Transcript Impact of Health Care Provider Communication on Patients With

Impact of Health Care Provider
Communication on Patients With
Overactive Bladder:
Results From a Large-Scale Study
Penn Center for Continence and Pelvic Health
University of Pennsylvania Health System
Philadelphia, Pennsylvania
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
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.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
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.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Economic Impact:
Direct and Indirect Costs
<65 y
≥65 y
Total
7371
8000
Total=$9169
7000
6000
2000 US
Dollars
(millions)
4276
5000
4000
3095
3000
1798
2000
977
821
1000
0
Women
Men
Hu T, et al. Urology. 2003:61:1123-1128.
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
Disease Progression
Decreasing Patient
Quality of Life
Medical
Consequences
Social
Consequences
Inconvenience
and Coping
Mechanisms
Early Stage
Depression
Anxiety
Job Loss
Isolation
Mid Stage
Assisted Living
and
Long-Term Care
Late Stage
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Patient/Provider Communication:
They Don’t Tell, We Don’t Ask
• 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.
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.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Survey:
Patient-Provider Communications
• Conducted by Harris Interactive®
• Examines issues of communication
between health care providers and
patients
• Assesses disease impact
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.
• 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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Survey Study Groups
Study Group
n
Women with no OAB symptoms (control group)
330
Current users of prescription OAB medications
309
Former users of prescription OAB medications
265
Women with OAB symptoms who never used
prescription drugs for OAB
324
Total
1228
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11–16, 2004, New Orleans, La.
Survey Results:
Elapsed Time Before Seeking Treatment
40
40
35
35
30
Portion of
Total
Patients
With OAB
Symptoms
(%)
(n=685)
25
20
12
15
8
10
5
0
<1 y
1-3 y
3-5 y
5+ y
Elapsed Time
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:
Communication With Health Care Providers
• Women with OAB symptoms report significantly more
physician visits per year than women without symptoms.
8†
9
Approximate
number of visits
in previous 12
months
8
8.5 †
6.9*
7
6
6
5
3.9
4
3
2
1
0
Control
Group
Total
With OAB
symptoms
Current
Medication
Users
Lapsed
Never
Medication Used OAB
Users
Medication‡
*P<.05 versus women without OAB. †P<.05 versus women who had never used an OAB medication.
‡Does not include women without OAB symptoms.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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?
33% had discussed
their symptoms
n=324
67% had not discussed
their symptoms
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:
Diagnosis by Health Care Providers
• The majority of respondents with OAB symptoms
reported that they had not been officially diagnosed or
treated.
80% not diagnosed
20% diagnosed
n=898
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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.
89% of discussions
initiated by patients
11% of OAB
discussions
initiated by
providers
n=685
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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?
Regular health
care provider
(84%)
Health care provider seen
for first time (16%)
n=685
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:
Type of Provider With Whom OAB Was
Initially Discussed
Doctor
Nurse Practitioner
6%
1%
Physician Assistant
Other
2%
n=685
91%
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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.
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*
*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:
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).
Statement
Women Agreeing or
Strongly Agreeing (%)
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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.
Percent of Participants
P.05
90
80
70
60
50
40
30
20
10
0
All Women With OAB
(n=685)
Current OAB Medication
Users (n=309)
Lapsed Users of OAB
Medication (n=265)
Never Used OAB
Medication (n=111)
*P<.05 compared with lapsed medication users and those who had never used an OAB medication.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Impact of OAB on
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:
Respondents Strongly Agreeing or Agreeing
That OAB Interferes With Their Jobs
P.05
Percent of Respondents
70
60
50
40
30
20
All Women with OAB
(n=898)
Current OAB Medication
Users (n=309)
Lapsed Users of OAB
Medication (n=265)
Never Used OAB
Medication (n=324)
10
0
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:
Effect of OAB Severity on Relationships
With Family, Partners, and Friends
P.05
P.05
80
Percent of Participants
P.05
70
60
50
40
30
Mild OAB (n=285)
Moderate OAB (n=321)
Severe OAB (n=292)
20
10
0
Impact on
Relations
With Family
Impact on
Relations
With Partner
Impact on
Relations
With Friends
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Survey Results:
Impact of OAB on Intimacy and Sex Life
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
0
10
20
30
40
50
60
Patients Agreeing With Each Statement (%)
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
• Many patients have inaccurate
impressions of the condition.
• Many patients are too embarrassed
to discuss OAB symptoms.
• Many clinicians do not probe
patients on OAB symptoms, even
when the patient is at risk.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
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.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Treatment Approaches for OAB
• Nonpharmacologic therapy
– Behavioral modification
• Voiding modification
• Fluid/dietary modification
– Physiotherapy
• Pelvic floor exercises
• Biofeedback
• Functional electrical stimulation
• Pharmacotherapy
• Surgical therapy
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
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Anticholinergic Pharmacotherapy
for 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.
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
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
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/obstetricsgynecology nurses
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.
Thank you.
Presented at the 19th Annual Conference of the American Academy of Nurse Practitioners, June 11-16, 2004, New Orleans, La.