Consenso Baiona sobre Incontinencia Fecal: Asociación Española de Coloproctología / Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

La incontinencia fecal (IF) constituye un importante problema sanitario, tanto a nivel individual como para los diferentes sistemas de salud, lo que origina una preocupación generalizada para su resolución o, al menos, disminuir en lo posible los numerosos efectos indeseables que provoca, al margen del elevado gasto que ocasiona. Existen diferentes criterios relacionados con las pruebas diagnósticas a realizar, y lo mismo acontece con relación al tratamiento más adecuado, dentro de las numerosas opciones que han proliferado durante los últimos años, no siempre basadas en una rigurosa evidencia científica. Por dicho motivo, desde la Asociación Española de Coloproctología (AECP) nos propusimos elaborar un Consenso que sirviese de orientación a todos los profesionales sanitarios interesados en el problema, conscientes, no obstante, de que la decisión terapéutica debe tomarse de manera individualizada: características del paciente/experiencia del terapeuta. Para su elaboración optamos por la técnica de grupo nominal. Los niveles de evidencia y los grados de recomendación se establecieron de acuerdo a los criterios del Oxford Centre for Evidence-Based Medicine. Por otra parte, en cada uno de los ítems analizados se añadieron, de forma breve, recomendaciones de los expertos.(AU)

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a Consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.(AU)

Impacto económico del tratamiento a largo plazo de la incontinencia fecal grave / Economic burden of long-term treatment of severe fecal incontinence

Objetivo Conocer el coste económico a largo plazo asociado al tratamiento de la incontinencia fecal grave mediante SNS frente al tratamiento conservador sintomático y la colostomía definitiva. Métodos Estudio descriptivo pormenorizado de los costes del proceso asistencial (intervenciones, consultas, dispositivos, pruebas complementarias, hospitalización, etc.) de 3 alternativas de tratamiento de la incontinencia fecal empleando herramientas de gestión y contabilidad analítica del propio Servicio de Salud con base en datos de actividad clínica. Se estimó, en cada caso, la frecuencia de uso de recursos sanitarios o la cantidad de productos dispensados en farmacias (medicación, pañales, material de ostomía, etc.). Se incluyeron costes derivados de situaciones adversas. Se incluyeron pacientes con incontinencia fecal grave, definida por una puntación superior a 9 en la escala de severidad de Wexner, en los que han fracasado los tratamientos de primera línea. Se emplearon datos de una cohorte consecutiva de 93 pacientes a los que se realizó una SNS entre los años 2002 y 2016; de pacientes intervenidos de colostomía definitiva (n=2); hernia paraestomal (n=3) y estenosis de colostomía (n=1). Resultados El coste medio acumulado en 10 años por paciente en cada alternativa fue: 10.972,9€ para el tratamiento sintomático (62% pañales); 17.351,57€ para la SNS (95,83% intervenciones; 81,6% dispositivos), y 25.858,54€ para la colostomía definitiva (70,4% material de ostomía) Conclusiones El manejo de la incontinencia fecal grave implica un gran impacto en términos económicos. La colostomía es la alternativa que más costes directos genera, seguida de la SNS y el tratamiento sintomático (AU)

Introduction Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. Methods Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3), and colostomy stenosis (n=1). Results The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories). Conclusions Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment (AU)

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial).

BACKGROUND: After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment. METHODS: The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes. DISCUSSION: The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial. TRIAL REGISTRATION: Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

From stigma to the spotlight: A need for patient-centred incontinence care.

Incontinence is not a single disorder but a family of related conditions with different etiologies and treatments; it is a chronic disability that carries an enormous stigma. In few disorder/treatment pairings, there is the need to reinvent care more urgent and clear than in the area of incontinence. Patient-centred care has been realized to improve outcomes, quality of care, and patient satisfaction while concurrently reducing healthcare costs. To improve continence care and move it away from "cleaning up accidents" to a patient-centred care model, in which the disorder is managed to best practice guidelines, does not require investigative or developmental prowess but a simple, concentrated effort to diffuse existing knowledge to close the knowledge gaps, both at the clinical language level for clinical nurses and family physicians, as the gatekeepers to specialist care, and in simplified layperson's language for the healthcare worker, family carer, and person living with incontinence.

A prospective "bottom up" study of the costs of faecal incontinence in ambulatory patients.

