Presented at the 19 th Annual Conference of the American Academy of Nurse Practitioners, June 11– 16, 2004, New Orleans, La. Impact of Health Care Impact of Health Care Provider Communication on Provider Communication on Patients With Overactive Patients With Overactive Bladder: Bladder: Results From a Large-Scale Results From a Large-Scale Study Study Diane K. Newman, Diane K. Newman, RNC, MSN, CRNP, FAAN RNC, MSN, CRNP, FAAN Penn Center for Continence and Pelvic Health Penn Center for Continence and Pelvic Health University of Pennsylvania Health System University of Pennsylvania Health System Philadelphia, Pennsylvania Philadelphia, Pennsylvania
Transcript
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Impact of Health Care Provider Impact of Health Care Provider Communication on Patients With Communication on Patients With
Overactive Bladder: Overactive Bladder: Results From a Large-Scale StudyResults From a Large-Scale Study
Diane K. Newman, Diane K. Newman, RNC, MSN, CRNP, FAANRNC, MSN, CRNP, FAAN
Penn Center for Continence and Pelvic HealthPenn Center for Continence and Pelvic Health
University of Pennsylvania Health SystemUniversity of Pennsylvania Health System
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Presentation OutlinePresentation Outline
• Impact of overactive bladder (OAB)Impact of overactive bladder (OAB)• Quality of care received by patients with OABQuality of care received by patients with OAB
• HarrisHarris®® survey survey – Methods and participantsMethods and participants– Communication with health care providersCommunication with health care providers– Impact of OAB on quality of lifeImpact of OAB on quality of life
• Implications for nurse practitionersImplications for nurse practitioners• SummarySummary
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
What Is Overactive Bladder? What Is Overactive Bladder? 2002 ICS Terminology2002 ICS Terminology
• Overactive bladder (OAB) is a symptom Overactive bladder (OAB) is a symptom syndromesyndrome– Urgency, with or without urge incontinence, Urgency, with or without urge incontinence,
usually with frequency and nocturiausually with frequency and nocturia
– The absence of pathologic or metabolic conditions The absence of pathologic or metabolic conditions that might explain these symptomsthat might explain these symptoms
ICS=International Continence Society.Abrams P, et al. Neurourol Urodyn. 2002;21:167-178.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Overactive Bladder: The NumbersOveractive Bladder: The Numbers• An estimated 33 million adults in the An estimated 33 million adults in the
US experience urge or mixed urinary US experience urge or mixed urinary incontinence and OAB. incontinence and OAB.
Wein AJ. Urology. 2002;60(Suppl 5A):7-12.Merkelj I. Southern Med J. 2001;94:952-957.Roberts RO. J Amer Geriatr Soc. 1998;46:467-472.Johnson TM. J Amer Geriatr Soc. 2000;48:894-902.
• Urge urinary incontinence occurs in Urge urinary incontinence occurs in 40% to 70% of elderly patients who 40% to 70% of elderly patients who present with complaints. present with complaints.
• It is estimated that fewer than 40% It is estimated that fewer than 40% seek treatment.seek treatment.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Economic Impact:Economic Impact:Direct and Indirect CostsDirect and Indirect Costs
3095
4276
7371
977 821
1798
0
1000
2000
3000
4000
5000
6000
7000
8000
Women Men
<65 y ≥65 y Total
Hu T, et al. Urology. 2003:61:1123-1128.
2000 US Dollars
(millions)
Total=$9169
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Impact on Quality of Life With Impact on Quality of Life With Disease ProgressionDisease Progression
Mid StageMid Stage
DepressionDepressionAnxietyAnxiety
Job LossJob LossIsolationIsolation
Early StageEarly Stage
InconvenienceInconvenienceand Coping and Coping MechanismsMechanisms
De
cre
asin
g P
ati
en
t Q
ua
lity
of
Lif
e Social Consequences
Late StageLate Stage
Assisted LivingAssisted Livingandand
Long-Term CareLong-Term Care
Medical Consequences
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Patient/Provider Communication:Patient/Provider Communication: They Don’t Tell, We Don’t AskThey Don’t Tell, We Don’t Ask
Cohen SJ, et al. J Gerontol. 1999;54:M34-37.EDUCATE study. Morb Mortal Wkly Rep. 1995;44(40):747,753-754.Branch LG, et al. J Am Geriatr Soc. 1994;42:1257-1261.
