Gage H, Avery M, Flannery C, Williams P, Fader M. Community Prevalence of Long-Term Urinary Catheter Use. Neurourology and Urodynamics2016 Feb 15. doi: 10.1002/nau.22961. [Epub ahead of print]

Abstract

Objectives: To calculate the prevalence of long term catheter use in the community in two areas in the south and west of England

Subjects/ patients (or materials) and methods: People in England register with general practices to access health care through a National Health Service. Catheters are provided by prescription free of charge. In 2008, patients using urinary catheters for over three months were identified, and demographic information collected, from databases of general practices, using catheter prescribing records. The age and sex distributions of people in each practice were obtained from capitation claims. Overall, and age and sex-specific prevalence were calculated separately for each area, and compared.

Results: A total of 583 long term catheter users (329 south, 254 west) were identified from 404,328 people registered with practices. The overall population prevalence is similar in both locations (0.146% southern, 0.141% western). Extrapolating for the United Kingdom, this is over 90,000 long term catheter users. Prevalence increases with age (0.732% in over 70 years, 1.224 over 80), especially amongst men. Overall, higher proportions have neurological (vs. non-neurological) reasons (62.9% vs. 37.1%) and use urethral (vs suprapubic) catheters (59.7% vs. 40.3%). Compared to men, more women tend to use suprapubic (56.4% vs. 29.3%) and have a catheter for neurological reasons (71.8% vs. 56.2%, p=0.053)

Conclusions: Previous evidence on prevalence of long term catheter use is sparse, and of variable quality. The strength of this study is utilisation of a reliable source of data (catheter prescriptions) from a large population of patients.

249 words

3-6 keywords

Long term catheter use Prevalence Community England

Introduction

Lower urinary tract symptoms (LUTS) include problems with storage, voiding or post micturition and may affect as many as 42% of the adult population. Urinary incontinence is estimated to affect approximately 8% of those with LUTS [1]. For some, the management of incontinence is so problematic that the only adequate means of control is an indwelling catheter. Published evidence, often small scale or anecdotal, overwhelmingly indicates that long term catheters are highly problematic and burdensome to patients, carers and health services [2-4], with complications such as recurrent blockages and leakage occurring in many [5]. Much recent research on urinary catheters has focussed on short term use; understanding of routes to long term use has been identified as a gap in knowledge [6].

In 2008, a large study was undertaken by the authors in England to gather information on the characteristics of long term catheter users in the community, their quality of life and costs of management. The ultimate aim was to inform optimisation of catheter care and scope for technical developments [7], but data were also gathered that enabled the estimation of the prevalence of long term catheter use. The objective of this paper is to report the findings related to the prevalence of long term catheter use in the community in two areas in the south and west of England

Patients and methods

The study was conducted in the areas covered by Primary Care Research Networks (PCRN) in the south (Southampton, Portsmouth, Hampshire, Dorset, Wiltshire, Isle of Wight) and west (Bristol, South Gloucestershire, Somerset, Swindon, North Somerset, Bath and North East Somerset,, Gloucestershire) of England, in 2008. One of the functions of the PCRNs (which were subsequently incorporated in Local Clinical Research Networks) was to help recruit participants into research studies. The PCRNs advertised for general practices in each area to participate in the study. Volunteer practices were reimbursed for assisting with the identification of people with long term urinary catheters in their data bases, using searches based on prescribing records. Since people in England gain access to the National Health Service (NHS) through registration with a local general practice, and catheter supplies are provided free of charge through general practitioners’ (GPs) prescriptions, this was considered a reliable way to obtain lists of long term catheter users. Each identified patient was given a unique 5 digit study number showing site (south or west), practice code, patient number in practice. Participant study numbers were linked to names and contact details, and this information was kept separately by each practice (to maintain patient anonymity to researchers).

General practices provided the research team with the records of all patients with long term catheters for the 12 month period prior to the date they were identified. Records were labelled using the patient’s study number; all names were removed. Data were extracted from the records by the research team and transferred to a separate database including: sex, year of birth, reason for catheter, type of catheter, co-morbidities, catheter-related services and supplies over the 12 month period. Three months was considered the threshold for defining long term catheter usage, so any patient whose catheter use had started within the previous three months was excluded. Participants’ post codes were used to assign an index of multiple deprivation (IMD) score, taken from Public Health England General Practice Research Profiles [8] for each practice as a whole. The IMD is an official government measure of relative deprivation of small areas in England based on factors such as income, employment, housing, crime, health and education. Reasons for using a catheter were coded as neurological (spinal cord injury, conditions such as multiple sclerosis, stroke) or non neurological (typically for men with prostate-related symptoms, and women due to obstetric or gynaecological problems). As part of the larger study, local district nurses (who provide much of the long term catheter management for GPs) were asked to provide additional information on patients that had been identified through the GP record searches. This process resulted in the identification of additional long term catheter users who were then included in the analysis.

