Supplements New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatmen
New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatment Costs
Overactive bladder (OAB) is a common
urinary dysfunction that
includes urinary urgency, frequency,
nocturia, and/or urge urinary incontinence.
OAB is estimated to occur in 33
million Americans or approximately 16.5%
of the population.1,2 In the long-term care
setting, it is estimated that as many as half of
all residents suffer from incontinence,3,4 and
it is considered to be a serious medical concern
for several reasons. First, OAB is associated
with medical and quality of life
consequences that further compromise the
health and well-being of both institutionalized
and community-dwelling patients.
Specifically, incontinence has been associated
with an increased risk of urinary tract
infections, pressure ulcers, falls, and fractures,5-7 which may severely compromise
patient function and overall health. Second,
incontinence consumes medical resources
and staff and provider time, driving up the
cost of care.8 This supplement to The
American Journal of Managed Care features
several articles on the medical, quality
of life, social, and economic impact of OAB.
As described in articles by Ko et al, OAB
exacts a profound toll on quality of life;
incontinence frequently results in social isolation,
depression, and the inability to lead a
normal, fulfilling life.9-11
In addition to substantial medical and
quality of life sequelae of OAB, the economic
impact is great. The estimated total economic
cost for urinary incontinence (UI)
and OAB was $19.5 billion and $12.6 billion,
respectively in 2000.12 For both conditions,
70% was incurred in the community and 30%
in institutions.12 When indirect costs, such
as lost wages and productivity, are included,
the annual cost of incontinence increases to
more than $26 billion, with institutional
care accounting for more than $8.4 billion
(23%).13 For managed care, OAB is a significant
driver of health plan costs. A recent
insurance claims analysis shows annual
spending for patients with OAB to be nearly
5-fold greater than for patients without the
condition ($5018 vs $1767, respectively).14
Pharmacotherapy is effective for many
patients and usually is recommended in
addition to behavioral modification when
that measure alone fails.15 Yet, despite evidence
that interventions can control both
incontinence and OAB, they remain underdiagnosed
and undertreated. As described
by Jumadilova et al in this supplement,
pharmacotherapy for UI may be underutilized
in the nursing home setting.16 This
may be a result of physician uncertainty
regarding the appropriateness of pharmacotherapy
across a range of patients with
varied illnesses and functional abilities.
Here, as well as in the community setting,
healthcare providers and patients alike
continue to believe the myth that urinary
problems are simply a normal and
inevitable part of aging, and some patients
are simply too embarrassed to talk to their
healthcare providers about UI.4,10,17 As
reported by Shaya et al in this publication,
patients who do seek treatment frequently
do not adhere to prescribed treatment regimens
for a variety of reasons, including
the uncomfortable side effects (most
notably dry mouth) associated with many
OAB medical treatments.18,19 Another reason
for low adherence to therapy is ineffective
patient counseling by healthcare
providers, which can lead to unmet patient
expectations in the initial days and weeks of
Achieving timely diagnosis and consistent
treatment requires a shared understanding
among patients, caregivers, and healthcare
providers that OAB and UI in adults can usually
be improved.20 Roberts et al report that
tolterodine is associated with significantly less
dry mouth than oxybutynin,21 which may
prompt patients to continue treatment over
the longer term. Clinical effectiveness, as well
as tolerability and cost of the therapy, will
have the greatest impact on patients'adherence
to long-term treatment. Persistence, as
described in the article by Perfetto et al, contributes
to cost savings.22 Another article by
Varadharajan et al suggest small economic
advantages of extended-release tolterodine
compared with extended-or immediate-release
oxybutynin among people with OAB
who have commercial insurance.23
Clinicians can play an important role in
educating patients about their health condition,
treatment options, and disease management.
Prospective studies that evaluate
the clinical and economic outcomes of OAB
therapies can further help healthcare providers
and patients to select the most appropriate
1. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327-336.
2. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of difference in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46:473-480.
3. Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gynecol. 2001;98:398-406.
4. Tannenbaum C, DuBeau CE. Urinary incontinence in the nursing home: practical approach to evaluation and management. Clin Geriatr Med. 2004;20:437-452, vi.
5. Prochoda KP. Medical director's review of urinary incontinence in long-term care. J Am Med Dir Assoc. 2002;3(1 suppl):S11-S15.
6. Brown JS, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc. 2000;48:721-725.
7. Wagner TH, Hu TW, Bentkover J, et al. Health-related consequences of overactive bladder. Am J Manag Care. 2002;8(19 suppl):S598-S607.
8. Shih YC, Hartzema AG, Tolleson-Rinehart S. Labor costs associated with incontinence in long-term care facilities. Urology. 2003;62:442-446.
9. Ko Y, Lin SJ, Salmon JW, Bron M. The impact of urinary Incontinence on quality of life of the elderly. Am J Manag Care. 2005;11:S103-S111.
10. Shaw C. A review of the psychosocial predictors of help-seeking behaviour and impact on quality of life in people with urinary incontinence. J Clin Nurs. 2001;10:15-24.
11. Hunskaar S, Sandvik H. One hundred and fifty men with urinary incontinence. III. Psychosocial consequences. Scand J Prim Health Care. 1993;11:193-196.
12. Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004;63:461-465.
13. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology. 1998;51:355-361.
14. Zhou SZ, Jensen G. Insurance claims costs for overactive bladder disorder. Drug Benefit Trends. 2001;13:45-58.
15. Lemack GE. Overactive bladder: optimizing quality of care. Am J Manag Care. 2001;7(2 suppl):S46-S61.
16. Jumadilova Z, Zyczynski T, Paul B, Narayanan S. Urinary incontinence in nursery home: resident characteristics and prevalence of drug treatment. Am J Manag Care. 2005;11:S112-S120.
17. Mitteness LS, Barker JC. Stigmatizing a "normal" condition: urinary incontinence in late life. Med Anthropol Q. 1995;9:188-210.
18. Shaya FT, Blume S, Gu A, Zyczynski T, Jumadilova Z. Persistence with overactive bladder pharmacotherapy in a medicaid population. Am J Manag Care. 2005;11:S121-S129.
19. O'Conor RM, Johannesson M, Hass SL, Kobelt- Nguyen G. Urge incontinence. Quality of life and patients'valuation of symptom reduction. Pharmacoeconomics. 1998;14:531-539.
20. Fantl J, Newman D, Colling J. Clinical Practice Guideline Number 2: Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, Md: Agency for Health Care Policy and Research; 1996.
21. Roberts R, Garely A, Bavendam T. Safety and tolerability of tolterodine for the treatment of overactive bladder in adults. Am J Manag Care. 2005;11:S158-S162.
22. Perfetto EM, Subedi P, Jumadilova Z. Treatment of overactive bladder: a model comparing extended-release formulations of tolterodine and oxybutynin. Am J Manag Care. 2005;11:S150-S157.
23. Varadharajan S, Jumadilova Z, Girase P, Ollendorf DA. Economic impact of extended-release tolterodine versus extended-release oxybutynin among commercially insured persons with overactive bladder. Am J Manag Care. 2005;11:S140-S149.