• Fewer than half of OAB patients inform physicians of their symptoms.
• Physicians often fail to ask patients about symptoms.
– Reasons include embarrassment, belief that incontinence is a normal part of aging, and fear of surgery.
– Only 40% of patients who ask for help report receiving treatment suggestions.
– Fewer than 25% of patients are asked about OAB symptoms.– Reasons include time constraints, lack of awareness about
available, effective treatments, and patient embarrassment.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
• Conducted by Harris Interactive®
• Examines issues of communication between health care providers and patients
• Assesses disease impact
Survey:Patient-Provider Communications
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Survey Methods • Methods
– Survey utilized the Harris Poll® Online Panel, a database of individuals 18 y who participate in online surveys.
• Eligibility
•The survey was– Self-administered online– Approximately 25 minutes in duration– In compliance with code and standards of Council
of the American Survey Research Organization and code of the National Council of Public Polls
– Female, aged 40-65 years– At least a high school education– Annual income $35,000
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Survey Study Groups
Study GroupStudy Group nn
Women with no OAB symptoms (control group)Women with no OAB symptoms (control group) 330330
TotalTotal 12281228
Current users of prescription OAB medicationsCurrent users of prescription OAB medications 309309
Women with OAB symptoms who never used Women with OAB symptoms who never used prescription drugs for OABprescription drugs for OAB 324324
Former users of prescription OAB medicationsFormer users of prescription OAB medications 265265
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Elapsed Time Before Seeking TreatmentElapsed Time Before Seeking Treatment
4035
8
12
0
5
10
15
20
25
30
35
40
<1 y 1-3 y 3-5 y 5+ y
Portion of Total
Patients With OAB
Symptoms (%)
(n=685)
Elapsed Time
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Communication With Health Care ProvidersCommunication With Health Care Providers
• Women with OAB symptoms report significantly more Women with OAB symptoms report significantly more physician visits per year than women without symptoms.physician visits per year than women without symptoms.
*P<.05 versus women without OAB. †P<.05 versus women who had never used an OAB medication.‡Does not include women without OAB symptoms.
Approximate
number of visits
in previous 12
months
0Total
With OAB symptoms
Control Group
3.9
6.9*
1
2
3
4
5
6
7
8
9 8† 8.5
6
Current Medication
Users
Lapsed Medication
Users
Never Used OAB
Medication‡
†
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:
Women Who Had Never Used OAB MedicationsWomen Who Had Never Used OAB Medications
Q: Have you ever discussed your OAB symptoms with a health care provider?Q: Have you ever discussed your OAB symptoms with a health care provider?
33% had discussed their symptoms
n=324
67% had not discussed their symptoms
• A majority of women with OAB symptoms who had never A majority of women with OAB symptoms who had never used an OAB medication had never discussed symptoms used an OAB medication had never discussed symptoms with a health care provider.with a health care provider.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Diagnosis by Health Care ProvidersDiagnosis by Health Care Providers
• The majority of respondents with OAB symptoms The majority of respondents with OAB symptoms reported that they had not been officially diagnosed or reported that they had not been officially diagnosed or treated. treated.
20% diagnosed
n=898n=898
80% not diagnosed
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Communication With Health Care ProvidersCommunication With Health Care Providers
• The majority of discussions about OAB symptoms The majority of discussions about OAB symptoms were initiated by patients, while few had been were initiated by patients, while few had been initiated by providers. initiated by providers.
11% of OAB discussions initiated by providers
n=685n=685
89% of discussions initiated by patients
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Regular Health Care Providers vs New Regular Health Care Providers vs New
Health Care ProvidersHealth Care ProvidersQ: Thinking back to the first time you discussed OAB with a health care Q: Thinking back to the first time you discussed OAB with a health care provider, was the provider you discussed it with your regular health care provider, was the provider you discussed it with your regular health care provider or a health care provider you were seeing for the first time? provider or a health care provider you were seeing for the first time?
