Beyond EMPOWER: From Study Findings to Scalable Care at University Hospitals

UH Research & Education Institute

Urinary incontinence affects millions of women, yet many never discuss symptoms with a healthcare provider. At University Hospitals, the EMPOWER study helped identify new ways to find women who need care and connect them to treatment, leading to a screening program that has already reached more than 280,000 patients.

The transition is giving investigators an opportunity to examine what happens after implementation, including how to convert screening into clinical action, which components of the EMPOWER intervention can be sustained at scale and how emerging technologies might extend the model to other underdiagnosed conditions.

“What EMPOWER allowed us to do is to figure out what actually works,” says Goutham Rao, MD, Chair of the Department of Family Medicine and Community Health at UH and Case Western Reserve University School of Medicine.

Designing EMPOWER for Real-World Primary Care

EMPOWER grew from an Agency for Healthcare Research and Quality initiative aimed at improving the management of UI, a highly prevalent condition that remains markedly undertreated. Up to 60 percent of women experience UI, yet only 12.5 percent receive care, according to Adonis Hijaz, MD, Director of the Center of Female Pelvic Medicine and Surgery and Vice Chair of Academics and Research for the UH Urology Institute.

“If something is ‘common,’ it doesn’t mean it has to be normal,” says Dr. Hijaz.

The UH implementation study examined whether a multimodal intervention could improve identification and nonsurgical management of UI while strengthening primary care's ability to address the condition.

More than 15,000 women were screened across 76 UH primary care centers in Northeast Ohio. Four hundred women who screened positive enrolled in the study, which evaluated three approaches: usual care with patient education; patient education plus nurse navigation; and patient education and nurse navigation augmented by a chatbot. Clinician education and training were also integral to the implementation strategy.

A central consideration was whether the intervention could function within existing clinical workflows.

“We wanted to make sure that the intervention was the least burdensome to the primary care physicians,” says Dr. Hijaz.

Screening identified UI in approximately 58 percent of patients, with nearly half reporting moderate-to-severe symptoms. Physicians participating in EMPOWER training also reported greater confidence in evaluating and managing UI, prescribing medications and referring patients to specialty care and physical therapy.

For Dr. Rao, a health services researcher and principal investigator of the AHRQ-funded UH ADVANCE Diagnostic Center of Excellence, EMPOWER demonstrated the value of treating underdiagnosis as a health care delivery problem.

“EMPOWER is truly transformative in terms of those discussions,” he says. Study data showed that conversations about UI occurred much more frequently following implementation.

From Findings to Clinical Practice

The aftermath of EMPOWER is now providing a real-world test of how those findings translate at scale.

UH embedded the International Consultation on Incontinence Questionnaire into its electronic medical record for women presenting for annual visits in primary care and OB-GYN settings. More than 280,000 women have been presented with the questionnaire, with approximately 24 percent completing it. Among respondents, more than 48 percent reported UI and more than 42 percent reported moderate, severe or markedly severe symptoms.

The expanded screening confirms the magnitude of the diagnostic opportunity. It also exposes the next implementation challenge in that identification alone does not ensure treatment.

“Once you screen [and] identify, you want to empower patients in the ability to act on it or empower physicians,” Dr. Hijaz says.

For UH investigators, the focus is therefore shifting toward how screening results can trigger efficient, sustainable clinical pathways, enabling primary care clinicians to initiate management or connect patients with appropriate specialty care.

Human Navigation, AI and Scalability

EMPOWER also provided insight into which components of the intervention were most useful.

“The nurse navigator, that human touch, was really, really effective,” says Dr. Rao, while the chatbot evaluated during EMPOWER was less successful.

The rapid evolution of artificial intelligence since EMPOWER was designed, however, is creating a new research opportunity. Rather than replacing human navigation, AI could potentially augment it.

Dr. Rao envisions AI-enabled outreach that engages patients before an appointment, identifies concerns that might otherwise go unreported and synthesizes relevant information for the clinician.

“There’s something that is relatively inexpensive and can be scaled across the system,” he says, “and it can be used for a number of problems that are underdiagnosed and undertreated.”

Defining the Next Phase of Research

The next iteration may also move screening beyond the traditional clinical encounter.

Dr. Hijaz is considering a direct-to-patient model that could identify individuals with significant symptoms and connect them more readily with an appropriate continence care pathway. He and Dr. Rao have discussed the concept as a potential focus for follow-up research and grant funding.

Important questions remain. EMPOWER did not measure whether the intervention shortened the interval between symptom onset and care-seeking. Investigators also must determine how best to convert large-scale screening into action while maintaining clinician capacity and preserving the effective human components identified through the study.

Those questions make the post-EMPOWER period scientifically significant.

The study brought systematic screening, clinician education, navigation and technology into real-world primary care. UH's subsequent system-level implementation now provides an opportunity to examine how those components perform at greater scale, and which could be adapted to other diagnostic gaps.

The evolution from EMPOWER to system-level screening therefore represents more than dissemination of a completed study. It creates a platform for the next generation of implementation research at UH to determine how evidence-based interventions can move from identification to action and, ultimately, become sustainable models for closing persistent gaps in care.

“EMPOWER showed us that identifying the problem is only the first step,” says Dr. Hijaz. “The opportunity now is to build on what we learned, creating pathways that move patients from identification to treatment and determining whether that model can be scaled to other gaps in care.”