eMJA: Doran et al, Economic costs of urinary incontinence in community-dwelling Australian women

Medicine and the Community

Economic costs of urinary incontinence in community-dwelling Australian women

Christopher M Doran, Pauline Chiarelli and Jill Cockburn

MJA 2001; 174: 456-458
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Abstract - Methods - Results - Discussion - References - Authors' details
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Abstract

Objective: To estimate the economic cost of urinary incontinence in community-dwelling Australian women aged 18 years and over for the year 1998.
Design: Extrapolation of data from studies of women with incontinence to the Australian population of women aged 18 years and over in 1998.
Main outcome measures: Estimated prevalence of urinary incontinence in 1998, and estimated cost in Australian dollars of resource use and personal costs related to management of incontinence.
Results: An estimated 1 835 628 community-dwelling women over the age of 18 years had urinary incontinence in 1998. The total annual cost of this urinary incontinence is estimated at $710.44 million, or $387 per incontinent woman, comprising $338.47 million in treatment costs and $371.97 million in personal costs. An estimated 60% of women with incontinence in 1998 were aged 40 years or over. Assuming the prevalence of incontinence remains constant and, allowing for inflation, we project that the total annual cost in 20 years' time will be $1267.85 million, 93% ($1.18 billion) of which will constitute costs associated with women aged over 40 years.
Conclusions: Urinary incontinence imposes a considerable drain on Australian healthcare resources. More research is needed to understand the magnitude of the problem and potential gains from continence promotion.

Urinary incontinence is a major clinical problem that has a profound effect on quality of life and activities of daily living.^1-3 Women with urinary incontinence report fear, shame and humiliation, and worry about the odour of urine from pads and wet underclothing.⁴ Urinary incontinence is physically debilitating and socially incapacitating, and is associated with loss of self-confidence, feelings of helplessness, depression and anxiety.³

Studies of the prevalence of urinary incontinence suggest that it is widespread among women of all ages.⁵ Australian community-based studies have reported incontinence in 19% of women aged 10-29 years, 40% of women aged 30-44 years, 50% of women aged 45-59 years, 30% of women aged 60-74 years, and 42% of women aged over 75 years.⁶ Recent data from the Women's Health Australia (WHA) project, a longitudinal study of three age cohorts (18-23 years, 45-50 years and 70-75 years), conducted by staff of the universities of Newcastle and Queensland and funded by the Commonwealth Department of Health and Aged Care, support these findings.^7,8

The probability of incontinence increases with age,^9-11 and the nature of incontinence changes from stress incontinence to urge incontinence¹² as a result of an increasing prevalence of multiple disorders and organ dysfunction with age. This change has significant implications for clinical management.¹³ While stress incontinence is typically managed with strengthening exercises for pelvic floor muscles, with or without neuromuscular electrostimulation and surgery, management of urge incontinence might also include a bladder-training program, transcutaneous electrostimulation aimed at the spinal micturition reflex centre and drugs.¹⁴

Urinary incontinence has a considerable financial impact on both individuals and the healthcare system. One United States study has reported costs of US$26.3 billion in 1995 for individuals aged 65 years and over, or US$3565 per incontinent individual.¹⁵ Little is known of the economic impact of urinary incontinence in Australia, but the Australian National Women's Health Policy Statement estimated that individuals may pay up to $1200 a year for incontinence pads, and that 25% of nursing time in nursing homes was spent managing incontinence, at an annual cost of $450 million.¹⁶ A recent study of 100 community-dwelling Australian women aged between 25 and 85 years reported a median total direct cost (including personal and treatment costs) of $12.89 per week.¹⁷

Our aim was to comprehensively examine the economic costs of urinary incontinence in community-dwelling women in Australia for the year 1998.

Methods

We used a similar approach to that used by Hu et al in the US,^15,18,19 in that we used information from a variety of sources in our estimates. However, rather than using national utilisation figures¹⁹ and a "top-down" approach, we used a "bottom-up" approach, taking estimates derived from relevant studies and extrapolating them to the 1998 population of Australian women aged over 18 years.

We estimated the cost of urinary incontinence as the total value of all resources used or lost by ill individuals, treatment providers or others as a result of the illness.¹⁵ Direct costs include resources used for diagnosis, treatment and care of urinary incontinence, while indirect costs include the value of lost earnings and time spent by carers. Intangible costs²⁰ related to psychological, physical and social effects were not included.

Estimating prevalence

The WHA project provides the most comprehensive information on the prevalence of urinary incontinence in Australian women.^7,8 It reported incontinence in 12.8% of women aged 18-23 years, 36.1% of women aged 45-50 years and 35% of women aged 70-75 years, and a prevalence of help-seeking among incontinent women in each cohort of 22.9%, 45.5% and 44.6%, respectively.²¹

We assumed that the prevalence of incontinence and help-seeking in the three age cohorts could be applied to broader age groups of 18-39 years, 40-69 years and over 70 years, and used Australian Bureau of Statistics (ABS) figures for the resident population in these age groups²² to estimate the total number of incontinent Australian women who did and did not seek help in 1998.

