JAGS 38:292-295, 1990
Impact of Urinary Incontinence on Health-Care Costs Teh-wei Hu,PhD
11 illness requires resources for diagnosis, treatment, and patient care. Urinary incontinence is no exception. Unlike cancer, heart ,disease, and AIDS, however, little is known about the impact of urinary incontinence on health-care costs. This is partly because incontinence is not a lifethreatening illness and thus society views it as an inconvenience rather than an illness, and partly because the medical-care-utilization data-collection system within the National Center for Health statistics does not have a special category for urinary incontinence. This article documents and estimates the magnitude of the impact of urinary incontinence on the cost of health care so that society in general can better recognize the hidden costs of urinary incontinence. Knowing the magnitude of the cost impact of urinary incontinence is important to the medical community in determining priorities for health-care services and research among various illnesses. The cost impact of urinary incontinence includes the overall effect on the allocation of resources at the societal as well as the institutional or individual level. Resources that come directly from the economy are used to diagnose, treat, care for, and rehabilitate incontinent individuals. The value of these resources is called the direct costs of incontinence and can be assessed directly from the market value of goods and services. These direct costs are the health-care costs referred to in this article. Indirect costs include the loss of work time during an incontinent individual’s physician visits or hospitalization, and/or the time spent by family members in caring for an incontinent individual. Indirect costs are assessed from opportunity costs or from the imputed value of resources. By
A
From the School of Public Health, University of California, Berkeley, California. Prepared for the National Institutes of Health Consensus Development Conferenceon Urinary Incontinencein Adults, Bethesda, Maryland, October 3-5, 1988. Address correspondence and reprint requests to Teh-wei Hu, PhD, University of California, Berkeley, School of Public Health, Department of Social and Administrative Health Sciences, Berkeley, CA 94720.
1990 by the American Geriatrics Society
definition, indirect costs are often subject to various assumptions, and thus the estimated magnitude of indirect costs is less definitive. This article will focus only on the direct health-care costs of incontinence.
ESTIMATION FRAMEWORK Urinary incontinence is an illness symptom that can result from multiple causes -eg, senile dementia, urinary tract infection, or loss of bladder function. Therefore, some of the health-care costs of urinary incontinence would be attributable to other diseases. This article focuses on the costs of the overall symptoms of urinary incontinence, regardless of their causes. Direct health-care costs of incontinence begin with diagnostic and medical evaluation, and then include the costs of treatment, routine care, and rehabilitation and/ or therapy. In addition, there are other cost consequences of incontinence, such as skin irritation, urinary tract infections, and falls, as well as additional nursinghome admissions and hospital stays. Not every incontinent individual incurs all of these costs. Because of the nature of incontinence, many patients ignore the diagnostic and treatment stages, and incur only the routinecare costs. At each stage, however, epidemologic investigation is needed to determine the frequency and amount of medical-care utilization that result from urinary incontinence. The diagnostic and medical evaluation category includes physician consultation and examination, laboratory tests, and various diagnostic procedures. These are mostly outpatient services. Patients with urinary incontinence could seek medical treatment, including surgery and/or medication. Hospital stays will be included in the costs of surgical procedures. The costs of routine incontinence care include three major cost items: labor, supplies, and laundry. Routine costs vary significantly depending on (1) the care setting; (2) the degree of incontinence; (3) the functional status of the patient; and (4) the techniques used to manage the urinary incontinence. In examining these four factors, it is important to separate the cost estimates for the community from the costs in institutional settings. Patients in the community include all age levels 0002-8614/90/$3.50
IAGS-MARCH 1990-VOL 38, NO. 3
URINARY INCONTINENCE AND HEALTH-CARE COSTS
293
