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Assumptions used in estimating a population benchmark

The assumptions used in estimating a population benchmark for a paediatric continence service of 0.8% or 800 per 100,000 population aged 19 years and under per year are based on the following sources of information:

  • epidemiological data on the prevalence and incidence of paediatric continence problems
  • activity data on inpatient and outpatient attendances for continence problems, including constipation, bedwetting and daytime wetting
  • current practice where existing paediatric continence services are in place

For the purpose of this commissioning guide the population has been defined as children and young people aged 19 years and under. Approximately 24% of the population in England is aged 19 years and under.

Epidemiological data

A paediatric continence service provides treatment and advice for children and young people with continence problems, most commonly idiopathic constipation, bedwetting and daytime wetting. All are common conditions, affecting approximately 900,000 children and young people in the UK[1]. However, evidence suggests that only around 100,000 children and young people will typically access treatment, so it is likely that many potential cases remain undiagnosed or untreated.

Table 1 shows the prevalence of bedwetting, daytime wetting and daytime faecal incontinence in England. The overall prevalence rate of bedwetting and daytime wetting declines with age.

Table 1: Prevalence of bedwetting, daytime wetting and daytime faecal incontinence (soiling and constipation)[2,3]

Prevalence (%)
Age (years) Bedwetting Daytime wetting Daytime faecal incontinence
4.5 30 15.5 29
9.5 9.5 4.9 27.5

Constipation occurs in approximately 0.7% to 29.6%[4] of children and young people, depending on the definition used and the populations considered. It becomes a chronic condition in more than one third of patients[5]. Approximately 95% of children referred for assessment of their constipation have no underlying pathological condition[6]. The peak incidence of constipation is at toddler to preschool age[7].

Activity data

The ‘Hospital episode statistics' (HES) database contains details of all admissions to NHS hospitals in England. It includes data on private patients treated in NHS hospitals, patients who were resident outside England and care delivered by treatment centres (including those in the independent sector) funded by the NHS.

The analysis of inpatient data from HES suggests that in 2008/09 there were around 14,500 hospital admissions in England for continence problems, including constipation, bedwetting or daytime wetting, among children and young people aged 19 years and under. Most of these admissions (12,500) were for constipation, of which 80% were emergency admissions.

The analysis of outpatient data suggests that in 2008/09 there were around 18,000[3] first hospital attendances in England for constipation among children and young people aged 19 years and under. It is estimated that there were few attendances for bedwetting or daytime wetting.

It was the view of the topic advisory group that in areas where there is no existing service, establishing a paediatric continence service using a primary or community care model could lead up to an 80% reduction in emergency admissions and a significant reduction in secondary care activity. The potential for cost savings by reducing consultant-led outpatient appointments is examined further in the commissioning and benchmarking tool.

Current practice

Data from IMS Disease Analyser, a database that holds patient data from a sample of GP practice systems, indicate that, in 2009, 0.61% of children and young people aged 19 years and under presented for treatment for and had a recorded diagnosis of idiopathic constipation. This equates to around 75,000 children and young people.

Additionally, in 2009 around 27,000 or 0.22% of children and young people aged 19 years and under presented for treatment and had a recorded diagnosis of daytime wetting or bedwetting.

Around 5000 children and young people had a dual diagnosis of constipation and daytime wetting or bedwetting.

Therefore around 100,000 children and young people presented for treatment in primary care in 2009 for idiopathic constipation and/or daytime wetting or bedwetting.

Table 2 shows the proportion of children and young people aged 0 to 5 and 6 to 19 who visited their GP in 2009 with a diagnosis of constipation or enuresis. Two thirds (66%) of visits for constipation were children aged 5 or under. Around one fifth (21%) of visits for bedwetting or daytime wetting were children aged 5 or under.

Table 2. Proportion of children and young people 0 to 5 and 6 to 19 who visited their GP in 2009 with a diagnosis of constipation and/or daytime wetting or bedwetting

Diagnosis Age 0 to 5 Age 6 to 19 Total
Constipation 66% 34% 100%
Bedwetting or daytime wetting 21% 79% 100%
Constipation and bedwetting or daytime wetting 19% 81% 100%

Treatment for paediatric continence could take place in a number of settings and be delivered by a number of healthcare professionals, such as GPs, paediatricians, health visitors and school nurses. For the purpose of this commissioning guide it has been assumed that the patient record held by the GP will be updated with details of treatment by these healthcare professionals and therefore data from the IMS disease analyser will capture diagnoses made by all of these healthcare professionals.

Conclusions

Based on the epidemiological data and other information outlined above, it is concluded that a population benchmark for a paediatric continence service is 0.8% or 800 per 100,000 population aged 19 years and under per year. This is based on the following assumptions:

  • In 2009 approximately 100,000 children and young people aged 19 years and under presented for treatment in primary care for idiopathic constipation and/or daytime wetting or bedwetting.
  • The prevalence of these conditions is high and only a small proportion of the estimated population with the conditions currently present for treatment.

Use the paediatric continence service commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.

References

1. NHS Modernisation Agency (2003) Good practice in paediatric continence services - benchmarking in action. London: Department of Health

2. Butler R, Heron J (2008) The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scandinavian Journal of Urology and Nephrology. 42; 257-64

3. Swithinbank LV, Heron J, Von Gontard A et al. (2010) The natural history of daytime urinary incontinence in children: a large British cohort. Acta Pædiatrica 99: 1031-36

4. Van den Berg MM, Bennings MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. American Journal of Gastroenterology 101: 2401-9

5. National Institute for Health and Care Excellence (2009) Constipation in children: the diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE

6. University of Michigan Health System (2008) Guidelines for clinical care. Functional constipation and soiling in children. Michigan: University of Michigan Health System

7. Prynn P (2008) Practical advice for managing constipation in infants. Continence UK 2(3)

This page was last updated: 02 March 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.