Health care provider seen for first time (16%)
n=685
Regular health care provider
(84%)
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results:Type of Provider With Whom OAB Was Type of Provider With Whom OAB Was
Initially DiscussedInitially Discussed
Doctor Nurse Practitioner Physician Assistant Other
91%
1% 2%6%
n=685
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Harris Survey:Harris Survey: Discussion of Common ComorbiditiesDiscussion of Common Comorbidities
TOTAL (n=685)
Discussed With Regular Provider
(n=559)
Discussed With First-Time Provider
(n=126)
ANXIETY 16 13 29*
DEPRESSION 19 14 46*
NET 22 16 53*
• When first discussing OAB with a health care provider, less than 25% of patients reported that providers asked if they were experiencing other conditions, such as depression or anxiety.
*P<.05 compared with group who had discussed OAB with their regular providers.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results: Knowledge of Health Care ProvidersKnowledge of Health Care Providers
• Most respondents who had discussed OAB with a health care provider feel their providers have a thorough understanding of OAB treatments,
but only half (54%) report that providers discuss possible side effects of OAB medications (n=685).
Statement Statement Women Agreeing or Women Agreeing or
Strongly Agreeing (%)Strongly Agreeing (%)
My health care provider has a thorough understanding of new treatments, medications, or information available about OAB.
82
71My health care provider understands how OAB impacts my life.
54My health care provider discusses with me the possible side effects of OAB medications.
30My health care provider considers OAB to be a serious medical problem.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results: Discussion With Health Care Provider Discussion With Health Care Provider
in Previous 12 Monthsin Previous 12 Months• Only 68% of those who had discussed their condition with a Only 68% of those who had discussed their condition with a health care provider (n=685) had done so in the previous 12 months. health care provider (n=685) had done so in the previous 12 months.
0
10
20
30
40
50
60
70
80
90
Per
cen
t o
f P
arti
cip
ants
All Women With OAB(n=685)
Current OAB MedicationUsers (n=309)
Lapsed Users of OABMedication (n=265)
Never Used OABMedication (n=111)
*P<.05 compared with lapsed medication users and those who had never used an OAB medication.
PP.05.05
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Impact of OAB on Impact of OAB on Quality of Life Quality of Life
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results: Respondents Strongly Agreeing or Agreeing Respondents Strongly Agreeing or Agreeing
That OAB Interferes With Their JobsThat OAB Interferes With Their Jobs
0
10
20
30
40
50
60
70
Pe
rce
nt
of
Re
sp
on
de
nts
All Women with OAB(n=898)
Current OAB MedicationUsers (n=309)
Lapsed Users of OABMedication (n=265)
Never Used OABMedication (n=324)
PP.05.05
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:Survey Results: Effect of OAB Severity on Relationships Effect of OAB Severity on Relationships
With Family, Partners, and FriendsWith Family, Partners, and Friends
Impact onRelations
With Family
Impact onRelations
With Partner
Impact onRelations
With Friends
0
10
20
30
40
50
60
70
80
Per
cen
t o
f P
arti
cip
ants
Mild OAB (n=285)
Moderate OAB (n=321)
Severe OAB (n=292)
P.05P.05
P.05
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results: Survey Results: Impact of OAB on Intimacy and Sex LifeImpact of OAB on Intimacy and Sex Life
P.05In general, I have felt unattractive.
P.05I haven’t had much
interest in sex.
P.05I have been satisfied with my sex life.
Patients Agreeing With Each Statement (%)
0 10 20 30 40 50 60
Women With OAB (n=898) Women Without OAB (n=330)
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Limitations of Harris SurveyLimitations of Harris Survey
• Did not include menDid not include men• Did not include women younger than Did not include women younger than
40 y or older than 65 y40 y or older than 65 y• Diagnosis of OAB among those Diagnosis of OAB among those
surveyed was based on responses to surveyed was based on responses to previous surveys rather than on an previous surveys rather than on an examination by a physician examination by a physician
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
What Are the Problems?What Are the Problems?
