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- MATERIALS AND METHODS
- CONFLICT OF INTEREST
Increasing and competing demands on healthcare budgets coupled with the ageing populations in most Western countries is acknowledged to have caused pressure on health expenditure. In addition growing awareness of health issues, particularly those affecting older adults are prominent in both the medical literature and the popular media. Overactive bladder syndrome (OAB) and urinary incontinence (UI) are examples of such health issues. OAB is a highly prevalent condition affecting 12–17% of men and women [1–3]. About 28% of men and 49% of women reporting OAB symptoms also report UI with the vast majority being urgency UI (UUI) . The condition is known to have serious impact on quality of life (QoL) and well-being [4,5].
Relatively few published studies exist that describe the cost of illness for OAB [6–8] but several exist for UI [9–14]. These studies vary in terms of the epidemiological data used, approach taken (bottom-up or top-down), costs included (direct, indirect or intangible) and country or regions for which costs are reported. Direct costs relate to diagnosis, delivering and/or receiving treatment as well as treating sequelae of the condition. Indirect costs include work absenteeism, impaired performance at work (presenteeism), and changes in job status. Intangible costs cover those that impact a persons well being and QoL and are difficult to calculate in monetary terms.
Annual direct costs of OAB were recently investigated from a social perspective in Germany and estimated at €3.98 billion . The authors found a large share (45%) of the total costs were for nursing care (€1.80 billion) and medication (2%) had the smallest share (i.e. €0.08 billion). Another study documented that institutionalized patients account for 25% of the total costs of OAB in the USA . Studies in the UK and USA have documented direct costs associated with UI care exceed those associated with other common chronic illnesses such as coronary care and cancer care .
There are several other conditions closely associated with OAB that may also influence the total costs. These conditions include, but are not limited to depression, disturbed sleep, falls and fractures, skin infections, and UTIs [16–22]. Some authors propose the evidence for an association between the risk of falling and the presence of UI in older people merits targeted interventions . It has been found that these conditions are related to a significant cost in patients with OAB [6,11,19].
In 2002, the ICS released updated, standardized definitions for OAB, incontinence, and other LUTS . OAB was described as ‘urgency, with or without urgency incontinence, usually with frequency and nocturia, in the absence of pathological or metabolic conditions that might be able to explain these symptoms’. Urgency UI (UUI) comprises a subset of the total OAB population and is defined as an ‘involuntary leakage accompanied by or immediately preceded by urgency’.
To address the need for current prevalence data using the ICS 2002 definition, a large epidemiological survey, the EPIC study, was undertaken in Canada, Germany, Italy, Sweden and the UK . The study was primarily designed to investigate the self-reported prevalence of OAB in the general population and to evaluate the impact of OAB on patient bother, healthcare-seeking behaviours and other consequences such as depression, and work productivity [24–26].
The objective of the present research was to use data provided by EPIC and other recent cost of illness studies to report updated estimates of the direct cost to the national healthcare and social services of six Western countries: Canada, Germany, Italy, Spain, Sweden and the UK. In addition we sought to quantify the indirect cost to society of lost productivity associated with people having OAB symptoms.
- Top of page
- MATERIALS AND METHODS
- CONFLICT OF INTEREST
This studied showed the annual direct costs of OAB in six countries to be ≈€3.9 billion with additional costs for nursing home stays (€4.7 billion per year) and loss productivity due to work absenteeism (€1.1 billion is per year). The estimated total cost therefore for the ≈25 million patients with OAB in these countries is €9.7 billion. This analysis differed from other published studies because most other studies used incremental costs associated with OAB compared with the general population. Hence, the present cost estimates are slightly lower than previously published studies [6–8]. Varying the excess proportion of patients with OAB who experienced depression, costs associated with physician visits related to OAB symptoms as well as costs related to OAB medications exerted the most effect on annual cost estimates.
The EPIC study  was the first major multinational population-based study to assess the prevalence of OAB based on the 2002 ICS definitions of LUTS . The OAB definition change  resulted in estimates of fewer people reporting OAB symptoms than in previously published figures . It was also the first multinational population-based study to examine associations between OAB symptoms and depression, and the impact of OAB symptoms on work productivity. The present report, which was based on previous studies, used real-life population-based survey data to estimate the incremental impact of these cost consequences.
Sensitivity analysis revealed that costs related to medical visits and treatment exert the most effect on the total direct costs (excluding nursing home and lost productivity costs). Difference in costs related to OAB may vary substantially between countries as do country practice for the average number of visits per year, and the frequency of specialist visits. In addition, the overall population size with OAB symptoms has an impact. These factors are very influential for the total costs for physician visits and treatment patterns, which probably account for the differences seen. Previous work  reported pad use to be the primary cost driver and the probability of pad use and numbers of pads used were based on expert estimates. The present study used actual population-based survey data to populate the model, which may account for the differences seen.
One other study  in the USA used a similar methodology to ours for calculating OAB-related lost productivity costs in the USA. They reported lost productivity costs to be equal to ≈$841 million, which was comparable with our estimate of €1.1 billion. One of the limitations of the present study is that we were unable to extend the estimate of productivity loss associated with OAB to also include the productivity loss while at work (e.g. presenteeism). Recent research, suggests that presenteeism accounts for a larger proportion of productivity losses than absenteeism in OAB [24,25]. Many of the cost consequences in this model (e.g. depression, UTIs, fractures, skin infections) have been shown to be associated with OAB but caution should be used in interpreting this data, as more research is needed to prove a causal link.
This cost of illness estimates in the present study may under-estimate the true economic burden, as we have not been able to include all indirect costs (e.g. loss productivity data due to presenteeism was not included). The present study did not capture the psychological burden or the impact on health-related QoL caused by OAB. Future research should consider these issues to evaluate the total impact of OAB. However, the estimated cost burden to the healthcare sector even without these components is sufficiently large that countries with ageing populations should evaluate cost-effective treatments for OAB that have the potential to reduce both the human and economic burden.