Journal of Gerontological Nursing

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The Cost-Effectiveness of DISPOSABLE VERSUS REUSABLE DIAPERS A Controlled Experiment in a Nursing Home

Teh-wei Hu, PhD; D Lynne Kaltreider, MEd; Jessie Iguo, RN, DrPH

Abstract

It has been estimated that about 50% of the elderly residing in nursing homes are incontinent. Caring for incontinent elderly is both time-consuming and costly. Nursing home administrators are concerned about their patients' well-being, but cost control is also an important element in their decision about which type of incontinence management to use. If researchers in the health-care profession can identify cost-effective incontinence management methods, they will make a major contribution to the welfare of incontinent patients as well as to the economic benefits of nursing homes.

Nursing home administrators are often approached by manufacturers of various types of disposable brieis (or diapers). They are urged to participate in a company's product adoption evaluation program, and attempts are made to convince the administrators that the company's products are cost-effective. Many nursing homes are still not convinced about the outcome, and they are especially wary of manufacturers' claims of cost savings for two reasons: the product evaluations are carried out by the manufacturers themselves and often do not follow a scientific or clinical research protocol, and nursing home administrators are not provided with the concrete and full spectrum of benefits of using disposable briefs.

This article reports on a study comparing the cost-effectiveness of a disposable incontinence product with that of reusable cloth diapers, which are commonly used in nursing homes. The disposable product is a close-to-thebody system for incontinence management that includes two components: a form-fitting washable pant available in a range of sizes and made of lightweight stretchable mesh; and a disposable body-contoured protective pad with a moisture-proof backing available in several protection levels. A third party evaluation implemented under a randomized controlled clinical trial should provide an objective and definitive assessment of these two alternative methods of managing incontinence. In this study, cost is defined as the value of resources incurred to the home in using two types of incontinence management; effectiveness is defined as various outcomes, such as skin condition and cost savings, in using the two types of management.

Table

Average skin scores for each participant were calculated from data collected during the skin assessment. Each of eight areas of the body (upper thighs, inner thighs, buttocks, coccyx, hips, rectal area, groin, perineum (for females) and scrotum (for males)) were examined during the assessment for the following five conditions: erythema, rash, excoriation, blister, and skin breakdown (including decubitus ulcers as well as other open areas not on bony prominences). Presence of any of the five conditions was coded according to an intensity level of 1 = slight, 2 = moderate, 3 = moderately severe, and 4 = severe. Depending on several factors, the following grades were given: 0 = excellent, 1 = good, 2 = fair, and 3 = poor.

The grades for each area were based on the number of conditions in the area, the severity of each condition (eg, slightly red versus very red), and the size of the area affected (eg, nickel-size versus entire area, such as inner thigh). In other words, each specific condition in each area was assessed. The grades for all eight areas of a single participant were then averaged to obtain an overall grade for that person.

During the 5-week implementation period, physicians' orders related to skin care were carried out as usual. The home's policy concerning skin care is routine washing but no special peri care (eg, application of peri sprays, special creams or lotions, or heat treatments) unless some skin breakdown (ie, rash or redness) is present. That policy was continued during the study.

At the end of the 5-week implementation phase, all 68 participants had post-treatment…

It has been estimated that about 50% of the elderly residing in nursing homes are incontinent. Caring for incontinent elderly is both time-consuming and costly. Nursing home administrators are concerned about their patients' well-being, but cost control is also an important element in their decision about which type of incontinence management to use. If researchers in the health-care profession can identify cost-effective incontinence management methods, they will make a major contribution to the welfare of incontinent patients as well as to the economic benefits of nursing homes.

Nursing home administrators are often approached by manufacturers of various types of disposable brieis (or diapers). They are urged to participate in a company's product adoption evaluation program, and attempts are made to convince the administrators that the company's products are cost-effective. Many nursing homes are still not convinced about the outcome, and they are especially wary of manufacturers' claims of cost savings for two reasons: the product evaluations are carried out by the manufacturers themselves and often do not follow a scientific or clinical research protocol, and nursing home administrators are not provided with the concrete and full spectrum of benefits of using disposable briefs.