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Communication Challenges Communication Challenges
• Many clinicians do not probe Many clinicians do not probe patients on OAB symptoms, even patients on OAB symptoms, even when the patient is at risk.when the patient is at risk.
• Many patients have inaccurate Many patients have inaccurate impressions of the condition.impressions of the condition.
• Many patients are too embarrassed Many patients are too embarrassed to discuss OAB symptoms.to discuss OAB symptoms.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Challenges by SettingChallenges by Setting
• Community: poor detection and Rx by PCPsCommunity: poor detection and Rx by PCPs
• Homebound: geared to “acute illness,” Homebound: geared to “acute illness,” limited in durationlimited in duration
• Assisted living: social, not medical care modelAssisted living: social, not medical care model
• Nursing homesNursing homes– Regulatory focus on documentation, not careRegulatory focus on documentation, not care– Nursing shortageNursing shortage– NihilismNihilism– Lack of urinary incontinence expertiseLack of urinary incontinence expertise
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
What Are the Solutions?What Are the Solutions?
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Developing Clinical Developing Clinical Awareness of OABAwareness of OAB
• Look for signs and symptoms of OAB.Look for signs and symptoms of OAB.
• Ask diagnostic questions about OAB Ask diagnostic questions about OAB as part of routine clinical dialogue.as part of routine clinical dialogue.
• Clearly present treatment options, Clearly present treatment options, advantages, and drawbacks.advantages, and drawbacks.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
• Do activities like running, sneezing, coughing, Do activities like running, sneezing, coughing, laughing, or bending cause urine leakage?laughing, or bending cause urine leakage?
• Do you have leakage when rushing to the toilet?Do you have leakage when rushing to the toilet?• If your bladder feels full, how long can you hold If your bladder feels full, how long can you hold
your urine? your urine? • Do you wake more than twice at night to urinate?Do you wake more than twice at night to urinate?
• Do any of the following occur when you urinate?Do any of the following occur when you urinate? (Red Flag Signs/Symptoms)(Red Flag Signs/Symptoms)
– Difficulty getting urine startedDifficulty getting urine started– Slow stream or “dribbling” Slow stream or “dribbling” – Discomfort or pain Discomfort or pain – Blood in the urineBlood in the urine– Feeling that your bladder did not empty completelyFeeling that your bladder did not empty completely
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Treatment Approaches for OABTreatment Approaches for OAB
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Goals of Anticholinergic Agents
• Ameliorate detrusor instability by altering Ameliorate detrusor instability by altering the autonomic tone of the bladder and by the autonomic tone of the bladder and by relaxing smooth-muscle spasmsrelaxing smooth-muscle spasms
• Prevent or eliminate OAB by reducing:Prevent or eliminate OAB by reducing:– Frequency Frequency – UrgencyUrgency– NocturiaNocturia– Urge urinary incontinenceUrge urinary incontinence
–Attractive for patients with multiple Attractive for patients with multiple comorbidities and medicationscomorbidities and medications
–Better pharmacotherapy for patients Better pharmacotherapy for patients with GI issues or inability to tolerate with GI issues or inability to tolerate oral therapyoral therapy
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
SummarySummary
• Great untapped potential toGreat untapped potential to– Increase number of treated OAB patientsIncrease number of treated OAB patients– Increase QoL and decrease morbidityIncrease QoL and decrease morbidity– Use understanding of QoL factors to target Use understanding of QoL factors to target
treatment for better outcomestreatment for better outcomes– Involve health care system in detection, Involve health care system in detection,
medication, and outcomes assessmentmedication, and outcomes assessment– Create new partnerships between primary care Create new partnerships between primary care
providers, urologists, obstetricians, providers, urologists, obstetricians, gynecologists, and urology/obstetrics-gynecologists, and urology/obstetrics-gynecology nursesgynecology nurses
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