(middle-ageor elderly), whereas patients in institutions calculated separately for nursing-home incontinent elare usually elderly. Patients in the community receive derly versus incontinent individuals (both young and mostly usual care, including diapers and changes of old) in the community. clothing and bedding, whereas the care for patients in Urinary incontinence-related health care in the nursinstitutions often involves some in-dwelling urinary ing home can be considered in five broad categories: catheters, bladder training or scheduled toileting, and/ diagnostic and medical evaluation, treatment (surgery/ or medication. The cost of caring for incontinent indi- drug), routine care (with or without a catheter), conseviduals also varies between private residences and quences of incontinence (skin irritation, urinary tract nursing homes. For instance, the imputed value of time infections, falls), and additionaladmission due to inconand laundry costs is usually lower at home than the costs tinence. It was estimated that 800,000 incontinent indiof labor and supplies used in nursing homes. Therefore, viduals are in nursing homes. Under each category, the it would be useful to examineseparately the health costs estimated frequency of usage from published statistics of caring for urinary incontinentindividualsin the com- and studies is multiplied by the unit costs of each munity and in institutions. health-care service to obtain the estimated cost components. The detailed statistical data sources are reported DATA SOURCES AND EMPIRICAL ESTIMATES by H U . ~Table 1 presents the incontinence-related Data Sources Estimation of the impact of urinary health-care costs in nursing homes as estimated at the incontinence on health-care costs relies on the preva- 1987 price level. The total health-care cost incurred at lence data for incontinence and on the amount of nursing homes in caring for incontinent elderly was health-care utilization and the unit costs of these $3.26 billion. Routine costs constituted about 61% of health-care services. Incontinence can occur at all ages, this figure, 5870 or $1.9 billion of which were accounted but the elderly, considered as those aged 65 or older, for by nursing time spent on the incontinent elderly, have a much higher prevalence rate and thus have re- supplies such as reusable or disposal diapers, and ceived more attention from the health-care professions. laundry costs. The average costs of routine care for inIt has been estimated that 970 of the elderly in the coun- continent elderly in nursing homes without the use of try are incontinent,' 296 of females between the ages of catheters was estimated at $6.00 per day per person, 25 and 64 are incontinent,* and 50% of nursing-home whereas the average cost of care for incontinent elderly residents are in~ontinent.~,' Based on the actual size of with catheters was estimated at $3.00 per day per perthese populations, 2.6 million community elderly are The second largest cost item under the nursing home incontinent, 1.2 million females between the ages of 25 and 64 are incontinent, and 800,000 elderly in nursing homes are incontinent-a total of 4.6 million incontinTABLE 1. URINARY INCONTINENCE-RELATED ent individuals in our society. HEALTH-CARE COSTS IN NURSING HOMES The costs of incontinence-related health-care services (IN MILLIONS OF DOLLARS AT 1987 PRICES) have been studied by numerous authors5-10;however, Percent the amount of incontinence-related health-care utilizaof Total Cost Category Dollar Amount tion has not been systematically reported. An earlier 6.0 0.2 study by the autho? relied on both U.S.and British data Diagnostic and medical evaluation to infer the amount of health-care utilization by incontinent individuals in the community and in the nursing Treatment Surgery 1.2 0.04 home. This article is an update of the author's earlier Pharmacy/Drug 0.7 0.02 study. It includes the costs of incontinence-related health care incurred by the nonelderly population (fe- Routine care Without catheter 1,906.2 58.4 males between the ages of 25 and 64) and is calculatedin With catheter 104.7 3.2 terms of the 1987 dollar value. The major cost differences between younger incontinent individuals and el- Incontinence consequences derly incontinent individuals in the community are that Skin irritation 70.6 2.2 Urinary tract infection 85.3 2.6 (1) the younger individuals do not require assistance Falls 1.2 0.04 from other familymembers; and (2) the consequencesof incontinence such as falls and skin irritation are much Added admissions due to 1,087.7 33.3 less prevalent among younger incontinent individuals. incontinence
Empirical Estimates Because of the obvious differences in the type of health-careservices and the unit cost of these health-care services between nursing homes and the community, the empirical cost estimates are
Total nursing-home costs
$3,263.8
100.0
Source: H u T-W:The Economic Impact of Urinary Incontinence. CIin Geriatr Med 2:673-687. 1986.5These figures have been updated by costof-medical-care inflationary rate of 1.218 from 1984 to 1987.