This article reports on a study comparing the cost-effectiveness of a disposable incontinence product with that of reusable cloth diapers, which are commonly used in nursing homes. The disposable product is a close-to-thebody system for incontinence management that includes two components: a form-fitting washable pant available in a range of sizes and made of lightweight stretchable mesh; and a disposable body-contoured protective pad with a moisture-proof backing available in several protection levels. A third party evaluation implemented under a randomized controlled clinical trial should provide an objective and definitive assessment of these two alternative methods of managing incontinence. In this study, cost is defined as the value of resources incurred to the home in using two types of incontinence management; effectiveness is defined as various outcomes, such as skin condition and cost savings, in using the two types of management.

Table

TABLE 1PRODUCT USE FREQUENCY AND PRODUCT COST (DAILY PER PERSON)

TABLE 1

PRODUCT USE FREQUENCY AND PRODUCT COST (DAILY PER PERSON)

The specific aims of the study were to:

* Determine the full cost differences between using the disposable product and reusable cloth diapers;

* Compare the skin condition of residents using the two products; and

* Compare the overall cost-effectiveness of a disposable versus a reusable cloth product.

METHODS

The research design for the study was based on random assignment of subjects to two types of incontinence management: use of the disposable product and use of reusable cloth diapers. Based on a number of cost studies, the average cost of routine care of urinary incontinent nursing home patients ranges from $4 to $8 per day, with a mean of $6 per day and a variance of $4.1 If the expected effectiveness of a disposable diaper is a 20% cost reduction, the expected cost savings would be about $1 .20 per day. With a 1% level of error and a onetailed test, the required sample size for this study would be about 26 subjects in each group. Given a 10% attrition rate, 30 subjects would be required for each group for a total sample of 60 for the two groups. A study of a doublelayered launderable bed sheet by Williams et al used 36 subjects in a crossover design.2

The home selected for the study is a church-affiliated home, located in rural south central Pennsylvania with a resident population of 284 (216 females and 68 males) at the time of the study; 83 of the residents were classified as requiring skilled care and 201 as requiring intermediate care. The estimated incontinence rate at the home was 60%, with double incontinence (urinary and fecal) the norm. Subjects were recruited from skilled and intermediate nursing care units, without regard to their cognitive or mental health status, sex, orage.

The director of nursing polled the nursing staff on each floor and identified 102 incontinent residents as potential subjects for the study. The only criterion was that the residents average at least one wet episode each day. Several weeks before the start of the project, each of these individuals was assessed on the following criteria: level of activity, type of incontinence (dribbler, average, heavy), and whether the resident was obese, combative, contracted, alert, or had other significant characteristics.

During the 4-day baseline period, all wet/soiled incontinence products (cloth underpads and snap briefs) were placed in separate bags by the nursing aides for each incontinence episode. These soiled/wet products were then counted and weighed for each individual by shift, and the presence or absence of fecal incontinence was also tallied. These data on frequency, volume, and type of incontinence were used, along with each resident's sex and ambulatory status, to produce 42 matched pairs of residents, the members of which were then randomly assigned to either the treatment (disposable) or the control (cloth) condition. Death and voluntary withdrawal during the treatment period resulted in 34 pairs being retained in the final stage of the study.

During the 5 weeks of implementation, the nursing home's regular nursing aides used both products (disposable and reusable diapers) and bagged each person's incontinence products and incontinence wet/soiled laundry separately. Throughout the implementation period, the treatment group used the disposable product and the control group used reusable cloth diapers. All care remained the same for the two groups. Unlike the Williams et al2 study, which used a 2-week implementation period, and Solberger,3 who used a 3-week implementation period, the 5-week implementation period in this study provides details on observed changes in skin condition between the pre- and post-assessments and documents weekly changes in skin condition for a subsample of participants. The study protocol was completed in 1 ½ months.

RESULTS

The frequency and volume of incontinence, functional status, and skin condition of all subjects were assessed prior to program implementation, and skin condition was reassessed upon its completion. The nurse-researcher who assessed the skin condition was blind to the residents' treatment status. These data are used in evaluating the costs and effectiveness of the two products. The unit of analysis in this study is each individual subject. The matched random assignment to the disposible diaper group and the cloth group produced two remarkably similar groups.

The data for the study were collected via several instruments. A brief background survey that asked for each participant's name, age, sex, functional status, weight, and height was completed by the nursing home staff. During the baseline period, volume and frequency of incontinence and number of incontinence products used were tallied on special forms designed for that purpose. These data were recorded by person, episode, shift, and day. During the actual implementation period (when both disposable and cloth diapers were being used), counts were made of all incontinence products and incontinence-related laundry used by individual by shift. These data were recorded on shift sheets and then tallied daily and weekly.

