Economic evaluation of duloxetine for the treatment of women with stress urinary incontinence: a Markov model comparing pharmacotherapy with pelvic floor muscle training.
ABSTRACT Duloxetine is a serotonin and norepinephrine reuptake inhibitor and may be useful for treating women with stress urinary incontinence (SUI) in general practice.
The objective of this study was to examine the cost-effectiveness of 2 duloxetine strategies (duloxetine alone and duloxetine after inadequate response to pelvic floor muscle training [PFMT]) compared with PFMT or no treatment for women aged>or=50 years with SUI.
A Markov model with a 3-month cycle length was developed, with a time horizon of 5 years. Incontinence severity was based on incontinence episode frequency per week (IEF/week). Four SUI health states were distinguished in the model: no SUI (0 incontinence episode [IE] per week), mild SUI (19 IEs/week), moderate SUI (10-25 IEs/week), and severe SUI (>or=26 IEs/week). Transition probabilities were calculated, based on published evidence, expert opinion, and demographic data. Outcomes were expected total societal costs and expected IEs. The analysis was performed from the societal perspective of The Netherlands, and all costs were reported in year-2002 euros. One-way sensitivity and probabilistic sensitivity analyses were performed.
In the model, providing PFMT cost euro0.03/IE avoided, compared with no treatment. Duloxetine after inadequate PFMT cost euro3.81/IE avoided, compared with PFMT One-way sensitivity analyses indicated that these results were robust regarding variation in age, IEF/week, and discount rate. Below the ceiling ratio of euro3.65/IE avoided, PFMT had the highest probability of being cost-effective. With higher ceiling ratios, duloxetine after inadequate PFMT had the highest cost-effectiveness probability.
Treating patients with duloxetine after inadequate PFMT response yielded additional health effects in the model, but would require society in The Netherlands to pay euro3.81/IE avoided for women aged>or=50 years with SUI being treated in general practice. It is up to policy-makers to determine whether this ratio would be acceptable.
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ABSTRACT: To evaluate clinically and urodynamically the effect of pelvic floor muscle exercise on genuine stress incontinence 5 years after cessation of a structured training program. All 23 women who had participated in a 6-month intensive pelvic floor muscle exercise regimen participated in the follow-up study. Mean age was 50.7 years (range 30-70). The assessment included history by interview, use of subjective rating instruments (leakage index and social activity index), vaginal palpation, measurement of pelvic floor muscle strength by use of vaginal pressure measurement, cystometry, urethral pressure profiles during cough, and pad test with standardized bladder volume. Three of 23 women had been treated surgically. Sixteen (70%) were exercising the pelvic floor muscles once a week or more. This included two of the women treated surgically. Of the 20 women not treated surgically, 70% were satisfied and did not want further treatment. Fifteen of 20 (75%) did not show any visible leakage during cough, and 11 had positive closure pressure during cough. There was a statistically significant increase in the scores of the leakage index and the pad test (P < .05) but not on the social activity index (P = .09). Pelvic floor muscle strength was reduced from a mean of 22 cm H2O (95% confidence interval [CI] 17-26.9) to 19.1 (95% CI 13.2-24.9) (P = .113) during the 5-year period. There was a significant increase in incontinence measured by pad test and leakage index 5 years after cessation of organized pelvic floor muscle exercise. However, 75% showed no leakage during stress test, and 70% were satisfied with the condition. Seventy percent were exercising the pelvic floor muscles at least once a week, and pelvic floor muscle strength was maintained.Obstetrics and Gynecology 02/1996; 87(2):261-5. · 4.80 Impact Factor
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ABSTRACT: Female urinary incontinence is a prevalent condition, but only about one-third of women seek treatment. To describe the health care provision for women with urinary incontinence from a European perspective, selecting France, Germany, Spain, Sweden, and the United Kingdom as examples, and to investigate whether specific barriers for treatment exist. Available health care system information, a literature review and clinical expert information identified patterns of treatment provision. In Spain, Sweden, and the UK, access to medical care in general is primarily through the general practitioners. However, in Spain and Sweden, women with urinary incontinence can directly visit specialists. In France and Germany, women have equal access to either general practitioners or specialists. Aside from general practitioners, gynaecologists play a major role in urinary incontinence care in all countries except the UK. In Germany, urologists are also involved in initial female urinary incontinence care; however, only in about 16% of women. There are no waiting lists in France and Germany for appointments with physicians or procedures, contrary to Spain, which has long waiting lists. Access to general practitioners in the UK is unrestricted whereas advanced diagnosis and treatment in secondary care requires long waits. A specific Swedish policy mandates that no woman is required to wait longer than 3 months for incontinence visits and related surgery. In Sweden and the UK, specialist nurses and other health care workers provide incontinence services. Almost all treatment options for urinary incontinence are at least in part reimbursed. However, various co-payments and fees in France, Germany, Spain and Sweden exist and constitute out-of-pocket expenses for women if no complementary additional private health insurance is available. In some countries, financial incentives for physicians to provide incontinence services are low, raising concerns about their interest to engage in continued patient care. Information about service provision in Europe for women with urinary incontinence is limited and makes it difficult to understand barriers to treatment seeking. A broad European perspective may promote optimised treatment access in the future for this widespread and under-recognised condition.Maturitas 12/2005; 52 Suppl 2:S3-12. · 2.84 Impact Factor
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ABSTRACT: To determine the outcome of pelvic floor muscle exercises for genuine stress incontinence after 5 years. Questionnaires were sent to 48 women, mean age 57 years, with troublesome stress incontinence treated as outpatients by a skilled female physiotherapist to elucidate a self-assessment of therapy outcome and to determine patients' compliance concerning fulfillment of home exercises and attitude toward physiotherapy. Patients' self-assessment responses indicated cured, much improved, some improvement, or unchanged/worse and incidence of anti-incontinence surgery after physiotherapy. The overall cure/much improvement rate for physiotherapy at the end of therapy was 54% and 5 years later it was 58% (confidence interval, 43 to 72); (P = 1.000, binomial test). Thirteen women (27%) underwent surgery. Seven unoperated women (15%) showed only some improvement or relapse and may have been undertreated. Severity of symptoms before therapy was an important factor in therapy outcome but not in therapy maintenance. Frequency of home practicing was comparable in those who had surgery afterward and those who had not. There was no clear linear relationship in long-term effect and frequency of home practicing. Severity of symptoms and behavioral changes bias this relationship. Physiotherapy was well tolerated, as 73% would still prefer it as first choice. Pelvic floor muscle exercises were recommended to friends or relatives by 77% of the patients. Once a certain level of incontinence is established with pelvic floor muscle exercises, that level is maintained over 5 years.Urology 02/1995; 45(1):113-7; discussion 118. · 2.42 Impact Factor