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New Approach to Incontinence Care at UH Aims to Eliminate Barriers for Patients and Providers

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UH Clinical Update | June 2023

Researchers at UH are developing and testing an innovative new approach to diagnosing and treating women with urinary incontinence. The EMPOWER study, funded by a $3 million grant from the Agency for Healthcare Research and Quality (AHRQ), aims to eliminate some of the long-standing barriers among both patients and providers that stand in the way of optimal care.

Why it matters: Hesitation to discuss the issue on the part of patients and lack of time and competing demands among providers can both lead to undiagnosed urinary incontinence and untreated symptoms. Women may mistakenly think their urinary incontinence is just a normal part of aging and opt to suffer in silence.

The EMPOWER approach: To implement its goals, the EMPOWER study involves large-scale screening, empowering patients to discuss urinary incontinence with their providers, provider education and training, practice facilitation through nurse navigation and a novel mobile-platform chatbot to engage patients in self-management of their condition.

“Out-of-the-box approaches like this are needed to help solve such a long-standing problem,” says principal investigator Adonis Hijaz, MD, Vice Chairman of the Department of Urology at UH Cleveland Medical Center and Lester Persky Professor of Urology at Case Western Reserve University School of Medicine.

“We all know that urinary incontinence is under-reported and under-treated,” he says. “That's common knowledge. But we also know how important the primary care physicians are as gatekeepers for the health care of their patients. Therefore, we’re creating an integrated, multi-level approach that includes patients, providers and system aspects to address key barriers to diagnosing and managing urinary incontinence in the primary care setting.”

“Urinary incontinence is a problem that is very common in primary care, and neither physicians nor patients are really aware of all of their options,” adds UH family physician Goutham Rao, MD, co-PI on the study and Jack Medalle Professor and Chairman of the Department of Family Medicine and Community Health at UH and Case Western Reserve University. “As a health services researcher interested in how we deliver primary care, I believe it fits very neatly into that bucket of problems that are under-diagnosed under-managed and have a big impact on quality of life, but where primary care physicians feel overwhelmed. How do they manage this on top of everything else?”

A Better Way to Identify the Problem

To address this concern, EMPOWER relies entirely on the patient, rather than the provider, to self-identify as having a problem with urinary incontinence. Patients answer four questions through a brief paper survey in the primary care waiting room or click a link or use a QR code on their phone – removing some of the barriers for both the patient and the provider, including the initial potential stigma of discussing the problem.

“The fundamental principle behind EMPOWER is that it's minimally burdensome to primary care physicians,” Dr. Rao says.

So far, Dr. Hijaz and Dr. Rao have received screening questionnaires from 5,000 women from the northwest, southwest, central and south regions, with 60 percent reporting urinary incontinence and 50 percent of these saying that the problem was moderate to severe. In the fall, screening will proceed to the northeast and southeast practices.

What Treatment Approach Works Best?

Women who choose to enroll in the EMPOWER study are being randomly assigned to three treatment approaches: Some are receiving standard urinary incontinence care, including behavior therapy, pelvic floor physical therapy and medications, plus patient education; Others are receiving this care, plus the assistance of a nurse navigator; A third group is receiving the first two interventions and additional access to a chatbot (an AI-powered conversational agent) to help them successfully navigate the care pathway.

Dr. Hijaz says he has high hopes for what the chatbot might help patients in the study accomplish.

“We believe that the chatbot and the nurse navigation support will have a significant impact on patient’s outcome,” he says. “Patients will communicate freely with the chatbot and nurse navigator without feeling embarrassed or ashamed of talking about the problem. The reinforcement and guidance they receive will results in a measurable outcome improvement that we will collect at baseline and then at six months.”

Opportunities for Provider Education

On the provider side, Dr. Hijaz and other members of the team are providing one-hour seminars on urinary continence for UH primary care providers who want to learn more about the most current treatment options. Additionally, they’re offering interested primary care providers access to an eight-week “master class” on urinary incontinence offered by the UH specialty experts through the ECHO University of Chicago platform.

“If we want to reach a stage where we are increasing the diagnosis and treatment of this condition in the setting of the primary care, I thi

Redefining the Standard of Care

To truly make EMPOWER successful in redefining urinary incontinence care will require everyone’s participation, he says.

“I really urge the providers to help us make this successful and hand out screening questionnaires in their offices,” he says. “Use the EMPOWER team in the UH Urology Institute as resources. We have the capacity as a Primary Care Institute within University Hospitals, because of the number of offices, the strength of the organization and the organizational structure to make a difference. We hope that the project we're doing here can be a model copied on the national level to help woman with incontinence. EMPOWER will leave behind tools that the primary care physicians and their office staff can use to continue to manage these patients going forward. Patients, too, stand to benefit from the expertise available in the UH Urology Institute. No matter which arm of the study they fall in, participants will all receive the latest evidence-based care for urinary incontinence – with significant implications for quality of life.”

For more information about how your patients can participate in the EMPOWER study, please email EMPOWER.Study@uhhospitals.org or call 216-286-7235. Or, to refer a patient for urinary incontinence care in general, please call 216-714-7773.

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