Eighty-two percent of each group was female; the groups were almost evenly matched in level of activity, with 56% of the disposable diaper group and 59% of the cloth group unable to bear weight. The average volume of incontinence during the baseline period was similar for the two groups: 1 .056 gm per day for the disposable diaper group and 1 ,073 gm per day for those in the cloth group. The average daily frequency of incontinence during baseline was 6.9 episodes per day for the disposable diapered individuals and 6.5 episodes per day for the cloth group. As noted, fecal incontinence was quite prevalent in the facility; both groups averaged slightly more than one episode per day during baseline. The pre-skin assessment showed similar skin conditions in the two groups, with individuals in the cloth group having a slightly better starting skin condition (1.1 for the cloth group versus 1.2 for the disposable diaper group, on a scale of 1 to 3 with 0 = excellent, 1=good, 2 = fair, and 3 = poor).

Table

TABLE 2INCONTINENCE-RELATED LAUNDRY USAGE*

TABLE 2

INCONTINENCE-RELATED LAUNDRY USAGE*

The findings are examined under the following headings: product and laundry usage, cost of laundry, and skin condition.

Product and Laundry Usage

Use of Incontinence Products. The disposable system consists of washable pants used with disposable pads. The pants come in four sizes; the size used is determined by the resident's size. The disposable pads come in four protection levels: light, standard, heavy, and overnight. Their use is determined by the resident's degree of incontinence. The cloth system used at the nursing home studied consists of three products that are used independently of one another: a snap brief, a small underpad, and a large underpad. The underpads are used not only to absorb the incontinence but to lift and position residents as well. Since the disposable system that was evaluated did not, at the time of the study, include any type of pad for underneath the resident, the home's regular cloth underpad was used under some of the disposable product people.

Table 1 shows no differences in the amount of usage of these two products during the 4-week data collection period. The daily average usage was 1.3 disposable pants, 4.2 disposable pads, and 1.7 cloth pads. Thus, the total number of pads for the disposable product users was 5.9 per day. Because the average daily use of pants was 1.3 pants, and because the average life of these pants is 30 washings, the number of pants is not included in the product frequency calculation. The cloth users used 6 large underpads, 0.6 snap brief, and almost no regular underpads, for a total daily average of 6.6 cloth incontinence products . A simple f-test indicates no statistically significant difference between the two groups at the 1% level, two-tailed test.

Given the number of pieces of these two products that were used and their per unit costs, the daily product costs were $2.48 for disposable product residents and $2.61 for cloth product residents (Table 1). The costs for the disposable product are the average market prices charged to a nursing home. The costs for the cloth product are based on the actual charges to the nursing home by a laundry service and include the use of the product as well as its laundering. The magnitude of differences is relatively small and not statistically significant.

Incontinence-Related Laundry Usage. Incontinence-related laundry usage includes underwear, slacks, sheets, mattress covers, blankets, bedspreads, washcloths, hand towels, bath towels, and patient gowns. Again, the laundry usages were counted for each individual and weighed when soiled or wet.

Table 2 indicates that residents in the disposable product group produced fewer incontinence-related pieces of laundry and lower poundage, averaging 2.8 pieces/3.1 pounds per day, compared with about 4 pieces/5.0 pounds per day for the cloth users. The differences between the two groups are statistically significant at the 1% level, two-tailed test. The cloth group used many more blankets and sheets, whereas the disposable product residents used more washcloths. Thus, the average soiled weight per piece is higher for cloth residents than for the group using the disposable product.

Table

TABLE 3COSTS OF LAUNDRY, PER POUND SOILED WEIGHT

TABLE 3

COSTS OF LAUNDRY, PER POUND SOILED WEIGHT

Table

TABLE 4COMPARISON OF TOTAL INCONTINENCERELATED LAUNDRY COSTS BETWEEN DISPOSABLE AND CLOTH PRODUCTS*

TABLE 4

COMPARISON OF TOTAL INCONTINENCERELATED LAUNDRY COSTS BETWEEN DISPOSABLE AND CLOTH PRODUCTS*

The composition of laundry usage by the two groups is different in each shift. In general, users of the disposable product used more washcloths than the cloth product users, especially during the evening shift. Cloth users used more laundry during all three shifts, but the difference was greatest during the night shift, especially in sheets and mattress covers, blankets and bedspreads, and resident gowns. On the average, the cloth users changed or used two to three times more underwear, dresses, blouses, slacks, sheets, blankets, bedspreads, and resident gowns than the users of the disposable product.