294 HU
category is the added nursing-home admissions that result from incontinence. One reason family members send their elderly relatives to nursing homes is incontinence. To assess the magnitude of the effect of incontinence on nursing-home admissions, a survey of incontinent patients among six nursing homes in Pennsylvania indicated that 5% of them indicated incontinence as the main reason for being admitted to the nursing h0me.l' Thus, it was assumed that 5%of incontinent patients in nursing homes would not reside at nursing homes were they continent. Given the annual costs of nursing-home care, $27,350 per person," the total costs of added nursing-home admissions resulting from incontinence would be $1.08 billion dollars. The nursing-home incontinence-care costs for diagnosis, evaluation, and treatment are relatively small $6 million for diagnostic and medical evaluation, $1.2 million for surgical services, and $0.7 million for pharmacy/drug prescriptions. The cost consequences of incontinence, such as skin irritation, urinary tract infection, and falls, are rather difficult to estimate. No national data are available for these incidents. Surveys in six nursing homes in Pennsylvania indicated that 35% of incontinent patients had a rash or skin redness requiring skin medication and nursing care, 12% required a physician's prescription for extensive skin treatment (including heat treatment), and 3% have decubitus ulcer^.^ The costs of care for skin irritation ranged from $55 to $166 per year depending on the seriousness of the skin condition. Given the incidence of skin condition and the costs of care, the total costs of care of skin irritation was $70.6 million. Incidence of urinary tract infection due to incontinence was estimated to be about 20% of incontinence patient^.^,' Given the costs of treatment of the infection, the total cost of treatment was $85 million. Based on the Canadian study of falls in relation to incontinence due to wet floor and injury,13the cost of falls resulting from incontinence was estimated to be $1.2 million. Putting these nursing-home incontinence-related costs of $3.26 billion in a different perspective, on the average, nursing homes spent about $4,104 for each incontinent elderly person in 1987, or more than 10%of total national nursing-home costs. The costs of urinary incontinence-related health care in the community are presented in Table 2. Community costs include both younger (aged 24-64) and older (aged 2 65) incontinent individuals. The total costs of community care were $7 billion, of which about $4.8 billion was spent for elderly incontinent care and $2.2 billion for younger incontinent individuals. The pattern of cost distribution among incontinent individuals in the community indicates that $4.2 billion, or about 60% of the total community-care costs, are spent on routine care. This figure is derived from the assumption of $2.50 per day for an incontinent individual living in the community, regardless of age. The $2.50
IAGS-MARCH 1990-VOL 38, NO. 3
TABLE 2. URINARY INCONTINENCE-RELATED HEALTH-CARE COSTS IN THE COMMUNITY (IN MILLIONS OF DOLLARS AT 1987 PRICES) Cost Category
Diagnostic and medical evaluation Treatment Surgery Pharmacy/drug
Dollar Amount
Percent of Total
14
0.2
14 7
0.1
4,200
60.0
112 140 56
2.0 0.8
Longer hospital stays
2,457
35.1
Total community costs
$7,000
100.0
Routine care Incontinence consequences Skin imtation Urinary tract infection Falls
0.2
1.6
Source: Hu T-W:The Economic Impact of Urinary Incontinence. Clin Geriatr Med 2:673-687, 1986.5Added to this is use of health care by the female population aged 24 - 64; the figure is adjusted by the cost of medical care inflationary rate of 1.218 from 1984 to 1987.
includes the cost of disposable pads or reusable briefs and laundry costs. The second largest incontinence-related health-care cost category is longer hospital stays due to incontinence. A study by Katz et a16found that an incontinent individual may stay nine days longer in hospitals in a given year. Given the size of the noninstitutionalized incontinent elderly population who use hospitals (517,600 persons), this implied an additional 4.6 hospital days attributable to urinary incontinence. These hospital costs become $2.4 billion a year. The remaining incontinence-related health-care costs include about $112 million for skin irritations, $140 million for urinary tract infections, and $56 million as the result of falls. Finally, about $14 million is spent for outpatient diagnostic and medical evaluation, $14 million for surgical treatment relating to incontinence, and $7 million for pharmacy/drug usage relating to incontinence. Dividing the total community cost by the number of incontinent individuals, the average cost per person would be $1,848 in 1987 dollar value. Although the total costs of urinary incontinence in the community are more than twice the total nursing-home costs for urinary incontinence ($7 billion versus $3.3 billion), the per capita cost of urinary incontinence in nursing homes is more than twice the community-care costs ($4,104 versus $1,848). The higher per capita costs for nursinghome incontinent elderly result mainly from the more severe incontinence and the higher labor and supply costs incurred in nursing homes as compared to private residences. The higher total incontinence-care costs in
