects a significant portion of the elderly population. The increase in the incidence of incontinence is not only dependent on age but also on the onset of concomitant ageing issues such as infection, polypharmacy, and decreased cognitive function. If incontinence is left untreated, a host of dermatological complications can occur, including incontinence dermatitis, dermatological infections, intertrigo, vulvar folliculitis, and pruritus ani. The presence of chronic incontinence can produce a vicious cycle of skin damage and inflammation because of the loss of cutaneous integrity. Minimizing skin damage caused by incontinence is dependent on successful control of excess hydration, maintenance of proper pH, minimization of interaction between urine and faeces, and prevention of secondary infection. Even though incontinence is common in the aged, it is not an inevitable consequence of ageing but a disorder that can and should be treated. Appropriate clinical management of incontinence can help seniors continue to lead vital active lives as well as avoid the cutaneous sequelae of incontinence.

[Incontinence in old age: a social and economic problem]

Being afflicted with urinary incontinence in old age represents manifold medical, social, and economic problems and restrictions. The objective loss of control and decreased self-confidence result in reduced social interactions and lead to isolation and ostracism accompanied by withdrawal and depression. Giving up leisure time activities, losing social contacts, and the increasing need for long-term care often lead inevitably to a higher degree of dependency and institutionalization. In addition, the taboo still placed on this problem by those affected as well as by the attending physicians has resulted in too few patients receiving adequate diagnosis and being offered sensible treatment options. These problems can only be solved by an interdisciplinary approach. Further information, continuing education, and sensitivity toward these aspects are needed. Only then can incontinence in old age as a social and economic problem exacerbated by the demographic changes be improved.

Meta-Analysis of Pelvic Floor Muscle Training

BACKGROUND

Although many studies have reported the effectiveness of pelvic floor muscle training (PFMT) for treating female urinary incontinence, the magnitude of the effect and the optimal configuration of the parameters of the training have not been clearly determined.

OBJECTIVES

The aims of this meta-analysis were: (a) to calculate the effect size of pelvic floor muscle training compared to no treatment on incontinent episodes, urine leakage amount, and perceived severity of urine loss, and (b) to identify parameters of PFMT and subjects' characteristics influencing the magnitude of the effects.

METHODS

The search for relevant literature published from 1980 to 2005 consisted of using several computerized databases, citation searching, and footnote chasing. Twelve studies met the inclusion criteria, and were reviewed and coded.

RESULTS

The overall mean weighted effect size on incontinent episodes, urine leakage amount, and perceived severity were -0.68 (Z = 5.89, p < .001), -1.48 (Z = 2.64, p = .008), and -1.66 (Z = 1.68, p = .092), respectively. The studies with women having stress urinary incontinence showed a mean weighted effect size of -0.77 (Z = 7.03, p < .001), whereas studies with women having any type of urinary incontinence showed a mean weighted effect size of -0.47 (Z = 4.40, p < .001). The mean weighted effect size for studies including subjects over 60 years mean age was -0.54 (Z = 6.21, p < .001), whereas that of studies in which the average age was younger than 60 years was -0.94 (Z = 6.58, p < .001).

DISCUSSION

The treatment effect of PFMT on the incontinent episodes may be greater in younger women with only stress urinary incontinence. It appears that the number of daily contractions and the length of training period are not related to effect sizes on the condition that training includes at least daily 24 contractions and keeps for at least 6 weeks.

Quality improvement initiatives for urinary incontinence in nursing homes

Clinical practice guidelines based on research data and expert opinion provide more than adequate guidance for NHs to implement an incontinence quality improvement initiative that will meet the expectations laid out in the federal surveyor guidance for Tag F 315. All quality improvement initiatives take time, effort, leadership support, and coordination by a champion who is dedicated to program success. Simple policies, procedures, and documentation tools can be of critical value in improving the quality of incontinence care. While incontinence management may not be the highest priority for clinicians who care for NH residents suffering from numerous geriatric syndromes and medical conditions, a basic approach to assessment and targeted treatment can improve the quality of life of incontinent residents, prevent complications, improve family satisfaction with care, and facilitate the efficient use of staff resources for this labor intensive condition.

A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence

OBJECTIVES

To assess the efficacy and cost-effectiveness of pelvic floor muscle therapies (PFMT) in women aged > or = 40 years with urodynamic stress incontinence (USI) and mixed UI.

