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Yang X, Zhang A, Zhu R, Sayer L, Bassett S, Woodward S. Group-based PFMT programme for preventing and/or treating UI in pregnant women: protocol of a randomized controlled feasibility study. Pilot Feasibility Stud 2023; 9:180. [PMID: 37907990 PMCID: PMC10617193 DOI: 10.1186/s40814-023-01410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Urinary incontinence (UI) is a prevalent health problem in women worldwide. Many women experience UI during pregnancy. The National Institute for Health and Care Excellence (NICE) recommended pelvic floor muscle training (PFMT) as the first-line conservative treatment for UI. However, it is not widely implemented due to the limited number of healthcare trainers. Group-based PFMT has been used with older women and a limited number of maternity studies. But the effectiveness of the group-based PFMT needs to be investigated because the overall quality of the studies is low. Therefore, this study aims to assess the feasibility of delivering a group-based PFMT programme for pregnant women in Nanjing city. METHODS This feasibility study will be conducted in Nanjing Maternity and Child Health Care Hospital in China, using a mixed methods design to investigate the feasibility and acceptability of delivering group-based PFMT to pregnant women. Pregnant women with or without the symptoms of UI will be included. This study aims to recruit 48 pregnant women with 24 in each arm. Participants will receive either the group-based PFMT delivered by a midwife or usual antenatal care which includes only verbal instruction on PFMT. The study will assess the completion rates, acceptability of outcome measures, recruitment and retention rate and calculate an appropriate sample size for a future study. DISCUSSION The results of this study will inform the design and implementation of a definitive randomized clinical trial to explore the effectiveness of the intervention. TRIAL REGISTRATION ClinicalTrials.gov, NCT05242809.
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Affiliation(s)
- Xiaowei Yang
- Department of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
- Department of Clinical Teaching and Research, Nanjing Vocational Health College, Nanjing, China.
| | - Aixia Zhang
- Nursing Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Rong Zhu
- Nursing Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Lynn Sayer
- Department of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sam Bassett
- Department of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sue Woodward
- Department of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Kim EK, Muñoz JM, Hong CX, Agrawal S, Kreines FM, Harvie HS. Variation in diagnosis of urinary incontinence in women by provider and patient demographic factors. World J Urol 2023; 41:821-827. [PMID: 36745191 DOI: 10.1007/s00345-023-04309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/20/2023] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Urinary incontinence (UI) among women is under-recognized in primary care setting. We hypothesized that UI is, therefore, more commonly diagnosed by specialists. Our aim was to determine the rate of UI diagnosis by provider and patient demographics, and whether these factors affect the likelihood of UI diagnosis. METHODS Retrospective study using electronic medical records from 2010 to 2019. Ambulatory patient encounters by adult females were identified. Encounters with new diagnosis of UI (stress, urgency, mixed, or unspecified) were identified using ICD 9 and 10 codes. The following data were extracted: diagnosing provider specialty and sex, patient age, BMI, race, estimated household income, insurance coverage and type, and primary care provider (PCP). Rate of UI diagnosis was calculated using proportions. Univariable comparison and multivariable logistic regression were performed. RESULTS 576,110 patient encounters were captured. 14,378 patient encounters had UI diagnosis (2.5%). UI population had the following characteristics: Mean age of 60.1 ± 15.5 years, 65.6% identified as white, 75.7% had a PCP, and 87.9% had insurance. UI diagnosis rate was < 1% for PCPs. Multivariable logistic regression showed that urogynecologists and female providers were more likely to diagnose UI; patient demographics associated with UI diagnosis included older age, elevated BMI, white race, commercial insurance, and having a PCP. Estimated household income did not have a significant effect. CONCLUSION Diagnosis of UI is seldom made by PCPs. Race, insurance, and having a PCP may affect the likelihood of receiving UI diagnosis. Continued efforts to promote equity in recognizing UI may be warranted.
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Affiliation(s)
- Edward K Kim
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Jaclyn M Muñoz
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Christopher X Hong
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Surbhi Agrawal
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Fabiana M Kreines
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Heidi S Harvie
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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Eckhardt S, Takashima Y, Zigman J, Yuan V, Alvarez P, Truong C, Yazdany T. The impact of physician-directed and patient-directed education on screening, diagnosis, treatment, and referral patterns for urinary incontinence. Int Urogynecol J 2022; 33:2121-2126. [PMID: 35507034 DOI: 10.1007/s00192-022-05187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to evaluate the impact of patient- and physician-directed education in the primary care setting on screening, diagnosis, treatment, and referral patterns to Urogynecology for urinary incontinence (UI). METHODS This was a prospective, multi-phase, before-and-after study conducted over a 3-year period. New female patients, 40 years and older, seen in the Internal Medicine (IM) clinic of our institution, were included. Phase 1 intervention consisted of UI lectures for IM residents. Phase 2 intervention involved placement of patient-directed posters throughout the IM clinic. Prior to phase 1, charts of new patients were reviewed as the control group to establish a baseline rate of screening, diagnosis, treatment initiation, and referrals. The same data were collected for 4 months after both phase 1 and phase 2. A washout period of 1 year occurred between phase 1 and phase 2. RESULTS A total of 410 charts were reviewed and included 200 control, 92 phase 1, and 118 phase 2 patients. In the control group, 13% of patients were screened for UI. There was no significant increase in screening after phase 1 (15% vs 13%, p = 0.6); however, there was a significant increase after phase 2 (32.2% vs 13%, p < 0.001). There was no difference in treatment initiation for patients with a positive screen after either phase. CONCLUSION In our study, providing an informative lecture to an IM referral base did not improve UI screening. Alternatively, directly targeting patients through posters significantly improved screening rates in the primary care setting, demonstrating that simple interventions can improve screening for conditions that are difficult to discuss such as UI.
