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New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatment Costs
C. Daniel Mullins, PhD; and Leslee L. Subak, MD
The Impact of Urinary Incontinence on Quality of Life of the Elderly
Yu Ko, MS; Swu-Jane Lin, PhD; J. Warren Salmon, PhD; and Morgan S. Bron, PharmD, MS
Safety and Tolerability of Tolterodine for the Treatment of Overactive Bladder in Adults
Richard G. Roberts, MD, JD; Alan D. Garely, MD; and Tamara Bavendam, MD
Medical Costs After Initiation of Drug Treatment for Overactive Bladder: Effects of Selection Bias on Cost Estimates
Nicole M. Nitz, PhD; Zhanna Jumadilova, MD, MBA; Theodore Darkow,   PharmD; Jennifer R. Frytak, PhD; and Tamara Bavendam, MD
Economic Impact of Extended-release Tolterodine versus Immediate-and Extended-release Oxybutynin Among Commercially Insured Persons With Overactive Bladder
Sujata Varadharajan, MS; Zhanna Jumadilova, MD, MBA; Prafulla Girase, MS; and Daniel A. Ollendorf, MPH
Urinary Incontinence in the Nursing Home: Resident Characteristics and Prevalence of Drug Treatment
Zhanna Jumadilova, MD, MBA; Teresa Zyczynski, PharmD, MBA, MPH; Barbara Paul, MD; and Siva Narayanan, MS, MHS
Treatment of Overactive Bladder: A Model Comparing Extended-release Formulations of Tolterodine and Oxybutynin
Eleanor M. Perfetto, PhD; Prasun Subedi, MS; and Zhanna Jumadilova, MD, MBA

New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatment Costs

C. Daniel Mullins, PhD; and Leslee L. Subak, MD

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 therapy.

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 treatments.

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.

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