PATIENTS AND METHODS

In a three-arm randomized controlled trial in Leicestershire and Rutland UK, 238 community-dwelling women aged > or = 40 years with USI in whom previous primary behavioural intervention had failed were randomized to receive either intensive PFMT (79), vaginal cone therapy (80) or to continue with primary behavioural intervention (79) for 3 months. The main outcome measure was the frequency of primary UI episodes, and secondary measures were pad-test urine loss, patient perception of problem, assessment of PF function, voiding frequency, and pad usage. Validated scales for urinary dysfunction, and impact on quality of life and satisfaction were collected at an independent interview.

RESULTS

All three groups had a moderate reduction in UI episodes after intervention but there was no statistically significant difference among the groups. There were marginal improvements in voiding frequency for all groups, with no statistically significant difference among them.

CONCLUSIONS

In women who have already had simple behavioural therapies (including advice on PFM exercises) for urinary dysfunction, the continuation of these behavioural therapies can lead to further improvement. The addition of vaginal cone therapy or intensive PFMT does not seem to contribute to further improvement. The improvement in pelvic floor function was significantly greater in the PFMT arm than in the control arm although this did not translate into changes in urinary symptoms.

Disease burden of overactive bladder: quality-of-life data assessed using ICI-recommended instruments

Overactive bladder (OAB) is characterised by the storage symptoms of urgency, with or without urge incontinence, and usually with urinary frequency and nocturia. OAB is a common condition that affects people of all ages within society. It has an estimated prevalence of 16% and is known to adversely affect quality of life (QOL). Assessment of the QOL of patients is important to understanding both the burden of disease and improvement after treatment. In clinical practice, the physician's assessment of the disease burden of OAB has been shown to be inaccurate and non-reproducible. Psychometrically robust self-completion questionnaires provide a valid, reproducible and rapid assessment of patient-reported disease impact that can elicit the impact of symptoms, and they are also useful for the evaluation of the efficacy of an intervention. Many different questionnaires have been developed to assess the QOL impact of OAB. Generic instruments measure very broad aspects of health and are suitable for a wide range of patient groups and general population screening. They can be applied to patients with any medical condition and provide a measure of morbidity but are less sensitive to clinically relevant change in conditions such as OAB. Condition-specific questionnaires offer greater sensitivity and responsiveness to change in the assessment of QOL of specific patient groups. Single-item global assessment questionnaires are useful in conditions such as OAB that have multiple and varied symptoms, and reflect an individual's needs, concerns and values. Patient-derived outcome measures are used in real-world clinical practice, clinical trials, health economic research and healthcare planning.

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.

Increasing costs of urinary incontinence among female Medicare beneficiaries

PURPOSE

We measured the financial burden of urinary incontinence in the United States from 1992 to 1998 among women 65 years old or older.

MATERIALS AND METHODS

We analyzed Medicare claims for 1992, 1995 and 1998 and estimated spending on the treatment of urinary incontinence. Total costs were stratified by type of service (inpatient, outpatient and emergency department).

RESULTS

Costs of urinary incontinence among older women nearly doubled between 1992 and 1998 in nominal dollars, from $128 million to $234 million, primarily due to increases in physician office visits and ambulatory surgery. The cost of inpatient services increased only slightly during the period. The increase in total spending was due almost exclusively to the increase in the number of women treated for incontinence. After adjusting for inflation, per capita treatment costs decreased about 15% during the study.

CONCLUSIONS

This shift from inpatient to outpatient care likely reflects the general shift of surgical procedures to the outpatient setting, as well as the advent of new minimally invasive incontinence procedures. In addition, increased awareness of incontinence and the marketing of new drugs for its treatment, specifically anticholinergic medication for overactive bladder symptoms, may have increased the number of office visits. While claims based Medicare expenditures are substantial, they do not include the costs of pads or medications and, therefore, underestimate the true financial burden of incontinence on the aging community.

