Rating Improvements in Urinary Incontinence
Rating Improvements in Urinary Incontinence
Objective: to determine whether patients' perceptions of improvement following behavioural interventions for urinary incontinence (UI) correspond with physicians' global ratings of change, and to compare both these ratings with more objective UI outcome measures.
Methods: consecutive new female patients aged 65 years and older recruited from outpatient UI clinics in Quebec received a behavioural management protocol for UI. At 3-month follow-up, patients and physicians were independently asked for their global impression of change in UI status. Patients completed 3-day voiding diaries and a UI-specific quality-of-life index before and after treatment.
Results: 108 patients (mean age 73 ± 5 years, range 65-86 years) with stress, urge and mixed UI participated. There was concordance between patients' and physicians' ratings of change in 57% of cases. Among the remaining cases, patients were 1.6 times as likely to report significant improvements compared to physicians. Patients' ratings correlated more strongly with improvements in UI episodes in the voiding diary (r = 0.4, P = 0.002 versus r = 0.3, P = 0.004 for physicians) and on the quality-of-life index (r = -0.5, P < 0.0001 versus r = -0.4, P < 0.0001 for physicians).
Conclusion: physicians underestimate clinically meaningful changes in UI in older women following behavioural interventions.
Urinary incontinence (UI) is arguably one of the most common geriatric symptoms. Despite its high prevalence, its association with adverse health outcomes, and the fact that there are evidence-based treatment options available, many health-care practitioners do not routinely screen for UI. Even among those who do screen for and treat UI, successful management is often confounded by the complexity of contributing factors and decisions surrounding therapeutic interventions.
One of the greatest difficulties in UI care is defining when a satisfactory improvement in UI status has been achieved. Outcome measures, such as voiding diaries, pad tests, or quality-of-life questionnaires, are recommended for use by the 3rd International Consultation on Urinary Incontinence. However, due to time constraints, logistic difficulties and unfamiliarity with the tools, these are seldom used by clinicians in routine practice. Even when they are used, there is rarely consensus among the different measures as to the benefits achieved. In most practices, physicians and nurses rely loosely on their clinical judgement to gauge whether satisfactory improvements have been attained, and whether their patients require more aggressive treatment.
A number of studies suggest that clinicians differ from patients in their expectations for UI treatment outcomes. In a survey of 100 women with UI, 17% expected a complete cure of all bladder irregularities after treatment. Only 3% of 156 clinicians surveyed perceived complete cure as a realistic goal. Forty-three per cent of the women responded that they would be satisfied with a good improvement that no longer interfered with their quality of life. This was what most incontinence care providers (85%) hoped to achieve as a successful outcome. Overall, there was found to be poor agreement between clinicians' and patients' attitudes towards the acceptability of symptoms after treatment. The majority of clinicians thought that small amounts of leakage were generally acceptable, although this was not the case for patients, with less than a third of them considering this to be a satisfactory residual treatment outcome.
The discrepancy between clinicians' and patients' expectations regarding UI treatment outcomes may explain differences between clinical impressions of success and patient satisfaction following incontinence surgery. Among 112 women aged 33-102 undergoing tension-free vaginal tape surgery for stress or mixed incontinence, only 66% of the women reported being cured, whereas their clinicians gauged an 89% post-surgical cure rate. In a different surgical study for UI treatment, 68% of women said they would recommend the operation to a friend at 1-year follow-up. Satisfaction rates among the surgeons were much higher; 94% said they would treat the women exactly the same way. Taken together, the data from these different studies suggest that patients have higher expectations regarding treatment outcomes and are more frequently disappointed with the results of interventions.
Only one comparison of physician and patient assessments of improvement has been reported following pharmacologic treatment of UI. In a placebo-controlled trial of duloxetine treatment for stress UI in younger and middle-aged women in the 18-65 age group agreement regarding improvement was only moderate, with 42% of ratings being different. As in the surgical studies, when improvement ratings differed, clinicians rated improvement greater than did patients in 54% of cases.
To our knowledge, no study has examined whether a dichotomy exists between clinicians' and patients' impression of UI treatment outcomes in non-surgical populations of older incontinent women. Behavioural management of UI, including lifestyle modification, pelvic floor muscle exercises, and bladder re-training, remains the first-line treatment for urge, stress and mixed UI, the most common UI types seen in older women. The decision to proceed to more aggressive treatment strategies, such as medication or surgery, should be based on clinician and patient dissatisfaction with these conservative measures. A better understanding of the way older women and their clinicians evaluate treatment outcomes is critical to ensure that the patient's goals are met, and that consensus is achieved prior to proceeding to more aggressive treatment options that may entail greater risk.
The objective of this study was to determine to what extent older women's perceptions of improvement in UI status following behavioural management for UI correspond with physicians' global ratings of change. We also compared patients' and physicians' ratings of improvement with more objective UI outcome measures, such as voiding diaries and quality-of-life measures to better understand whence their judgements were derived.
