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Indwelling catheter use in home care in Europe
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Age and Ageing 2005; 34: 377–381 The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afi094 All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Published electronically 18 May 2005
Indwelling catheter use in home care: elderly,
aged 65ⴙ, in 11 different countries in Europe
LIV WERGELAND SØRBYE
1
, HARRIET FINNE-SOVERI
2
, GUNNAR LJUNGGREN
3
, EVA TOPINKOVÁ
4
,
R
OBERTO BERNABEI
5
1
Diakonhjemmet University College, Box 184, 0319 Oslo, Norway
2
STAKES, Lintulahdenkuja 4, PO Box 220, FIN-00531, Helsinki, Finland
3
Centre for Gerontology and Health Economics, Karolinska Institute, Crafoords v. 12, S-113 24 Stockholm, Sweden
4
Department of Geriatrics, 1st Medical Faculty, Charles University and Institute of Postgraduate Medical Education, Londýnská
15, 12000 Prague 2, Czech Republic
5
Via Sabotino 12, 00195 Rome, Italy
Address correspondence to: L. Sørbye. Fax: (+47) 22 451 950. Email: sorbye@diakonhjemmet.no
Abstract
Objective: to describe possible differences/patterns in the use of indwelling urinary catheters (IUC) in Europe.
Design: a prospective, population-based, assessment study.
Setting: the target population was 4,455 (random sample of 405 from each of 11 countries) aged 65+ receiving home care.
Methods: the clients were assessed by using the Resident Assessment Instrument MDS-HC; epidemiological and medical
characteristics of clients and service utilisation were recorded.
Measurements: the frequency of use of IUC related to the patients’ activities of daily living (ADL) and cognitive
functioning.
Results: the sample consisted of 4,010 informants: 74% female, with mean age 82.3 ± 7.3 years; men 80.9 ± 7.5 years and
female 82.8 ± 7.3 years. A total of 216 (5.4%) clients were using IUC. In Italy 23% were using a catheter compared with 0%
in The Netherlands. Catheter use was more common in men than in women (11.5% versus 3.3%). Use of IUC was signifi-
cantly correlated to certain diseases and symptoms and increase in care burden and formal services. Twenty-six per cent of
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L. W. Sørbye et al.
378
the informants with indwelling catheters scored three or more on a hierarchical ADL scale (0–6). The clients using IUC in
the Nordic countries were less dependent on care than in the other European countries. Models built on multivariate analysis
explained 37% of the use of IUC. Tradition and attitudes may explain the differences between the sites.
Conclusions: catheter use is associated with formal or family care burden. The need for nursing home placement ought to
be considered in some cases. A stricter criterion for using IUC may be considered in the southern European countries.
Keywords: elderly, home care, indwelling urinary catheter, quality of care, care burden, RAI-HC, elderly
Introduction
Urinary incontinence (UI) is a significant cause of disability and
dependency; it is distressing and disproportionately affects older
people [1–3]. The frequency in different samples varies from 15
to 30% depending on the study [4, 5]. About 50% of those who
live at home and receive formal services are incontinent [6, 7].
However, only few studies document the prevalence rates
for indwelling urinary catheters (IUC) in home care. In a popu-
lation study of urinary incontinence in the age group 70–97
years, Molander et al. [8] stated that IUC were not often used.
Smith concluded in a review that the prevalence of IUC was
4% [9], whereas a prevalence rate of 10% was found in Japan
by Gotoh et al. [10]. The complications associated with IUC
cause significant morbidity and mortality [11, 12].
Objective
To find out among the clients receiving home care in
11 European sites: (i) the characteristics of the population
that has an indwelling catheter compared with those that have
not; (ii) the differences in practices between the sites; (iii) the
predictors for indwelling catheters for clients in home care.
Methods
Population
The study was performed in 11 European countries: Czech
Republic, Denmark, Finland, France, Germany, Iceland,
Italy, The Netherlands, Norway, Sweden and the UK.
Home care agencies providing home care services to older
persons living in a defined geographical urban area were
chosen by the partners to represent as well as possible the
practices of each of the countries. In each of the sites, the
randomly selected study population comprised 405 persons,
aged 65 years or over, and of those all together 4,010 sub-
jects were finally enrolled in the study. The mean age of the
participants was 82 years and 74% were female [13].
Data collection
In the present study, we used the data collection performed
by using Minimum Data Set version 2.0 for home care
(MDS-HC 2,0) at the baseline. The MDS assessment con-
sists of more than 300 internationally validated variables or
scales and has good inter-observer reliability [13–15]. Serv-
ice utilisation, physical capacity, cognitive skills and psycho-
social characteristics of the clients were assessed and
recorded by specially trained nurses. Indwelling catheter
was defined as any catheter inserted to ensure urinary drain-
age, including catheters inserted suprapubicly or via the uri-
nary tract. Use of an indwelling catheter was assessed as
‘yes’ or ‘no’. Missing values were interpreted as no use of
IUC.