For the purposes of calculating prevalence, the age and sex distributions of people registered with each practice in 2008 were obtained retrospectively (in July 2013) from Public Health England’s National General Practice Profiles [8]. These data are available as they form the basis for capitation payments to practices. The characteristics of the practices were described with medians and ranges chosen as relevant indicators of the properties of the sample. Overall and age and gender-specific prevalence were calculated separately for the south and west areas. The characteristics of the sample of long term catheter users (age, neurological or non neurological reason for use and catheter type) were compared, reporting descriptive statistics with chi-squared (of Fisher’s Exact) tests, and Mann Whitney U tests, as appropriate.

A favourable ethical opinion was obtained from the SouthmeadResearch Ethics Committee prior to the start of the project.

Results

Description of sample

Of a total of 724 practices (396 in the south, 328 in the west PCRN areas), 23 in the south and 28 in the west (with corresponding practice populations of 224,624 and 179,695) volunteered to take part in the study. Data from five practices were excluded from the calculation of the prevalences, one in the south (because of concerns that the practice staff had selectively not provided the research team with records of some long term catheter users such as those with terminal illness) and four in in the west (becausechanges in practice configurations caused uncertainties around the age and sex data extracted from the national data base). A total of 583 long term catheter users (329 south, 254 west,) were identified from these practices. Amongst these, there was some missing information for 28 patients; both age and sex were known for 311 in the south (11 without sex, 6 without age, 1 without sex and age) and 244 in the west (8 without sex, 2 without age). Descriptive information on the 46 included practices is given in Table 1.

Table 1 goes here

The age, sex and overall prevalence by area and type of catheter are shown in Table 2. Age and sexspecific prevalence are slight underestimates because patients with missing information are omitted from the calculations. Prevalence rise with age, especially for men, (0.677% for women, 1.659% for men over 80 years), but the patterns are similar for both locations; overall prevalence of 0.146% (south) and 0.141% (west) (Table 2). Of users for whom age, sex and the type of catheter were known, 314 (59.7%) had urethral and 212 (40.3%) suprapubic. Comparing men and women for catheter type, significantly fewer men than women had suprapubic (89, 29.3% vs. 115, 56.4%) than urethral (216, 70.8% vs. 89, 43.6%) (p<0.0005).

Table 2 goes here

Most long term catheter use was for neurological reasons (n=326 (62.9%) vs. n=192 (37.1%) non neurological, 65 missing data). When these data are broken down by age (9 missing) and sex (20 missing), the proportions with non-neurological reasons increase significantly with age, for both men and women. Overall, compared to men, there was a tendency for higher proportions of women to have a long term catheter for neurological reasons (56.2% vs. 71.8%, p=0.053) (Table 3).

Table 3 goes here

Amongst the 258 urethral catheter users for whom sex and reason for use is known, there was no difference between men and women with respect to the prevalence of neurological reasons. However, examining the 191 suprapubic catheter users for whom sex and reason for use were known shows a significantly higher prevalence of neurological reasons amongst women than men (78.4% vs. 65.0%, p=0.04) (Table 3).

Comparing catheter type for reason for use, there was no significant difference in the proportions of men with neurological reasons having urethral or suprapubic catheters. However, amongst women there was a tendency for higher proportions of those with neurological reasons to use suprapubic, rather than urethral, catheters (78.4% vs. 65.9%, p=0.053). The proportions of patients who used suprapubic catheters fell with increasing age, both in the neurological and non neurological groups (Table 3).

Discussion

This is the first study to use GP records to calculate the prevalence of long term catheter use in the community. It adds to the limited knowledge about the extent of catheter use in community dwelling adults in the UK. This method enabled identification of catheter users without relying on self-report. Extrapolating the prevalence in this study to the United Kingdom (population of 64 million) over 90,000 people use long term indwelling catheters.

Over half of use was attributed to neurological conditions, and the proportion of users with non-neurological conditions rises with age especially amongst men in both sites. Women, but not men, with neurological conditions favour suprapubic catheters

The overall population prevalence in this study was calculated over large areas and found to be similar in both the south (0.146%) and west (0.141%) of England; in those over 70 years of age it was 0.732%, and those over 80, 1.224%. Recent studies of long term catheter users have tended to focus on the incidence of problems, but did not seek to identify all users in an area [4,5]. Although much has been written on the high incidence of morbidity associated with long term catheter use, and the microbiology of catheter-related urinary tract infections [9], evidence on prevalence of use is very limited. Available data in England comes from two studies that are now some 20 years old. One, based on a postal survey of district nurses, nursing homes and A&E departments over a two year period in Bristol reported 0.07% population prevalence and 0.5% in people over 75 [10]. Results from the other study indicate that 4% of people in domiciliary care have long term catheters [11]. Across Europe, considerable variability in use of indwelling catheters by older people receiving home care has been recorded, ranging from 0% in the Netherlands to 23% in Italy [12]. Studies within residential care facilities typically report prevalence of up to 10% [13,14].