IAGS-MARCH 1990-VOL 38, NO.3
the community result from the much larger number of individuals with incontinence symptoms in the community versus the number of those in nursing homes. CONCLUDING REMARKS Magnitude of Costs This article has estimated that the direct health-care costs relating to urinary incontinence were more than $10 billion in 1987 prices. This article does not discuss the indirect costs of urinary incontinence. The inclusion of the indirect costs would make the total economic impact of urinary incontinence even greater. Comparing the $10 billion direct costs to recent estimates of the direct health-care costs of two major illnesses-AIDS ($1.8 billion in 1987 prices)" and senile dementia ($15.1 billion in 1987 prices)llthe magnitude of the impact of urinary incontinence on health-care costs is quite substantial. Society and the medical profession should be aware of the magnitude of the cost impact of urinary incontinence. Given the magnitude of this cost impact, the potential economic benefits from medical research and intenrention into urinary incontinence would include not only improved physical and psychological well-being for incontinent individuals, but also improved economic well-being for the society. The society could save the resources currently used for urinary incontinence and use them for other productive activities. It should be noted that these cost estimates rely on data sources such as the prevalence rate, unit cost of services, and amount of health-care utilization. Because not all of these data are complete and up to date, various assumptions have been made in order to derive this figure. Different assumptions may generate dollar cost estimates greater or less than $10 billion. A more definitive estimate of the cost of urinary incontinence would require reliable epidemiologic data and health-care utilization data related to urinary incontinence. Reimbursement When society is incurring these costs of care, one is inclined to ask: (1) Who is paying these costs, ie, what is the distributional impact of these costs? and (2) What are the alternative approaches to reducing the costs of urinary incontinence, ie, what are the economic incentives and efficiency issues? Under current private medical insurance policies and government Medicaid and Medicare programs, the costs of routine care for urinary incontinence, which are about 6O9b of the total costs, are not usually reimbursed by insurance policies or the government. A few states reimburse extra funds to nursing homes for incontinent patients under their Medicaid program. Otherwise, these routine-care costs are absorbed by individuals at home or by nursing homes. Only portions of the diagnosis or treatment of urinary incontinence are reimbursed by insurance companies or by public insurance programs. For instance, urodynamic evaluation, surgical procedures, and catheterization can be reimbursed
URINARY INCONTINENCE AND HEALTH-CARE COSTS
295
by various insurance programs because these are considered medical procedures. The current reimbursement scheme provides more economic incentives for nursing homes to catheterize their incontinent residents than to give them disposable or reusable absorbent briefs. The use of catheterization may cause more physical discomfort and possible urinary tract infection and may lead to higher medical costs. Again, however, the cost of treatment for these infections can be reimbursed by the insurance program and need not be borne by the nursing home. This one example illustrates some of the cost consequences of reimbursement policies on nursinghome management of incontinent residents. Studies have indicated that certain biofeedback and behavioral training can be effective in reducing incontinence in the community setting as well as in nursing homes. More cost-effectiveness studies are needed to identify the most efficient approach for certain types of incontinence so that resources can be used most effectively. In summary, public policymakers, medical researchers, and health-care professionals should work together to increase continence for all individuals, thereby reducing the costs of incontinence-related health-care services. REFERENCES 1. Harris T Aging in the eighties, prevalence and impact of urinary problems in individuals age 65 years and over. NCHS Advance Data, Number 121, National Center for Health Statistics, U.S.
Public Health Service,l986 2. Henog R Prevalence and inadence of urinary incontinence in a community-dwelling population. J Am Geriatr Soc 38:273-281, 1990 3. Hu T-W, Igou J, Kaltreider L, et al: Cost-EffectivenessEvaluation 4. 5. 6. 7. 8.
of Bladder Training. The Pennsylvania State University, University Park, PA, 1988 Ouslander JG, Kane RL, Abrass I B Urinary incontinence in elderly nursing home patients. JAMA 2 4 8 1194-1198,1982 Hu T-W The economic impact of urinary incontinence. Clin Geriatr Med 2(4):673-687,1986 Katz S, Papsidero J, Stevens R Cost of incontinence. Center for Policy Analysis in Aging and Long-term Care, Michigan State University, East Lansing, MI (unpublished paper), 1982 Ouslander JG, Kane RL The cost of urinary incontinence in nursing homes. Med Care 22:69-79,1983 Sowell V, Schnelle JF, Hu T-W. A cost comparison of five methods of managing urinary incontinence. Rev Bull 13:411-
