JU INSIGHT Economic Evaluation of a Web-Based Management Support System for Children With Urinary Incontinence

By: Amy Von Huben, PhD, School of Public Health, The University of Sydney, Australia Menzies Centre for Health Policy and Economics, The University of Sydney, Australia; Martin Howell, PhD, School of Public Health, The University of Sydney, Australia Menzies Centre for Health Policy and Economics, The University of Sydney, Australia; Deborah Richards, PhD, School of Computing, Macquarie University, Sydney, Australia; Sana Hamilton, MPH, The Children’s Hospital at Westmead, Sydney, Australia; Kirsten Howard, PhD, School of Public Health, The University of Sydney, Australia Menzies Centre for Health Policy and Economics, The University of Sydney, Australia; Armando Teixeira-Pinto, PhD, School of Public Health, The University of Sydney, Australia; Jonathan C. Craig, PhD, College of Medicine and Public Health, Flinders University, Adelaide, Australia; Chris Seton, PhD, The Children’s Hospital at Westmead, Sydney, Australia; Karen Waters, PhD, The Children’s Hospital at Westmead, Sydney, Australia University of Sydney, Australia; Aniruddh Deshpande, PhD, The Children’s Hospital at Westmead, Sydney, Australia University of Sydney, Australia School of Medicine and Public Health, University of Newcastle, New South Wales, Australia; Karen M. Scott, PhD, University of Sydney, Australia; Patrina H. Y. Caldwell, PhD, The Children’s Hospital at Westmead, Sydney, Australia University of Sydney, Australia | Posted on: 17 Jul 2024

Von Huben A, Howell M, Richards D, et al. An economic evaluation of a web-based management support system for children with urinary incontinence: the eADVICE Trial. J Urol. 2024;212(1):185-195. doi:10.1097/JU.0000000000003970

Study Need and Importance

Children who require specialist urology outpatient care typically wait for substantial periods, potentially worsening health and quality of life. Effectiveness results of the Electronic Advice and Diagnosis Via the Internet following Computerized Evaluation (eADVICE) randomized controlled trial found the use of the web-based program delivered by embodied conversational agent during the waiting period doubled the proportion of children who were dry at 6 months (from 10% to 23%) and improved quality of life. However, the cost-effectiveness of the eADVICE program was questioned by the finding that some parents of children dry at 6 months still wanted a physical clinic appointment. Fortunately, an economic evaluation of eADVICE was undertaken as a substudy of the trial.

What We Found

A trial-based cost-effectiveness analysis over the trial horizon of 6 months found eADVICE to be cost saving as well as beneficial (dominant) over usual care (Table). Health care costs were reduced by $188 Australian (95%CI $61 to $315) per participant (US $141 [95%CI $46 to $237]) with significant improvements in the 4 preplanned economic analysis outcome measures. Multiple imputation, sensitivity, and scenario analysis confirmed the robustness of the finding.

		Treatment group		Increment
	Complete case	eADVICE N = 88	Control N = 98	Mean/risk difference (95%CI)	Incremental cost-effectiveness of eADVICE
Cost	Total cost (AUD), mean (±SD)	864 (±428)	1052 (±423)	−188 (−315, −61)	Cost saving
	Dry patients, No. (%)	20 (22.7)	10 (10.2)	0.13 (0.02, 0.23)	Dominant^a
	Insignificant wetting, No. (%)^b	22 (25.6)	10 (10.3)	0.15 (0.04, 0.26)	Dominant^a
Benefits	Infrequent bedwetting, No. (%)^c,d	39 (45.3)	31 (32.0)	0.15 (0.02, 0.28)	Dominant^a
	QoL, mean difference (95%CI)^c,e	3.5 (3.3, 3.8)	3.9 (3.6, 4.1)	0.37 (0.03, 0.71)	Dominant^a
	Imputed data	eADVICE N = 120	Control N = 119	Mean/risk difference (95%CI)	Incremental cost−effectiveness of eADVICE
Cost	Total cost (AUD), mean (±SD)	806 (±73)	1020 (±42)	−214 (−331, −97)	Cost saving
Benefits	Dry patients, No. (%)	28 (22.9)	14 (11.9)	0.11 (0.01, 0.20)	Dominant^a
	Insignificant wetting, No. (%)^b	27 (22.6)	12 (10)	0.12 (0.03, 0.22)	Dominant^a
	Infrequent bedwetting, No. (%)^c,d	62 (52)	45 (37.6)	0.17 (0.05, 0.29)	Dominant^a
	QoL, mean difference (95%CI)^c,e	3.4 (2.7, 4.1)	3.8 (3.3, 4.2)	0.34 (0.05, 0.63)	Dominant^a
Abbreviations: AUD, Australian dollars; eADVICE, Electronic Advice and Diagnosis Via the Internet following Computerized Evaluation; QoL, quality of life.
^aDominant = cost saving and beneficial.
^bInternational Children’s Continence Society insignificant wetting = less than once a month measured over 3 months or more day and night.
^cAdjusted for imbalances at baseline.
^dInternational Children’s Continence Society infrequent bedwetting = less than 4 nights per week.
^eQoL as measured by the reduction in modified Pediatric Incontinence Questionnaire score.

Limitations

Findings may not be generalizable to clinics with short waiting periods. Conversely, the 6-month analysis horizon may not fully capture the net benefits from eADVICE use over the full waiting period when waiting times are longer. Although scenario analysis considered additional costs to minimize inequity of access in affordability and languages, decision-makers need to consider other potential disparity factors such as access to parents’ time, computer skills, private devices and physical spaces, and reliable internet.

Interpretation for Patient Care

An individualized, evidence- informed, web-based program delivered by an embodied conversational agent is cost-effective for children with urinary incontinence awaiting a specialist appointment. This type of program also has the potential to provide cost-effective solutions for other specialist clinics with long waitlists.