Créditos del BCB a las EPNE

The main difference between the recommended model and the existing model of care is that in the new model there is an emphasis in primary care on PFE and bladder training managed by continence nurse practitioners (CNPs). This results in a reduction in the number of patients who go through to secondary care. The service in secondary care remains similar to the current service.

Future service configuration and associated costs

The Leicestershire MRC Incontinence Study has evaluated a new nurse-led continence service,232which may be the principle upon which continence services will be based in the future. Figure 15 shows the structure of part of the study and patient flow through the service. An economic evaluation of this new service will be compared to that of an existing continence service.

Assessment and conservative treatment in primary care by Continence Nurse Practitioner using bladder training and pelvic floor exercises

Urodynamic investigation Drug therapy Pelvic floor exercises (with feedback) Surgery (0.25%) (0.18%) (0.3%) (0.7%) (5.5%)

The prevalence of individuals eligible for assessment and treatment in primary care for this model was based upon screening the local population through a postal questionnaire and home interview to establish severity of symptoms. In the new model, management in primary care would be provided in the main by CNPs with support from the GP in the first instance and referral to secondary care as appropriate.

All costs for these services are based on costing work carried out as part of the evaluation of the nurse-led continence services. These evaluations of the nurse-led continence services are ongoing, so the published costs may be revised in subsequent publications. All costs are in UK pounds for the year 2000. Although it is proposed that these costs should provide an estimate of the costs of this type of service, there are a number of caveats that need to be considered. The services evaluated were set up as part of a research project so workload and patterns of working may differ from those to be found in normal practice. Also, although the entry criteria for these services were based on symptoms relating to urinary incontinence, some of those admitted to the services would also have symptoms that related to voiding problems. Therefore, not all the resource used necessarily relates to urinary incontinence. In addition, these services were aimed at those over 40 years of age and so do not address the needs of those below this age.

All patients were seen by the CNP over an eight-week treatment period, with three planned visits, together with additional visits depending on the interventions provided and the degree of support deemed necessary by the nurse. Each patient underwent a one-hour assessment visit, which included taking a clinical history, physical examination, urinalysis, a mid-stream specimen of urine (MSU), a bladder scan to estimate post-void residual volume of urine, blood pressure, weight, height and, in women, vaginal examination. All patients were instructed in how to complete a urinary diary and pad test. Patients were seen one week after provision of the diary and pad test, which were then reviewed and a treatment regime was begun. A battery of clinical interventions could be implemented by the nurses, including bladder re- education for frequency, urgency and urge incontinence, Canesten for vaginal candida, pelvic floor awareness for stress incontinence, antibiotics for urinary tract infection, topical oestrogen for atrophic vaginitis, medication change for symptoms caused by loop diuretics, and advice on diet and fluid intake. Each CNP had a maximum caseload of 60 patients. Up to three visits could be scheduled over the subsequent five weeks, before a final assessment. Preliminary results of the costs for these services for older adults are given in Table 11.

Table 11: Costs* for the new model of care as developed in the Leicestershire MRC Incontinence Study for people aged 40 or over.

Total number of contacts (% of study population)

Unit cost Cost per 1000 people in Leicestershire over 40

Treatment in primary care 7,147 (5.5%) £163 £9,008

Urodynamics 906 (0.7%) £154 £1,076

Pelvic floor 329 (0.25%) £293 £745

Drug therapy (oxybutynin) 390 (0.3%) £418 £1,261

Surgery** 237 (0.18%) £1,966 £3,602

Total £15,691

The total cost for the new service is estimated at £15 691 per 1000 per annum. This is likely to be an overestimate for several reasons:

 The services evaluated were set up as part of a research project, so workload and patterns of working may differ from those to be found in normal practice.

 Although the entry criteria for these services were based on symptoms relating to urinary incontinence, some of those admitted to the services would also have symptoms that related to voiding problems and this is likely to result in an overestimate of resource use.

Estimate of current service costs

Costs for the conventional incontinence service were estimated from a survey carried out as part of the Leicestershire MRC Incontinence Study. Respondents were asked for details of services they had used in the last year. The survey was carried out on 29 268 community residents over the age of 40. The percentages of respondents who used each category of service are given in Table 12. Since this was a snapshot of patients’ experiences in just one year, none reported any surgery therefore an estimate of this was made using average rates and cost for surgery for the over 40s in the UK, calculated using OPCSstatistics. Preliminary results of the costs for these services for older adults are given in Table 12.

The total cost for existing services is estimated at £10 856 per 1000 per annum. This is likely to be an underestimate for several reasons:

 Costs are based on just the previous year’s experience of a sample of respondents.

 Costs were used for a single contact as there is no data on the numbers of times respondents contacted a service.

 Costs for urodynamics are not included, as only values for consultations with a hospital doctor were available.

Table 12: Estimate of costsawith conventional pattern of care based on survey of service contacts of 29,268 community dwelling adults aged 40 and over.

Proportion using this service

Unit cost Average cost per 1000 Any health care professional 11.2%

GP 8.7% £1888 £1,566

Hospital doctor 2.9% £61234 £1,769

Physiotherapist 1.5% £1688 £240

Specialist continence nurse 1.2% £1788 _£200

Other nurse 1.2% £1788 £200

Antibiotics 4.0% £2234 £91

Other medications 2.2% £60235 £1,323

Surgeryb £975

Pelvic floor exercises urinary diary 1.5% £293236 £4,493

Total £10,856

a_{For the year 2000 (preliminary results subject to revision).} b_{This value is taken from HRG and OPCSdata.}