Cost Analysis

Cost of Laundry. Cost information is critical to the study. One may question how cost savings (ie, laundry costs or skin care costs) can be accurately identified and quantified since only a portion of the incontinent residents in the nursing home participated in the study, whereas the laundry operations serve the entire facility. Separation of laundry for the research subjects required special manpower to collect the data on each individual's type of product usage and number of pieces of incontinence-related laundry changes on a daily basis. At the same time, the cost per piece of laundry was obtained from product suppliers, and the cost per pound laundry was estimated from the actual resources used in the laundry operation.

The cost of laundry can be considered under two categories: direct costs, which vary according to the volume of the laundry operation and include labor wages and fringe benefits, chemicals, water and sewer, energy costs, linen replacement; and repair of laundry equipment. Indirect costs include the space costs (rent), taxes, insurance, and general administration. To estimate the cost per pound of laundry, one has to account for both these cost categories.

Table 3 summarizes the cost information according to direct and indirect cost categories. The estimated cost per pound of laundry is 28 cents at the nursing home studied. Of the total costs, 16 cents, or about 57% of total costs, are wages and fringe benefits. Of the 16 cents of labor costs, 24% is for employees' fringe benefits. The second largest cost of laundry is energy costs (gas and electricity), about 3 cents. The total direct cost is about 25 cents. This nursing home has very low indirect costs, about 3 cents per pound, primarily because much of the equipment and space in this facility has already been depreciated.

The estimated laundry costs for this nursing home are lower than Phillips and Associates' general estimates of 32 cents to 36 cents per pound.4 One possible difference is that the estimates from Phillips et al are from the state of Minnesota, whereas this study's nursing home is located in rural Pennsylvania where wages are lower.

The estimate of 28 cents per pound could still be considered relatively high according to nursing home administrators or laundry operations. One explanation is the common perception that laundry costs do not include insurance or taxes, general administrative costs, or even space costs. Also, laundry costs vary according to wash volumes. For instance, in one very efficiently run large nursing home in Pennsylvania, laundry costs are about 23 cents per pound.

The assumption of the magnitude of laundry costs has important implications for the magnitude of cost-savings that can result from using the disposable system. Instead of focusing on one cost estimate, this study will provide four estimates, ranging from 23 cents to 36 cents.

Comparison of Incontinence-Related Laundry Costs for the Two Groups. Because product costs were not significantly different for disposable and cloth use at the studied facility, no product cost comparison will be made. Only laundry usage costs for the two products will be calculated and compared. Table 4 provides the laundry cost comparison based on four different unit costs of laundry. The cost of incontinence-related laundry ranges from 7 1 cents to $1.12 per disposable product resident per day, whereas the cost for cloth residents ranges from $1.15 to $1.80 per person per day. Thus, laundry cost savings for users of the disposable product will range from 44 cents to 68 cents per day or from $161 to $248 per person on an annual basis. It is obvious that the higher the laundry costs, the larger the savings in using the disposable system.

Skin Condition

All 68 participants (34 matched pairs) had at least two skin assessments, one pretreatment and one posttreatment. The initial assessment was done 1 week prior to implementation of the program before residents were assigned to the treatment and control groups. The nurse-researcher on the project team completed all of the skin assessments using a modified version of an assessment tool reported by Wells5 and Beber.6

Table

TABLE 5MEAN SCORE OF SKIN ASSESSMENT GRADES*

TABLE 5

MEAN SCORE OF SKIN ASSESSMENT GRADES*

Average skin scores for each participant were calculated from data collected during the skin assessment. Each of eight areas of the body (upper thighs, inner thighs, buttocks, coccyx, hips, rectal area, groin, perineum (for females) and scrotum (for males)) were examined during the assessment for the following five conditions: erythema, rash, excoriation, blister, and skin breakdown (including decubitus ulcers as well as other open areas not on bony prominences). Presence of any of the five conditions was coded according to an intensity level of 1 = slight, 2 = moderate, 3 = moderately severe, and 4 = severe. Depending on several factors, the following grades were given: 0 = excellent, 1 = good, 2 = fair, and 3 = poor.