Statistical analyses
Variables previously known to associate with the use of
indwelling catheters were extracted from the database for
the current analyses, which were then performed using SAS
statistical software (Gary Inc., www.statsoftinc.com). First,
the associates of indwelling catheter use were identified
(chi-square analysis for dichotomised variables and Stu-
dent’s t-test for continuous variables). Then the associates
of catheter use were entered one by one into multivariate
models in clinically meaningful groups. The strongest pre-
dictors for indwelling catheters were entered into the final
model to combine the sites with the clinical factors.
Results
Of the 4,010 persons in the study, IUC was found in
216 persons (5.4%) and the variation between sites was 0–23%.
Table 1 shows that IUC was used more often in males
than in females (11.5% versus 3.3%, P < 0.0001). Use of
catheters followed different patterns in males compared
with females with advancing age (Figure 1).
Table 2 presents comparisons of clients with and with-
out IUC as to the tested clinical features; it also shows the
type of dependency on services as to the clients with IUC
compared with those without it.
Table 1. Use of IUC by gender and by site among the home
care clients in 11 European countries
n =4,010.
Site Number
IUC in
males (%)
IUC in
females (%) Overall %
........................
.
.............
.
..
.
..............
.
....................
.
............
Czech Republic 428 7.8 0.6 2.1
Denmark 469 5.0 0.3 1.3
Finland 187 2.9 2.0 2.1
France 381 15.0 6.2 8.7
Germany 607 15.7 3.1 6.2
Iceland 405 2.9 1.0 1.5
Italy 412 30.7 18.5 23.1
The Netherlands 198 0 0 0.0
Norway 388 6.4 1.4 2.8
Sweden 246 3.0 0.6 1.2
UK 289 9.5 1.9 3.8
Overall n (%) 4,010 (100) 119 (11.5) 97 (3.3) 216 (5.4)
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Indwelling catheter use in home care in Europe
379
0
2
4
6
8
10
12
14
16
18
20
<75 75-79 80-84 85-89 >90
IUC, Males (%) IUC, Females (%)
Figure 1. Urinary indwelling catheters by gender and age among the home care clients in 11 European countries (n =4,010).
Table 2. Comparison of clinical features and need for help among the home care clients with and without an indwelling
catheter in 11 European countries
n =4,010.
Indwelling catheter
inserted n (%)
No indwelling catheter
inserted n (%) P value
.....................................................................................................
.
..............................
.
...........................
.
...................
Diseases
Stroke with hemiplegia n =247 19 (8) 228 (92) 0.0975
Any type of diagnosed dementia n =514 46 (10) 468 (91) 0.0001
Multiple sclerosis n =032 7 (22) 25 (78) 0.0001
Parkinsonism n =200 23 (12) 177 (89) 0.0001
Any cancer n =321 34 (11) 287 (89) 0.0001
Urinary tract infection n =201 38 (19) 163 (81) 0.0001
Renal failure n =129 10 (8) 119 (92) 0.2264
Symptoms and signs
Difficulties in urinating or urinating three or more times during the night n =525 9 (2) 516 (98) 0.0001
Worsening of bladder incontinence within past 90 days n =409 41 (10) 368 (90) 0.0001
Fever n =70 14 (20) 56 (80) 0.0001
Grade 1–4 pressure ulcers n =296 77 (26) 219 (74) 0.0001
Terminal prognosis n =32 6 (19) 26 (81) 0.0008
Decline in mood within past 90 days n =470 37 (9) 433 (92) 0.0111
Functional capacity
ADL > 3 (scale =0–6) n =515 134 (26) 381 (74) 0.0001
CPS > 3 (scale =0–6) n =419 88 (21) 331 (79) 0.0001
Issues related to quality of life and care-giver burden and use of formal services
Client is alone most of the day n =1154 13 (1) 1141 (99) 0.0001
Does not go out of her/his home n =1421 160 (11) 1261 (89) 0.0001
Informal care-giver feels distressed n =259 48 (19) 211 (81) 0.0001
Informal care-giver is dissatisfied with provided support n =112 18 (16) 94 (84) 0.0001
Informal care-giver unable to continue n =184 22 (12) 162 (88) 0.0001
Use of formal services
No review of the medications within past 180 days n =669 16 (2) 653 (98) 0.0002
Hospital admission within past 90 days n =698 83 (12) 615 (88) 0.0001
Visit to emergency room (without hospital admission) n =246 16 (7) 230 (94) 0.4229
Unscheduled emergent care n =324 24 (7) 300 (93) 0.0928
Visits of home carer within past 7 days n =1629 68 (4) 1561 (96) 0.0049
Visits of nurse within past 7 days n =1295 101 (9) 1194 (92) 0.0001
Visits of home-help within past 7 days n =1635 33 (2) 1602 (98) 0.0001
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L. W. Sørbye et al.
380
The explanatory value for the first model consisting of
only the 11 sites was 17%, when all the other sites were
compared with the samples collected from The Netherlands
and Sweden. The explanatory value for the model consist-
ing of diagnoses was 7%, for cognitive and physical func-
tional capacity 23% and for the symptoms 14%. The
combined results are presented in Table 3.
Discussion
The AdHOC Study was designed to compare outcomes of
different models of community care using a structured com-
parison of services and a comprehensive standardised
assessment instrument across 11 European countries [13].