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Affiliation(s)
- Sarah Eckhardt
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, CA, 90509, USA.
| | - Yoko Takashima
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, CA, 90509, USA
| | | | | | - Pedro Alvarez
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, CA, 90509, USA
| | - Christina Truong
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, CA, 90509, USA
| | - Tajnoos Yazdany
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, CA, 90509, USA
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Dumoulin C, Morin M, Danieli C, Cacciari L, Mayrand MH, Tousignant M, Abrahamowicz M. Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:1284-1293. [PMID: 32744599 PMCID: PMC7400216 DOI: 10.1001/jamainternmed.2020.2993] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Urinary incontinence is one of the most prevalent health concerns experienced by older women (aged ≥60 years). Individual pelvic floor muscle training (PFMT) is the recommended first-line treatment for stress or mixed urinary incontinence in women, but human and financial resources limit its delivery. Whether group-based PFMT performs as well as individual PFMT in this population remains unclear. OBJECTIVE To assess the efficacy of group-based PFMT relative to individual PFMT for urinary incontinence in older women. DESIGN, SETTING, AND PARTICIPANTS The Group Rehabilitation or Individual Physiotherapy (GROUP) study is a single-blind, randomized, noninferiority trial conducted in 2 Canadian research centers, from July 1, 2012, to June 2, 2018. A total of 362 community-dwelling women aged 60 years or older with symptoms of stress or mixed urinary incontinence were enrolled. INTERVENTIONS After an individual session conducted to learn how to contract pelvic floor muscles, participants completed 12-week PFMT as part of a group of 8 women (n = 178) or in individual sessions (n = 184). MAIN OUTCOMES AND MEASURES The primary outcome measure was the percentage reduction in urinary incontinence episodes at 1 year, as reported in a 7-day bladder diary and relative to pretreatment baseline. Secondary outcomes included lower urinary tract-related signs, symptoms, and quality of life immediately following treatment and at 1 year. Per-protocol analysis was used. RESULTS Among 362 women who were randomized (mean [SD] age, 67.9 [5.8] years), 319 women (88%) completed the 1-year follow-up and were included in the per-protocol analysis. Median percentage reduction in urinary incontinence episodes was 70% (95% CI, 44%-89%) in individual PFMT compared with 74% (95% CI, 46%-86%) in group-based PFMT. The upper boundary of the 95% CI for the difference in the percentage reduction in urinary incontinence episodes at 1 year was lower than the prespecified margin for noninferiority of 10% (difference, 4%; 95% CI, -10% to 7%; P = .58), confirming noninferiority. Individual PFMT and group-based PFMT had similar effectiveness for all secondary outcomes at 1 year. Adverse events were minor and uncommon. CONCLUSIONS AND RELEVANCE Results of the GROUP study suggest that group-based PFMT is not inferior to the recommended individual PFMT for the treatment of stress and mixed urinary incontinence in older women. Widespread use in clinical practice may help increase continence-care affordability and treatment availability. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02039830.
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Affiliation(s)
- Chantale Dumoulin
- School of Rehabilitation, Faculty of Medicine, Université de Montréal and Research Center of the Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center of the Centre Hospitalier de l'Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Coraline Danieli
- Research Institute of the McGill University Health Center, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Licia Cacciari
- School of Rehabilitation, Faculty of Medicine, Université de Montréal and Research Center of the Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Marie-Hélène Mayrand
- Department of Obstetrics and Gynecology and Social and Preventive Medicine, Université de Montréal, Research Center of the Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Michel Tousignant
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center of the Centre Hospitalier de l'Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University and Research Institute of the McGill University Health Center, Montreal, Québec, Canada
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Prevention of Stress Urinary Incontinence in Women. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-019-00570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dumoulin C, Morin M, Mayrand MH, Tousignant M, Abrahamowicz M. Group physiotherapy compared to individual physiotherapy to treat urinary incontinence in aging women: study protocol for a randomized controlled trial. Trials 2017; 18:544. [PMID: 29145873 PMCID: PMC5689182 DOI: 10.1186/s13063-017-2261-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 10/17/2017] [Indexed: 11/23/2022] Open
Abstract
Background Urinary incontinence (UI), one of the most prevalent health concerns confronting women aged over 60 years, affects up to 55% of older community-dwelling women—20–25% with severe symptoms. Clinical practice guidelines recommend individualized pelvic floor muscle training (PFMT) as a first-line treatment for stress or mixed UI in women, although lack of human and financial resources limits delivery of this first-line treatment. Preliminary data suggest that group-based treatments may provide the answer. To date, no adequately powered trials have evaluated the effectiveness or cost-effectiveness of group compared to individual PFMT for UI in older women. Given demographic projections, high prevalence of UI in older women, costly barriers, and group PFMT promising results, there is a clear need to rigorously compare the short- and long-term effectiveness and cost-effectiveness of group vs individual PFMT. Methods/Design The study is designed as a non-inferiority randomized controlled trial, conducted in two facilities (Montreal and Sherbrooke) in the Canadian province of Quebec. Participants include 364 ambulatory, community-dwelling women, aged 60 years and older, with stress or mixed UI. Randomly assigned participants will follow a 12-week PFMT, either in one-on-one sessions or as part of a group, under the supervision of a physiotherapist. Blinded assessments at baseline, immediately post intervention, and at one year will include the seven-day bladder diary, the 24-h pad test, symptoms and quality of life questionnaires, adherence and self-efficacy questionnaire, pelvic floor muscle function, and cost assessments. Primary analysis will test our main hypothesis that group-based treatment is not inferior to individualized treatment with respect to the primary outcome: relative (%) reduction in the number of leakages. Discussion Should this study find that a group-based approach is not less effective than individual PFMT, and more cost-effective, this trial will impact positively continence-care accessibility and warrant a change in clinical practice. Trial registration ClinicalTrials.gov, NCT02039830. Registered on 12 December 2013; Study protocol version 2; 21 November 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2261-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chantale Dumoulin
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Research Centre of the Institut Universitaire de Gériatrie de Montréal, 4565 Queen Mary M-5816, Montreal, QC, H3W 1W5, Canada.
| | - Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke and Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Marie-Hélène Mayrand
- Department of Obstetrics and Gynecology and Social and Preventive Medicine, Université de Montréal and Research Center of the Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Michel Tousignant
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke and Research Center on Aging, Sherbrooke, QC, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
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Primary care providers' experience, management, and referral patterns regarding pelvic floor disorders: A national survey. Int Urogynecol J 2017; 29:109-118. [PMID: 28547268 DOI: 10.1007/s00192-017-3374-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/20/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Primary care physicians can impact womens' access to care. We assessed primary care providers' experience and management regarding pelvic floor disorders. METHODS This Institutional Review Board approved study invited internal and family Medicine Program Directors to complete and distribute to faculty an online survey designed to query demographics, perceptions, management, and referral patterns regarding urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP) in females. RESULTS A total of 872 residency Program Directors were invited: 74 emails were incorrect; 391 physicians responded. Respondents were evenly distributed with respect to age, gender, and region. The majority practiced family Medicine, identified their practice as community/academic, and practiced >10 years. Forty-one percent perceived UI and 54% believed OAB prevalence to be 11-30%. Most initiated treatment for UI (97%) and OAB (96%), referring to urology when consultation was necessary. Half believed POP prevalence to be <10% of women, and often referred POP to Gynecology. Only 25% reported being 'very familiar' with urogynecology, and 46% were unaware of such providers in their area. Female providers were more likely to screen for OAB (p = .018) and POP (p = .004) and be familiar with urogynecology (p = 0.038). Providers practicing in the Midwest were most likely, while those in the West were least likely, to be aware of urogynecologists for referral, (p = < .001). CONCLUSIONS Primary care providers nationally are familiar with UI and OAB, but less familiar with POP. Nearly half were uncertain of urogynecologists to whom they could refer. Outreach to these providers may improve patient access to care.
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Primary care providers' attitudes, knowledge, and practice patterns regarding pelvic floor disorders. Int Urogynecol J 2016; 28:447-453. [PMID: 27796426 DOI: 10.1007/s00192-016-3134-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/18/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Understanding barriers to seeking care for pelvic floor disorders is necessary. We sought to assess familiarity with pelvic floor disorders, as well as identify screening and referral patterns among primary care providers. METHODS This Institutional Review Board approved study was distributed through a secure online server (SurveyMonkey®). Primary care providers within a large healthcare system were invited to participate in a 14-question survey regarding the prevalence, diagnosis, and treatment of urinary incontinence (UI), overactive bladder (OAB) syndrome, and pelvic organ prolapse (POP). Demographic information was collected. Descriptive statistics and associations were calculated. RESULTS A total of 360 emails were delivered, 108 responded (response rate 30.0 %). Respondents were evenly distributed with respect to age and years in practice. Providers correctly estimated the prevalence of UI and OAB, and most reported treating these conditions themselves (92.6 % and 88.9 %, respectively). If treatment failed, however, referral was most often (68.1 %) to urology. The majority reported not screening for POP, and 50.9 % believed the prevalence to be rare. Referrals for POP were most often (61.1 %) to urogynecology. Male providers were less likely to screen for POP than female providers (p < 0.001). Only a minority (35.2 %) described being 'very familiar' with urogynecology, and 19.4 % were unaware of such providers within the system. CONCLUSIONS Primary care providers within a large healthcare system were more familiar with UI and OAB than POP, often underestimating the prevalence of POP. Nearly one-fifth were unaware of urogynecologists within their system. Educational outreach regarding pelvic floor disorders and the urogynecology specialty would likely improve patient access to care.
