Urinary incontinence affects adults of all ages, with an especially high prevalence among elderly women. Incontinence is estimated to affect 17–55% of community-dwelling people and up to 50% of nursing home residents, making it one of the most prevalent chronic diseases.1–11 Additionally, incontinence is often medically unrecognized, with only one-quarter to one-half of individuals seeking medical attention.7
Cost of illness for urinary incontinence has been addressed by several studies, most of which focus on a particular subpopulation (gender, age, or institutionalization status), type of incontinence (stress, urge, mixed, neurogenic), or cost type (direct, indirect).12–20 The most recent estimate of the annual direct costs of incontinence in all ages was $16.4 billion (in 1994 dollars), $11.2 billion in the community, and $5.2 billion in nursing homes.20 The estimated direct cost of incontinence increased by 250% over 10 years, with previous estimates of $6.6 billion in 198413 and $10.3 billion in 1987.16 This increase in cost is greater than can be accounted for by medical inflation.21
The purpose of this study was to estimate the annual direct costs of urinary incontinence for all age groups in the United States. Although we used similar methods and assumptions as previous cost of incontinence studies,13,16,19,20 we attempted to increase the accuracy of the cost estimates by using updated incontinence prevalence data and surgical rates and primary data for routine care costs. To allow for comparison with the most recent published study, we used 1995 cost estimates. In addition, we included the younger (15–39 years) as well as older (40 and more years) incontinent population, stratified costs by type of therapy (behavioral, pharmacologic, surgical), and estimated direct cost by residence (community dwelling, institutionalized), gender, age group (young, middle age, elderly), and type of urinary incontinence (stress, urge, mixed).
MATERIALS AND METHODS
We used a prevalence-based epidemiologic model to estimate the annual costs of urinary incontinence in the United States.22,23 Diagnostic evaluation and treatment strategies were based on algorithms described in the Agency for Health Policy and Research Clinical Practice Guidelines for Urinary Incontinence Management.21 Annual direct medical costs in 1995 dollars were estimated from the patient perspective for routine care costs in the community-dwelling population and societal perspective for all other costs.
Prevalence of urinary incontinence, defined as experiencing at least one incontinent episode over the past year, was estimated from a comprehensive review of published cross-sectional and cohort studies (Table 1).1–11 Prevalence rates for urinary incontinence were applied to 1995 population statistics from US census reports24 to estimate the incontinent population in 1995. Five percent of elderly (65 years of age and older) men and women were assumed to reside in institutions, and 95% were estimated to reside in the community.1,2,8 All people under 65 years of age were assumed to reside in the community.
Prevalence was stratified by age, gender, residency location, and type of incontinence. The community-dwelling population was divided into three age groups: younger (15–39 years of age), middle-aged (40–64 years), and elderly (65 years and older). In community-dwelling women, we estimated the distribution of the type of incontinence as 9% urge, 27% stress, 56% mixed, and 8% other, and in community-dwelling men, 35% urge, 8% stress, 29% mixed, and 28% other incontinence.1 Institutionalized men and women were not stratified by type of incontinence because specific diagnosis is rare in this setting and data on this distribution are not available.
Baseline annual probability estimates were determined from published studies of comparable patients (Table 1). When probabilities were unavailable from the literature, medical experts in incontinence were asked to make estimates. These probabilities were confirmed by an informal survey in three nursing homes and a long-term care facility in the San Francisco Bay Area. All incontinent people in institutions were assumed to require routine care, including additional labor, supplies, and laundry because of incontinence, and 15% were estimated to require indwelling catheters.13,17 Half of community-dwelling non-elderly incontinent people were assumed to require routine care including supplies, laundry, and dry cleaning.13
Only people with diagnosed incontinence (5% in the community and 50% in institutions) were eligible for treatment, which included behavioral (bladder training, scheduled toileting, pelvic muscle exercises), pharmacologic, and surgical (retropubic urethropexy, needle bladder suspension, suprapubic sling, artificial sphincter, and periurethral injection procedures) therapies.21 Age-specific probability of women undergoing surgical therapy was estimated from the 1993 National Hospital Discharge Survey.25 Using data from prior studies and confirmed by medical expert opinion, we assumed that all women diagnosed with stress incontinence and 50% with mixed incontinence were considered candidates for surgery (160,000 cases in 1995).18,25 Because there are few data on surgical therapy use in men and the National Hospital Discharge Survey rate for surgical therapy is too small to be reliably reported,18,25 this probability was assumed at 80% of the age-specific rates for women by consensus of three urologists. Pharmacologic therapy use, including anticholinergic, tricyclic antidepressant, alpha-adrenergic agonist, estrogen, and combination estrogen plus alpha-adrenergic agonist medications, was estimated for community-dwelling people by type of incontinence and gender (Table 1).
