Overview: Smart Continence Care in Dutch Residential Facilities
Smart continence care (SCC) is an innovative approach that uses sensor-equipped incontinence materials (IMs), detachable clips, and mobile/web platforms to inform caregivers when a change is needed. This technology aims to optimize continence care for people with profound intellectual and multiple disabilities (PIMD) living in Dutch residential facilities, where 24/7 support is common. The study discussed here evaluates the cost-effectiveness and cost-utility of SCC compared with regular continence care (RCC) from a societal perspective, alongside a cluster-randomized trial (CRT).
Study Design and Setting
The economic evaluation ran parallel to a CRT across six Dutch long-term care organizations, involving 165 enrolled participants, with 156 included in intention-to-treat analyses (74 RCC; 82 SCC). Randomization occurred at the organizational level, assigning facilities to RCC, waiting-list RCC, or SCC. Data were collected at baseline (T0), six weeks (T1), and twelve weeks (T2), with additional considerations about T3. The primary clinical outcome in the base analysis was the change in weekly leakages; the economic evaluation used both cost data and health-related quality of life (HRQoL) outcomes to derive QALYs through a proxy EQ-5D-5L assessment completed by professional caregivers.
Intervention vs. Control: How SCC Worked
Participants in the SCC group used IMs with integrated sensors and a clip that communicates with caregivers’ mobile devices. Notifications (green/orange/red) guided on-demand changes, with the goal of reducing unnecessary IM changes and preventing leakage events. RCC continued standard regimes based on fixed schedules or observed needs. Implementation involved dedicated project teams, ambassadors, supplier-led training, and ongoing evaluation to tailor SCC to individual needs.
costs and Resource Use
Costs were captured from a societal perspective across five categories: total health care costs, intervention costs, costs for participants and families, and other health care costs. Intervention costs dominated, largely driven by staff time devoted to continence care. Laundry, wound care, and skin care represented a small portion of total costs. The study did not include medication costs due to time constraints, and some environmental costs for IT infrastructure were excluded for scope reasons. Resource use was tracked via continence care diaries spanning T0–T2.
Key Findings: Costs, Effectiveness, and Quality of Life
From adjusted analyses, SCC incurred higher total societal costs over 12 weeks compared with RCC (mean difference about €352; 95% CI broadly spanning zero). In clinical terms, SCC did not reduce weekly leakages; in fact, the point estimate suggested a slight increase in leakages with SCC (–1.058 fewer leakages favored RCC, with a CI crossing zero). On quality of life, the estimated QALY difference was minimal and uncertain, reflecting measurement challenges in this population. The base-case cost-utility analysis (CUA) showed substantial uncertainty, with a 0–50% probability of SCC being cost-effective at typical willingness-to-pay (WTP) thresholds for QALYs in the range of €0–€100,000. Notably, sensitivity analyses that varied SCC pricing under different implementation scales demonstrated scenarios where SCC could become cost-effective, especially with larger discounts and scale and when focusing on reducing IMCs rather than leakages alone.
Sensitivity and Scenario Insights
Several sensitivity analyses explored alternative outcomes (e.g., weekly IMCs, time spent on continence care) and price variations tied to a revised supplier pricing model. A smaller implementation setting (fewer participants, modest discounts) showed higher uncertainty about cost savings, while a larger deployment with added discounts improved the probability of cost-effectiveness. A key takeaway is that implementation quality heavily influences outcomes; one organization with known implementation difficulties skewed results, underscoring the importance of stable rollout and staff buy-in.
Strengths, Limitations, and Implications
The study boasted a robust CRT design, adherence to Dutch economic evaluation guidelines, and advanced statistical handling of missing data and clustering. However, limitations include a 12-week horizon (excluding start-up amortization), potential learning curves for SCC use, incomplete medication cost data, and the use of EQ-5D-5L—a tool with noted limitations for people with PIMD. Despite mixed QoL results, SCC may offer value by generating granular data to tailor personalized care and reduce unnecessary IM changes, though this did not consistently translate to staff time savings in the short term.
Conclusions and Future Directions
From a societal viewpoint, SCC for persons with PIMD in Dutch residential care did not demonstrate clear cost-effectiveness or cost-utility within a 12-week window, given higher costs and uncertain QoL gains. Nevertheless, the observed reduction in weekly IMCs in some analyses suggests a potential benefit in reducing care interruptions for residents, which could translate to quality-of-life improvements over a longer horizon or with optimized implementation. Future work should aim to develop valid QoL instruments tailored to people with PIMD, explore longer-term economic evaluations, and examine provider-level cost-effectiveness to help care organizations decide on scalable SCC adoption.
Practical Takeaways for Policy and Practice
– SCC can inform more personalized continence care and may reduce unnecessary IM changes, but short-term cost impacts are not favorable across the board.
– Successful implementation and scale, coupled with favorable pricing, appear crucial for achieving cost-effectiveness gains.
– Decision-makers should consider longer-term horizons and provider perspectives alongside societal costs when evaluating SCC adoption for PIMD populations.
