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2 LIBRARY Michigan State University

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4 DEVELOPMENT OF A PHYSICAL ASSESSMENT TOOL FOR UTILIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE IN AMBULATORY CARE BY Michelle Fedewa A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 2000

5 ABSTRACT DEVELOPMENT OF A PHYSICAL ASSESSMENT TOOL FOR UTILIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE IN AMBULATORY CARE BY Michelle Fedewa Urinary incontinence should not be accepted by women as an inevitable and untreatable condition. provider is the cornerstone of evaluation. The primary care Evaluation components include: physical, diagnosis, screening, thorough history and initiation of treatment and/or referral. A physical assessment tool will assist the primary care provider in data collection.

6 TABLE OF CONTENTS Page LI ST OF FIGURES O O O O O O O O 0 O O O O O O O O O O 0. iv INTRODUCTION Background Problem Statement Project Purpose Conceptual Definitions m4>hrahi CONCEPTUAL FRAMEWORK Health Promotion Model O 00 REVIEW OF LITERATURE Prevalence and under-reporting Quality of Life costs 0 O O O O O O O O O O O O O O O O O O O O O Underdiagnosis Evidence Based Medicine and Practice Guidelines. PROJECT DEVELOPMENT Overview Description of Evaluation Components Implementation IMPLICATIONS FOR PRACTICE IMPLICATIONS FOR RESEARCH IMPLICATIONS FOR PROFESSIONAL EDUCATION SUMMARY... APPENDICES: Appendix Appendix Appendix Appendix Appendix Appendix Appendix A: Urinary Incontinence Screening Questions B: Incontinence Impact Questionnaire and Urogenital Distress Inventory: Short Forms C: Incontinence History Form D: Bladder Record : Physical Exam Tool F: Provider Letter and Information... G: Information Packet LIST OF REFERENCES iii

7 LIST OF FIGURES Page Figure 1: Health Promotion Conceptual Model. Figure 2: Health Promotion Conceptual Model with Decision and Action Phases Figure 3: AHCPR Guidelines for Management of Urinary Incontinence in Primary Care.. 32 Figure Pelvic Muscle Rating Scale. 42 iv

8 INTRODUCTION Background Urinary incontinence (involuntary leaking of urine) is a prevalent, under diagnosed and underreported condition. It can occur when any of the normal functions of the bladder are disrupted. Today, urinary incontinence in women of all ages is seen as a major healthcare concern. Increased awareness of this condition began in 1988 at the National Institutes of Health Consensus Conference on Adult Urinary Incontinence. Following this, in December 1989, the US Department of Health and Human Services Agency for Health Care Policy and Research (AHCPR) was established and in 1992 issued the first publication of Clinical Practice Guidelines for Adult Urinary Incontinence. These summarized and evaluated the most recent research and clinical care in the field. These guidelines were designed to enhance the quality, effectiveness and appropriateness of the health care in the area of incontinence. Since that time there has been an increased focus on the problem of urinary incontinence. These Guidelines were updated in 1996 and three documents were released by the AHCPR: 1) The Clinical Practice Guideline; 2) Urinary Incontinence in Adults: Acute and Chronic Management; and3) The Quick Reference Guide,

9 Understanding Incontinence (AHCPR, 1996). These documents emphasize the problem of urinary incontinence and provide the foundation for assessment and treatment methods. Urinary incontinence is a common problem that affects a significant proportion of the otherwise healthy general population. Approximately twenty percent of women between the ages of 25 and 64 years experience urinary incontinence (Herzog & Fultz, 1990). The prevalence will increase as the "baby boomer" segment of the American population continues to age. Although urinary incontinence is most common in elderly women (Lagace et a1., 1993; Burgio, Matthews, & Engel, 1991) it is not an inevitable part of aging. Many women affected by incontinence will not seek treatment because of the belief that incontinence is a normal part of aging and/or childbirth, because of embarrassment, and/or the belief that urinary incontinence cannot be treated (Jolleys, JV 1988). According to Burgio et a1. (1994) fewer than half of the individuals living in the community consult their health care providers about this problem. Quality-of-life (QOL) is effected by urinary incontinence. Many women cope with the problem by utilizing the widespread availability of absorbent products that helps control the problem (Rekers, Drogendijk, Valkenburg, & Riphagen, 1992) or by making adjustments in their lifestyles. Dependency on these products gives the woman a feeling of security and acceptance of the condition and decreases motivation to seek evaluation and treatment