414,1987 9. Weissert WG: Long-term care: current policy and direction for the 80s. Paper presented at the White House Conference on Aging, Long-Term Care Session, Washington, DC, 1981 10. Williams T, Foerster J, Proder J, et al: A new double-layered launderable bed sheet for patients with urinary incontinence. J Am Geriatr Soc 29:520-524,1981 11. Huang AL, Cartwright W, Hu T-W Economic costs of senile dementia in the United States, 1985. Public Health Rep 103(1):3-7, 1988 12. Strahan G: Nursing home characteristics: preliminary data from the 1985 National Nursing Home Survey, NCHS Advance Data, Number 131, National Center for Health Statistics, U.S. Public Health Service, 1987 13. Ashley MF, Gryfe CI, Aimes A: A longitudinal study of falls in an elderly population: 11. some circumstancesof falling. Age Ageing 6211-220,1977 14. ScitovskyAA, Rice D Estimatesof the directand indirect costs of
Acquired Immunodefiaency Syndrome in the United States, 1985.1986.1991. Public Health ReD 102(1):5-17,1987
Impact of Urinary Incontinence on Health-Care Costs Teh-wei Hu,PhD
11 illness requires resources for diagnosis, treatment, and patient care. Urinary incontinence is no exception. Unlike cancer, heart ,disease, and AIDS, however, little is known about the impact of urinary incontinence on health-care costs. This is partly because incontinence is not a lifethreatening illness and thus society views it as an inconvenience rather than an illness, and partly because the medical-care-utilization data-collection system within the National Center for Health statistics does not have a special category for urinary incontinence. This article documents and estimates the magnitude of the impact of urinary incontinence on the cost of health care so that society in general can better recognize the hidden costs of urinary incontinence. Knowing the magnitude of the cost impact of urinary incontinence is important to the medical community in determining priorities for health-care services and research among various illnesses. The cost impact of urinary incontinence includes the overall effect on the allocation of resources at the societal as well as the institutional or individual level. Resources that come directly from the economy are used to diagnose, treat, care for, and rehabilitate incontinent individuals. The value of these resources is called the direct costs of incontinence and can be assessed directly from the market value of goods and services. These direct costs are the health-care costs referred to in this article. Indirect costs include the loss of work time during an incontinent individual’s physician visits or hospitalization, and/or the time spent by family members in caring for an incontinent individual. Indirect costs are assessed from opportunity costs or from the imputed value of resources. By
A
From the School of Public Health, University of California, Berkeley, California. Prepared for the National Institutes of Health Consensus Development Conferenceon Urinary Incontinencein Adults, Bethesda, Maryland, October 3-5, 1988. Address correspondence and reprint requests to Teh-wei Hu, PhD, University of California, Berkeley, School of Public Health, Department of Social and Administrative Health Sciences, Berkeley, CA 94720.
1990 by the American Geriatrics Society
definition, indirect costs are often subject to various assumptions, and thus the estimated magnitude of indirect costs is less definitive. This article will focus only on the direct health-care costs of incontinence.
ESTIMATION FRAMEWORK Urinary incontinence is an illness symptom that can result from multiple causes -eg, senile dementia, urinary tract infection, or loss of bladder function. Therefore, some of the health-care costs of urinary incontinence would be attributable to other diseases. This article focuses on the costs of the overall symptoms of urinary incontinence, regardless of their causes. Direct health-care costs of incontinence begin with diagnostic and medical evaluation, and then include the costs of treatment, routine care, and rehabilitation and/ or therapy. In addition, there are other cost consequences of incontinence, such as skin irritation, urinary tract infections, and falls, as well as additional nursinghome admissions and hospital stays. Not every incontinent individual incurs all of these costs. Because of the nature of incontinence, many patients ignore the diagnostic and treatment stages, and incur only the routinecare costs. At each stage, however, epidemologic investigation is needed to determine the frequency and amount of medical-care utilization that result from urinary incontinence. The diagnostic and medical evaluation category includes physician consultation and examination, laboratory tests, and various diagnostic procedures. These are mostly outpatient services. Patients with urinary incontinence could seek medical treatment, including surgery and/or medication. Hospital stays will be included in the costs of surgical procedures. The costs of routine incontinence care include three major cost items: labor, supplies, and laundry. Routine costs vary significantly depending on (1) the care setting; (2) the degree of incontinence; (3) the functional status of the patient; and (4) the techniques used to manage the urinary incontinence. In examining these four factors, it is important to separate the cost estimates for the community from the costs in institutional settings. Patients in the community include all age levels 0002-8614/90/$3.50