Complications included skin breakdown, simple urinary tract infections (UTI), UTI requiring hospitalization, and falls (Table 1).12,13 Complication rates for the community-dwelling elderly were assumed to be one-third of the rates observed in the nursing home population for skin irritations. Skin irritations and falls were assumed to occur at 50% of the elderly rate for the middle-age group and in none of the younger age group. Urinary tract infections resulted in hospitalization in 1% of institutionalized patients with UTI.13 Five percent of nursing home admissions and subsequent residencies were assumed to result primarily from incontinence.13
We used the average national Medicare reimbursement for physician services26 and hospitalizations to estimate direct costs (Table 2).27 These reimbursements are the “cost” that society pays for healthcare services for people at least 65 years old in the Unites States and are a reasonable assumption of societal cost for people under 65 years old. We have selected Medicare reimbursement as an estimate of what society pays for incontinence care in the United States, and, therefore, will use cost and reimbursement as equivalent terms in this study. Surgical costs were assumed using average national Medicare reimbursement rates or Washington State Medicare health claims data (MedPARS).18,19,26,27 If national rates were unavailable, we pooled cost estimates in the literature or used San Francisco area charges adjusted with our local cost-to-charge ratio (0.45, personal communication, University of California, San Francisco, Hospital Finance Department, 1999).22 All costs were adjusted to l995 US dollars using the Consumer Price Index inflation rates for medical care.28 Discounting was not required because this analysis has a 1-year time horizon.
Types of expenditures included routine care, diagnostics, evaluations, treatments, and complications. Routine care costs for institutionalized patients were estimated from pooled data of several comprehensive studies.12–15,17 Because few data are available on routine costs for community-dwelling people, we estimated these costs using a survey administered in a San Francisco incontinence center. This survey included women presenting to a urogynecology clinic for care with any severity of incontinence who experienced urine loss in the past month (n = 135). This sample size provided moderate precision (95% confidence interval [CI] of 15%). Women responding to the survey had a distribution of incontinence severity that is likely similar to or more severe than the distribution of severity in the incontinent population (16 [11%] women had monthly, 41 [31%] weekly, and 69 [51%] daily incontinence). Participants were asked to itemize the number and type of resources used specifically for bladder control problems such as pads, protection, hygiene and deodorant products, loads of wash, and dry cleaning. Average national costs for these products were then applied to calculate a total cost.29 Women in the survey used an average of three absorbent pads per day ($6/week), did one extra load of laundry per week ($1.20/week), and incurred average weekly dry cleaning expenses ($2.40/week), for an average cost of $1.20 per day. This cost was conservative compared with routine care cost estimates used in prior incontinence cost studies that ranged from $3.1019 to $5.1512,13 per day in 1995 dollars. Recent studies in Italy30 and the United States31 estimated pad costs that were 25–50% of our estimates.
A basic evaluation for incontinence included consultation for history and physical examination, measurement of postvoid residual volume, and urinalysis.21 Supplementary analyses were assumed to occur in 20% and in all people undergoing surgery, including blood tests and complex urodynamic testing. The cost of behavioral therapy included six office visits for community-dwelling people and the hourly charge for assistance with prompted voiding while awake in institutionalized people.12,14,19,26,27 Annual costs of pharmacologic therapy were estimated using the minimum average wholesale price of commonly prescribed medications.32
Previously determined costs of skin breakdown and falls were updated to 1995 dollars.13 Outpatient-treated UTI included a physician visit, urine culture and sensitivity, 3-day oral antibiotic therapy, and hospitalization in 1% of institutionalized people with UTI.26,27 The annual charge for additional nursing home residency was estimated as $59,495 based on the annualized reimbursement by Medicare.33 Individuals were assumed to require a full year of institutionalization and to include people already living in an institution because of incontinence, additional admissions, and discharges.
Indirect costs were not included in this analysis. Morbidity costs (eg, work lost because of urinary incontinence or paid or unpaid caregivers) were not included because resource use resulting from incontinence is unclear. Because urinary incontinence does not contribute directly to mortality, we assumed no additional indirect costs of death.
Sensitivity analyses were performed over a reasonable range identified in the literature or over a range of 50–200% of the basecase estimate (Tables 1 and 2). Sensitivity analyses were also performed assuming that 100% of people with incontinence were diagnosed rather than the 5% used in the baseline analysis.
