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Urinary incontinence is a distressing and debilitating condition
which will become more prevalent as our population ages. The personal
suffering of those who find urine running down their legs is difficult
to measure, but we know that quality of life is severely impaired. It is
disturbing that only about a third of those affected actually seek
medical help, because of lack of knowledge (on the part of the patient
or the provider) about available treatments,1 as well as patients'
embarrassment about revealing their "lack of control".
For patients with urinary incontinence, the cost of buying pads and
other appliances is a major burden. Indeed, some women are forced to
reuse their commercial pads by opening them and restuffing them with
toilet paper, or to dry their urine-soaked disposable pads on a heater
for later use to reduce costs.2
The "cost" of a disease or condition is not adequately described by the
dollars spent in the healthcare system. Nonetheless, in the current
climate of economic healthcare rationalisation, it is still useful
to calculate the measurable costs of a condition, as least to justify
expenditure on this rather than upon some other medical problem. The
cost of an illness comprises three components:3 "direct costs",
which include personal costs (eg, pads and replacement of
urine-soaked clothes), and treatment costs (met by patients and by
several government subsidies); "indirect costs", which include
lost productivity both in the home and in outside employment; and
"intangible costs", which are most difficult to measure
financially, but include psychological distress and impaired
physical or mental health.
The costs of urinary incontinence, for the sufferer and for the
Australian healthcare system, have not been previously
ascertained. The report by Doran and colleagues in this issue of the
Journal4 represents the first
attempt to estimate the direct costs of incontinence for all
community-dwelling Australian women. Their calculations were made
possible by two recent events. Firstly, the Women's Health Australia
(WHA) project, a large, ongoing national longitudinal
epidemiological survey, has made it possible to gain an accurate
picture of the prevalence of incontinence in 41 724 young (18-23
years), middle-aged (45-50 years) and older (70-75 years)
women.5 It also identified women who
did and did not seek help. Secondly, an Australian group devised and
validated a test instrument to measure the direct personal and
treatment costs of incontinence in 100 community-dwelling
women.2
Doran et al have extrapolated from the WHA prevalence data, using
Australian Bureau of Statistics population figures, to deduce the
total number of incontinent women in this country. They then used
estimates from the second study to calculate the personal costs for
all affected women, and added the treatment costs of those who sought
help, to derive an annual cost for incontinence of $387 per
incontinent woman, or $710 million (in 1998 prices). As the authors
indicate, these figures do not include indirect or intangible costs.
Equally important in terms of human suffering is the high prevalence
of incontinence among Australian nursing home residents, and this
also imposes a huge financial burden. One report found that urinary
incontinence affected 77% of a sample of 1659 such residents, and that
up to 25% of nursing staff time was spent dealing with urinary
leakage.6 The long term care of each
incontinent nursing home resident was estimated to cost $45 000 per
annum, or $450 million a year (1991 prices). Many incontinent nursing
home residents are not provided basic management, such as being taken
to the toilet at regular intervals, owing to a lack of trained nurses in
such facilities. Cost-effective strategies, such as applying
continence pads instead of changing wet beds (with laundry savings of
$40 per incontinent resident per month),7 are not routinely employed.
So, what are we doing about the problem of incontinence and its great
financial cost?
There is hope on the horizon. The World Health Organization (WHO) has
recently focused on the problem. At the first international WHO
consultation on incontinence, in June 1998, a team of 24 committees
(including five Australian clinicians and scientists) considered
the best way to eradicate incontinence. The issue of cost, and our poor
knowledge of the magnitude of the problem, was a major
concern.3 The proceedings have been
widely disseminated, and the second Consensus Meeting will be held in
July 2001. The WHO concluded that incontinence should be considered a
disease rather than a condition, in view of its debilitating effects
upon health and wellbeing.
In Australia, the Commonwealth Department of Health and Aged Care has
recently provided $15 million over five years to fund a National
Continence Management Strategy.8 Its expert advisory
committee, which includes nurse continence advisors and
representatives from general practice, urology, urogynaecology,
colorectal surgery, physiotherapy and geriatric medicine, first
met in September 1998. Funds are allocated to ensure more education of
healthcare providers, wider dissemination of information about
treatment to the public, and to develop a national management
framework. As a first step, a Continence Helpline has been
established (see Box). Three pilot projects about new ways to
increase the uptake of continence treatment are under way in Perth,
Wangaratta and the Hunter region. Recently, over one million dollars
was allocated to testing innovative treatments. A project to measure
all costs of incontinence for patients and for the tiers of funding
subsidy is currently being assessed.
The efforts of WHO and the Australian Government are laudable, but we
must rise to the challenge of helping those with incontinence as
individual doctors. By tactful enquiries of patients with known risk
factors,9 we may begin to identify the
silent two-thirds majority of affected patients who are frightened
to seek help. By starting conservative treatment and, where
appropriate, initiating a full investigation at an early stage, we
can render help quickly before the problem has become entrenched,
refractory and even more costly.
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Janette P Green, Irenie Smoker, Maria Theresa Ho and Kate H Moore. Urinary incontinence in subacute care — a retrospective analysis
of clinical outcomes and costs Med J Aust 2003; 178 (11): 550-553. [Healthcare]