Urinary incontinence: economic burden and new choices in pharmaceutical treatment

In the year 2000, an estimated 17 million community-dwelling adults in the United States had daily urinary incontinence (UI), and an additional 33 million suffered from the overlapping condition, overactive bladder. Estimates of the total annual cost of these conditions range up to 32 billion US dollar; the largest components are management costs and the expenses associated with nursing home admissions attributable to UI. In most cases, patients with UI can be treated with pharmaceutical agents, in addition to behavioral therapy. Until recently, pharmaceutical therapy for UI has been limited, especially because the adverse effects of available agents resulted in poor adherence to treatment regimens. Recent innovations in molecular design and new dosage forms of UI medications offer the promise of fewer and less severe adverse effects and, thus, better treatment outcomes for patients. Additionally, the availability of multiple agents within a therapeutic class offers health care providers a spectrum of choices with which to personalize treatment for each individual patient. New pharmacologic treatment options for UI have the potential to allow greater independence for older persons who reside at home and to delay or avoid the costs of admission to long-term care facilities. Alternate dosage forms, which include patches and sustained-release formulations, may benefit patients who have difficulty chewing, swallowing, or remembering to take medications. Although these newer products are generally more expensive than older forms of therapy, they typically have more favorable cost-effectiveness ratios. Access to these new medications for patients enrolled in public and private health care plans may help to reduce the economic and social burden of UI care.

Fraction of nursing home admissions attributable to urinary incontinence

OBJECTIVE

To calculate the proportion of nursing home admissions of the elderly that is attributable to urinary incontinence (UI).

METHODS

The fraction of nursing home admissions attributable to UI was computed from published values for the prevalence of UI and relative risks corrected for variables independently associated with nursing home admission.

RESULTS

The attributable fraction of nursing home admissions due to UI in the elderly population was 0.10 (95% confidence interval [CI] 0.08-0.13) for men and 0.06 (95% CI 0.05-0.09) for women. Extrapolation to the US population in 2000 suggests an annualized cost of nursing home admissions due to UI of 6.0 billion dollars (3.0 billion dollars each for elderly men and women).

CONCLUSIONS

The estimates of the fraction of nursing home admissions attributable to UI exceed those previously assumed and show an imbalance between the sexes. Policies that support reimbursement for treatments of UI in the community might help prevent or delay institutionalization and offset some of the costs.

The "costs" of urinary incontinence for women

OBJECTIVE

To estimate costs of routine care for female urinary incontinence, health-related quality of life, and willingness to pay for incontinence improvement.

METHODS

In a cross-sectional study at 5 U.S. sites, 293 incontinent women quantified supplies, laundry, and dry cleaning specifically for incontinence. Costs were calculated by multiplying resources used by national resource costs and presented in 2005 United States dollars (2005). Health-related quality of life was estimated with the Health Utilities Index. Participants estimated willingness to pay for 25-100% improvement in incontinence. Potential predictors of these outcomes were examined using multivariable linear regression.

RESULTS

Mean age was 56 +/- 11 years; participants were racially diverse and had a broad range of incontinence severity. Nearly 90% reported incontinence-related costs. Median weekly cost (25%, 75% interquartile range) increased from 0.37 dollars (0, 4 dollars) for slight to 10.98 dollars (4, 21 dollars) for very severe incontinence. Costs increased with incontinence severity (P < .001). Costs were 2.4-fold higher for African American compared with white women (P < .001) and 65% higher for women with urge compared with those having stress incontinence (P < .001). More frequent incontinence was associated with lower Health Utilities Index score (mean 0.90 +/- 0.11 for weekly and 0.81 +/- 0.21 for daily incontinence; P = .02). Women were willing to pay a mean of 70 dollars +/- 64 dollars per month for complete resolution of incontinence, and willingness to pay increased with income and greater expected benefit.

CONCLUSION

Women with severe urinary incontinence pay 900 dollars annually for incontinence routine care, and incontinence is associated with a significant decrement in health-related quality of life. Effective incontinence treatment may decrease costs and improve quality of life.

LEVEL OF EVIDENCE

III.

Economic evaluation of duloxetine for the treatment of women with stress urinary incontinence: a markov model comparing pharmacotherapy with pelvic floor muscle training

BACKGROUND

Duloxetine is a serotonin and norepinephrine reuptake inhibitor and may be useful for treating women with stress urinary incontinence (SUI) in general practice.

OBJECTIVE

The objective of this study was to examine the cost-effectiveness of 2 duloxetine strategies (duloxetine alone and duloxetine after inadequate response to pelvic floor muscle training [PFMT]) compared with PFMT or no treatment for women aged>or=50 years with SUI.