The use of IUC varied from 0 to 23% from site to site and
showed a mean prevalence of 5.5%. These devices were
more often found in men than in women in each of the
sites. Occurrence of catheter use was not higher with
advancing age in females; however, an increase of catheters
was seen in ageing males. The diseases with a relationship to
catheter use were those previously shown in the literature
[11–12]. The tendency to insert catheters in males in older
age groups, with advanced dementia, pressure ulcers and poor
functional ability, were our main findings. This occurred
particularly if the client suffered from cancer, multiple scle-
rosis, or if he or she resided in one of the following three
sites: France, Germany or Italy. The explanatory value for
these findings was 37% (r
2
=0.37).
The frequency of catheter use accords well with the few
previously estimated figures [9]. The presence of cognitive
decline, more serious than moderate dementia, increased the
risk of receiving a catheter almost two-fold; at the same time
the presence of a diagnosis of dementia ceased being signific-
ant in the multivariate model. Thus, not the disease per se, but
the severity of it, is of importance. At the same time the pres-
ence of severe functional decline increased the risk for receiv-
ing IUC a little over four-fold. The presence of pressure ulcers
almost doubled the risk for catheter use. Multiple sclerosis is
not a prevalent disease in this population whereas cancer is
seen slightly more often. When present, the risk for receiving a
catheter increases 6- and 2-fold correspondingly. More fre-
quent use of IUC in males than in females is most certainly
explained by prostate problems that increase with advancing
age. Unfortunately, questions about urinary retention are not a
part of the MDS questionnaire, and this fact makes it some-
what hard to trace the true cause for inserting the catheter.
Variations from country to country in the prevalence of
catheter use may still partially be explained by the case-mix
of the clients. It is of interest that when adjusting the regres-
sion model for dementia and functional capacity in addition
to diseases, the differences vanished between Nordic coun-
tries, The Netherlands and the UK, representing the north-
ern parts of Europe. The Central European or Southern
European region appeared to host different care patterns or
culture of care compared with those living in the north. One
reason for the difference between the sites in the prevalence
of indwelling catheter use could be habit-based instead of
evidence-based practice. Some of the European countries
really had restricted use of IUC, corresponding to the view
of Ouslander [16]. The predictors for the use of indwelling
catheters among the home care clients in Europe (Table 3)
document a complexity in the problem situation [17].
A study from Switzerland documented that the presence
of a urinary catheter was a predictor of unscheduled services
[18]. In our sample the users of IUC had a urinary tract
infection 6.5 times more often than those without a
catheter. Landi et al. [12] conclude that an uncritical use of
IUC should be considered an indicator of poor quality care.
Pilloni et al. [19] documented that intermittent catheterisa-
tion reduces the urinary tract infection. If one has to use an
indwelling catheter, Robinson [20] specifies that fundamen-
tal principles have to be followed. Even if the consequences
of catheter use are beyond the scope of this cross-sectional/
national analysis, the association between catheters and
informal carers’ care-giver burden is alarming.
Conclusion
The use of indwelling catheters among home care clients in
Europe was most frequent in the oldest males with advanced
dementia and poor physical function. The risk for receiving
catheters was additionally increased if the client suffered from
multiple sclerosis, cancer or pressure ulcers and resided in any
of the following sites: France, Germany or Italy.
Moreover, use of urinary catheters was associated with
increased care-giver burden. More research is warranted to
show whether IUC is predicting long-term care placement
among the home care clients in Europe, and if so, will there
be differences between countries.
Key points
• Use of indwelling catheters was most frequent in the oldest
males with advanced dementia and poor physical function.
• The risk for receiving catheters was additionally increased
if the client resided in France, Germany or Italy.
Table 3. Predictors for IUC among home care clients in 11
European countries
n =4,010. r
2
=0.3663.
Odds ratio 95% CI
.............................................
.
............................
.
............
Urinary tract infections 6.51 3.91–10.8
Multiple sclerosis 5.89 2.08–16.7
ADL > 3 4.64 3.10–6.92
Male gender 3.53 2.56–4.87
Any type of cancer 2.23 1.39–3.57
CPS > 3 1.87 1.26–2.77
Grade 1–4 pressure ulcers 1.82 1.22–2.72
Czech Republic 2.48 0.64–9.61
Denmark 2.58 0.64–9.67
Finland 2.95 0.63–10.6
France 6.08 1.75–21.1
Germany 5.60 1.65–19.0
Iceland 2.58 0.63–10.6
Italy 14.0 4.12–47.1
The Netherlands 1.00 1.00–1.00
Norway 3.67 0.99–13.7
Sweden 1.00 1.00–1.00
UK 4.90 1.30–18.5
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Indwelling catheter use in home care in Europe
381
• Use of urinary catheters was associated with increased
care-giver burden.
Acknowledgement
We are grateful to interRAI, a collaborative network of
researchers in over 20 countries committed to improving
health care for people who are elderly, frail, or disabled.
Funding
European Commission Vth Framework Programme, con-
tract number QLRT-2000-00002
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