BACKGROUND AND AIM: The few studies that have examined direct costs of faecal incontinence are limited in that they employed retrospective databases, postal surveys, and focused upon institutionalised patients or post partum women. The aim of the current study was to identify the direct pre-treatment costs of faecal incontinence expended by a range of home dwelling patients and identify relationships between costs and severity of incontinence. METHODS: Consecutive patients attending an outpatient clinic for treatment of faecal incontinence were interviewed using a questionnaire, modeled on the Dowel Bryant Incontinence Cost Index. The information collected included costs of: (i) basic personal hygiene: pads, laundry, wipes, cleansers; (ii) medication: loperamide, creams and stool bulking agents; and (iii) diagnostic: medical attendance, anorectal physiology, colonoscopy. Costs were broken down into personal expenses, government costs, and costs to health funds. A St Mark's Faecal Incontinence Severity Score was recorded. RESULTS: A total of 100 consecutive patients consented (15 males, 85 females) mean age 70.8 (SD12) years. Mean St Mark's score was 12 (SD4.5). The median total patient cost was $437.72 AUD (range 0-2807) per annum. Government costs were $537AUD (range 135-1657), and health fund median $0 AUD (0-1628). Incontinence severity correlated with personal expense only median $283.75AUD (range 0-2350). The aged were more incontinent but costs did not increase in relation to age. CONCLUSION: Faecal incontinence results in a substantial financial burden for both patients and Government. Effective treatments which relieve the financial burden of faecal incontinence, are likely to be economically advantageous into the future for both patients and Government.

Bowel management program for pediatric postoperative fecal incontinence in China: A surgeon's experience.

The purpose of this article is to report the status of the efficacy of and long-term adherence to the Bowel Management Program (BMP) for fecal incontinence (FI) postoperation in China.Children over 3 years of age with FI postoperation referred to our medical center were included in the study. Evaluations were performed before and 2 years after their clinic visit. The cost of bowel care, improvement in incontinence, health-related quality of life, and family functioning with the BMP were analyzed.A total of 48 children with FI were included in our study, of whom 38 were boys. The median treatment fee was 660.1 dollars. The complications included abdominal pain (4 patients, 8%), occasional vomiting (2 patients, 4%), and hypoglycemia (1 patient, 2%). The incontinence status and health-related quality of life improved significantly after the BMP. Despite the good outcome of the BMP, half of the patients discontinued the program.The BMP is an effective approach to manage FI and improve the patients' quality of life. Poor long-term adherence is currently the main challenge affecting the BMP application in China.

[Economic impact of AFId management with modern management system in Intensive Care patients: comparison between ICUs]. / Impatto economico di gestione dell'IFAd nei pazienti in Terapia Intensiva con i moderni sistemi di gestione FMS: confronto tra Rianimazioni.

. Economic impact of AFId management with modern management systems in Intensive Care patients: comparison between ICUs. INTRODUCTION: Acute fecal incontinence associated with diarrhea (AFId) affects up to 40% of intensive care unit (ICU) patients and may be responsible for pressure ulcers (PU). The FMS (Fecal Management System) though improving the management of these patients is not often provided due to its cost. AIM: To measure the costs of the use of FMS compared to routine care in three intensive care units (ICU) of Piedmont (Italy). METHODS: All patients admitted from January to June 2016, > 18 years with at least three AFId episodes in the previous 24 hours were included. The costs for hygiene, medications and nursing time spent were calculated on 10 patients without FMS, accounting for the mean number of diarrhea attacks (3.04 per day), and mean days of FMS use. RESULTS: The FMS generated savings compared to routine care in nursing time, equipments for hygiene and pressure sores medications in patients with sacral sores. Savings depended on length of use (LoU) of the device: ICU with 10 patients (7 with PUs), mean LoU FMS 11.9 days, savings 1.210 euros; ICU with 10 patients (2 with PUs), mean LoU FMS 17.3 days, savings 5.317 euros; ICU with 45 patients (11 with PUs) mean LoU FMS 9.3 days, cost increase 1.057 euros. The cost of FMS is quickly amortised in patients with PUs. No FMS patients developed a new PUs. CONCLUSIONS: The FMS gives rise to savings when used in patients with PUs or for more than 10 days. The savings related to the prevention of PUs should be also added.

Fear and overprotection in Australian residential aged-care facilities: The inadvertent impact of regulation on quality continence care.

