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:
where:
E = equivalent annual cost
K = purchase price of equipment
S = resale value
r = discount (interest rate)
n = equipment lifespan
A(n, r) = annuity factor6(n years at interest rate r)
Pelvic floor muscle training
Description of treatment and assumptions
It is difficult to define a ‘standard’ or ‘typical’ pelvic floor muscle training (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
7 in a hospital physiotherapy department.
There are a total of six sessions with the therapist
8The 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
Table S.1
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| Item | Quantity | Unit cost | Cost |
|---|
| Gloves | 6 | £0.02 | £0.11 |
| KY Jelly | 1 | £0.80 | £0.80 |
| Couch roll | 6 | £0.04 | £0.22 |
| Paper towels | 24 | Less than £0.01 | £0.07 |
| Wipes | 12 | £0.03 | £0.30 |
| Total | | | £1.50 |
Total cost for bladder training: £94
Pelvic floor muscle training + 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 NeuroTracTM Simplex (hand-held single-channel EMG unit), a Neen Educator R _ 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
Table S.2
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| Item | Quantity | Unit cost | Cost |
|---|
| Neen Educator | 1 | 19.50 | 19.50 |
| Neen Periform | 1 | £10.25 | £10.25 |
| Total | | | £29.75 |
Equipment
Table S.3
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| Item | Cost | Equivalent annual cost | Cost/patient |
|---|
| Verity NeuroTrac Simplex | £99 | £19.84 | £4.96 |
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.
Labour costs
1/3 × £129.50 = £43933
Table S.4
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| Item | Quantity | Unit cost | Cost |
|---|
| Neen Educator | 1 | 19.50 | 19.50 |
| Neen Periform | 1 | £10.25 | £10.25 |
| Total | | | £29.75 |
Total cost for bladder training: £94
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 ‘Peri-calm’).
Patient has two follow-up appointments
10, 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
Table S.5
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| Item | Quantity | Unit cost | Cost |
|---|
| Gloves | 3 | £0.02 | £0.06 |
| KY Jelly | 3 | £0.80 | £2.40 |
| Couch roll | 3 | £0.04 | £0.11 |
| Paper towels | 12 | Less than £0.01 | £0.04 |
| Wipes | 6 | £0.03 | £0.15 |
| Neen Periform | 1 | £10.25 | £10.25 |
| Total | | | £13.01 |
Equipment
Table S.6
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| Item | Cost | Equivalent annual cost | Cost/patient |
|---|
| Neen Pericalm | £83.89 | £19.84 | £4.20 |
Total cost for bladder training: £94
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
11, 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
Table S.7
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| Item | Quantity | Unit cost | Cost |
|---|
| KY Jelly | 13 | £0.80 | £10.38 |
| Gloves | 13 | £0.02 | £0.24 |
| Couch roll | 13 | £0.04 | £0.47 |
| Paper towels | 52 | £0.00 | £0.16 |
| Wipes | 26 | £0.03 | £0.65 |
| Neen Periform | 1 | £10.25 | £10.25 |
| Total | | | £22.15 |
Equipment
Table S.8
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| Item | Cost | Equivalent annual cost | Cost/patient |
|---|
| Genesis Medical Nomax 2 | £220 | £41.29 | £0.21 |
| Data Reader | £285 | £53.49 | £0.27 |
Total cost for bladder training: £94
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
Table S.9
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| Item | Quantity | Unit cost | Cost |
|---|
| Gloves | 5 | £0.02 | £0.09 |
| KY Jelly | 1 | £0.80 | £0.80 |
| Couch roll | 5 | £0.04 | £0.18 |
| Paper towels | 20 | Less than £0.01 | £0.06 |
| Wipes | 10 | £0.03 | £0.25 |
| Assessment forms | 1 | £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)
Table S.10
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| Drug | Dose | Daily frequency | Cost per pack (£) | Pack size | Cost per day (£) | Cost for 12 weeks (£) | Cost for 1 year (£) | Cost for 1 year incl. GP review (£) |
|---|
| Duloxetine | 40 mg | 2 | 30.80 | 56 | 1.10 | 92 | 402 | 423 |
| Flavoxate | 200 mg | 3 | 11.87 | 90 | 0.40 | 33 | 144 | 165 |
| Oxybutynin | 5 mg | 2 | 4.14 | 84 | 0.10 | 8 | 36 | 57 |
| ER oxybutynin | 10 mg | 1 | 24.68 | 30 | 0.82 | 69 | 300 | 321 |
| Oxybutynin patches | 3.9 mg | 0.29 | 27.20 | 8 | 0.97 | 82 | 355 | 376 |
| Propiverine | 15 mg | 3 | 24.45 | 56 | 1.31 | 110 | 478 | 499 |
| Solifenacin | 5 mg | 1 | 27.62 | 30 | 0.92 | 77 | 336 | 357 |
| Solifenacin | 10 mg | 1 | 35.91 | 30 | 1.20 | 101 | 437 | 458 |
| Tolterodine | 2 mg | 2 | 30.56 | 56 | 1.09 | 92 | 398 | 419 |
| ER tolterodine | 4 mg | 1 | 29.03 | 28 | 1.04 | 87 | 378 | 399 |
| Trospium | 20 mg | 2 | 26.00 | 60 | 0.87 | 73 | 316 | 337 |
Various conservative treatments combined
PFMT + duloxetine
Description of treatment and assumptions
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 1/2 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
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
- 6
Converts a present value into an annuity, a series of equal annual payments.
- 7
Remuneration for a continence nurse specialist grade f–g/band 6–7 is similar.
- 8
Estimates from GDG members that four to eight sessions are typically offered.
- 9
Teaching time is one third of that for PFMT; see link. 933
- 10
Again, actual practice on follow-up may vary.
- 11
Again actual practice on follow up may vary
