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.

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