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National Collaborating Centre for Women's and Children's Health (UK). Urinary Incontinence: The Management of Urinary Incontinence in Women. London: RCOG Press; 2006 Oct. (NICE Clinical Guidelines, No. 40.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Appendix ECosting first-line conservative treatments for urinary incontinence

In costing potential first-line conservative treatments, it is necessary to focus solely on the resources associated with those treatments considered by the GDG. This is not to say that assessment and treatment should not be offered during the same session but that those resources devoted to determining treatment option or the need for a referral should not be considered as part of the cost of providing treatment.

Considerable heterogeneity exists within many of the conservative treatments for UI. As far as possible, the cost estimates presented here are based on ‘standard’ or ‘typical’ treatment (as informed by expert opinion on the GDG) but in practice such a standard may not exist. Therefore, the actual costs of particular conservative treatments will vary according to the actual practice followed.

Labour costs

Labour costs can be considered a variable cost of producing a given treatment. This means that for each additional patient treated, there is a demand on staff time and therefore labour costs vary with the quantity of treatment supplied.

For the purposes of this costing, labour costs are based on Unit Costs of Health and Social Care 2004.932 This provides a unit cost (cost per hour, cost per consultation, etc.) for a range of professional staff working in a health- or social care setting. As far as possible, the unit costs are based on the long run opportunity costs of employing an additional member of staff. Therefore, in addition to wages/salary the unit costs also include salary oncosts, qualifications and continuing training. The calculations also make an allowance for the impact that holidays, sickness and training days have on the actual hours worked.

Importantly for the costings undertaken here, they also incorporate the direct overheads associated with delivering health care through professional and capital costs. Direct overheads, includes those activities such as clerical support and administration which relate directly to the provision of a particular service or treatment. Capital costs relate to the costs of building and land but for hospital-based staff, at least, exclude equipment.

Consumable costs

These are also variable costs and relate to resources that are used up in the provision of a service or treatment. It cannot be reused. Again, these costs vary with the quantity of treatment actually provided.

Equipment (capital) costs

In an economic evaluation, capital costs (which include equipment, buildings and land) should not be ignored. After all, buying medical equipment carries an opportunity cost. That said, these costs differ from operating costs such as labour and consumables in certain respects. The purchase of equipment requires an upfront payment (or investment) before treatment can begin. This payment is a fixed cost and does not vary with the quantity of treatment provided. This capital can then often be used over a number of years before it needs to be replaced.

Capital costs have two facets:

  • Opportunity cost – the money spent on the equipment could have been invested in some other venture yielding positive benefits. This is calculated by applying an interest rate to the sum invested in the equipment.
  • Depreciation cost – the equipment has a certain lifespan and depreciates over time. Eventually, the equipment has to be replaced.

In economic evaluation, the usual practice is to annuitise the initial capital outlay over the expected life of the equipment. This gives an ‘equivalent annual cost’, which can then be divided by the number of patients treated annually to assign a unit cost of using that equipment. Calculating the equivalent annual cost means making an allowance for the differential timing of costs, which involves discounting.

The formula for calculating the equivalent annual cost is given below:

E = (K − [S ÷ {1 + r}n]) ÷ A(n, r)

where:

E = equivalent annual cost

K = purchase price of equipment

S = resale value

r = discount (interest rate)

n = equipment lifespan

A(n, r ) = annuity factor* (n years at interest rate r )

Pelvic floor muscle training

Description of treatment and assumptions

It is difficult to define a ‘standard’ or ‘typical’ PFMT session and therefore costs will vary according to the actual practices employed.

  • Costings are based on treatment being undertaken by a senior 1 grade women’s health physiotherapist in a hospital physiotherapy department.
  • There are a total of six sessions with the therapist.
  • The initial session lasts 1 hour; subsequent sessions last half an hour.
  • Consumables at the initial session include gloves, single-use KY Jelly, wipes (×2), paper towels (×4).
  • Consumables at subsequent sessions include gloves, wipes (×2), paper towels (×4).
  • Additional consumables may include exercise diaries and advice leaflets (often provided free by companies) but these are negligible and not included.

