What's new: the AHCPR guideline update on urinary incontinence

The Agency for Health Care Policy and Research (AHCPR) released their first updated guideline in March, 1996. Three documents were released: the Clinical Practice Guideline, Urinary Incontinence in Adults: Acute and Chronic Management; the Quick Reference Guide, Managing Acute and Chronic Urinary Incontinence; and the Patient Guide, Understanding Incontinence. The new areas are outlined and addressed. Unlike the 1992 version, the update emphasizes the problem of urinary incontinence (UI) in a specific population, those with chronic "intractable" incontinence. It provides an algorithm in the Quick Reference Guide for selecting appropriate behavioral, pharmacologic, and surgical treatments and supportive devices for use in managing UI. The concept of "prevention" of UI and the promotion of healthy bladder habits is introduced. The updated guideline developed recommendations for each assessment and treatment method. Specific interventions that can impact individuals with chronic "intractable" incontinence are discussed including toileting assistance programs, physical and environmental alterations, fluid and dietary management, management of nighttime voiding, and other measures and supportive care. Skin care and social and organizational environmental factors are also discussed. In August, 1996 the AHCPR released two additional, original documents, the Caregiver Guide, Helping People with Incontinence, and Alert for Directors of Nursing, which are briefly discussed.

Urinary incontinence management in the USA: the role of the nurse

Urinary incontinence (UI) is a prevalent medical problem in the USA. Approximately 12 million Americans are incontinent of urine. Hu et al (1994) estimate that the costs of managing the problem are $10 billion annually. In persons aged 65 years and older the incidence of UI is 30% or more it is estimated that more than 60% of people with UI never mention their problem to a doctor of nurse. This is a sad fact considering that UI is a highly treatable, if not curable, problem. In the USA, advanced practice nurses, nurse practitioners and clinical nurse specialists who have advanced educational and master's degrees and clinical practice requirements are making a significant impact on the management of UI. This article outlines the role of advanced practice nurses in the diagnosis and behavioural management of UI.

A review of the quality-of-life aspects of urinary urge incontinence

Urinary incontinence (UI) is prevalent and costly, occurring in 15 to 30% of the US population over the age of 60 years. Among people aged 15 to 64 years, UI occurs in 1.5 to 5% of men and 10 to 25% of women. Severe incontinence occurs in 6% of the general US population, and it is estimated that $US10 billion per year is spent in direct costs alone on care for these patients. This review presents a description of the various types of UI and describes the prevalence and costs of the condition. In addition, 3 approaches to assessing the impact of UI on quality of life are discussed, namely generic measures, disease-specific measures and qualitative approaches. We also review papers on UI and sexual functioning, UI in men, and some aspects of treatment. The review was conducted in the process of developing a new disease-specific measure for urinary urge incontinence (UUI). In general, the literature suggests that UUI has a greater impact than stress incontinence on quality of life, and that UI affects social and psychological functioning more than physical functioning. Only in a minority of individuals is the impact of UI disabling; however, most individuals with UI show significant reduction in their social functioning. Several studies suggest that the impact of UI is not solely a function of its severity, but also depends on individual coping abilities. Some studies also indicate that the social problems associated with UI grow with time, but it is not clear if that is a function of increasing severity of the condition, or the particular adaptations required for coping with this problem. An important distinction appears to be the ability of individuals to avoid public notice of their condition because of uncontrolled accidents. In summary, there is a need for a new measure of the quality-of-life impact of UUI that is based on the literature and on in-depth interviews with patients.

Quality of life of persons with urinary incontinence: development of a new measure

OBJECTIVES

Our objective was to develop a self-report quality of life measure specific to urinary incontinence (I-QOL) that could be used as an outcome measure in clinical trials and in patient care centers.

METHODS

The I-QOL was developed from interviews of 20 individuals with urinary incontinence. Refining the questionnaire was accomplished by structured interviews of 17 individuals with urinary incontinence. Testing the I-QOL's psychometric properties involved two administrations (n = 62) along with measures of psychologic well-being and functional status.

RESULTS

The rigorous development process ensured that the measure was complete and understandable. The I-QOL proved to be internally consistent (alpha 0.95) and highly reproducible (r = 0.93; 18 days; SD 4). For discriminant validity, severity of incontinence (P < 0.0001) and number of medical appointments in the past year to treat incontinence (P < 0.0001) significantly predicted I-QOL scores. Convergent validity analyses confirmed our predictions that the I-QOL scores were more closely related to overall well-being than bodily pain.

CONCLUSIONS

The I-QOL proved to be valid and reproducible as a self-administered measure for assessing quality of life of patients with urinary incontinence.

A cost and value analysis of two interventions with incontinent nursing home residents

OBJECTIVE

More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences.

DESIGN

The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance.

PARTICIPANTS

Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value.

MEASUREMENT

The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room).

RESULTS

Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers,

CONCLUSION

Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.

Collagen injections for treatment of urinary incontinence secondary to intrinsic sphincter deficiency

The injection of glutaraldehyde cross-linked collagen (Contigen) is a recently approved method for treating patients with urinary incontinence secondary to intrinsic sphincter deficiency (ISD). Forty-five patients with ISD, 33 males and 12 females, with a mean age of 60 years (range 5-87 years) have been treated with collagen at our institution since its Food and Drug Administration approval. The etiology of incontinence was radical retropubic prostatectomy (RP) in 22, neurogenic bladder (NB) in 11, and Type III female stress urinary incontinence (FISD) in 12 individuals. The whole group underwent an average of 1.76 treatment sessions (range 1-4), and a mean collagen injection volume of 12.26 cc (range 5-27.5 cc) was delivered per session. There were no postoperative complications. Six patients achieved total continence, 28 were still incontinent but improved, 9 experienced no change, while 2 developed worsening incontinence. Further analysis indicated that male patients with ISD as a result of RP may achieve some degree of improvement, but the chances for eradicating incontinence are minimal, whereas female patients with FISD and individuals with ISD secondary to NB significantly benefit from collagen injection therapy. Longer follow-up is needed to determine the durability of these encouraging results.