Objective: to determine whether patients' perceptions of improvement following behavioural interventions for urinary incontinence (UI) correspond with physicians' global ratings of change, and to compare both these ratings with more objective UI outcome measures.
Methods: consecutive new female patients aged 65 years and older recruited from outpatient UI clinics in Quebec received a behavioural management protocol for UI. At 3-month follow-up, patients and physicians were independently asked for their global impression of change in UI status. Patients completed 3-day voiding diaries and a UI-specific quality-of-life index before and after treatment.
Results: 108 patients (mean age 73 ± 5 years, range 65-86 years) with stress, urge and mixed UI participated. There was concordance between patients' and physicians' ratings of change in 57% of cases. Among the remaining cases, patients were 1.6 times as likely to report significant improvements compared to physicians. Patients' ratings correlated more strongly with improvements in UI episodes in the voiding diary (r = 0.4, P = 0.002 versus r = 0.3, P = 0.004 for physicians) and on the quality-of-life index (r = -0.5, P < 0.0001 versus r = -0.4, P < 0.0001 for physicians).
Conclusion: physicians underestimate clinically meaningful changes in UI in older women following behavioural interventions.
Urinary incontinence (UI) is arguably one of the most common geriatric symptoms. Despite its high prevalence, its association with adverse health outcomes, and the fact that there are evidence-based treatment options available, many health-care practitioners do not routinely screen for UI. Even among those who do screen for and treat UI, successful management is often confounded by the complexity of contributing factors and decisions surrounding therapeutic interventions.
One of the greatest difficulties in UI care is defining when a satisfactory improvement in UI status has been achieved. Outcome measures, such as voiding diaries, pad tests, or quality-of-life questionnaires, are recommended for use by the 3rd International Consultation on Urinary Incontinence. However, due to time constraints, logistic difficulties and unfamiliarity with the tools, these are seldom used by clinicians in routine practice. Even when they are used, there is rarely consensus among the different measures as to the benefits achieved. In most practices, physicians and nurses rely loosely on their clinical judgement to gauge whether satisfactory improvements have been attained, and whether their patients require more aggressive treatment.
A number of studies suggest that clinicians differ from patients in their expectations for UI treatment outcomes. In a survey of 100 women with UI, 17% expected a complete cure of all bladder irregularities after treatment. Only 3% of 156 clinicians surveyed perceived complete cure as a realistic goal. Forty-three per cent of the women responded that they would be satisfied with a good improvement that no longer interfered with their quality of life. This was what most incontinence care providers (85%) hoped to achieve as a successful outcome. Overall, there was found to be poor agreement between clinicians' and patients' attitudes towards the acceptability of symptoms after treatment. The majority of clinicians thought that small amounts of leakage were generally acceptable, although this was not the case for patients, with less than a third of them considering this to be a satisfactory residual treatment outcome.
The discrepancy between clinicians' and patients' expectations regarding UI treatment outcomes may explain differences between clinical impressions of success and patient satisfaction following incontinence surgery. Among 112 women aged 33-102 undergoing tension-free vaginal tape surgery for stress or mixed incontinence, only 66% of the women reported being cured, whereas their clinicians gauged an 89% post-surgical cure rate. In a different surgical study for UI treatment, 68% of women said they would recommend the operation to a friend at 1-year follow-up. Satisfaction rates among the surgeons were much higher; 94% said they would treat the women exactly the same way. Taken together, the data from these different studies suggest that patients have higher expectations regarding treatment outcomes and are more frequently disappointed with the results of interventions.
Only one comparison of physician and patient assessments of improvement has been reported following pharmacologic treatment of UI. In a placebo-controlled trial of duloxetine treatment for stress UI in younger and middle-aged women in the 18-65 age group agreement regarding improvement was only moderate, with 42% of ratings being different. As in the surgical studies, when improvement ratings differed, clinicians rated improvement greater than did patients in 54% of cases.
To our knowledge, no study has examined whether a dichotomy exists between clinicians' and patients' impression of UI treatment outcomes in non-surgical populations of older incontinent women. Behavioural management of UI, including lifestyle modification, pelvic floor muscle exercises, and bladder re-training, remains the first-line treatment for urge, stress and mixed UI, the most common UI types seen in older women. The decision to proceed to more aggressive treatment strategies, such as medication or surgery, should be based on clinician and patient dissatisfaction with these conservative measures. A better understanding of the way older women and their clinicians evaluate treatment outcomes is critical to ensure that the patient's goals are met, and that consensus is achieved prior to proceeding to more aggressive treatment options that may entail greater risk.
The objective of this study was to determine to what extent older women's perceptions of improvement in UI status following behavioural management for UI correspond with physicians' global ratings of change. We also compared patients' and physicians' ratings of improvement with more objective UI outcome measures, such as voiding diaries and quality-of-life measures to better understand whence their judgements were derived.
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