The annual direct cost of urinary incontinence in the United States was estimated as $16.3 billion, $12.4 billion (76%) for women and $3.8 billion (24%) for men (Table 3). Costs are presented as total costs with data on women specified in the text if the proportion of total costs for women for each cost category was more than 5% different from the proportion for men. A majority of costs were consumed by people living in the community ($10.8 billion) compared with those in nursing homes ($5.5 billion). In the United States, 19 million people with incontinence live in the community compared with 0.8 million in nursing homes. The cost per year for each institutionalized person with urinary incontinence was $3687 (excluding the cost of added admissions to nursing homes) compared with $552 for a community-dwelling person with incontinence, which reflects the higher costs of routine care for institutionalized people. The elderly, including the community-dwelling and nursing home populations, accounted for $7.6 billion (61%) for women and $3.2 billion (84%) for men. Costs for women over 65 years of age were more than twice the costs for those under 65 years ($7.6 and $3.6 billion, respectively).
For women, the largest cost category was routine care (70% of total costs), followed by nursing home admissions (14%), treatments (9%), complications (6%), and diagnosis and evaluations (1%) (Table 3). The proportion of costs used for routine care was greater in the community (79%) than in nursing homes (51%). Additional nursing home admissions accounted for a smaller proportion of costs for women (14%) than for men (19%). This cost category was similar to the costs of all treatments and complications combined. Costs for community-dwelling women ($8.6 billion, 69% of costs for women) were greater than for institutionalized women ($3.8 billion, 31%).
Treatment accounted for 8% of total costs ($1.3 billion), including $146 million (11% of treatment costs) for behavioral, $114 million (9%) for pharmacologic, and $1032 million (80%) for surgical therapy. Women accounted for a large proportion of treatment costs (91%), with surgical therapy accounting for 88% of costs. Overall, the surgical treatment cost burden was four times greater than the costs of behavioral and pharmacologic treatments combined.
Treatment costs were analyzed by type of incontinence. Stress incontinence accounted for 82% of total treatment costs, mixed incontinence 12%, urge incontinence 4%, and other incontinence 2%. Treatment expenditures differed by gender, with 85% of women's treatment costs for stress incontinence, 12% mixed incontinence, 2% urge incontinence, and 1% other incontinence for women and 55% of men's treatment costs for stress incontinence, 14% mixed incontinence, and 22% urge incontinence.
Univariate sensitivity analyses were performed for all probabilities, rates, and costs over the ranges presented in Tables 1 and 2. Total costs were most sensitive to changes in incontinence prevalence, routine care costs, and nursing home admission rate and costs (Figure 1). For complications and treatments, total costs were similarly affected when either rates or costs were varied. When prevalence of urinary incontinence was varied over the range observed by a recent literature review,3 we observed a range of a 61% decrease to a 46% increase in total costs compared with the basecase analysis. When cost of routine care was varied from the lowest published cost34,35 and lowest quartile observed in our survey to 150% of published costs,12,13,19 we observed a range of a 21% decrease to a 41% increase in total costs compared with the basecase analysis. If 100% of the urinary incontinent prevalent population was diagnosed and thus received some type of treatment, total direct costs would increase by 152% to $40.9 billion.
The annual direct cost of urinary incontinence estimated in this study ($16.3 billion) is similar to a previously published estimate of $17.4 billion ($10.3 billion in 1987 dollars adjusted to 1995 dollars).16Table 4 presents annual costs of several common chronic and acute diseases of the elderly,36 including costs of urinary incontinence for women only and for the entire adult population estimated in this study. We observed similar total costs despite including updated data and using different modeling assumptions in this study. We assumed lower routine care costs for the community-dwelling population ($1.20 versus $3.10 per day) and higher incontinence prevalence. If we assumed the higher routine care cost,19 total costs for urinary incontinence increased 41%, to $23 billion. Although the most recent prior studies used incontinence prevalence of 9%16 to 19%19 for all community-dwelling elderly and 2%16 for all nonelderly, we used more recently published, gender- and age-specific prevalence estimates of 35% for elderly women, 22% for elderly men, 10% for nonelderly women, and 1.5% for nonelderly men. These differences in routine care costs and incontinence prevalence are consistent with our results of lower per patient costs for community-dwelling people ($552) and higher institutionalized nursing per patient costs ($3687) compared with the previous study that included elderly and non-elderly people ($3132 and $6956, respectively, in 1995 dollars).16
Definitions of incontinence also affect prevalence estimates. We selected a broad definition of incontinence prevalence (at least one incontinent episode in the past year) because this is one of the most commonly reported numbers and this population is likely to have symptoms that are bothersome enough to require intervention (eg, protective pads, laundry, medical care).
