Impact of Health Care Provider Communication on Patients With Overactive Bladder: Results From a Large-Scale Study

1. Diane K. Newman, RNC, MSN, CRNP, FAAN Penn Center for Continence and Pelvic Health University of Pennsylvania Health System Philadelphia, Pennsylvania Impact of Health Care Provider Communication on Patients With Overactive Bladder: Results From a Large-Scale Study

2. Presentation Outline • Impact of overactive bladder (OAB) • Quality of care received by patients with OAB • Harris® survey • Methods and participants • Communication with health care providers • Impact of OAB on quality of life • Implications for nurse practitioners • Summary

3. What Is Overactive Bladder? 2002 ICS Terminology • Overactive bladder (OAB) is a symptom syndrome • Urgency, with or without urge incontinence, usually with frequency and nocturia • The absence of pathologic or metabolic conditions that might explain these symptoms ICS=International Continence Society. Abrams P, et al. Neurourol Urodyn. 2002;21:167-178.

4. Overactive Bladder: The Numbers • An estimated 33 million adults in the US experience urge or mixed urinary incontinence and OAB. • 33% report urge incontinence episodes. • Urge urinary incontinence occurs in 40% to 70% of elderly patients who present with complaints. • It is estimated that fewer than 40% seek treatment. • 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.

5. Total=$9169 2000 US Dollars (millions) Hu T, et al. Urology. 2003:61:1123-1128. Economic Impact:Direct and Indirect Costs

6. Medical Consequences Social Consequences Assisted Living and Long-Term Care Decreasing Patient Quality of Life Depression Anxiety Job Loss Isolation Inconvenience and Coping Mechanisms Early Stage Mid Stage Late Stage Impact on Quality of Life With Disease Progression

7. Fewer than half of OAB patients inform physicians of their 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. • Physicians often fail to ask patients about symptoms. • Fewer than 25% of patients are asked about OAB symptoms. • Reasons include time constraints, lack of awareness about available, effective treatments, and patient embarrassment. Patient/Provider Communication:They 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.

8. Survey:Patient-Provider Communications • Conducted by Harris Interactive® • Examines issues of communication between health care providers and patients • Assesses disease impact

9. Survey Methods • Methods • Survey utilized the Harris Poll® Online Panel, a database of individuals 18 y who participate in online surveys. • 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 • Eligibility • Female, aged 40-65 years • At least a high school education • Annual income $35,000

10. Women with no OAB symptoms (control group) 330 Current users of prescription OAB medications 309 265 Former users of prescription OAB medications Women with OAB symptoms who never used prescription drugs for OAB 324 1228 Total Survey Study Groups

11. 40 (n=685) Portion of Total Patients With OAB Symptoms (%) Elapsed Time Survey Results:Elapsed Time Before Seeking Treatment

12. † † 8.5 9 8 8 6.9* Approximate number of visits in previous 12 months 7 6 6 5 3.9 4 3 2 1 0 Current Medication Users Lapsed Medication Users Never Used OAB Medication‡ Control Group Total With OAB symptoms Survey Results:Communication With Health Care Providers • Women with OAB symptoms report significantly more 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.

13. 33% had discussed their symptoms n=324 67% had not discussed their symptoms Survey Results:Women Who Had Never Used OAB Medications • A majority of women with OAB symptoms who had never used an OAB medication had never discussed symptoms with a health care provider. Q: Have you ever discussed your OAB symptoms with a health care provider?

14. The majority of respondents with OAB symptoms reported that they had not been officially diagnosed or treated. 20% diagnosed 80% not diagnosed n=898 Survey Results:Diagnosis by Health Care Providers

15. 11% of OAB discussions initiated by providers 89% of discussions initiated by patients n=685 Survey Results:Communication With Health Care Providers • The majority of discussions about OAB symptoms were initiated by patients, while few had been initiated by providers.

16. Health care provider seen for first time (16%) Regular health care provider (84%) n=685 Survey Results:Regular Health Care Providers vs New Health Care Providers 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 or a health care provider you were seeing for the first time?

17. 1% 2% 6% n=685 91% Survey Results:Type of Provider With Whom OAB Was Initially Discussed

18. Harris Survey:Discussion of Common Comorbidities • 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.

19. My health care provider has a thorough understanding of new treatments, medications, or information available about OAB. 82 My health care provider understands how OAB impacts my life. 71 My health care provider discusses with me the possible side effects of OAB medications. 54 My health care provider considers OAB to be a serious medical problem. 30 Survey Results:Knowledge 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).