IAGS-MARCH 1990-VOL 38, NO. 3
URINARY INCONTINENCE AND HEALTH-CARE COSTS
293
(middle-ageor elderly), whereas patients in institutions calculated separately for nursing-home incontinent elare usually elderly. Patients in the community receive derly versus incontinent individuals (both young and mostly usual care, including diapers and changes of old) in the community. clothing and bedding, whereas the care for patients in Urinary incontinence-related health care in the nursinstitutions often involves some in-dwelling urinary ing home can be considered in five broad categories: catheters, bladder training or scheduled toileting, and/ diagnostic and medical evaluation, treatment (surgery/ or medication. The cost of caring for incontinent indi- drug), routine care (with or without a catheter), conseviduals also varies between private residences and quences of incontinence (skin irritation, urinary tract nursing homes. For instance, the imputed value of time infections, falls), and additionaladmission due to inconand laundry costs is usually lower at home than the costs tinence. It was estimated that 800,000 incontinent indiof labor and supplies used in nursing homes. Therefore, viduals are in nursing homes. Under each category, the it would be useful to examineseparately the health costs estimated frequency of usage from published statistics of caring for urinary incontinentindividualsin the com- and studies is multiplied by the unit costs of each munity and in institutions. health-care service to obtain the estimated cost components. The detailed statistical data sources are reported DATA SOURCES AND EMPIRICAL ESTIMATES by H U . ~Table 1 presents the incontinence-related Data Sources Estimation of the impact of urinary health-care costs in nursing homes as estimated at the incontinence on health-care costs relies on the preva- 1987 price level. The total health-care cost incurred at lence data for incontinence and on the amount of nursing homes in caring for incontinent elderly was health-care utilization and the unit costs of these $3.26 billion. Routine costs constituted about 61% of health-care services. Incontinence can occur at all ages, this figure, 5870 or $1.9 billion of which were accounted but the elderly, considered as those aged 65 or older, for by nursing time spent on the incontinent elderly, have a much higher prevalence rate and thus have re- supplies such as reusable or disposal diapers, and ceived more attention from the health-care professions. laundry costs. The average costs of routine care for inIt has been estimated that 970 of the elderly in the coun- continent elderly in nursing homes without the use of try are incontinent,' 296 of females between the ages of catheters was estimated at $6.00 per day per person, 25 and 64 are incontinent,* and 50% of nursing-home whereas the average cost of care for incontinent elderly residents are in~ontinent.~,' Based on the actual size of with catheters was estimated at $3.00 per day per perthese populations, 2.6 million community elderly are The second largest cost item under the nursing home incontinent, 1.2 million females between the ages of 25 and 64 are incontinent, and 800,000 elderly in nursing homes are incontinent-a total of 4.6 million incontinTABLE 1. URINARY INCONTINENCE-RELATED ent individuals in our society. HEALTH-CARE COSTS IN NURSING HOMES The costs of incontinence-related health-care services (IN MILLIONS OF DOLLARS AT 1987 PRICES) have been studied by numerous authors5-10;however, Percent the amount of incontinence-related health-care utilizaof Total Cost Category Dollar Amount tion has not been systematically reported. An earlier 6.0 0.2 study by the autho? relied on both U.S.and British data Diagnostic and medical evaluation to infer the amount of health-care utilization by incontinent individuals in the community and in the nursing Treatment Surgery 1.2 0.04 home. This article is an update of the author's earlier Pharmacy/Drug 0.7 0.02 study. It includes the costs of incontinence-related health care incurred by the nonelderly population (fe- Routine care Without catheter 1,906.2 58.4 males between the ages of 25 and 64) and is calculatedin With catheter 104.7 3.2 terms of the 1987 dollar value. The major cost differences between younger incontinent individuals and el- Incontinence consequences derly incontinent individuals in the community are that Skin irritation 70.6 2.2 Urinary tract infection 85.3 2.6 (1) the younger individuals do not require assistance Falls 1.2 0.04 from other familymembers; and (2) the consequencesof incontinence such as falls and skin irritation are much Added admissions due to 1,087.7 33.3 less prevalent among younger incontinent individuals. incontinence
Empirical Estimates Because of the obvious differences in the type of health-careservices and the unit cost of these health-care services between nursing homes and the community, the empirical cost estimates are
Total nursing-home costs
$3,263.8
100.0
Source: H u T-W:The Economic Impact of Urinary Incontinence. CIin Geriatr Med 2:673-687. 1986.5These figures have been updated by costof-medical-care inflationary rate of 1.218 from 1984 to 1987.