The total costs in the elderly ($10.8 billion) were almost double the costs for the nonelderly ($5.5 billion), reflecting the higher prevalence of incontinence and institutionalization among the elderly. Urinary incontinence is most prevalent in elderly women who accounted for the highest costs ($7.9 billion), representing more than half of the total societal cost of incontinence. The total costs for women compared with men of all ages were $12.4 billion and $3.8 billion, respectively. The consistently higher prevalence among women of all ages, which was more than twice that of elderly men and more than seven times that of nonelderly men, explained most of the higher costs for women compared with men.
Detailed analyses on costs of treatments showed that treatment costs were much lower than the costs of routine care and the cost of additional admissions to nursing homes. Although the average annual cost of treatment per diagnosed person ($1470) was higher than the average annual costs of routine care ($437), this analysis did not evaluate the decreased prevalence or severity of incontinence after treatment. Because studies have observed a direct association between routine care costs and incontinence severity34,37 and decreased resource use after effective incontinence treatment,38,39 the increased cost of treating incontinence may be offset by cost savings for routine care. Surgical treatments are more costly than routine care or pharmacologic treatment in the year of surgery, but usually achieve at least partial and often complete long-term cure. Surgical therapy, therefore, has much lower aggregate long-term costs compared with other therapies or routine care, which require continued investment.18 In a recent study of stress incontinence, 4 years of routine care costs were equal to the cost of one surgical treatment.18 Although surgery requires an initial investment, it may be a less costly or even be cost saving over the long term (longer than 4 years in this example), depending on long-term surgical success rates.18 Increasing efficacy of the currently available treatments or development of better treatments could decrease the total societal cost burden of incontinence.
The largest cost category, routine care, comprised 70% of total costs. Unlike the costs of diagnosis, treatment, and institutionalization, a majority of routine care costs are paid out of pocket by patients and not reimbursed by third party payers. This places a large cost burden directly on individuals, most often the elderly, who are adversely affected by disease as well as the cost of care. Although routine care costs in nursing homes have been well studied,12 routine care costs in the community are uncertain. In this study, routine care costs in the community were calculated based on a small survey. Our results were between the most recent cost of incontinence study estimate of $1130 per year19 and recent comprehensive studies of resource use that observed routine care costs between $70–225 per year.30,31,34 Future research on community-dwelling patients is needed to provide more accurate cost estimates, especially for routine care costs.
The cost of additional nursing home admissions because of incontinence ($2.4 billion; 15% of total cost) is the second largest cost category and is larger than the costs of all treatments combined. Incontinence is strongly associated with nursing home admission in community-dwelling elderly, with a relative risk of 2.5 (95% CI 2.1–2.9) for women and 3.7 (95% CI 3.2–4.4) for men.40 Appropriate diagnosis and treatment of urinary incontinence in the community, especially for those people at greatest risk of permanent institutionalization, may decrease the cost burden to society.40,41 The costs of diagnostics and evaluations are relatively small ($171 million; 1% of total cost), possibly reflecting the under-diagnosis.
Sensitivity analyses identified that incontinence prevalence and routine costs exert the most effect on the estimated annual cost of incontinence. The analysis was fairly robust to variations in all other variables. Incontinence prevalence studies use varying definitions of incontinence, from “ever” experiencing incontinence to incontinence within the past year or month, “current” incontinence, or daily incontinence. Our prevalence estimates are higher than those used in previous studies of incontinence costs, and are slightly lower than the two recent, comprehensive reviews, which weighted all studies equally.3,9 The prevalence and cost estimates in this study are averaged across all frequencies of urinary incontinence. If all individuals with incontinence presented for medical evaluation, total costs would increase by 152% to $41 billion. However, this would likely be offset by savings in routine care costs as incontinence severity improved.
Cost analyses of urinary incontinence have several limitations. There are few comprehensive studies and limited national data sets that provide prevalence estimates in the nonelderly. Accurate prevalence estimates are further limited by the hidden nature of incontinence, especially in community-dwelling people who infrequently seek medical care for incontinence. In addition, there are few data on routine care costs of community-dwelling people. Finally, the effects of urinary incontinence on indirect costs are not included in this analysis, probably resulting in an underestimation of costs.
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