This study has several limitations. Not all practices in the area volunteered to take part, and some had to be excluded from the analysis due to uncertainties about the data. However, both areas were large and included diverse socio-economic and ethnic groups and we believe the samples are representative. The similarity of the results in the two areas provides reassurance. The age and sex specific prevalence are slight underestimates because of the small number of cases where information on age and / or sex were missing. The analysis of reasons for having a catheter, and of catheter type, was also hindered by missing data, and assignment to either neurological or non neurological causes was dependent on researcher interpretation of clinical records, which may have led to errors. Three months was considered the threshold for defining long term catheter usage and the prevalence would have been higher if 30 days had been chosen, as specified in a recent Cochrane review [15]. The study was conducted carefully, using a unique and comprehensive method and we believe provides useful evidence about something where there has been little recent information.

Conclusion:

Previous evidence on prevalence of long term catheter use is sparse, and of variable quality. The strength of the study lies in the utilisation of a reliable source of data (catheter prescriptions) from a large population of patients registered with English general practice. It indicates that significant numbers of community-dwelling adults live with indwelling catheters. There is a need for a greater focus on this large group as they experience considerable morbidity, and the resource use associated with their management is costly.

Acknowledgements:

The authors thank: Jerome Cheynel and Tom Rowles for help with the data management; the project’s advisors Alan Cottenden, Katherine Moore, Anthony Timoney, Mary Wilde, and the patient representative Stewart Orme.The study was funded by Action Medical Research, Grant 4211. The views expressed are those of the authors and not necessarily those of the funding body.

References:

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Table 1: Description of the 46 practices included in the prevalence calculations

Practice characteristic / N = 46 practices* / Range / Median
List size (number of people) / 46 / 1,978 – 28,520 / 8,280
Proportion over 65 years / 45 / 10.1% - 38.1% / 18.2%
Number of long term catheter users / 46 / 2 - 24 / 9.5
Index of Multiple Deprivation score# / 45 / 39.4 – 4.85 / 13.5
*The number of practices is less than 46 when data on a variable is missing for the whole practice
# The IMD is an official government measure of relative deprivation of small areas in England based on factors such as income, employment, housing, crime, health and education.
Total practice list size / Total LTC users / Under 50 years / Over 50 years / Over 60 years / Over 70 years / Over 80 years
n / Pop / Prev.
% / n / Pop / Prev.
% / n / Pop / Prev.
% / n / Pop / Prev.
% / n / Pop / Prev.
% / M+F Prev.%
South1 / Female / 113522 / 120 / 11 / 66178 / .017 / 109 / 47344 / .230 / 89 / 32698 / .272 / 66 / 18404 / .359 / 44 / 8477 / .519 / .146
Male / 111102 / 191 / 10 / 68651 / .015 / 181 / 42451 / .426 / 170 / 27717 / .613 / 152 / 13841 / 1.098 / 104 / 4883 / 2.130
West2 / Female / 91,037 / 102 / 6 / 55,570 / .011 / 96 / 35,467 / ,271 / 79 / 23991 / .329 / 56 / 13369 / .419 / 35 / 6075 / .576 / .141
Male / 88,658 / 142 / 8 / 56945 / .014 / 134 / 31713 / .423 / 129 / 20197 / .639 / 119 / 9849 / 1.208 / 91 / 3520 / 2.585
South + West3 / Female / 204346 / 222 / 17 / 124758 / .014 / 205 / 79588 / .258 / 168 / 53091 / .316 / 122 / 28171 / .433 / 79 / 11661 / .677 / .144
Male / 205426 / 333 / 18 / 125294 / .014 / 315 / 80132 / .393 / 299 / 53481 / .559 / 271 / 28388 / .955 / 195 / 11751 / 1.659
Unknown sex / 206652 / 19 / 0 / 125903 / .000 / 19 / 80749 / .024 / 18 / 53924 / .033 / 13 / 28634 / .045 / 7 / 11854 / .059
South + West3 / F+M / 404319 / 574 / 35 / 247344 / ,014 / 539 / 156975 / .343 / 485 / 104603 / .464 / 406 / 55463 / .732 / 281 / 22955 / 1.224 / .144
South3 / Urethral / 224624 / 175 / 7 / 134829 / .005 / 168 / 89795 / .187 / 159 / 60415 / .263 / 146 / 32245 / .453 / 104 / 13360 / .778
Suprapubic / 129 / 13 / 134829 / .010 / 116 / 89795 / .129 / 94 / 60415 / .156 / 66 / 32245 / .205 / 41 / 13360 / .307
Unknown / 18 / 1 / 134829 / .001 / 17 / 89795 / .019 / 16 / 60415 / .026 / 14 / 32245 / .043 / 9 / 13360 / .067
West3 / Urethral / 179695 / 135 / 4 / 112515 / .004 / 131 / 67180 / .195 / 121 / 44188 / .274 / 109 / 23218 / .469 / 85 / 9595 / .886
Suprapubic / 79 / 8 / 112515 / .007 / 71 / 67180 / .106 / 60 / 44188 / .136 / 39 / 23218 / .168 / 18 / 9595 / .188
Unknown sex / 38 / 2 / 112515 / .002 / 36 / 67180 / .154 / 35 / 44188 / .079 / 32 / 23218 / .138 / 24 / 9595 / .250
1 Age or sex missing for 18; 2 Age or sex missing for 10; 3 Age missing for 9

Table 2: Age and sex specific and overall prevalence, by area