294 HU
category is the added nursing-home admissions that result from incontinence. One reason family members send their elderly relatives to nursing homes is incontinence. To assess the magnitude of the effect of incontinence on nursing-home admissions, a survey of incontinent patients among six nursing homes in Pennsylvania indicated that 5% of them indicated incontinence as the main reason for being admitted to the nursing h0me.l' Thus, it was assumed that 5%of incontinent patients in nursing homes would not reside at nursing homes were they continent. Given the annual costs of nursing-home care, $27,350 per person," the total costs of added nursing-home admissions resulting from incontinence would be $1.08 billion dollars. The nursing-home incontinence-care costs for diagnosis, evaluation, and treatment are relatively small $6 million for diagnostic and medical evaluation, $1.2 million for surgical services, and $0.7 million for pharmacy/drug prescriptions. The cost consequences of incontinence, such as skin irritation, urinary tract infection, and falls, are rather difficult to estimate. No national data are available for these incidents. Surveys in six nursing homes in Pennsylvania indicated that 35% of incontinent patients had a rash or skin redness requiring skin medication and nursing care, 12% required a physician's prescription for extensive skin treatment (including heat treatment), and 3% have decubitus ulcer^.^ The costs of care for skin irritation ranged from $55 to $166 per year depending on the seriousness of the skin condition. Given the incidence of skin condition and the costs of care, the total costs of care of skin irritation was $70.6 million. Incidence of urinary tract infection due to incontinence was estimated to be about 20% of incontinence patient^.^,' Given the costs of treatment of the infection, the total cost of treatment was $85 million. Based on the Canadian study of falls in relation to incontinence due to wet floor and injury,13the cost of falls resulting from incontinence was estimated to be $1.2 million. Putting these nursing-home incontinence-related costs of $3.26 billion in a different perspective, on the average, nursing homes spent about $4,104 for each incontinent elderly person in 1987, or more than 10%of total national nursing-home costs. The costs of urinary incontinence-related health care in the community are presented in Table 2. Community costs include both younger (aged 24-64) and older (aged 2 65) incontinent individuals. The total costs of community care were $7 billion, of which about $4.8 billion was spent for elderly incontinent care and $2.2 billion for younger incontinent individuals. The pattern of cost distribution among incontinent individuals in the community indicates that $4.2 billion, or about 60% of the total community-care costs, are spent on routine care. This figure is derived from the assumption of $2.50 per day for an incontinent individual living in the community, regardless of age. The $2.50
IAGS-MARCH 1990-VOL 38, NO. 3
TABLE 2. URINARY INCONTINENCE-RELATED HEALTH-CARE COSTS IN THE COMMUNITY (IN MILLIONS OF DOLLARS AT 1987 PRICES) Cost Category
Diagnostic and medical evaluation Treatment Surgery Pharmacy/drug
Dollar Amount
Percent of Total
14
0.2
14 7
0.1
4,200
60.0
112 140 56
2.0 0.8
Longer hospital stays
2,457
35.1
Total community costs
$7,000
100.0
Routine care Incontinence consequences Skin imtation Urinary tract infection Falls
0.2
1.6
Source: Hu T-W:The Economic Impact of Urinary Incontinence. Clin Geriatr Med 2:673-687, 1986.5Added to this is use of health care by the female population aged 24 - 64; the figure is adjusted by the cost of medical care inflationary rate of 1.218 from 1984 to 1987.
includes the cost of disposable pads or reusable briefs and laundry costs. The second largest incontinence-related health-care cost category is longer hospital stays due to incontinence. A study by Katz et a16found that an incontinent individual may stay nine days longer in hospitals in a given year. Given the size of the noninstitutionalized incontinent elderly population who use hospitals (517,600 persons), this implied an additional 4.6 hospital days attributable to urinary incontinence. These hospital costs become $2.4 billion a year. The remaining incontinence-related health-care costs include about $112 million for skin irritations, $140 million for urinary tract infections, and $56 million as the result of falls. Finally, about $14 million is spent for outpatient diagnostic and medical evaluation, $14 million for surgical treatment relating to incontinence, and $7 million for pharmacy/drug usage relating to incontinence. Dividing the total community cost by the number of incontinent individuals, the average cost per person would be $1,848 in 1987 dollar value. Although the total costs of urinary incontinence in the community are more than twice the total nursing-home costs for urinary incontinence ($7 billion versus $3.3 billion), the per capita cost of urinary incontinence in nursing homes is more than twice the community-care costs ($4,104 versus $1,848). The higher per capita costs for nursinghome incontinent elderly result mainly from the more severe incontinence and the higher labor and supply costs incurred in nursing homes as compared to private residences. The higher total incontinence-care costs in
IAGS-MARCH 1990-VOL 38, NO.3