Resource use and personal costs

A recent study developed the Dowell-Bryant Incontinence Cost Index (DBICI) to measure the total direct costs of urinary incontinence.¹⁷ This study applied the DBICI to 100 consecutive community-dwelling women attending continence clinics for treatment of their urinary incontinence. Personal cost estimates included weekly expenditure on pads, incontinence-related laundry and miscellaneous costs (such as dry cleaning, replacement of urine-soaked carpets and clothing), while treatment-cost estimates included visits to healthcare professionals, surgical procedures, medications and costs associated with travel and time off work in the previous year. We costed these resources by using standard fees from the Medical Benefits Schedule and Pharmaceutical Benefits Scheme or by actual costs incurred if women had private health cover.

We used the data from this study¹⁷ in conjunction with the prevalence estimates from the WHA project to estimate the resource implications and personal cost of urinary incontinence among women aged 18 years and over in Australia in 1998.

Results

We estimate that 1 835 628 community-dwelling women over the age of 18 years in Australia had urinary incontinence in 1998, and that 60% (1 109 506) of these women were aged 40-69 years (Box 1). An estimated 742 348 women sought help for their incontinence, of whom 68% were aged 40-69 years.

Box 2 shows that we estimate total annual treatment costs at $338.47 million, 48% of which was for visits to health professionals, and 25% of which was for investigations. Further, we estimate that total personal costs in 1998 were $371.97 million, 56.5% of which was borne by women who did not seek help (Box 3). The total annual cost of urinary incontinence in 1998 is estimated at $710.44 million, or $387 per woman with urinary incontinence.

Up to 90% ($640.98 million) of the total annual costs were incurred by women aged over 40 years. Given Australia's ageing population, assuming the same prevalence and taking inflation into account, the total cost of urinary incontinence in community-dwelling women is projected to be $1267.85 million in 20 years' time; 93% of this ($1.18 billion) will constitute costs associated with women aged over 40 years.

Discussion

Our estimates represent the first attempt to quantify the total economic impact of urinary incontinence in community-dwelling Australian women. However, our analysis has some limitations that need to be kept in mind when interpreting the results.

Importantly, our data sources differ in methodological rigour and comparability, so we have had to make a number of assumptions. Prevalence rates of incontinence reported from the WHA project have been extrapolated to a wider age range than originally measured.⁷ We applied the data of Dowell et al on treatment resource use universally to all age groups in our analysis, and without considering socioeconomic and demographic variations. Given that the type and severity of incontinence varies with age,^9-12 this assumption may not provide an accurate picture. We also applied the personal costs reported in Dowell et al¹⁷ to slightly different age groups. Finally, although the sample of 100 women used in Dowell et al represented a wide spectrum of age and severity of leakage, it may not have been representative of all community-dwelling women.¹⁷

Despite these limitations, our analysis is the most comprehensive assessment of the annual costs of urinary incontinence in community-dwelling women conducted in Australia to date. The total cost of $710.44 million is a conservative estimate of the cost of resources used in treatment and care of women with urinary incontinence. If we were to consider the reduced quality of life, lost earnings and the burden imposed on family, friends and carers, the total cost would be considerably higher.

From a woman's perspective, there are substantial personal costs involved in managing incontinence; research has found that women are willing to pay considerable amounts to reduce the symptoms of urinary incontinence.^23,24 From a health system perspective, the high cost of treatment and care of urinary incontinence clearly demonstrates that this is a serious medical condition that imposes a considerable drain on scarce healthcare resources.

We need more and better information on the consequences of urinary incontinence so that we do not have to make as many assumptions to estimate economic impact. In particular, we need to know the resource implications of the different types of incontinence, the effect on quality of life and the potential benefits from reducing the prevalence of urinary incontinence among Australian women. We also need to alert women to the risk factors for incontinence, strategies that may minimise or prevent incontinence, and the support and treatment options available. Given the demographic shift towards an older population and the escalating costs of healthcare provision and technology, this is an urgent need.

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(Received 28 Jun, accepted 18 Dec, 2000)

Authors' details

School of Population Health Sciences, Faculty of Medicine and Health Sciences, University of Newcastle, Newcastle, NSW.
Christopher M Doran, PhD, Research Fellow.
Pauline Chiarelli, MMedSci, Doctoral candidate.
Jill Cockburn, PhD, Professor of Behavioural Science in Relation to Medicine.

Reprints will not be available from the authors.
Correspondence: Professor J Cockburn, Locked Bag 10, Wallsend, NSW 2287.
jillcATmail.newcastle.edu.au