Managing Urinary Incontinence for Women in Primary Care: Environmental Scan (Base Year)

Issue

Urinary incontinence (UI) is a highly prevalent condition among women: Studies in the United States indicate that nearly 50 percent of women 40 years of age and older report symptoms that are consistent with UI. The prevalence of UI increases with age, although pregnancy and the postpartum period also are associated with a significant increase in UI.

UI has a significant impact on patients’ quality of life, morbidity, and mortality. Individuals with UI report lower quality of life scores and higher rates of depression. UI in women older than 65 is associated with greater sedentary behavior and increased risk for falls and fractures, which is a cause of significant morbidity, mortality, and high health care costs in this group. UI also can lead to poorer management of chronic medical conditions, such as heart failure and diabetes, because the medications used to treat these conditions can exacerbate untreated UI.

Despite the existence of screening tools and several evidence-based, effective, nonsurgical, potentially low-cost treatments for UI—including lifestyle changes, pelvic floor muscle training (PMFT), physical therapy, and medications—many women are not diagnosed or treated. Barriers to treatment include hesitancy among patients to discuss their symptoms with their healthcare providers, belief that UI is a normal part of aging, and lack of screening of higher-risk patients (i.e., women). Primary care clinicians are often best positioned to screen, diagnose, and initiate treatment for UI. However, primary care clinicians do not routinely ask patients about this problem, either because of a lack of knowledge and confidence in treating UI or the severe time constraints of the typical primary care visit.

The Agency for Healthcare Research and Quality's (AHRQ) Managing Urinary Incontinence initiative builds on the success of the agency's EvidenceNOW model to address these important gaps in nonsurgical UI care for women in the primary care setting. EvidenceNOW uses a health extension model (the use of practice coaches and other resources) to provide primary care practices with continued, relationship-based outreach and support for improving health care quality and implementing new evidence from patient-centered outcomes research into care delivery. As part of the Managing Urinary Incontinence initiative, AHRQ is funding five cooperative agreement (U18) grantees to develop primary care extension services to disseminate and implement improved nonsurgical treatment of UI for women—including screening, diagnosis, management, and specialty referral—within primary care practices in separate regions of the United States. The RAND Corporation, in partnership with Academy Health, has been contracted to support the Managing Urinary Incontinence grantees and evaluate the initiative. As part of this contract, RAND was asked to conduct an environmental scan of prior research on dissemination and implementation of evidence-based processes to improve screening, diagnosis, and management of UI for women in the primary care setting, to help inform the work of the grantees. This study describes the findings of that scan.

Approach

The methods for the environmental scan consisted of two approaches. First, we conducted a scoping review of English-language, peer-reviewed and grey literature covering 2012 through 2022 that assessed dissemination and implementation (D&I) approaches to improving UI care for women in primary care settings, including community and home settings in which treatment is managed by primary care professionals. Second, we manually scanned generic (i.e., non–UI-related) D&I tools and materials from other EvidenceNOW projects that were catalogued on AHRQ's website that might be applicable to UI care improvement and the work of the Managing Urinary Incontinence grantees.

Key Findings

Descriptions of the Studies

Of the 1,328 publications identified in the literature searches, 30 publications that reported on 14 studies met the inclusion criteria. In addition, we identified 43 generic D&I tools and materials of potential relevance on the EvidenceNOW website.

Most of the studies were conducted in the United States or the Netherlands. Settings included primary care practices, community health centers, and patients’ homes, as well as virtual settings, which included telehealth, interactive websites, and phone apps. Studies reported little information on practice characteristics, such as the total numbers and types of practitioners, or on the total numbers of patients eligible for study enrollment. Patients ranged in age from 21 to 90, with a mean age of 60; most studies included patients with stress, urgency, mixed, other UI, or some combination thereof.

Most of the strategies used by the studies to improve UI care focused on implementation of specific care interventions rather than broader dissemination strategies (e.g., practice coaches, learning collaboratives) and implementation strategies (e.g., continuous quality improvement). Examples of these specific changes in care process included implementation of a screening tool, change in the screening process, use of nurse practitioners (NPs) to manage UI care, or deployment of such telehealth tools as phone apps. Only three studies described a dissemination intervention component: One involved provider or staff education and training, and two incorporated on-site coordination and other direct technical assistance. Nine studies described at least one implementation intervention component: All of these involved an electronic or other tool. One also employed a care team engagement approach.

Most studies addressed multiple levels of the primary care system. For example, most studies with interventions for patients also included interventions for primary care providers, and a small number included an intervention at the practice or health care–delivery system level.

The stages of care that were addressed by the studies (screening and diagnosis, management, and specialty referral) also varied. Nearly half of studies addressed screening or diagnosis, most studies addressed UI management, and none directly addressed referral to specialty care.

Four types of outcomes were assessed: care process outcomes, health outcomes, health system outcomes, and economic outcomes. Most studies assessed care process or health outcomes: UI outcomes were assessed via numerous validated tools.

Patient Care and Health Outcomes

Process outcomes: Various process changes aimed at increasing UI screening tended to improve screening rates, but the numbers of studies were too small to draw definitive conclusions. One large study that tested the use of a self-management app demonstrated positive effects and identified patient facilitators and barriers to using the app. No studies were designed to examine the effects of an intervention on referral to specialty care.

Health outcomes: All studies reported improvements in at least one indicator of UI symptoms and quality of life in groups of women who received an intervention that involved prescreening, NP involvement in treatment, or use of an app; some of these improvements lasted at least a year.

System and Economic Outcomes

System outcomes: System outcomes included provider behavior change, provider acceptance of the intervention, and integration of a process change into practices. Too few studies assessed these outcomes to enable any conclusions to be drawn.

Economic outcomes: Four studies that assessed economic impacts of practice changes in various ways reported positive impacts in terms of cost effectiveness compared with that of usual care. Two studies assessed quality-adjusted life years, one compared costs with those for usual care, and one considered the reduced need to refer to specialty care.

Conclusions

The environmental scan identified only a small number of studies. Most of these did not assess broader implementation or dissemination strategies. Too few studies assessed any particular type of implementation or dissemination strategy to enable us to draw any firm conclusions about what works and what does not. Furthermore, although this environmental scan describes the methodological rigor of the individual studies, the nature of the scan approach means that it is not designed to evaluate the strength of the literature.

The findings of the current scan review suggest that improving screening is a critical first step to better treatment of UI for women in primary care, but additional focus on management and referral strategies is also needed.