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Abstract
UNLABELLED Urinary incontinence (UI) is a prevalent condition. Urinary incontinence impacts health, quality of life, and financial resources. Most barriers research is evaluated from the patient perspective. Research from physician perspective is needed to determine how best to address UI barriers. OBJECTIVE This study aimed to elucidate physician barriers to UI identification and treatment. METHODS After institutional review board waiver, we surveyed 78 NorthShore University HealthSystem primary care physicians. The survey was designed to assess physician comfort, familiarity with UI, and current practice patterns. RESULTS Fifty-five (71%) of the 78 physicians completed the survey. Most indicated that they clearly understood UI and that UI was a common problem in their practice. Fifty-six percent of the physicians were very comfortable inquiring about UI. Only 19% of the physicians were very comfortable diagnosing UI and 11% of the physicians were very comfortable treating UI. Fifty-nine percent of the physicians agreed that differentiating the different types of UI is difficult and 69% of the physicians believed that managing UI is difficult. However, only 26% of the physicians agreed that managing UI takes too much time. Overall, 65% of the physicians would like to diagnose and treat UI more in their practices. The most common barriers listed were (1) "not familiar with algorithm available for treatment," (2) "no good screening tool," and (3) "uncomfortable with diagnosis and treatment." CONCLUSIONS We initially thought that time would be the biggest barrier to care for UI, but we identified discomfort with diagnosis and treatment as barriers. The most common barrier was the lack of an accessible algorithm. Attention to physician education implementation of a screening tool algorithm for treatment of UI could improve UI identification.
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Schüssler-Fiorenza Rose SM, Gangnon RE, Chewning B, Wald A. Increasing Discussion Rates of Incontinence in Primary Care: A Randomized Controlled Trial. J Womens Health (Larchmt) 2015; 24:940-9. [PMID: 26555779 DOI: 10.1089/jwh.2015.5230] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A minority of women with urinary incontinence (UI) and even fewer with fecal incontinence (FI) report having discussed it with a health care provider in the past year. Thus our aim was to evaluate whether the use of an electronic pelvic floor assessment questionnaire (ePAQ-PF) improves communication about incontinence in primary care. METHODS Women 40 years and older who were scheduled for an annual wellness physical at an internal medicine clinic between August 2007 and August 2008 were randomized to complete the ePAQ-PF prior to (n = 145) or after (n = 139) their visit. Clinicians of women in the intervention group received the ePAQ-PF report prior to the visit. Outcome measures from clinic note abstraction included mention of UI (primary) and FI. Participant-reported outcome measures included discussion of UI and FI and initiator of discussion. RESULTS Discussions of UI was more common in the intervention group than the control group: (27% vs. 19%; odds ratio [OR], 1.6 95% confidence interval [95%CI] 0.9-2.8, particularly for women over 60 (33% vs. 12%; OR 3.8, 95%CI 1.2-11.8) and for women with UI (42% vs. 25%; OR 2.2, 95%CI 1.1-4.1). The intervention primarily led to an increase in clinician-initiated UI discussions which were more common in the intervention group (18% vs. 4%, OR 4.8, 95%CI 1.9-12.0) Participants in the intervention group more frequently reported discussion of FI (14% vs. 6%; OR 2.5, 95%CI 1.1-6.0) which was clinician initiated in over half the cases (9% vs. 3%; OR 3.5, 95%CI 1.1-11.0). CONCLUSIONS Use of the ePAQ-PF prior to clinic visits increases discussion of UI and FI, particularly clinician-initiated discussion. These findings suggest that such instruments may increase the detection and treatment of this often "silent" affliction.
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Affiliation(s)
- Sophia Miryam Schüssler-Fiorenza Rose
- 1 Spinal Cord Injury Service, Veteran Affairs Palo Alto Health Care System , Palo Alto, California.,2 Department of Neurosurgery, Stanford University , Stanford, California
| | - Ronald E Gangnon
- 3 Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin.,4 Department of Biostatistics and Medical Informatics, School of Pharmacy, University of Wisconsin , Madison, Wisconsin
| | - Betty Chewning
- 5 Department of Sonderegger Research Center, School of Pharmacy, University of Wisconsin , Madison, Wisconsin
| | - Arnold Wald
- 6 Department of Medicine, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin
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Mold JW, Fox C, Wisniewski A, Lipman PD, Krauss MR, Harris DR, Aspy C, Cohen RA, Elward K, Frame P, Yawn BP, Solberg LI, Gonin R. Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial. Ann Fam Med 2014; 12:233-40. [PMID: 24821894 PMCID: PMC4018371 DOI: 10.1370/afm.1624] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.