Labour costs

Contact time with patient:(1 × 1) + (5 × 0.5) = 3.5 hours
Unit cost:£37 per hour
Labour cost:£37 × 3.5 = £129.50

Consumables

ItemQuantityUnit costCost
Gloves6£0.02£0.11
KY Jelly1£0.80£0.80
Couch roll6£0.04£0.22
Paper towels24Less than £0.01£0.07
Wipes12£0.03£0.30
Total£1.50

Total cost for PFMT: £131 (£94 to £168)**

PFMT + biofeedback

Description of treatment and assumptions

Not only is it difficult to define a ‘standard’ for PFMT but biofeedback can also take many different forms. Costs will therefore vary according to actual practice and biofeedback equipment used:

  • Number of sessions and duration is typically the same as for ‘ordinary’ PFMT. Therefore, costs of PFMT + Biofeedback have been estimated by adding the costs associated with biofeedback to PFMT alone (see above).
  • Biofeedback is undertaken using a Verity NeuroTrac™ Simplex (hand-held single-channel EMG unit), a Neen Educator® and a Neen Periform vaginal probe.
  • It is assumed that the NeuroTrac device is loaned to patients for home use for 3 months and that it has a lifespan of 5 years (i.e. the cost of equipment is spread over 20 patients).
  • Educators and probes are for single-patient use and are treated as consumable costs.

PFMT costs: £131

Additional biofeedback costs

Consumables

ItemQuantityUnit costCost
Neen Educator1£19.50£19.50
Neen Periform1£10.25£10.25
Total£29.75

Equipment

ItemCostEquivalent annual costCost/patient
Verity NeuroTrac Simplex£99£19.84£4.96

Total cost for PFMT + biofeedback: £166

Cones

Description of treatment and assumptions

Treatment is often not provided by the NHS, and women will often buy cones over the counter after GP advice and self-treat. An estimate is provided here of the cost to the NHS of providing this as a first-line treatment, including the cost of cones.

  • It is assumed that the labour costs are one-third of those for PFMT***
  • Consumables are cones and KY Jelly.

Labour costs

⅓ × £129.50 = £43933

Consumables

ItemQuantityUnit costCost
KY Jelly1£1.29£1.29
Cones1£24.95£24.95
Total£26.24

Total cost for cones: £69

Electrical stimulation

Description of treatment and assumptions

  • Initial 1 hour appointment with senior 1 grade women’s health physiotherapist in a hospital physiotherapy department to determine appropriate programme.
  • Patient is loaned a neuromuscular stimulator for 3 months (Neen ‘Pericalm’).
  • Patient has two follow-up appointments††, lasting 30 minutes.
  • It is assumed that the Neen Pericalm device is loaned to patients for home use for 3 months and that it has a lifespan of 5 years (i.e. the cost of equipment is spread over 20 patients).
  • A Neen Periform vaginal electrode is used (×1).
  • Other consumables include gloves (×3), KY Jelly (×3), couch roll (×3), wipes (×6) and paper towels (×12).

Labour costs

Contact time with patient:(1 × 1) + (2 × 0.5) = 2 hours
Unit cost:£37 per hour
Labour cost:£37 × 2 = £74.00

Consumables

ItemQuantityUnit costCost
Gloves3£0.02£0.06
KY Jelly3£0.80£2.40
Couch roll3£0.04£0.11
Paper towels12Less than £0.01£0.04
Wipes6£0.03£0.15
Neen Periform1£10.25£10.25
Total£13.01

Equipment

ItemCostEquivalent annual costCost/patient
Neen Pericalm£83.89£19.84£4.20

Total cost for electrical stimulation: £91

Electrical stimulation (clinic based)

Description of treatment and assumptions

  • Initial 1 hour appointment with senior 1 grade women’s health physiotherapist in a hospital physiotherapy department to determine appropriate programme.
  • Patient has twelve follow-up appointments†††, lasting 30 minutes.
  • A Neen Periform vaginal electrode is used (×1).
  • Other consumables include gloves (×13), KY Jelly (×13), couch roll (×13), wipes (×26) and paper towels (×52).
  • In addition it was assumed that the following clinic equipment was used: Genesis Medical Unomax Data Reader.
  • It was assumed that these equipment items would each have a lifespan of 5 years and be used on 200 patients per year.

Labour costs

Contact time with patient:(1 × 1) + (12 × 0.5) = 7 hours
Unit cost:£37 per hour
Labour cost:£37 × 7 = £259

Consumables

ItemQuantityUnit costCost
KY Jelly13£0.80£10.38
Gloves13£0.02£0.24
Couch roll13£0.04£0.47
Paper towels52£0.00£0.16
Wipes26£0.03£0.65
Neen Periform1£10.25£10.25
Total£22.15

Equipment

ItemCostEquivalent annual costCost/patient
Genesis Medical Nomax 2£220£41.29£0.21
Data Reader£285£53.49£0.27

Total cost for clinic-based electrical stimulation: £282

Bladder training

Description of treatment and assumptions

  • Costings are based on treatment being undertaken by a senior 1 grade women’s health physiotherapist‡‡ in a hospital physiotherapy department.
  • Patients are seen five times over a 4 month period.
  • Initial appointment is 1 hour, follow-up sessions last 15–30 minutes.
  • Bladder/baseline charts are normally provided free by pharmaceutical companies.
  • Other consumables include gloves (×5), KY Jelly (×1), couch roll (×5), assessment forms (×1), wipes (×10) and paper towels (×20).

