Development of quality indicators for women with urinary incontinence

Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care

OBJECTIVE

To compare the quality of urinary incontinence care for women in the safety-net and non-safety-net settings prior to referral to a specialist.

METHODS

We performed a retrospective review of 200 women from two non-safety-net hospitals and 188 women from two safety-net hospitals who were referred to Urogynecology and Reconstructive Surgery specialists for bothersome UI between March 2017 and March 2020. We evaluated the care that women received 12-months prior to referral, by measuring adherence to a set of previously developed quality indicators (QIs), for example the performance of a urinalysis or pelvic exam.

RESULTS

Women seen in safety-net hospitals were more likely to receive QI-compliant care than women in the non-safety-net hospitals prior to referral, with 55.53% of appropriate care given in the safety-net vs. 40.3% in the non-safety-net setting (p<0.01). Clinicians in the safety-net hospitals were more likely to adhere to QIs in patients with general, stress, and urgency incontinence.

CONCLUSIONS

Women were more likely to receive timely, quality-based UI care in the safety net compared to the non-safety-net setting. This may be in part due to aspects unique to the safety-net system, including an eConsult referral system, which guides referring clinicians in appropriate management steps that should be taken prior to the specialist visit, as well as women's health focused primary care clinics.

Quality Indicators in the Clinical Specialty of Urology: A Systematic Review

CONTEXT

In health care, monitoring of quality indicators (QIs) in general urology remains underdeveloped in comparison to other clinical specialties.

OBJECTIVE

To identify, synthesise, and appraise QIs that monitor in-hospital care for urology patients.

EVIDENCE ACQUISITION

This systematic review included peer-reviewed articles identified via Embase, MEDLINE, Web of Science, CINAHL, Global Health, Google Scholar, and grey literature from 2000 to February 19, 2021. The review was carried out under the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used the Appraisal of Indicators through Research and Evaluation (AIRE) tool for quality assessment.

EVIDENCE SYNTHESIS

A total of 5111 articles and 62 government agencies were screened for QI sets. There were a total of 57 QI sets included for analysis. Most QIs focused on uro-oncology, with prostate, bladder, and testicular cancers the most represented. The most common QIs were surgical QIs in uro-oncology (positive surgical margin, surgical volume), whereas in non-oncology the QIs most frequently reported were for treatment and diagnosis. Out of 61 articles, only four scored a total of ≥50% on the AIRE tool across four domains. Aside from QIs developed in uro-oncology, general urological QIs are underdeveloped and of poor methodological quality and most lack testing for both content validity and reliability.

CONCLUSIONS

There is an urgent need for the development of methodologically robust QIs in the clinical specialty of general urology for patients to enable standardised quality of care monitoring and to improve patient outcomes.

PATIENT SUMMARY

We investigated a range of quality indicators (QIs) that provide health care professionals with feedback on the quality of their care for patients with general urological diseases. We found that aside from urological cancers, there is a lack of QIs for general urology. Hence, there is an urgent need for the development of robust and disease-specific QIs in general urology.

Quality of pre-operative assessment for mid urethral slings in women who present with mesh complications

OBJECTIVE

To study quality of pre- and post-operative evaluation in women undergoing mid-urethral synthetic sling surgery who subsequently have complications.

MATERIALS AND METHODS

Study inclusion was chart availability for preoperative clinical history, examination, urodynamics and/or post-operative visit in women with mesh complications 2014-2021 in a tertiary practice. The primary outcome was compliance with quality indicators and guidelines for preoperative and post-operative clinical evaluation and urodynamics.

RESULTS

122 women had preoperative, 102 urodynamic reports and 108 post-operative charts available for review. Only clinical history and examination showed moderate compliance (71% nature, 57% severity, 87% exam) with quality indicators, all other quality indicators were low. including documentation of counselling of mesh risks (11%) and risks of incontinence surgery (17%) . Compliance with guidelines (optimal care) was also low (bladder diary 61%, all others ≤41%). Post-operative evaluation did not comprehensively screen for complication e.g., flow rate/post-void residual performed in 9%. A significant proportion had an early adverse symptom (55%) or intervention e.g. trimming of exposure (40%) CONCLUSION: Compliance with quality indicators and guidelines was generally low for pre-operative evaluation and urodynamic testing. There was inadequate content and length of post-operative evaluation despite a significant proportion presenting with adverse symptoms at first postoperative follow-up. Future research could target these areas for development of tools to improve compliance and education of health providers.