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Affiliation(s)
- James W Mold
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Tannenbaum C, Agnew R, Benedetti A, Thomas D, van den Heuvel E. Effectiveness of continence promotion for older women via community organisations: a cluster randomised trial. BMJ Open 2013; 3:e004135. [PMID: 24334159 PMCID: PMC3863125 DOI: 10.1136/bmjopen-2013-004135] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The primary objective of this cluster randomised controlled trial was to compare the effectiveness of the three experimental continence promotion interventions against a control intervention on urinary symptom improvement in older women with untreated incontinence recruited from community organisations. A second objective was to determine whether changes in incontinence-related knowledge and new uptake of risk-modifying behaviours explain these improvements. SETTING 71 community organisations across the UK. PARTICIPANTS 259 women aged 60 years and older with untreated incontinence entered the trial; 88% completed the 3-month follow-up. INTERVENTIONS The three active interventions consisted of a single 60 min group workshop on (1) continence education (20 clusters, 64 women); (2) evidence-based self-management (17 clusters, 70 women); or (3) combined continence education and self-management (17 clusters, 61 women). The control intervention was a single 60 min educational group workshop on memory loss, polypharmacy and osteoporosis (17 clusters, 64 women). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was self-reported improvement in incontinence 3 months postintervention at the level of the individual. The secondary outcome was change in the International Consultation on Incontinence Questionnaire (ICIQ) from baseline to 3-month follow-up. Changes in incontinence-related knowledge and behaviours were also assessed. RESULTS The highest rate of urinary symptom improvement occurred in the combined intervention group (66% vs 11% of the control group, prevalence difference 55%, 95% CI 43% to 67%, intracluster correlation 0). 30% versus 6% of participants reported significant improvement respectively (prevalence difference 23%, 95% CI 10% to 36%, intracluster correlation 0). The number-needed-to-treat was 2 to achieve any improvement in incontinence symptoms, and 5 to attain significant improvement. Compared to controls, participants in the combined intervention reported an adjusted mean 2.05 point (95% CI 0.87 to 3.24) greater improvement on the ICIQ from baseline to 3-month follow-up. Changes in knowledge and self-reported risk-reduction behaviours paralleled rates of improvement in all intervention arms. CONCLUSIONS Continence education combined with evidence-based self-management improves symptoms of incontinence among untreated older women. Community organisations represent an untapped vector for delivering effective continence promotion interventions. TRIAL REGISTRATION ClinicalTrials.gov ID number NCT01239836.
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Affiliation(s)
- Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Rona Agnew
- Glasgow Caledonian University, Glasgow, UK
| | - Andrea Benedetti
- Departments of Medicine and of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Doneal Thomas
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, Quebec, Canada
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Abstract
PURPOSE The purpose of this manuscript is to discuss the need for use of evidence based practice (EBP) in LTC, the current use of evidence in long term care facilities and what we know about adoption of the use of EBP in LTC. METHODS Literature review and reporting of findings from the M-TRAIN study that was a quasi-experimental design to test the effectiveness of an intervention to increase the use of EBPs for urinary incontinence and pain in 48 LTC facilities. RESULTS Barriers to adopting EBPs include lack of available time, lack of access to current research literature, limited critical appraisal skills, excessive literature to review, non-receptive organizational culture, limited resources, and limited decision-making authority of staff to implement change. Strategies to promote adoption of EBP include the commitment of management; the culture of the home; leadership; staff knowledge, time, and reward; and facility size, complexity, the extent that members are involved outside the facility, NH chain membership, and high level of private pay residents. Findings from the M-TRAIN add, stability of nurse leader and congruency between the leaders perception of their leadership and the staff's perception of the leadership. CONCLUSION There is clear evidence of the need and the benefits to residents of LTC and to the health care system yet adoption of EBP continues to be slow and sporadic. There is also evidence for the process of establishing best evidence and many resources to find the available EBPs. The urgent need now is finding ways to best get the EBPs implemented in LTC. There is growing evidence about best methods to do this but continued research is needed. Clearly, residents in LTC deserve the best care possible and EBPs represent an important vehicle by which to do this.
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Affiliation(s)
- Janet K Specht
- University of Iowa, John A. Hartford Center for Geriatric Nursing Excellence, Iowa City, Iowa 52242, USA.
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Akyuz A, Kok G, Kilic A, Guvenc G. In Her Own Words: Living with Urinary Incontinence in Sexual Life. SEXUALITY AND DISABILITY 2013. [DOI: 10.1007/s11195-013-9325-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Rapid human immunodeficiency virus testing in the pediatric emergency department: a national survey of attitudes among pediatric emergency practitioners. Pediatr Emerg Care 2012. [PMID: 23187980 DOI: 10.1097/pec.0b013e3182767add] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Human immunodeficiency virus (HIV) continues to be a significant public health concern for adolescents and young adults. Since 2006, the Centers for Disease Control and Prevention has recommended more aggressive routine screening for HIV for patients presenting to the emergency department (ED). Our objectives were to design and validate a survey of physician barriers toward the use of rapid HIV testing in the pediatric ED and then to use this validated tool to conduct a national survey of pediatric emergency practitioners' attitudes toward rapid HIV testing in the ED. METHODS Survey design and initial validation steps were conducted with a panel of health care practitioners familiar to HIV testing. Several variables were identified as possible barriers toward rapid HIV testing. The survey was sent via electronic software to a national sample of pediatric emergency practitioners over 2 listservs. The previously identified variables were evaluated by factor analysis for internal consistency and homogeneity, and confirmatory factor analysis was conducted via promax and varimax rotation. All factor analyses were conducted using Stata software. Once the validation was complete, the surveys were sent to groups of pediatric emergency practitioners who had previously identified as having rapid HIV testing available in their EDs. Standard descriptive statistics were used, and group differences were evaluated with t test and χ(2) test. RESULTS Four factors were identified during the validation process as being the most important barriers for rapid HIV testing in the pediatric ED: self efficacy, familiarity, external barriers, and a previously unidentified factor, which we interpreted as related to barriers to the specific environment of one's own ED. A total of 80 participants returned the final, validated survey. The participants came from 9 different pediatric emergency medicine groups (5 in areas of low rates of HIV infection, 4 in areas of high rates of HIV infection). Self-reported rates of testing were not different based on HIV infection rate in the community or the respondent's level of training. High testing was more common when a guideline was reported (39%) than when it was not (13.3%; difference, 25.7%; 95% confidence interval, 2.9%-48.5%). Of the 4 factors identified, we found statistically significant differences in scores on all 4 factors between high versus low testers, with high testers disagreeing more strongly with the various barrier questions proposed. We found no difference in the factor scores between areas of high versus low HIV infection rates. CONCLUSIONS Our results suggest that several factors related to perceived provider barriers are associated with rates of HIV testing in the ED and that personal factors (eg, level of training) and community HIV prevalence were not associated with rates of testing. Our results confirm what has been speculated by numerous authors and provide data to inform efforts to improve compliance with national recommendations for increased testing.