An overview of urinary incontinence in adults: assessments and behavioral interventions

Urinary incontinence affects millions of Americans. Often the goal of treatment is to improve the condition, prevent complications and provide comfort. Behavioral interventions can improve the condition in 54-75% of patients with urge and/or stress incontinence and can cure 12-16% of patients. Advanced practice nurses (APNs) are in a unique position of both providing direct care to patients who experience these problems and educating other nurses about signs, symptoms and appropriate nursing interventions for urinary incontinence. The scope of the problem, costs of urinary incontinence and potential cost savings with treatment are discussed in this article. Acute and chronic urinary incontinence and the necessary assessments to be performed by the APN are reviewed. Bladder training, habit training, prompted voiding and pelvic muscle exercises are the behavioral interventions used with urinary incontinence. Adjunct therapy, including biofeedback, vaginal cones and electrical stimulation, also is discussed.

Costs and management of urinary incontinence in long-term care

The three aims of the study were (1) to assess the impact and cost of urinary incontinence in long-term care, (2) to determine whether 24-hour incontinence monitoring provides information that improves management, and (3) to ascertain whether costs (nursing time and laundry) could be reduced. The setting was two 24-bed long-term care units in an urban hospital. The research was conducted in three stages. During the initial stage, the impact of incontinence was measured on each unit. Impact was defined as total number of incontinent episodes, nursing time spent changing these patients, and laundry costs, measured during a 7-day period on each unit. After this phase of the investigation, individualized 24-hour incontinence monitoring, followed by recommendations and implementation of care plan, was carried out on one unit. No monitoring or recommendations for care were completed on the other unit, which served as a control. During the third phase of the study, the number of incontinent episodes, nursing time, and laundry costs were again measured on both units. Initially (58%) of residents (24/48) were incontinent, representing 859 episodes of urinary leakage each week that required 45 hours of nursing time to change clothing, containment devices, and bed linens. The direct costs of the nursing time and laundry, expressed in Canadian dollars were $8.60/day per incontinent resident. After 24-hour monitoring of 10 residents one on unit, suggestions were made for various incontinence management programs. An unexpected but simple recommendation was a change to a better containment system for urinary leakage. When impact was measured, a 13% reduction in the number of incontinent episodes was found.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of urinary incontinence on publicly financed home care services to low-income elderly people

Urinary incontinence (UI) has been shown to be prevalent and a risk factor for permanent institutionalization; yet it is not routinely measured in research of home care utilization. A retrospective cohort design is used to directly estimate the effect of UI on the public costs of home care services to elderly individuals. Multivariate analyses controlling for other individual, household, and supply characteristics demonstrate that those with UI generate significantly greater public costs for home care services. Patterns of service use suggest palliative rather than rehabilitative service, raising questions regarding the effective use of resources.

Spina bifida: the personal and financial cost of incontinence

Spina bifida is a congenital defect in the spinal column in which one or more vertebrae fail to form. The effect of spina bifida on continence is usually complicated by the effect of hydrocephalus on the ability to learn and master the necessary skills to overcome the problems. The childhood and adolescence of some individuals who have spina bifida has been ruined by professionals who chose to ignore the wider implications of severe congenital disability and its effects upon the child's education, personal and social development, and the quality of family life. A holistic approach to management, from birth onwards, should facilitate the interdisciplinary cooperation which is vital if these human tragedies are to be avoided.

Intravaginal maximal electrical stimulation in the treatment of urinary incontinence

Urinary incontinence imposes a large economic burden, estimated at $10 billion per year. As the cost of health care continues to rise, conservative therapeutic measures are becoming more attractive. Anecdotal reports suggest that electrical stimulation may be up to 87% effective in the treatment of urinary incontinence. Investigators use different stimulation devices and protocols and make a comparison of results difficult. The true efficacy of electrical stimulation for the treatment of urinary incontinence is unknown since there have been no controlled clinical trials. Within our referral-based urogynecology practice, we employ intermittent, intravaginal maximal electrical stimulation in conjunction with bladder drills and pelvic floor exercises. Over a one-year period we treated 76 women with urinary incontinence: 19 with stress incontinence (SUI), 30 with detrusor instability (DI) and 27 with mixed incontinence (MI). After six weeks, our overall objective improvement rate was 76%; 89% of patients with SUI, 73% with DI and 70% with MI met the criteria for improvement. Long-term follow-up averaged 6 months, with a range of 2-12. Of patients who showed an initial objective improvement, 87% maintained that improvement. Intravaginal electrical stimulation may be effective therapy for urinary incontinence. Controlled clinical trials are needed to determine its efficacy and standardize stimulation protocols before its widespread use.

Urinary incontinence: assessment, treatment, and reimbursement

Urinary incontinence is a significant problem for elderly people. Home care nurses are in a unique position to identify urinary incontinence and manage it in the home setting. Nurses can help to decrease incontinence by assessing for problems, making nursing diagnoses, and implementing appropriate treatment plans. Well-planned and documented continence care is a reimbursable nursing service for home care agencies.

A comparison of nursing approaches for the promotion and management of continence in the U.K. and Denmark

Incontinence is recognized as a health problem of sizeable proportions affecting a wide age range of the population. This paper compares the nursing approaches for the promotion and management of continence within the U.K. and Denmark. Semi-structured interview of key health professionals within Denmark was undertaken. The information collected forms the basis for a comparison of prevalence of incontinence, clinical practice, management, education and research.