The Impact of Provider Sex and Experience on the Quality of Care Provided for Women with Urinary Incontinence

BACKGROUND

Although specialists are skilled in the management of urinary incontinence, primary care clinicians are integral in early diagnosis and initiation of management in order to decrease overuse of specialty care and improve the quality of specialist visits. We measured the quality of incontinence care provided by primary care clinicians prior to referral to a specialist and evaluated the impact of provider variables on quality of care.

METHODS

We performed a retrospective review of 200 women referred for urinary incontinence to a Female Pelvic Medicine and Reconstructive Surgery specialist between March 2017 and July 2018. We measured primary care adherence to 12 quality indicators in the 12 months prior to specialist consultation. We stratified adherence to quality indicators by clinician sex and years of experience.

RESULTS

Half of women with incontinence underwent a pelvic examination or had a urinalysis ordered. Few patients with urge urinary incontinence were recommended behavioral therapy (14%) or prescribed medication (8%). When total aggregate scores were compared, female clinicians performed the recommended care 47% ± 25% of the time, compared with 35% ± 23% for male clinicians (P = .003). Increasing years of experience was associated with worse overall urinary incontinence care (r -0.157, P = .02).

CONCLUSIONS

We found low rates of adherence to a set of quality indicators for women with urinary incontinence, with male clinicians performing significantly worse than female clinicians. Improvement of incontinence care in primary care could significantly reduce costs of care and preserve outcomes.

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators

OBJECTIVE

Development and validation of a set of quality indicators for vulnerable women during the perinatal period.

DESIGN

A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals.

SETTING

The Flemish Region and the Brussels Capital Region in Belgium.

PARTICIPANTS

Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals.

FINDINGS

The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

The Quality of Care Provided to Women with Urinary Incontinence in 2 Clinical Settings

PURPOSE

Our aim was to test the feasibility of a set of quality of care indicators for urinary incontinence and at the same time measure the care provided to women with urinary incontinence in 2 clinical settings.

MATERIALS AND METHODS

This was a pilot test of a set of quality of care indicators. A total of 20 quality of care indicators were previously developed using the RAND Appropriateness Method. These quality of care indicators were used to measure care received for 137 women with a urinary incontinence diagnosis in a 120-physician hospital based multispecialty medical group. We also performed an abstraction of 146 patient records from primary care offices in Southern California. These charts were previously used as part of ACOVE (Assessing Care of Vulnerable Elders Project). As a post-hoc secondary analysis, the 2 populations were compared with respect to quality, as measured by compliance with the quality of care indicators.

RESULTS

In the ACOVE population, 37.7% of patients with urinary incontinence underwent a pelvic examination vs 97.8% in the multispecialty medical group. Only 15.6% of cases in the multispecialty medical group and 14.2% in ACOVE (p = 0.86) had documentation that pelvic floor exercises were offered. Relatively few women with a body mass index of greater than 25 kg/m(2) were counseled about weight loss in either population (20.9% multispecialty medical group vs 26.1% ACOVE, p = 0.76). For women undergoing sling surgery, documentation of counseling about risks was lacking and only 9.3% of eligible cases (multispecialty medical group only) had documentation of the risks of mesh.

CONCLUSIONS

Quality of care indicators are a feasible means to measure the care provided to women with urinary incontinence. Care varied by population studied and yet deficiencies in care were prevalent in both patient populations studied.

Measuring the quality of care provided to women with pelvic organ prolapse

OBJECTIVE

Health care providers are increasingly being evaluated by the quality of care they provide. Our aim was to assess the feasibility of recently developed quality indicators (QIs) for pelvic organ prolapse (POP) and identify possible deficits in care.