10 (Staber & Loboe, 1985). Studies completed by Grimby et al. (1993), Hunskaar and Vinsnes, (1991), and Jackson, (1997) concluded that women experiencing urinary incontinence were more socially isolated and had significant effects on their daily lives. Most women with urinary incontinence reside in the community (Burgio et al., 1991). Primary care providers can take an active role in identifying, evaluating and managing urinary incontinence in these women. There is a growing body of knowledge concerning the clinical care of individuals with urinary incontinence. Several federal and private organizations have provided research funding for the study of urinary incontinence (AHCPR, 1996). Many current studies indicate that urinary incontinence has effective treatments but that there is a need for increased awareness of the problem by healthcare providers and the public at large. Alleviating barriers to obtaining treatment, such as embarrassment and misconceptions about incontinence, requires public education and dissemination of information about incontinence by health care providers. Such information will dispel myths and destigmatize the problem. Targeting of appropriate groups for health education, clinical assessment, and intervention is necessary to alleviate and/or modify incontinence. Providers can be proactive in promoting continence among women by increasing public awareness, providing education, and consistently and

11 purposely asking about urinary incontinence with each contact. EIle m_sl L m nl Urinary incontinence is a complex problem. It is associated with a significant impact on aspects of quality of life (QOL). From the existing data it is not difficult to gauge the reality of the widespread occurrence and existing need to improve identification, evaluation and treatment in the primary care setting. In order to do this, the author suggests the development of a tool to assist the primary care provider in implementing the AHCPR practice guidelines. BMW Primary healthcare providers need to ask women about incontinence as a part of routine screening and physical examinations. There is increased availability of various treatment modalities as well as improved information and education to assist in correcting commonly held misconceptions about urinary incontinence (i.e., the inevitability and untreatability). This enables more women to receive treatment for this prevalent and largely underreported condition. Many primary care physicians and advanced practice nurses, (APN) may not be sufficiently trained in the identification, management and appropriate referral of urinary incontinence. The outcome of this scholarly project is to develop an ambulatory care physical assessment tool to assist in systematically implementing the

12 AHCPR clinical guidelines for physical examination. The goal is to ultimately increase the clinicians' likelihood of exploring urinary incontinence with women and to improve women's quality of life, decrease their urinary symptoms and related costs through better urinary incontinence identification and care. This tool will enhance the providers' ability to identify characteristics of urinary incontinence, and to initiate interventions and/or referral when appropriate. This project is of particular importance for advanced practice nurses due to their focus on health promotion and disease prevention. i! J I E' 'l' Definitions: Urinary Incontinence. Urinary incontinence is a problem characterized by the involuntary loss of urine (Sampselle, Bums, Dougherty, Neuman, Thomas, & Wyman, 1997) that is sufficient to be a problem (U.S. Department of Health and Human Services, 1996). The International Continence Society defines urinary incontinence as the involuntary loss of urine that can be demonstrated objectively and which constitutes a social or hygienic problem. Quality_gfi_Lifig. Negative effects on a person's well being, especially on daily activities and psychological distress are well documented (Costa, & Mottet, 1997). Assessments of QOL are particularly important as related to urinary incontinence because this problem has little or no 5

13 impact on mortality, (Jackson, 1997) but impacts significantly on morbidity. QOL is a subjective concept influenced by personal and cultural values, beliefs, selfconcepts, goals, age and life expectancy. Several domains that can be measured related to health include physical, emotional and social function, role performance, pain, sleep and disease-specific symptoms (Kelleher et al., 1997). CONCEPTUAL FRAMEWORK Health_2rgm9tign_nodel Pender's model (see Figure 1) was developed to complement health prevention models such as the Health Belief Model developed by Rosenstock, Hochbaum, and Kegeles in the 1950's. The Health Belief Model or Health Protection Model is focused on disease and action specific steps. This model also focuses on efforts to move away from states of illness and injury. Pender's Health Promotion Model (HPM) differs in focus as the goal of health promotion results in growth, maturity, and an expression of human potential. Pender's model initiates action to enhance the quality of human life. Health promotion focuses on efforts to move towards a state of a high-level of health and well being. The Health Promotion Model (HPM) is an approach oriented model. It depicts the multidimensional nature of individuals interacting with their environment as they pursue health (Pender, 1996). The Health Promotion Model is constructed from two theoretical basis; the theory of expectancy-value and social 6

14 Behavior-Specific Cognitions and Affect Behavioral, Outcomes Perceived benefits of action Individual Characteristics > and Experiences Perceived barriers to action Immediate competing demands (low control) and preferences (high control) Perceived self-efficac > y Prior related behavior Activity-related affect Interpersonal influences factors; biological > (family, peers, + Commitment to a plan of action behavior Personal Health promoting psychological T providers) sociocultural norms, support, models Situational influences; options demand characteristics aesthetics Figure l. Penders Health Promotion Model (Fender, 1996).