The grades for each area were based on the number of conditions in the area, the severity of each condition (eg, slightly red versus very red), and the size of the area affected (eg, nickel-size versus entire area, such as inner thigh). In other words, each specific condition in each area was assessed. The grades for all eight areas of a single participant were then averaged to obtain an overall grade for that person.

During the 5-week implementation period, physicians' orders related to skin care were carried out as usual. The home's policy concerning skin care is routine washing but no special peri care (eg, application of peri sprays, special creams or lotions, or heat treatments) unless some skin breakdown (ie, rash or redness) is present. That policy was continued during the study.

At the end of the 5-week implementation phase, all 68 participants had post-treatment skin assessments and were given a second overall skin grade. This assessment was done within 3 days after treatment ended when residents were no longer identified as being in either the treatment or control group. From the pretreatment and post-treatment skin grades, it was possible to determine how many participants in each group deteriorated, improved, or stayed the same from pre-to post-skin assessment.

Mean scores were calculated from the pre- and post-treatment overall grades for both the treatment and control group participants, as shown in Table 5. On average, the skin condition of the users of the disposable product improved, whereas that of the cloth users deteriorated. The differences are statistically significant at the 1% level.

An alternative approach to evaluating the differences in the skin condition of residents using the two systems is to use regression analysis, controlling for the possible differences in incontinence status (ie, fecal, volume) and the baseline skin condition. The results clearly show that the disposable product users improved their skin condition, on the average, by .45 (on the scale from O to 3, O being excellent condition). Since the average skin condition of those residents at pretreatment was 1.22, between good and fair, the improvement of .45 in their scores implies a 37% improvement in their skin condition at the end of the experiment. Regression analysis also suggests that when the skin condition and being in the disposable system are combined, the net outcome for the skin condition is that users of the disposable product with severe skin condition benefit more from the product, ie, the more severe the condition, the more the improvement demonstrated by residents using the disposable products.

DISCUSSION

A variety of briefs or diapers are available for nursing homes to use for their incontinent residents. This randomized clinical study examined the costs and care outcomes for two alternatives: reusable versus disposable diapers. The results show differences in costs and outcomes for these two products, in favor of the disposable product.

Product costs should not be the only factor a nursing home administrator uses in choosing a particular diaper. It is also important to consider the related laundry costs. In this study, although product costs were similar, the cost savings on laundry favored the disposable product. The magnitude of cost differences for any particular facility depends on the market price of the products and the actual laundry costs in that home.

Skin condition is another major factor for nursing homes to consider when choosing a particular incontinence product. Improved skin condition is a direct benefit for nursing home residents; it also indirectly affects the costs of skin care. This study found the disposable diaper superior to the cloth reusable diaper vis-a-vis skin condition.7

REFERENCES

  • 1. Hu TW. The economic impact of urinary incontinence. In Ouslander J, ed. Clinics in Geriatric Medicine. 1986.
  • 2. Williams T, Foerster J, Procter J, et al. A new double-layered launderable bed sheet for patients with urinary incontinence. J Am Geriatr Soc. 1981; 29:520-524.
  • 3. Solberger FG. A hospital study of a new absorbent bed pad for incontinent patients. Med J Aust. 1977; 1:583-586.
  • 4. Phillips & Associates. Cost of laundry in nursing homes. Minneapolis, Minn: 1986.
  • 5. Wells T. Promoting urinary continence for the elderly in the hospital. Nursing Times. 1975; 71:1908-1909.
  • 6. Beber CR. Freedom for the incontinent. Am 7 Nurs. 1980; 180:483-484.
  • 7. Hu TW, Kaltreider DL, Igou J. Incontinence products: Which is best? Geriatric Nursing. 1989;10(4):184-186.

TABLE 1

PRODUCT USE FREQUENCY AND PRODUCT COST (DAILY PER PERSON)

TABLE 2

INCONTINENCE-RELATED LAUNDRY USAGE*

TABLE 3

COSTS OF LAUNDRY, PER POUND SOILED WEIGHT

TABLE 4

COMPARISON OF TOTAL INCONTINENCERELATED LAUNDRY COSTS BETWEEN DISPOSABLE AND CLOTH PRODUCTS*

TABLE 5

MEAN SCORE OF SKIN ASSESSMENT GRADES*

10.3928/0098-9134-19900201-07

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