20. P.05 *P<.05 compared with lapsed medication users and those who had never used an OAB medication. Survey Results:Discussion With Health Care Provider in Previous 12 Months • Only 68% of those who had discussed their condition with a health care provider (n=685) had done so in the previous 12 months.

21. Impact of OAB on Quality of Life

22. P.05 Survey Results:Respondents Strongly Agreeing or Agreeing That OAB Interferes With Their Jobs

23. P.05 P.05 P.05 80 70 60 50 Percent of Participants 40 Mild OAB (n=285) 30 Moderate OAB (n=321) Severe OAB (n=292) 20 10 0 Impact on Impact on Impact on Relations Relations Relations With Family With Partner With Friends Survey Results:Effect of OAB Severity on Relationships With Family, Partners, and Friends

24. Women With OAB (n=898) Women Without OAB (n=330) I have been satisfied with my sex life. P.05 I haven’t had much interest in sex. P.05 In general, I have felt unattractive. P.05 10 20 30 40 50 60 0 Patients Agreeing With Each Statement (%) Survey Results: Impact of OAB on Intimacy and Sex Life

25. Limitations of Harris Survey • Did not include men • Did not include women younger than 40 y or older than 65 y • Diagnosis of OAB among those surveyed was based on responses to previous surveys rather than on an examination by a physician

26. What Are the Problems?

27. Communication Challenges • Many patients have inaccurate impressions of the condition. • Many clinicians do not probe patients on OAB symptoms, even when the patient is at risk. • Many patients are too embarrassed to discuss OAB symptoms.

28. Challenges by Setting • Community: poor detection and Rx by PCPs • Homebound: geared to “acute illness,” limited in duration • Assisted living: social, not medical care model • Nursing homes • Regulatory focus on documentation, not care • Nursing shortage • Nihilism • Lack of urinary incontinence expertise

29. What Are the Solutions?

30. Developing Clinical Awareness of OAB • Look for signs and symptoms of OAB. • Ask diagnostic questions about OAB as part of routine clinical dialogue. • Clearly present treatment options, advantages, and drawbacks.

31. Screening Strategies:Questionnaires • Annual assessment • Self-administered questionnaire in waiting room • Nurse-administered questionnaire in examination room • Standardized symptom questionnaire • If result is positive, perform more detailed assessment

32. Screening Strategies:Detailed Assessment • Do activities like running, sneezing, coughing, laughing, or bending cause urine leakage? • Do you have leakage when rushing to the toilet? • If your bladder feels full, how long can you hold your urine? • Do you wake more than twice at night to urinate? • Do any of the following occur when you urinate? • (Red Flag Signs/Symptoms) • Difficulty getting urine started • Slow stream or “dribbling” • Discomfort or pain • Blood in the urine • Feeling that your bladder did not empty completely

33. Treatment Approaches for OAB • Nonpharmacologic therapy • Behavioral modification • Voiding modification • Fluid/dietary modification • Physiotherapy • Pelvic floor exercises • Biofeedback • Functional electrical stimulation • Pharmacotherapy • Surgical therapy

34. Goals of Anticholinergic Agents • Ameliorate detrusor instability by altering the autonomic tone of the bladder and by relaxing smooth-muscle spasms • Prevent or eliminate OAB by reducing: • Frequency • Urgency • Nocturia • Urge urinary incontinence • Minimize anticholinergic adverse events

35. Anticholinergic Pharmacotherapyfor Overactive Bladder • Oral immediate-release formulations • Oxybutynin • Tolterodine • Oral extended-release formulations* • Oxybutynin • Tolterodine • Transdermal delivery • Oxybutynin transdermal system *Extended release better tolerated than immediate release. Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.

36. Oxybutynin Transdermal Delivery System for OAB • Advantages • Improved safety profile • Attractive for patients with multiple comorbidities and medications • Better pharmacotherapy for patients with GI issues or inability to tolerate oral therapy

37. Summary • Great untapped potential to • Increase number of treated OAB patients • Increase QoL and decrease morbidity • Use understanding of QoL factors to target treatment for better outcomes • Involve health care system in detection, medication, and outcomes assessment • Create new partnerships between primary care providers, urologists, obstetricians, gynecologists, and urology/obstetrics-gynecology nurses

38. Thank you.