METHODS

A Markov model with a 3-month cycle length was developed, with a time horizon of 5 years. Incontinence severity was based on incontinence episode frequency per week (IEF/week). Four SUI health states were distinguished in the model: no SUI (0 incontinence episode [IE] per week), mild SUI (19 IEs/week), moderate SUI (10-25 IEs/week), and severe SUI (>or=26 IEs/week). Transition probabilities were calculated, based on published evidence, expert opinion, and demographic data. Outcomes were expected total societal costs and expected IEs. The analysis was performed from the societal perspective of The Netherlands, and all costs were reported in year-2002 euros. One-way sensitivity and probabilistic sensitivity analyses were performed.

RESULTS

In the model, providing PFMT cost euro0.03/IE avoided, compared with no treatment. Duloxetine after inadequate PFMT cost euro3.81/IE avoided, compared with PFMT One-way sensitivity analyses indicated that these results were robust regarding variation in age, IEF/week, and discount rate. Below the ceiling ratio of euro3.65/IE avoided, PFMT had the highest probability of being cost-effective. With higher ceiling ratios, duloxetine after inadequate PFMT had the highest cost-effectiveness probability.

CONCLUSIONS

Treating patients with duloxetine after inadequate PFMT response yielded additional health effects in the model, but would require society in The Netherlands to pay euro3.81/IE avoided for women aged>or=50 years with SUI being treated in general practice. It is up to policy-makers to determine whether this ratio would be acceptable.

Predictors of Medication Adherence and Associated Health Care Costs in an Older Population With Overactive Bladder Syndrome: A Longitudinal Cohort Study

PURPOSE

We examined the relationship between self-reported health status data, subsequent antimuscarinic medication adherence and health care service use in older adults with OAB syndrome in a managed care setting.

MATERIALS AND METHODS

This was a longitudinal cohort study of older adults in the southeastern United States with OAB who completed a health status assessment, used antimuscarinic medications and were enrolled in an HMO continuously for 1 to 3 years. Demographic, clinical and use related economic variables were also retrieved from the administrative claims data of patient HMOs. Prescription refill patterns were used to measure medication adherence. Associations were examined with a sequential, mixed model regression approach.

RESULTS

A total of 275 patients were included. The severity of comorbidity (Charlson index), patient perception of quality of life (Short Form-12 scores) and total number of prescribed medications during the year prior to enrollment in a Medicare HMO were independently associated with decreased antimuscarinic MPRs after enrollment. After controlling for other variables increased antimuscarinic MPR remained the strongest predictor of decreased total annual health care costs (5.6% decrease in annual costs with every 10% increase in MPR, p < 0.001).

CONCLUSIONS

We found strong associations between decreased antimuscarinic medication adherence and increased health care service use in older adults with OAB in a managed care setting. Health status assessments completed at enrollment had the potential to identify enrollees at higher risk for nonadherent behaviors and poor health related outcomes.

Disruptive effects of overactive bladder and urge urinary incontinence in younger women

Although most studies of overactive bladder (OAB) have investigated older patients, many younger women suffer from OAB syndrome with and without urge urinary incontinence. OAB in these women is associated with an increased risk of depression, sexual dysfunction, sleep disruption, and lost productivity in the workplace. Many patients adopt coping strategies rather than seeking treatment; therefore, available treatments are underused in this population.

Cost-Consequence Analysis Evaluating the Use of Botulinum Neurotoxin-A in Patients with Detrusor Overactivity Based on Clinical Outcomes Observed at a Single UK Centre

OBJECTIVE(S)

This study aimed to assess the resource utilisation, health benefits and cost-effectiveness of intra-detrusor injections of botulinum neurotoxin-A (BoNT/A) in patients with overactive bladder (OAB).

METHODS

101 patients with urodynamically-proven detrusor overactivity of either neurogenic (NDO; n = 63) or idiopathic (IDO; n = 38) origin received intra-detrusor injections of 200-300 units of BoNT/A in 20-30 ml saline as part of a research protocol. Twenty-nine patients received repeat injections after 7-26 months. Symptom severity and urodynamic parameters were assessed at 0, 4 and 16 weeks. The cost of therapy was quantified based on the NHS resources used by typical patients and was used to calculate the cost-effectiveness of BoNT/A compared with standard care from the perspective of the UK NHS.