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Wright J, McCormack B, Coffey A, McCarthy G. Evaluating the context within which continence care is provided in rehabilitation units for older people. Int J Older People Nurs 2012; 2:9-19. [PMID: 20925827 DOI: 10.1111/j.1748-3743.2007.00046.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aim. This paper presents the first phase of an all Ireland 2-year study between the University of Ulster and University College Cork, to determine the contextual indicators that enable or hinder person centred continence care and management in rehabilitation settings for older people. The primary outcome of the study was the development of a tool to enable practitioners to assess the practice context within which continence care is provided. The main focus of this paper is the value of understanding practice 'context' (culture, leadership and evaluation) and its impact to the provision of person centred continence care. Background. The literature highlights the effect of continence problems on the quality of life of older people. Incontinence is often seen by health care professionals and older people as an inevitable consequence of ageing and difficult to treat. Furthermore, health care professionals do not always have the necessary skills and knowledge of best practice in continence care and treatments. The Promoting Action on Research Implementation in Health Services (PARIHS) framework utilized in the study proposes that successful implementation of evidence in practice is dependent on the inter-relationship of three key elements; the nature of the evidence, the quality of the context and expert facilitation. Kitson et al. propose that for successful implementation, evidence needs to be robust, the context receptive to change and appropriate facilitation is needed. Consequently understanding practice 'context' and its impact on the provision of person centred continence care is of value. Methods. Case study methodology with several data collection methods was utilized to measure all aspects of 'context' as identified by the PARIHS framework. Methods include: Royal College of Physicians Audit Scheme, Staff Knowledge questionnaire, semi-structured observation of practice and multidisciplinary focus groups. Findings. The data were analysed in two stages. Stage 1 using both qualitative and quantitative (SPSS 12) methods. Stage 2 analysed all the data utilizing the characteristics of context from the PARIHS framework in order to identify the strong and weak characteristics of the context within which continence care was provided. Continence care and management in this study was found to be focused on continence containment rather than proactive management. The evidence suggests that the context (leadership, culture and evaluation) was weak and not conducive to person centred continence care and management. Conclusion. An analysis of the data using the context framework provided a picture of the context within the units and the identification of the specific contextual issues hindering and enabling the delivery of person centred continence care. This process has thus, added to our understanding of the importance of context to the provision of person-centred care.
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Affiliation(s)
- Jayne Wright
- Research Associate, Nursing Development Centre, Royal Hospital, University of Ulster, Belfast, UKDirector of Nursing Research University of Ulster and Royal Hospital Trust, Victoria Australia Nursing Development Centre, Royal Hospital, Adjunct Prof Monash University, Belfast, UKResearch Associate, School of Nursing and Midwifery, University of College Cork, Cork, Republic of IrelandHead of School, School of Nursing and Midwifery, University of College Cork, Cork, Republic of Ireland
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Roth CP, Ganz DA, Nickles L, Martin D, Beckman R, Wenger NS. Nurse care manager contribution to quality of care in a dual-eligible special needs plan. J Gerontol Nurs 2012; 38:44-54. [PMID: 22833891 DOI: 10.3928/00989134-20120606-10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.
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Holroyd-Leduc JM, Straus S, Thorpe K, Davis DA, Schmaltz H, Tannenbaum C. Translation of evidence into a self-management tool for use by women with urinary incontinence. Age Ageing 2011; 40:227-33. [PMID: 21224258 DOI: 10.1093/ageing/afq171] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND many older women with urinary incontinence remain under-treated. OBJECTIVE to develop and evaluate an evidence-based self-management urinary incontinence risk factor modification tool for older women. DESIGN the tool was developed using evidence from a systematic review and input from focus groups. A 6-month prospective cohort study using an interrupted time-series design was conducted to evaluate the tool. SETTING the tool was developed at the University of Toronto and then evaluated at the Universities of Calgary and Montreal, Canada. SUBJECTS the tool was developed with the help of focus groups of healthcare professionals and of older incontinent women. The tool was evaluated among 103 incontinent women aged 50 years or older. METHODS the tool includes six risk factors with modification strategies. The primary outcome was successful tool usage. Secondary outcomes included urinary leakage, change in self-efficacy and quality of life. RESULTS the tool was used by 95% [95% confidence interval (CI) 88-98] of women at some point. Urinary leakage rates were reduced by an average of 1.4 daily episodes (95% CI 1.0-1.8). Women reported significant improvement in self-efficacy and incontinence-related quality of life. CONCLUSIONS there appears to be a role for an evidence-based self-management urinary incontinence risk factor modification tool.