AIM: Most residents in residential aged-care facilities are incontinent. This study explored how continence care was provided in residential aged-care facilities, and describes a subset of data about staffs' beliefs and experiences of the quality framework and the funding model on residents' continence care. METHODS: Using grounded theory methodology, 18 residential aged-care staff members were interviewed and 88 hours of field observations conducted in two facilities. Data were analysed using a combination of inductive and deductive analytic procedures. RESULTS: Staffs' beliefs and experiences about the requirements of the quality framework and the funding model fostered a climate of fear and risk adversity that had multiple unintended effects on residents' continence care, incentivising dependence on continence management, and equating effective continence care with effective pad use. CONCLUSION: There is a need to rethink the quality of continence care and its measurement in Australian residential aged-care facilities.

Disparities in the Use of Sacral Neuromodulation among Medicare Beneficiaries.

PURPOSE: Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries. MATERIALS AND METHODS: We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software. RESULTS: A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p <0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p <0.0001) were more likely to be treated. Minority patients (OR 0.38, p <0.0001) and those living in the western United States (OR 0.52, p <0.0001) were less likely to receive treatment. CONCLUSIONS: Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.

Inpatient burden of childhood functional GI disorders in the USA: an analysis of national trends in the USA from 1997 to 2009.

BACKGROUND: Functional gastrointestinal disorders (FGIDs) are among the most common outpatient diagnoses in pediatric primary care and gastroenterology. There is limited data on the inpatient burden of childhood FGIDs in the USA. The aim of this study was to evaluate the inpatient admission rate, length of stay (LoS), and associated costs related to FGIDs from 1997 to 2009. METHODS: We analyzed the Kids' Inpatient Sample Database (KID) for all subjects in which constipation (ICD-9 codes: 564.0-564.09), abdominal pain (ICD-9 codes: 789.0-789.09), irritable bowel syndrome (IBS) (ICD-9 code: 564.1), abdominal migraine (ICD-9 code: 346.80 and 346.81) dyspepsia (ICD-9 code: 536.8), or fecal incontinence (ICD-codes: 787.6-787.63) was the primary discharge diagnosis from 1997 to 2009. The KID is the largest publicly available all-payer inpatient database in the USA, containing data from 2 to 3 million pediatric hospital stays yearly. KEY RESULTS: From 1997 to 2009, the number of discharges with a FGID primary diagnosis increased slightly from 6,348,537 to 6,393,803. The total mean cost per discharge increased significantly from $6115 to $18,058 despite the LoS remaining relatively stable. Constipation and abdominal pain were the most common FGID discharge diagnoses. Abdominal pain and abdominal migraine discharges were most frequent in the 10-14 year age group. Constipation and fecal incontinence discharges were most frequent in the 5-9 year age group. IBS discharge was most common for the 15-17 year age group. CONCLUSIONS & INFERENCES: Hospitalizations and associated costs in childhood FGIDs have increased in number and cost in the USA from 1997 to 2009. Further studies to determine optimal methods to avoid unnecessary hospitalizations and potentially harmful diagnostic testing are indicated.

Resource implications of running a sacral neuromodulation service: a 10-year experience.

AIM: In this study we reviewed our 10-year experience of the medium- to long-term success of sacral nerve stimulation (SNS) for faecal incontinence, with particular reference to the resource implications of running such a service. METHOD: All patients treated with permanent SNS implants for faecal incontinence from 2001 to 2012 were identified from a prospective database. The patients underwent follow up at 3 and 6 months, with annual review thereafter. They were divided into four groups: group 1, patients optimized after two reviews; group 2, patients optimized after further review; group 3, patients who failed to reach a satisfactory state; and group 4, patients who had a good initial result with subsequent failure. RESULTS: Eighty-five patients underwent permanent SNS with a median follow up of 24 (range: 3-108) months. Group 1 included 30 (35%) patients; group 2 included 27 (32%) patients [median of two (range: 2-6) additional visits]; group 3 included 18 (21%) patients [median of six (range: 3-10) additional visits]; and group 4 included 10 (12%) patients [median interval to failure was 54 (range: 24-84) months]. Twenty-seven per cent of our patients had an unsatisfactory outcome and the cost of follow up for these patients was £36,854 (48.7% of the total follow-up costs). CONCLUSION: The study highlights the significant resource implications of running an SNS service with a large proportion of patients requiring prolonged review, with more than one-quarter having an unsatisfactory outcome at a substantial cost.

Three-year cost-effectiveness model for non-animal stabilized hyaluronic acid and dextranomer copolymer compared with sacral nerve stimulation after conservative therapy for the management of fecal incontinence.