Labour costs

Contact time with patient:(1 × 1) + (4 × 0.375) = 2.5 hours
Unit cost:£37 per hour
Labour cost:£37 × 2.5 = £92.50

Consumables

ItemQuantityUnit costCost
Gloves5£0.02£0.09
KY Jelly1£0.80£0.80
Couch roll5£0.04£0.18
Paper towels20Less than £0.01£0.06
Wipes10£0.03£0.25
Assessment forms1£0.41£0.41
Total£1.50

Total cost for bladder training: £94

Drugs

Description of treatment and assumptions

  • Assumes one review consultation with GP.
  • The duration of GP consultations is 9.36 minutes (GMP workload survey).
  • Drug costs are for 52 weeks.

Labour costs

Contact time with patient:0.156 hours
Unit cost:£135 per hour
Labour cost:£135 × 0.156 = £21

Drug costs (taken from BNF 50, September 2005)

DrugDoseDaily frequencyCost per pack (£)Pack sizeCost per day (£)Cost for 12 weeks (£)Cost for 1 year (£)Cost for 1 year incl. GP review (£)
Duloxetine40 mg230.80561.1092402423
Flavoxate200 mg311.87900.4033144165
Oxybutynin5 mg24.14840.1083657
ER oxybutynin10 mg124.68300.8269300321
Oxybutynin patches3.9 mg0.2927.2080.9782355376
Propiverine15 mg324.45561.31110478499
Solifenacin5 mg127.62300.9277336357
Solifenacin10 mg135.91301.20101437458
Tolterodine2 mg230.56561.0992398419
ER tolterodine4 mg129.03281.0487378399
Trospium20 mg226.00600.8773316337

At the time of publication, costs for darifenacin were not yet available.

Various conservative treatments combined

PFMT + duloxetine

Description of treatment and assumptions

  • As for PFMT and drug therapy alone, except it is assumed that drug review can be part of a PFMT session with no time implication. The cost of this multicomponent treatment is therefore less than the sum of its parts.

Costs

PFMT cost:£131
Duloxetine cost:£423
Less GP review of medication:− £21

Total cost: £533

Lifestyle and physical therapy

Description of treatment and assumptions

  • It is assumed that the lifestyle advice is given by the therapist (senior 1 grade women’s health physiotherapist or continence nurse specialist).
  • Physical therapy is as described previously but with behavioural advice (fluid intake, BMI, constipation, smoking, etc.) incorporated into the first session and subsequent ½ hour sessions when necessary – this is assumed to add 15 minutes to contact time between patient and therapist.

The additional cost of adding lifestyle advice to physical therapy is the labour cost of that advice.

Labour costs

Contact time with patient:(1 × 0.25) = 0.25 hours
Unit cost:£37 per hour
Labour cost:£37 × 0.25 = £9.25

Combining behavioural advice with physical therapy adds approximately £9 to the cost of conservative treatment.

Bladder training + drugs

Description of treatment and assumptions

  • As for bladder training and drug therapy alone, except it is assumed that drug review can be part of a bladder training session with no time implication. The cost of this multicomponent treatment is therefore less than the sum of its parts.

Costs

Bladder training cost:£94
Oxybutynin cost:£57 (1 year’s treatment)
ER tolterodine:£399
Less GP review of medication:− £21

Total cost (bladder training + oxybutynin): £130

Total cost (bladder training + ER tolterodine): £472

Footnotes

*

Converts a present value into an annuity, a series of equal annual payments.

Remuneration for a continence nurse specialist grade f–g/band 6–7 is similar.

Estimates from GDG members that four to eight sessions are typically offered.

**

Range based on four to eight sessions.

***

Teaching time is one-third of that for PFMT; see Link.933

††

Again, actual practice on follow-up may vary.

†††

Again actual practice on follow-up may vary.

‡‡

Treatment is also undertaken by continence nurse specialists (grade e–h) in clinics; costs are similar.

Copyright © 2006, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Cover of Urinary Incontinence
Urinary Incontinence: The Management of Urinary Incontinence in Women.
NICE Clinical Guidelines, No. 40.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2006 Oct.

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