Smart Continence Care in Dutch Residential Care: What the Study Examines
People with profound intellectual and multiple disabilities (PIDMD) in Dutch residential facilities rely on intensive daily care, including continence management. This study evaluates a smart continence care (SCC) system against regular continence care (RCC) from a societal perspective, focusing on costs, quality of life, and care efficiency. The trial spans six care organizations and 165 participants, with data collected at baseline and two follow-up points within 12 weeks. The central aim is to determine whether SCC delivers cost-effective improvements for PIDMD and their caregivers.
What is Smart Continence Care?
SCC uses sensors embedded in incontinence materials (IM) and a detachable clip that transmits saturation data to caregivers’ mobile devices. Notifications (green, orange, red) guide timely IM changes, encouraging on-demand changes rather than rigid schedules. This technology promises better personalization of care, potential time savings for staff, and reduced unnecessary material changes.
Economic Evaluation: Design and Methods
The study followed a cluster randomized design across Dutch residential care locations, with 1:1 randomization to RCC or SCC, and a waiting-list cross-over after 12 weeks. Resource use and costs were captured through continence care diaries and the iMCQ instrument, focusing on five cost categories: societal costs, total health care costs, intervention costs, other health care costs, and participant/family costs. Prices were standardized to 2022 euros, and discounting was not required due to the 12-week horizon.
Outcomes included weekly leakages and weekly IMCs (to assess clinical effectiveness) and Quality-Adjusted Life Years (QALYs) using a proxy EQ-5D-5L instrument completed by professional caregivers. Analyses followed Dutch guidelines for economic evaluations and used robust methods to handle clustering and missing data, with results presented through cost-effectiveness planes and acceptability curves.
Main Findings: Costs, Effectiveness, and Uncertainty
From a societal perspective over 12 weeks, SCC incurred higher total costs by about €352 on average, with a wide confidence interval. Clinically, SCC did not reduce weekly leakages compared with RCC; in fact, the adjusted analysis suggested SCC may be associated with a small increase in leakages. This produced a negative signal on the primary clinical outcome, yielding an inferior ICER in the base-case analysis: an extra leakage per week for a higher cost.
However, the story is nuanced. SCC did reduce the number of weekly IMCs, which could indicate less unnecessary handling and interruptions of daily activities for PIDMD. Subgroup and sensitivity analyses showed contexts in which SCC could become more favorable—particularly when price models provided larger discounts or in large-scale implementations. The probability that SCC is cost-effective at common willingness-to-pay thresholds for QALYs hovered around 40% under the base case, rising modestly with favorable pricing scenarios.
Quality of Life and Measurement Challenges
QALYs were derived from proxies due to the inability of PIDMD individuals to self-report. The EQ-5D-5L instrument has known limitations for this group, and missing data were most prevalent in pain/comfort and anxiety/depression domains. The authors stress the need for a validated utility measure tailored to PIDMD to improve future economic evaluations.
Strengths, Limitations, and Practical Implications
Key strengths include a robust cluster randomized design, adherence to CHEERS and Dutch EEH guidelines, and advanced statistical methods to handle clustering and missing data. Crucially, baseline differences in staff time spent on continence care were corrected, acknowledging this variable as a major cost driver. Limitations include the short 12-week horizon, absence of started-out capital and maintenance costs for SCC, and incomplete medication cost accounting. In practice, implementation challenges—staff turnover, training needs, and device fit—emerged as significant determinants of SCC’s effectiveness.
Takeaways for Policy and Practice
- From a societal perspective, SCC is not clearly cost-saving for PIDMD in the short term, and may not reduce leakages. Decisions to implement should weigh potential non-monetary benefits, such as personalized care data and fewer unnecessary IM changes.
- Pricing models and larger-scale deployments can tilt the cost-effectiveness in favor of SCC, suggesting that care organizations could benefit from negotiating discounts and investing in staff training and integration with existing workflows.
- The need for a PIDMD-specific quality-of-life instrument is urgent to sharpen future cost-utility analyses and aid decision-makers in evaluating value beyond conventional metrics.
Conclusion
The economic evaluation of SCC for PIDMD in Dutch residential care shows mixed results: potential reductions in unnecessary IM changes are counterbalanced by higher short-term costs and no clear reduction in leakages. Proper implementation, longer-term follow-up, and a PIDMD-tailored quality-of-life measure are essential to determining whether SCC ultimately provides value in real-world care settings.