the community result from the much larger number of individuals with incontinence symptoms in the community versus the number of those in nursing homes. CONCLUDING REMARKS Magnitude of Costs This article has estimated that the direct health-care costs relating to urinary incontinence were more than $10 billion in 1987 prices. This article does not discuss the indirect costs of urinary incontinence. The inclusion of the indirect costs would make the total economic impact of urinary incontinence even greater. Comparing the $10 billion direct costs to recent estimates of the direct health-care costs of two major illnesses-AIDS ($1.8 billion in 1987 prices)" and senile dementia ($15.1 billion in 1987 prices)llthe magnitude of the impact of urinary incontinence on health-care costs is quite substantial. Society and the medical profession should be aware of the magnitude of the cost impact of urinary incontinence. Given the magnitude of this cost impact, the potential economic benefits from medical research and intenrention into urinary incontinence would include not only improved physical and psychological well-being for incontinent individuals, but also improved economic well-being for the society. The society could save the resources currently used for urinary incontinence and use them for other productive activities. It should be noted that these cost estimates rely on data sources such as the prevalence rate, unit cost of services, and amount of health-care utilization. Because not all of these data are complete and up to date, various assumptions have been made in order to derive this figure. Different assumptions may generate dollar cost estimates greater or less than $10 billion. A more definitive estimate of the cost of urinary incontinence would require reliable epidemiologic data and health-care utilization data related to urinary incontinence. Reimbursement When society is incurring these costs of care, one is inclined to ask: (1) Who is paying these costs, ie, what is the distributional impact of these costs? and (2) What are the alternative approaches to reducing the costs of urinary incontinence, ie, what are the economic incentives and efficiency issues? Under current private medical insurance policies and government Medicaid and Medicare programs, the costs of routine care for urinary incontinence, which are about 6O9b of the total costs, are not usually reimbursed by insurance policies or the government. A few states reimburse extra funds to nursing homes for incontinent patients under their Medicaid program. Otherwise, these routine-care costs are absorbed by individuals at home or by nursing homes. Only portions of the diagnosis or treatment of urinary incontinence are reimbursed by insurance companies or by public insurance programs. For instance, urodynamic evaluation, surgical procedures, and catheterization can be reimbursed
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by various insurance programs because these are considered medical procedures. The current reimbursement scheme provides more economic incentives for nursing homes to catheterize their incontinent residents than to give them disposable or reusable absorbent briefs. The use of catheterization may cause more physical discomfort and possible urinary tract infection and may lead to higher medical costs. Again, however, the cost of treatment for these infections can be reimbursed by the insurance program and need not be borne by the nursing home. This one example illustrates some of the cost consequences of reimbursement policies on nursinghome management of incontinent residents. Studies have indicated that certain biofeedback and behavioral training can be effective in reducing incontinence in the community setting as well as in nursing homes. More cost-effectiveness studies are needed to identify the most efficient approach for certain types of incontinence so that resources can be used most effectively. In summary, public policymakers, medical researchers, and health-care professionals should work together to increase continence for all individuals, thereby reducing the costs of incontinence-related health-care services. REFERENCES 1. Harris T Aging in the eighties, prevalence and impact of urinary problems in individuals age 65 years and over. NCHS Advance Data, Number 121, National Center for Health Statistics, U.S.
Public Health Service,l986 2. Henog R Prevalence and inadence of urinary incontinence in a community-dwelling population. J Am Geriatr Soc 38:273-281, 1990 3. Hu T-W, Igou J, Kaltreider L, et al: Cost-EffectivenessEvaluation 4. 5. 6. 7. 8.
of Bladder Training. The Pennsylvania State University, University Park, PA, 1988 Ouslander JG, Kane RL, Abrass I B Urinary incontinence in elderly nursing home patients. JAMA 2 4 8 1194-1198,1982 Hu T-W The economic impact of urinary incontinence. Clin Geriatr Med 2(4):673-687,1986 Katz S, Papsidero J, Stevens R Cost of incontinence. Center for Policy Analysis in Aging and Long-term Care, Michigan State University, East Lansing, MI (unpublished paper), 1982 Ouslander JG, Kane RL The cost of urinary incontinence in nursing homes. Med Care 22:69-79,1983 Sowell V, Schnelle JF, Hu T-W. A cost comparison of five methods of managing urinary incontinence. Rev Bull 13:411-
414,1987 9. Weissert WG: Long-term care: current policy and direction for the 80s. Paper presented at the White House Conference on Aging, Long-Term Care Session, Washington, DC, 1981 10. Williams T, Foerster J, Proder J, et al: A new double-layered launderable bed sheet for patients with urinary incontinence. J Am Geriatr Soc 29:520-524,1981 11. Huang AL, Cartwright W, Hu T-W Economic costs of senile dementia in the United States, 1985. Public Health Rep 103(1):3-7, 1988 12. Strahan G: Nursing home characteristics: preliminary data from the 1985 National Nursing Home Survey, NCHS Advance Data, Number 131, National Center for Health Statistics, U.S. Public Health Service, 1987 13. Ashley MF, Gryfe CI, Aimes A: A longitudinal study of falls in an elderly population: 11. some circumstancesof falling. Age Ageing 6211-220,1977 14. ScitovskyAA, Rice D Estimatesof the directand indirect costs of
Acquired Immunodefiaency Syndrome in the United States, 1985.1986.1991. Public Health ReD 102(1):5-17,1987