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Ruiz JG, Tunuguntla R, Charlin B, Ouslander JG, Symes SN, Gagnon R, Phancao F, Roos BA. The Script Concordance Test as a Measure of Clinical Reasoning Skills in Geriatric Urinary Incontinence. J Am Geriatr Soc 2010; 58:2178-84. [DOI: 10.1111/j.1532-5415.2010.03136.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Sran MM. Prevalence of urinary incontinence in women with osteoporosis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2009; 31:434-9. [PMID: 19604424 DOI: 10.1016/s1701-2163(16)34174-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the prevalence and frequency of urinary incontinence in women presenting to a specialist osteoporosis clinic. METHODS Participants included 412 female patients aged 22 to 94 years (mean 62 years) presenting to a hospital-based specialist multidisciplinary osteoporosis clinic over one year. The presence or absence of urinary incontinence, urgency without leakage, type of symptoms (stress, urge, mixed) and frequency of urinary incontinence were recorded. RESULTS Sixty-seven percent of patients (277/412) reported some symptoms of urinary incontinence, 23% reported no symptoms and 10% reported urgency without any leakage. Of those who reported some urinary incontinence, 51% reported symptoms of stress incontinence, urgency, and urge incontinence. Almost 40% of all patients (163/412) and 59% of those with any urinary incontinence (163/277) reported leakage at least once per week. CONCLUSION The prevalence of at least weekly urinary incontinence in this population is much higher than that reported in studies of other older adult female populations. There is also a high prevalence of incontinence accompanied by urgency in women with osteoporosis. Based on these results and because urinary incontinence can limit a woman's ability to be physically active and increase the risk of falls and fractures, screening for incontinence should be a routine part of osteoporosis management. Clinicians seeing patients for osteoporosis should consider the presence of incontinence when prescribing exercise for bone health and fall prevention.
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Affiliation(s)
- Meena M Sran
- BC Women's Hospital and Health Centre, Osteoporosis Program, Vancouver BC; Simon Fraser University, Injury Prevention and Mobility Laboratory, Burnaby, BC
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Kök G, Şenel N, Akyüz A. Nurses’ roles in identifying urinary incontinence and its effects on social life. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2008. [DOI: 10.1111/j.1749-771x.2008.00063.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wagg A, Cardozo L, Chapple C, Diaz DC, de Ridder D, Espuna-Pons M, Haab F, Kelleher C, Kolbl H, Milsom I, Van Kerrebroeck P, Vierhout M, Kirby M. Overactive Bladder and Continence Guidelines: implementation, inaction or frustration? Int J Clin Pract 2008; 62:1588-93. [PMID: 18822029 DOI: 10.1111/j.1742-1241.2008.01870.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Guidelines for the management of continence and overactive bladder are generally available across Europe. For a majority of countries, these have been adopted by professional societies in either urology or gynaecology for local use. There has, however, been little monitoring of formal implementation of these guidelines and seldom any attempt to audit their operation. The state of continence care therefore remains largely unknown. This article reviews current guidelines and their status across Europe and examines what might be relevant from other disease areas to promote successful implementation.
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Affiliation(s)
- A Wagg
- Department of Geriatric Medicine, University College Hospital, London, UK.
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Gender Differences in Healthcare-Seeking Behavior for Urinary Incontinence and the Impact of Socioeconomic Status. Med Care 2007; 45:1116-22. [DOI: 10.1097/mlr.0b013e31812da820] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Fung CH, Spencer B, Eslami M, Crandall C. Quality Indicators for the Screening and Care of Urinary Incontinence in Vulnerable Elders. J Am Geriatr Soc 2007; 55 Suppl 2:S443-9. [PMID: 17910569 DOI: 10.1111/j.1532-5415.2007.01354.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tian J, Atkinson NL, Portnoy B, Gold RS. A systematic review of evaluation in formal continuing medical education. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2007; 27:16-27. [PMID: 17385741 DOI: 10.1002/chp.89] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Physicians spend a considerable amount of time in Continuing Medical Education (CME) to maintain their medical licenses. CME evaluation studies vary greatly in evaluation methods, levels of evaluation, and length of follow-up. Standards for CME evaluation are needed to enable comparison among different studies and to detect factors influencing CME evaluation. METHODS A review of the CME evaluation literature was conducted on primary research studies published from January 2000 to January 2006. Studies assessing only satisfaction with CME were excluded, as were studies where fewer than 50% of the participants were practicing physicians. Thirty-two studies were included in the analyses. Determinations were made about evaluation methods, outcome measures, and follow-up assessment. RESULTS Only 2 of 32 reviewed studies addressed all evaluation levels: physician changes in knowledge and attitudes (level 2), practices (level 3), and improved patient health status (level 4). None of the studies using self-developed instruments (n = 10) provided reliability and validity information. Only 6 studies used validated scales. Twenty studies had a follow-up period of 6 months or less, and 11 had a follow-up period between 1 and 2 years. DISCUSSION A gold standard for evaluating the effectiveness of CME would include assessment of all 4 levels of evaluation. A valid, reliable, and adaptable CME evaluation questionnaire addressing variables in the second level is needed to allow comparison of effectiveness across CME interventions. A minimum 1-year postintervention follow-up period may also be indicated to investigate the sustainability of intervention outcomes.