BACKGROUND: Two new therapies for fecal incontinence (FI) are now available: non-animal stabilized hyaluronic acid and dextranomer copolymer (NASHA/Dx) and sacral nerve stimulation (SNS). PURPOSE: This study aimed to determine the cost-effectiveness of NASHA/Dx compared with SNS and conservative therapy (CT) for the treatment of FI after CT failure. METHODS: Decision tree models with Markov subbranches were developed to compare all direct costs and outcomes during a 3-year period from the viewpoint of the US third-party payer. Costs (in 2013 US dollars) of devices, medical and surgical care, and hospitalization were included. Outcomes included quality-adjusted life-years (QALYs) and incontinence-free days (IFDs). Both costs and outcomes were discounted at an annual rate of 3%. The incremental cost-effectiveness ratio was calculated for each outcome. One-way and probabilistic sensitivity analyses were performed to examine robustness of results and model stability. A budget impact analysis was also undertaken to estimate the potential cost and savings of NASHA/Dx for a payer with 1,000,000 covered lives. RESULTS: For the 3-year cost-effectiveness models, the expected cost was $9053 for CT, $14,962 for NASHA/Dx, and $33,201 for SNS. The numbers of QALYs were 1.769, 1.929, and 2.004, respectively. The numbers of IFDs were 128.8, 267.6, and 514.8, respectively. The incremental cost-effectiveness ratios per additional IFD gained were $42.60 for NASHA/Dx vs CT, $73.76 for SNS vs NASHA/Dx, and $62.55 for SNS vs CT. The incremental costs per QALY gained were $37,036 for NASHA/Dx vs CT, $244,509 for SNS vs NASHA/Dx, and $103,066 for SNS vs CT. The budget impact analysis evaluated the financial effect on the health care system of the use of NASHA/Dx and SNS. For the scenarios evaluated, when all of the patients receive NASHA/Dx, the net annual effect to the health care payer budget ranged from $571,455 to $2,857,275. When all of the patients receive SNS, the net annual effect to the health care payer budget ranged from $1,959,323 to $9,796,613. CONCLUSION: Both NASHA/Dx and SNS have produced significant improvements in FI symptoms for affected patients. NASHA/Dx is a cost-effective and more efficient use of resources for the treatment of FI when compared with SNS. The budget impact analysis suggests that although reimbursement for NASHA/Dx treatment initially adds costs to the health care system, it is significantly less expensive than SNS for patients who are candidates for either treatment.

Posterior tibial nerve stimulation for fecal incontinence: where are we?

Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures. Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today. Posterior tibial nerve stimulation (PTNS)--both the percutaneous and the transcutaneous routes--remains a relatively new entry in neurostimulation. Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment. However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence. This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS. The use of PTNS is slowly gaining acceptance. However, several questions remain unanswered in the delivery of PTNS. These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS. This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.

Cost-benefit analysis: patient care at neurological intensive care unit.

Modern quality definition relies on patient centeredness and on patient needs for particular services, continuous control of the service provided, complete service quality management, and setting quality indicators as the health service endpoints. The health service provided to the patient has certain costs. Thus, one can ask the following: "To what extent does the increasing cost of patient care with changes in elimination improve the quality of health care and what costs are justifiable?" As stroke is the third leading cause of morbidity and mortality in Europe and worldwide, attention has been increasingly focused on stroke prevention and providing quality care for stroke patients. One of the most common medical/nursing problems in these patients is change in elimination, which additionally affects their mental health.

A budget impact analysis comparing use of a modern fecal management system to traditional fecal management methods in two canadian hospitals.

