American Journal of Managed Care
Overactive bladder (OAB) is a commonurinary dysfunction thatincludes urinary urgency, frequency,nocturia, and/or urge urinary incontinence.OAB is estimated to occur in 33million Americans or approximately 16.5%of the population.1,2 In the long-term caresetting, it is estimated that as many as half ofall residents suffer from incontinence,3,4 andit is considered to be a serious medical concernfor several reasons. First, OAB is associatedwith medical and quality of lifeconsequences that further compromise thehealth and well-being of both institutionalizedand community-dwelling patients.Specifically, incontinence has been associatedwith an increased risk of urinary tractinfections, pressure ulcers, falls, and fractures,5-7 which may severely compromisepatient function and overall health. Second,incontinence consumes medical resourcesand staff and provider time, driving up thecost of care.8 This supplement to featuresseveral articles on the medical, qualityof life, social, and economic impact of OAB.As described in articles by Ko et al, OABexacts a profound toll on quality of life;incontinence frequently results in social isolation,depression, and the inability to lead anormal, fulfilling life.9-11
In addition to substantial medical andquality of life sequelae of OAB, the economicimpact is great. The estimated total economiccost 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, suchas lost wages and productivity, are included,the annual cost of incontinence increases tomore than $26 billion, with institutionalcare accounting for more than $8.4 billion(23%).13 For managed care, OAB is a significantdriver of health plan costs. A recentinsurance claims analysis shows annualspending for patients with OAB to be nearly5-fold greater than for patients without thecondition ($5018 vs $1767, respectively).14
Pharmacotherapy is effective for manypatients and usually is recommended inaddition to behavioral modification whenthat measure alone fails.15 Yet, despite evidencethat interventions can control bothincontinence and OAB, they remain underdiagnosedand undertreated. As describedby Jumadilova et al in this supplement,pharmacotherapy for UI may be underutilizedin the nursing home setting.16 Thismay be a result of physician uncertaintyregarding the appropriateness of pharmacotherapyacross a range of patients withvaried illnesses and functional abilities.Here, as well as in the community setting,healthcare providers and patients alikecontinue to believe the myth that urinaryproblems are simply a normal andinevitable part of aging, and some patientsare simply too embarrassed to talk to theirhealthcare providers about UI.4,10,17 Asreported by Shaya et al in this publication,patients who do seek treatment frequentlydo not adhere to prescribed treatment regimensfor a variety of reasons, includingthe uncomfortable side effects (mostnotably dry mouth) associated with manyOAB medical treatments.18,19 Another reasonfor low adherence to therapy is ineffectivepatient counseling by healthcareproviders, which can lead to unmet patientexpectations in the initial days and weeks oftherapy.
Achieving timely diagnosis and consistenttreatment requires a shared understandingamong patients, caregivers, and healthcareproviders that OAB and UI in adults can usuallybe improved.20 Roberts et al report thattolterodine is associated with significantly lessdry mouth than oxybutynin,21 which mayprompt patients to continue treatment overthe longer term. Clinical effectiveness, as wellas tolerability and cost of the therapy, willhave the greatest impact on patients'adherenceto long-term treatment. Persistence, asdescribed in the article by Perfetto et al, contributesto cost savings.22 Another article byVaradharajan et al suggest small economicadvantages of extended-release tolterodinecompared with extended-or immediate-releaseoxybutynin among people with OABwho have commercial insurance.23
Clinicians can play an important role ineducating patients about their health condition,treatment options, and disease management.Prospective studies that evaluatethe clinical and economic outcomes of OABtherapies can further help healthcare providersand patients to select the most appropriatetreatments.
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21. Roberts R, Garely A, Bavendam T. Safety and tolerabilityof tolterodine for the treatment of overactive bladderin adults. 2005;11:S158-S162.
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22. Perfetto EM, Subedi P, Jumadilova Z. Treatment ofoveractive bladder: a model comparing extended-releaseformulations of tolterodine and oxybutynin. 2005;11:S150-S157.
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23. Varadharajan S, Jumadilova Z, Girase P, OllendorfDA. Economic impact of extended-release tolterodineversus extended-release oxybutynin among commerciallyinsured persons with overactive bladder. 2005;11:S140-S149.