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Affiliation(s)
- Jing Tian
- Department of Public and Community Health, University of Maryland, College Park, MD 20742-2611, USA.
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Thomas DC, Johnston B, Dunn K, Sullivan GM, Brett B, Matzko M, Levine SA. Continuing medical education, continuing professional development, and knowledge translation: improving care of older patients by practicing physicians. J Am Geriatr Soc 2006; 54:1610-8. [PMID: 17038082 DOI: 10.1111/j.1532-5415.2006.00879.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Many community-based internists and family physicians lack familiarity with geriatrics knowledge and best practices, but they face overwhelming fiscal and time barriers to expanding their skills and improving their behavior in the care of older people. Traditional lecture-and-slide-show continuing medical education (CME) programs have been shown to be relatively ineffective in changing this target group's practice. The challenge for geriatrics educators, then, is to devise CME programs that are highly accessible to practicing physicians, that will have an immediate and significant effect on practitioners' behavior, and that are financially viable. Studies of CME have shown that the most effective programs for knowledge translation in these circumstances involve what is known as active-mode learning, which relies on interactive, targeted, and multifaceted techniques. A systematic literature review, supplemented by structured interviews, was performed to inventory active-mode learning techniques for geriatrics knowledge and skills in the United States. Thirteen published articles met the criteria, and leaders of 28 active-mode CME programs were interviewed. This systematic review indicates that there is a substantial experience in geriatrics training for community-based physicians, much of which is unpublished and incompletely evaluated. It appears that the most effective methods to change behaviors involved multiple educational efforts such as written materials or toolkits combined with feedback and strong communication channels between instructors and learners.
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Affiliation(s)
- David C Thomas
- Department of Medicine and Rehabilitation Medicine, Outpatient Services, Division of General Internal Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Abstract
INTRODUCTION As the U.S. population ages, primary care clinicians (PCCs) will encounter more patients with geriatric syndromes, such as urinary incontinence (UI) and falls. Yet, current evidence suggests that care of these conditions does not meet expected standards and that PCCs would benefit from tools to improve care of these conditions. Little is known about the role of computerized condition-specific templates for improving care of geriatric syndromes. AIM We sought to develop and assess the usefulness of condition-specific computerized templates in a primary care setting. SETTING A large academic Veterans Affairs medical center. PROGRAM DESCRIPTION We developed and tested the usefulness of 2 condition-specific computerized templates (UI and falls) that could be added on to an existing electronic health record system. PROGRAM EVALUATION Semistructured interviews were used to identify barriers to use of computerized templates. Usefulness and usability were assessed through a randomized-controlled trial involving standardized patients. DISCUSSION Use of condition-specific templates resulted in improved history and physical exam assessment for both UI and falls (P < .05). Our computerized, condition-specific templates are a promising method for improving care of geriatric conditions in a primary care setting, but require improvement in usability before widespread implementation.
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Affiliation(s)
- Constance H Fung
- VA Greater Los Angeles Healthcare System, Division of General Internal Medicine, David Geffen School of Medicine at UCLA, RAND Corporation, Los Angeles, CA, USA.
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Viktrup L, Summers KH, Dennett SL. Clinical practice guidelines on the initial assessment and treatment of urinary incontinence in women: a US focused review. Int J Gynaecol Obstet 2004; 86 Suppl 1:S25-37. [PMID: 15302565 DOI: 10.1016/j.ijgo.2004.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify clinical practice guidelines from prominent US organizations for the initial management of urinary incontinence (UI) in women and compare them with recommendations from the International Consultation on Incontinence (ICI). The challenge of implementing guidelines in the US was also identified. METHODS The medical literature was reviewed to identify relevant practice guidelines on the initial management of UI in community-dwelling women according to specific inclusion and exclusion criteria. Guidelines were compared with the ICI international gold standard relating to patient identification, initial therapy, and recommendation for specialist referral. Literature on programs to implement guidelines into clinical practice was reviewed. RESULTS There is general agreement on how females with UI should be initially managed based on guidelines, monographs, and technical bulletins from prominent US organizations. Though these recommendations are more than 5 years old, they are fairly similar to the latest guidelines developed by the ICI in 2001. Minor discrepancies are mainly related to the lack of updating US guidelines based on most recent knowledge. Implementing existing guidelines into clinical practice presents a challenge. CONCLUSION No evidence-based practice guidelines from prominent US organizations on the initial management of UI in women exist that are less than 5 years old, but the latest versions are in alignment with recent ICI/WHO guidelines. Although optimization of UI management may be the goal of guidances, the debate remains over whether these recommendations are actually effective in modifying practice. Simplifying and updating guidelines regularly may enhance adaptation in the initial management of UI in women.
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Affiliation(s)
- Lars Viktrup
- Clinical Research Physician at Eli Lilly Research Laboratories, Eli Lilly and Company Faris II, Drop Code 6112, Indianapolis, IN 46285, USA.
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