Intervention for Initial Management of Urinary Incontinence
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Nurse specialist intervention for initial management of urinary incontinence in primary care is more cost-effective than the usual general physician care after 1 year

Albers-Heitner CP, Joore MA, Winkens RAG, Lagro-Janssen ARM, Severens JL, Berghmans LCM. Cost-effectiveness of involving nurse specialists for adult patients with urinary incontinence in primary care compared to care-as-usual: An economic evaluation alongside a pragmatic randomized controlled trial. Neurourol Urodynam 2012; 31 (4): 526-534.

Why they did the study

International primary care guidelines for management of urinary incontinence (UI) indicate that for most UI patients, pelvic floor muscle and/or bladder training is the best noninvasive initial treatment in primary care to solve the problem. Despite these guidelines, however, training of primary physicians has so far neither been adequate or offered consistently in most countries. This care pathway results in costly management of UI, offering care rather than cure with a need to improve the primary care of UI. One way to achieve this could be to involve incontinence nurse specialists. However, little information is available on the cost-effectiveness of this care approach compared to standard physician care. The aim of this study was to determine the 12-month, societal cost-effectiveness of involving  nurse specialists in primary care of UI compared to care-as-usual by the primary care (family) physicians or general practitioner (GP).

How they did it

This was an economic evaluation Dutch study conducted from May 2005 to March 2008 alongside a pragmatic randomized controlled trial comparing UI patients receiving nurse specialist care with UI patients receiving care-as-usual in primary care practices in four regions.  Adult patients with stress, urgency, or mixed UI, already known as such or newly diagnosed by their GP were recruited and followed for 1 year. Randomization was computer-generated, with allocation concealment by sealed envelopes, of 175 patients per arm (N= 350). The sample size was based on a mean entry UI severity sum-score of 7.18 (SD= 6.64) on the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) and expected clinically important improvement of two points on the outcome scale (delta value 2/6.64 = 0.301) with a power of 80% and a two-sided significance level of 0.05.  Data were collected through postal questionnaires at baseline, and 3, 6, 9, and 12 months.

Six nurse specialists who had received specialized training and a competencies assessment provided the intervention. After initial medical UI diagnosis by a GP, the nurse specialists further specified the diagnosis and advised them on lifestyle, toileting habits, bladder and pelvic floor muscle training and, when appropriate, the choice of incontinence pads. Patients were treated for 1 year, with 5-7 visits during the first 3 months, followed by consultations at 6 and 12 months to monitor effect and adherence. Patients randomized to care-as-usual were not referred to the nurse specialist and  managed by their GP.

Three outcome measures were used: Quality Adjusted Life Year based on societal preferences for health outcomes (QALYsocietal), Quality Adjusted Life Year based on patient’s preferences for health outcomes (QALYpatient), and the newly developed Incontinence Severity weighted Life Year (ISLY) based on patient-reported UI severity and impact as assessed with the ICIQ-UI SF. The Dutch Health Care Insurance Board’s manual for cost research was applied for the identification, measurement, and evaluation of costs. Health care resource use, patient and family costs, and productivity costs were collected using self-administered three-monthly retrospective questionnaires. They included the costs of GP, medical specialist, and physiotherapist treatment, hospital admittance, incontinence pads, and medication. Patient and family costs comprised travel costs and out of-pocket costs for incontinence pads, medication, and other means or aids. The PROductivity and DISease Questionnaire (PRODISQ) was used to measure absence from paid and unpaid work. The costs of the nurse specialist intervention were based on the standard unit price for home care nursing and patient-level recording of contact hours on a Case Record Form. Costs were calculated by multiplying the volumes of health care by the corresponding unit prices. Total societal costs were calculated by adding up total health care costs, patient and family costs, and productivity costs. Cost-effectiveness analysis was based on a 23.71 € /hour rate for practice nurses who do most of their work in a GP setting and over a time frame of the first 3 months only which covered the most frequent consultations and most of the treatment effect.

What they found

There were 384 eligible patients; 186 were randomly allocated to the intervention and 198 to care-as-usual. The population predominantly consisted of women (93%), with a mean age of 65 and the groups were comparable.

The incremental QALYsocietal and QALYpatient in favor of the intervention group were 0.01 (95% BCI:  –0.05 to 0.08) and 0.02 (95% BCI: –0.02–0.06), respectively. Patients in both groups improved significantly in terms of ICIQ-UI scores (P < 0.001). Statistically significant differences in change scores between groups were found at 3 months, after correction for effect modifiers (P= 0.04) and in patients in the intervention group without self-reported anxiety/depression at baseline after 1 year (P= 0.03). The difference in ISLY in favor of the intervention group was 0.02 (95% BCI: – 0.03 to 0.07).

The mean health care costs amounted to 618 € in the intervention group, and 398 Euros in the control group (incremental costs 220 €; 95% BCI: € 99 to € 369). The largest proportions of these costs consisted of the costs of incontinence pads and intervention costs. The difference in health care costs between the groups was mainly due to the intervention costs. Mean health care costs for the intervention were 195 € (95% BCI: € 169 to € 224). Patient and family costs (out of pocket costs and travel costs) were low in both groups. There was no productivity loss from paid work and costs due to absence from unpaid work were also low in both groups. Total societal costs amounted to 677 € in the intervention group, and 453 € in the control group (incremental costs € 224; 95% BCI: € 80 to € 422). At a ceiling ratio of € 40,000 per QALYsocietal or QALYpatient , the probability that the intervention is cost-effective compared to care-as usual was 58% based on QALYsocietal and 77% based on QALYpatient.

Why it matters

Urinary incontinence is a highly prevalent clinical condition with well-known impact on general well-being and social functions. The economic burden of UI is, however, less appreciated.  Cost is associated with UI whether the patient is treated or not. If a patient seeks medical attention, then there are diagnostic and treatment costs. Costs are also incurred when UI is untreated. These include routine care costs (disposable garments and laundry), consequence costs (falls and hospital admissions), indirect costs (lost productivity) and intangible costs (pain, stress and suffering). In view of the ageing population worldwide, a further increase is expected in the prevalence of UI with important implications for the future demand for incontinence services and most importantly the associated health care costs.

This large economic study found that compared to care-as-usual, the involvement of nurse specialists costs € 16,742/QALYsocietal gained. Using QALYpatient or ISLY resulted in slightly more favorable cost-effectiveness outcomes.  Involving nurse specialists in UI primary care thus had an acceptable cost-effectiveness ratio in the Netherlands. 
An interesting finding was that the care-as-usual group also improved on the main outcome measures. A possible explanation is that UI improves spontaneously within the first year. It is not known how many patients in the control group were referred or seen by specialist UI caregiver. The follow-up of the trial is also too short to capture all treatment benefits at 1 year in the intervention group such as changes in patients’ lifestyle, use of pads, and health care services provided (e.g., operations prevented). Further economic research in this field should, therefore, focus on using a longer patient follow-up period and a wider sample of UI caregivers. It is also important to use standardized economic outcome evaluation measures of UI to ensure comparability across studies conducted in different settings.

Next question

Urinary incontinence is associated with considerable costs to the patient, family, health care system and society. Proper management of UI in primary care is associated with a significant improvement in patients’ quality of life as well as reduction in health care costs. The results of this study highlight the economic burden of UI whether a trained nurse specialist or a general physician care model is used for the primary management of UI and show that the former model is more cost-effective after 1 year. Further economic and epidemiological studies are needed to clarify if the same outcomes can be achieved by training family physicians/general practitioners in UI management and to determine if the reduction in patient referrals to specialist UI care givers as a result of this policy would lead to additional cost savings.

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