RESULTS

In an intent-to-treat analysis, 82% of patients showed a 25% or greater improvement in at least two out of five parameters (urinary frequency, urgency, urgency incontinence episodes, maximum cystometric capacity and maximum detrusor pressure) four weeks after treatment, reducing to 65% after 16 weeks. A 50% or greater improvement in the frequency of micturition, urgency or urgency incontinence was seen in 73% of patients at four weeks and 54% at 16 weeks. There were no significant differences between IDO and NDO patients in the proportion meeting these endpoints. Therapy cost pounds 826 per patient, with a cost-effectiveness ratio of pounds 617 per patient-year with > or = 25% clinical improvement.

CONCLUSION(S)

This study demonstrates that intra-detrusor BoNT/A is an effective treatment for OAB that is highly likely to be cost-effective in both idiopathic and neurogenic disease.

Pharmacological Management of Women with Mixed Urinary Incontinence

Mixed urinary incontinence (MUI) is a symptomatic diagnosis. It is defined by the International Continence Society as the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing and coughing. A search of medical databases revealed that only a small number of limited studies that assess the prevalence, epidemiology and treatment of MUI have been conducted. Most studies have looked separately at either stress urinary incontinence or urgency urinary incontinence. Thus, management of MUI involves a combination of treatments for both stress and urgency incontinence, but should concentrate initially on the most bothersome and/or predominant symptom. Initial management includes an accurate history and examination, which is supplemented by a bladder diary and quality-of-life questionnaire. Once a preliminary diagnosis is established, first-line therapy includes patient education and lifestyle interventions, such as weight loss. This is supplemented by pelvic floor muscle training and bladder training, which help with both components of MUI. Oral pharmacotherapy often acts synergistically with the previous treatments; however, only very few randomised, placebo-controlled trials have looked at the effects of pharmacotherapy on MUI. The two main classes of drugs are the antimuscarinics, which are effective in urgency incontinence, and the serotonin-norepinephrine re-uptake inhibitors, which are effective in stress incontinence. Combination of these two drug classes is a feasible option but has not been tested in any trials to date. Should these treatments fail, then patients should be referred for cystometry to confirm the diagnosis. Treatment options available following urodynamics include invasive minor and major surgical procedures, which either treat the stress or urgency component of MUI but not both. Surgical procedures carry the risk of infection, haemorrhage and failure.

[Cost effectiveness of screening for prostate cancer]

According to most experts, problems of prostate cancer (PC) have reached world-wide social and economic resonance at the turn of the 21st century. Costly programs of diagnosis and treatment of generalized PC and its complications require most spending. The general demographic situation and increased aging of male populations, both worldwide and in this country, make it clear that the total costs of medical aid to PC patients will inevitably grow. However, programs of screening for PC can help.

A description of health care provision and access to treatment for women with urinary incontinence in Europe — A five-country comparison

BACKGROUND

Female urinary incontinence is a prevalent condition, but only about one-third of women seek treatment.

OBJECTIVES

To describe the health care provision for women with urinary incontinence from a European perspective, selecting France, Germany, Spain, Sweden, and the United Kingdom as examples, and to investigate whether specific barriers for treatment exist.

METHODS

Available health care system information, a literature review and clinical expert information identified patterns of treatment provision.

RESULTS

In Spain, Sweden, and the UK, access to medical care in general is primarily through the general practitioners. However, in Spain and Sweden, women with urinary incontinence can directly visit specialists. In France and Germany, women have equal access to either general practitioners or specialists. Aside from general practitioners, gynaecologists play a major role in urinary incontinence care in all countries except the UK. In Germany, urologists are also involved in initial female urinary incontinence care; however, only in about 16% of women. There are no waiting lists in France and Germany for appointments with physicians or procedures, contrary to Spain, which has long waiting lists. Access to general practitioners in the UK is unrestricted whereas advanced diagnosis and treatment in secondary care requires long waits. A specific Swedish policy mandates that no woman is required to wait longer than 3 months for incontinence visits and related surgery. In Sweden and the UK, specialist nurses and other health care workers provide incontinence services. Almost all treatment options for urinary incontinence are at least in part reimbursed. However, various co-payments and fees in France, Germany, Spain and Sweden exist and constitute out-of-pocket expenses for women if no complementary additional private health insurance is available. In some countries, financial incentives for physicians to provide incontinence services are low, raising concerns about their interest to engage in continued patient care.

CONCLUSIONS

Information about service provision in Europe for women with urinary incontinence is limited and makes it difficult to understand barriers to treatment seeking. A broad European perspective may promote optimised treatment access in the future for this widespread and under-recognised condition.