STUDY DESIGN

A panel ranked 14 QIs based on the RAND appropriateness method assessing screening and diagnosis, pessary management, and surgery for POP. Retrospective chart abstraction was performed after identifying patients with a diagnosis of POP evaluated within a hospital-based multispecialty group using International Classification of Diseases, ninth edition, diagnosis codes.

RESULTS

Of 283 patients identified, 98% of those with a new complaint of vaginal bulge had a pelvic examination. The POP was described but not staged in 6% and not documented at all in 25.1%. Among those managed with pessaries, 98% had vaginal examinations at least every 6 months. Forty-nine percent of the patients who had surgery had complete preoperative POP staging. Only 20% of women undergoing apical surgery had documentation of counseling regarding different surgical options, and of the women who underwent a hysterectomy for POP, only 48% had a concomitant vault suspension. Although 71% had documentation about the risk of postoperative stress incontinence, only 14.5% had documented counseling regarding risks of mesh. Only 37% of patients implanted with mesh for POP had documented follow-up at 1 year. An intraoperative cystoscopy was performed in 86% undergoing cystocele repair or apical surgery.

CONCLUSION

The quality of care for women with POP can be feasibly measured with QIs. Processes of care were deficient in many areas, and our findings can serve as a basis for quality improvement interventions.

Valsalva leak point pressure-associated Q-tip angle and simple female stress urinary incontinence symptoms

PURPOSE

To clarify the association between clinically defined simple stress urinary incontinence (SUI) symptoms and urodynamic SUI, we examined the relationship between Valsalva leak point pressure (VLPP) as measured by the Q-tip test and Stamey grade in simple female SUI.

METHODS

Two hundred grade I or II female SUI patients with SUI symptom were examined by reviewing medical history; physical examination; urethral mobility as assessed by Q-tip test; stress test; and cystometry, including VLPP measurement. On the basis of the VLPP, patients were classified into urethral hypermobility [UH, subdivided into anatomical incontinence (AI) and equivocal incontinence (EI)] or intrinsic sphincter deficiency groups for analysis of the relationship between VLPP and Stamey grade and Q-tip angle.

RESULTS

Seventy-eight patients were included, and the mean patient age was 54 ± 7.5 years, mean SUI symptom duration 2.8 years (range 0.5-6 years), mean VLPP 103.6 ± 18.4 cm H2O, and mean Q-tip angle 28.6° ± 7.2°. Fifty-three patients were categorized as Stamey grade I, 25 as Stamey grade II, 51 as AI, and 27 as EI. VLPP was found to be negatively correlated with Q-tip angle (Rs = -0.798, Y = -0.313X + 60.95, P < 0.001), and classifications of VLPP and Stamey grade have positive correlation (χ (2) = 4.9130, P = 0.0267).

CONCLUSIONS

In simple female SUI, VLPP is associated with the Q-tip angle and Stamey grade, which may help to reduce some of urodynamic items.

Nationwide database of surgical treatment pattern for patients with stress urinary incontinence in Korea

PURPOSE

Nationwide database regarding stress urinary incontinence (SUI) is important for evaluating treatment patterns for SUI and for establishing appropriate national policies regarding SUI management. The purpose of this present study was to investigate surgical treatment patterns for women with SUI and analyze the current status of SUI management in Korea by using a nationwide database.

METHODS

Data used for investigating the surgical trends and changes in Korea were retrieved from the Health Insurance Review & Assessment Service from 2008 to 2011.

RESULTS

The number of surgical cases of SUI decreased continuously from 2008 to 2011. The proportion of transvaginal surgery using a midurethral sling increased continuously. Sling procedures were most commonly performed for women in their 40s followed by women in their 50s. Transvaginal surgery using a single sling or a readjustable sling was performed from 5.6% to 6.1%, which showed no significant change in the number of surgical cases.

CONCLUSIONS

There is a growing need for an appropriate national welfare policy and budget to care for aged and super-aged women in Korea. The early detection and intervention of silent SUI should be actively considered as an important preventive strategy to improve the quality of life in younger women.