PCORI funds implementation projects that integrate evidence developed through PCORI-funded studies into practice in the context of the body of related evidence. This project focuses on implementing findings of Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update.
1. What is the eligible evidence proposed for implementation?
It is well known to women with urinary incontinence (UI), their families, and the clinicians who care for them that bladder leakage or UI can adversely affect women’s social, professional, and personal lives. Numerous negative consequences of UI can influence women’s overall health. Bladder leakage leads to increased depression rates, social isolation, falls, and decreased quality of life. Many barriers prevent women from seeking care for bladder leakage, and women are seldom screened for bladder problems. Bladder leakage is common in adult women: estimates suggest that almost 50 percent of women experience some degree of bladder leakage, with increasing rates and severity with age.
The recent updated systematic review supported by PCORI and the Agency for Healthcare Research and Quality indicates that conservative management or behavioral therapy improves bladder leakage in many women and should be the first treatment for UI. While the negative impact of bladder leakage is well known among providers caring for these women, many clinicians—and hence many women—believe that bladder leakage is a normal part of aging. Given the known embarrassment associated with UI, many women do not seek care because they are never asked about—and never mention—their bladder symptoms. Even in healthcare systems with few obstacles to care, studies have shown that fewer than 5 percent of women with leakage were asked about UI by their providers.
Traditionally, UI screening and initiation of conservative management have occurred during in-person visits. The use of virtual care offers opportunities to conduct screening and provide education and conservative care to a much larger group of women who would otherwise not receive any treatment. This innovative approach offers the possibility of significant increases in the proportion of women with bothersome bladder leakage who recognize and disclose their condition and receive effective conservative management to significantly improve and potentially cure their symptoms and condition.
2. What is the goal of this implementation project?
This project aims to (1) normalize bladder leakage and facilitate improvement in the number of women who recognize, report, and receive care for their bladder leakage and (2) make conservative care widely and readily available and delivered to women whose lives are negatively affected by UI.
3. What is the project team doing?
The project team will send a personal message through the healthcare system’s secure, personalized electronic health record (EHR) portal to all women 60 years of age or older asking about bladder leakage. The secure messaging questions will ask about the nature of their symptoms, the type of leakage, and other factors and will offer self-treatment for 12 weeks supported by reminders and state-of-the-art, research-based forms of encouragement.
Training will be provided to clinicians and other health system staff to offer support and encouragement to any patients they encounter during the self-treatment program. A supplementary pre- and postintervention evaluation survey containing patient-centered questions about current symptoms and additional topics will be sent to a sample of women who do and do not complete the program.
The use of health system EHR-based tools and a personalized patient portal will facilitate large-scale, efficient, and confidential efforts to increase awareness and outreach and provide conservative management of women with bladder leakage. Widespread implementation of this approach in other healthcare settings that utilize EHRs containing patient portals will significantly increase the number of women treated for this problematic condition.
4. How is the team evaluating this project?
The patient surveys described above, supplemented by patient interviews plus interviews and surveys of clinical staff, will provide important data regarding the innovative implementation program’s effectiveness in increasing the use of conservative management approaches and improving symptoms and other patient outcomes.
Survey and interview data will be supplemented by data derived from the EHR and additional administrative data sources. The primary evaluation outcomes will be patient-centered, including patient engagement, symptom, and quality of life improvement; satisfaction with care; and the need for further treatment. Additional evaluation outcomes will include the utilization of health system resources and clinician and staff views of the program.
The project will inform future adoption of this innovative care approach by other healthcare systems. It will also inform development of additional, complementary methods to normalize bladder leakage and increase care-seeking and treatment in women who are not reached by the virtual program employed here and who are otherwise challenging to reach, engage, and treat. The evaluation interviews and surveys will help identify patient and system barriers and opportunities to strengthen the program for continued use within our health system and for spread to other health settings across the United States and internationally.
5. How is the team involving patients and others in making sure the findings reach people who can use them?
This project has highlighted patient perspectives and needs from project development to implementation, including the use of the patient portal and other resources to personalize outreach and treatment to each individual's healthcare needs and preferences. To maximize program responsiveness to patient preferences and perspectives and increase the likelihood of high patient engagement with the innovative program, the project team relied on patients' suggestions on how best to reach, engage, and support women. These suggestions included strategies to increase participation and program completion.
The project team identified and studied societal (racial, ethnic, age) diversity in embarrassment related to bladder leakage through multiple culturally diverse focus groups addressing topics and suggestions to improve engagement with the program. In addition, surveys will be sent to a random sample of women who were unable to be screened or elected not to perform the program to get their input. Multiple patient advocacy groups will serve on the advisory group and help inform women of the findings directly. Advocacy groups will be able to highlight the benefits of conservative care on their websites and newsletters. Engaging professional organizations through the project advisory board will encourage other systems to implement this novel program to supplement care provided by frontline providers.
This partnership of patients and providers will help motivate healthcare systems, payers, and governmental agencies from the bottom up to increase awareness of UI and the benefits of treatments and to drive the use of innovative patient-centered programs. This advocacy will help engage healthcare system stakeholders to assist clinicians in reaching more women. Given that this is a virtual program, the project will demonstrate a framework for other healthcare systems to develop similar programs and thus facilitate widespread adoption throughout the United States and beyond.
6. How will this project help ensure future uptake and use of the evidence?
Full societal benefit from medical research requires the uptake of research findings into clinical practice to decrease suffering related to the studied health condition. This project addresses many barriers to treating UI and offers innovative solutions to reach women who are negatively affected by bladder leakage. Patient portals are increasingly available and used to leverage providers’ efforts to address care gaps and efficiently manage chronic disease.
By demonstrating that virtual conservative care can be delivered and improve bladder leakage, this project’s work will encourage healthcare systems to expand their outreach to women. The project team will share this model with other healthcare systems. Once developed, there is minimal cost but tremendous benefit.
The project team believes this project will effectively demonstrate methods to screen and engage people affected by sensitive conditions and identify and overcome barriers to care that will allow for widespread adoption. The ability to "reach and treat" many women who are adversely affected by bladder leakage but do not seek or receive care has the potential to improve quality of life for millions of women.
Initial PCORI-Funded Research Study
This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.