Research suggests that fecal management systems (FMS) offer advantages, including potential cost savings, over traditional methods of caring for patients with little or no bowel control and liquid or semi-liquid stool. A budget impact model accounting for material costs of managing fecal incontinence was developed, and 1 year of experiential data from two hospitals' ICUs were applied to it. Material costs were estimated for traditional methods (ie, use of absorbent briefs/pads, skin cleansers, moisturizers) and compared with material costs of using a modern FMS for both average (normal-range weight) and complex (bariatric with wounds) ICU patients at hospital 1 and any ICU patient at hospital 2. Reductions in daily material costs per ICU patient using FMS versus traditional methods were reported by hospital 1 ($93.74 versus $143.89, average patient; $150.55 versus $476.41, complex patient) and by hospital 2 ($61.15 versus $104.85 per patient). When extrapolated to the total number of patients expected to use FMS at each institution, substantial annual cost savings were projected (hospital 1: $57,216; hospital 2: $627,095). In addition, total nursing time per day for managing fecal incontinence (ie, changing, cleaning, repositioning patients, changing pads, linens, and the like) was estimated at hospital 1, showing substantial reductions with FMS (120 minutes versus 348 minutes for average patients; 240 minutes versus 760 minutes for complex). Nursing time was not included in cost calculations to keep the analysis conservative. Results of this study suggest the materials cost of using the FMS in ICU patients was substantially lower than the cost of traditional fecal incontinence management protocols of care in both hospitals. Comparative studies using patient level data, materials, and nursing time costs, as well as complication rates, are warranted.

Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands.

AIM: Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM-) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms. METHOD: A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years. RESULTS: The former treatment protocol cost €22,651 per patient and the latter, after the introduction of SNM, cost €16,473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs. CONCLUSION: The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence.

Economic cost of fecal incontinence.

BACKGROUND: Despite its prevalence and deleterious impact on patients and families, fecal incontinence remains an understudied condition. Few data are available on its economic burden in the United States. OBJECTIVE: The aim of this study was to quantify per patient annual economic costs associated with fecal incontinence. DESIGN: A mail survey of patients with fecal incontinence was conducted in 2010 to collect information on their sociodemographic characteristics, fecal incontinence symptoms, and utilization of medical and nonmedical resources for fecal incontinence. The analysis was conducted from a societal perspective and included both direct and indirect (ie, productivity loss) costs. Unit costs were determined based on standard Medicare reimbursement rates, national average wholesale prices of medications, and estimates from other relevant sources. All cost estimates were reported in 2010 US dollars. SETTINGS: This study was conducted at a single tertiary care institution. PATIENTS: The analysis included 332 adult patients who had fecal incontinence for more than a year with at least monthly leakage of solid, liquid, or mucous stool. MAIN OUTCOME MEASURES: The primary outcome measured was the per patient annual economic costs associated with fecal incontinence. RESULTS: The average annual total cost for fecal incontinence was $4110 per person (median = $1594; interquartile range, $517-$5164). Of these costs, direct medical and nonmedical costs averaged $2353 (median, $1176; interquartile range, $294-$2438) and $209 (median, $75; interquartile range, $17-$262), whereas the indirect cost associated with productivity loss averaged $1549 per patient annually (median, $0; interquartile range, $0-$813). Multivariate regression analyses suggested that greater fecal incontinence symptom severity was significantly associated with higher annual direct costs. LIMITATIONS: This study was based on patient self-reported data, and the sample was derived from a single institution. CONCLUSIONS: Fecal incontinence is associated with substantial economic cost, calling for more attention to the prevention and effective management of this condition.

Outcome and cost analysis of sacral nerve modulation for treating urinary and/or fecal incontinence.

BACKGROUND: Sacral nerve modulation (SNM) is an established treatment for urinary and fecal incontinence in patients for whom conservative management has failed. OBJECTIVE: This study assessed the outcome and cost analysis of SNM compared to alternative medical and surgical treatments. METHODS: Clinical outcome and cost-effectiveness analyses were performed in parallel with a prospective, multicenter cohort study that included 369 consecutive patients with urge urinary and/or fecal incontinence. The duration of follow-up was 24 months, and costs were estimated from the national health perspective. Cost-effectiveness outcomes were expressed as incremental costs per 50% of improved severity scores (incremental cost-effectiveness ratio). RESULTS: The SNM significantly improved the continence status (P < 0.005) and quality of life (P < 0.05) of patients with urge urinary and/or fecal incontinence compared to alternative treatments. The average cost of SNM for urge urinary incontinence was ∈8525 (95% confidence interval, ∈6686-∈10,364; P = 0.001) more for the first 2 years compared to alternative treatments. The corresponding increase in cost for subjects with fecal incontinence was ∈6581 (95% confidence interval, ∈2077-∈11,084; P = 0.006). When an improvement of more than 50% in the continence severity score was used as the unit of effectiveness, the incremental cost-effectiveness ratio for SNM was ∈94,204 and ∈185,160 at 24 months of follow-up for urinary and fecal incontinence, respectively. CONCLUSIONS: The SNM is a cost-effective treatment for urge urinary and/or fecal incontinence.