15 cognitive theory. The expected-value theory incorporates concepts such as how the individual will engage in a specific action if the outcome of the action is of positive personal value and will bring about a desired outcome. Conversely, individuals will not invest their energy if the goal or outcome is of little value to them. Of particular interest to urinary incontinence is the theory of expectancy-value related to this model. As noted in the quality of life inventory studies, incontinent women were frequently dissatisfied with their present situations. According to the HPM theory the subjective value of change is the motivational component driving the individual who is most dissatisfied with their present situation towards favorable change because great rewards or benefits are associated with it. For example, improved continence resulting in decreased isolation, improved self-esteem or resumption of sexual intercourse would have high expectancy value. Social cognitive theory is a broad theoretical approach to explain human behavior and emphasizes the importance of cognitive processes in regulating behavior. Social cognitive theory provides a framework for interaction between the individual and environmental events, personal factors, and behaviors. Self-efficacy is a central construct in the HPM. HPM is similar to the Health Belief model in the belief that predictors of health-promoting behaviors can be 8

16 categorized into cognitive/perceptual factors (individual perceptions), modifying factors, and variables that affect the likelihood that an individual will take health-promoting action. These actions are the foundation for this theory. Pender believes that these behaviors are driven inner forces as well as external stimuli (Pender, 1996). The model has a decision-making and action phase (see figure 2). According to Pender (1996), health promotion is motivated by the desire to increase ones well being and to actualize human health potential. Assessment of the individual within the context of the HPM expands beyond physical assessment to also include examination of health beliefs and health behaviors. The health promotion model provides a framework to guide this project because women experiencing urinary incontinence utilize a problem-oriented approach to modify their environment, behavior and actions that enhance or alter their quality of life and experiences. Health promotion seeks to expand positive health and well being. This occurs at an individual level and improves one's personal decision making and health practices. Health promotion focuses on efforts to move toward a positive state of high level health and well being. Health promotion strategies effecting individual lifestyle and personal choices made within a social context have powerful influence over women's health prospects related to problems associated with urinary incontinence. Strategies such as modifying risk factors, exercise and diet 9

17 Characteristics. and Experiences Immediate competing demands (low control) and preferences (high control) Prior Commitment Health to a promoting plan of action behavior Action Phase Decision-Making Phase Figure 2. Penders Health Promotion Model (Pender, 1996) Behavioral Outcomes Behavior-Specific Cognitions and Affect Perceived benefits Individual. of action Perceived barriers to action Perceived self-efficac related - > y behavior Activity-related affect i v A Interpersonal Personal influences factors; biological _, (family, peers, psychological F providers) sociocultural norms, support, models Situational influences; Options demand characteristics aesthetics 10

18 can also improve their success of avoiding as well as stopping urinary incontinence. One must note that according to the quality of life inventory studies previously cited, many women with incontinence may have similar or shared experiences. The health care provider can identify these experiences and engage individuals in health promotion. For example, it is common for women with urinary incontinence to not seek health promoting behaviors, thus it is important for the healthcare provider to design interventions to engage the targeted population in these activities. Healthcare providers can assist women in utilizing the health promotion model by assuring opportunities for information exchange and social support among members of this targeted group. This must occur with each and every encounter. This paper will integrate the HPM concepts and focus on these education and intervention opportunities. Assnmplien There are many assumptions of the Health Promotion Model to consider. In order to apply the HPM to women with or potential for urinary incontinence these assumptions must be considered. The following are assumptions of the HBM (Pender, 1996). 0 Individuals desire to create living conditions where they can express their unique health potential. 0 Individuals are self-aware and can assess their own competencies. 11

19 0 Individuals value positive growth and want to achieve balance between change and stability. 0 Individuals want to regulate their own behavior. 0 Individuals interact with their environment change over time. 0 Health care providers are a part of the individuals interpersonal environment. 0 An individuals self initiated change is critical to behavior change. These assumptions again emphasize the active role an individual takes in pursing health behaviors and in modifying the environmental context for health behaviors (Pender, 1996). They are interdependent and are consistent with the application of social cognitive theory. The primary HPM concepts of concern in developing this project are: 1) Individual characteristics and experiences; 2) behavior-specific cognitions and affect; and 3) behavioral outcomes. These concepts are discussed within the framework of the Health Promotion Model as related to health care behavior. Each person has individual characteristics and past experiences that influence future actions. These include prior related behaviors and many personal factors such as biological, psychological and sociocultural components. Prior related behavior affects the likelihood that an individual will engage in health-promoting behaviors. 12

20 Pender believes that this is the best predictor of an individual to engage in health-promoting behaviors (Pender, 1996). Personal factors such as age, gender, menopausal status, self esteem, race and ethnicity directly influence cognitions and behaviors, however, many of these factors can not be changed and are not usually incorporated into interventions. E. E J l I E l. According to Pender prior related behavior has both direct and indirect effects on the individuals engaging in health promoting behaviors. An example of direct effects on current behaviors in a women with urinary incontinence is previous habit formation like excessive caffeine intake or use of incontinent pads. Habit strength accrues each time the behavior occurs (Pender, 1996). According to Bandura (1986) the actual enactment of a behavior and its associated feedback is a major source of efficacy or skill information. If positive outcomes are experienced initially the behavior is more likely to be repeated. For example, if an incontinent woman experiences increased continence with the performance of kegal exercises, she may be more likely to maintain a permanent exercise routine in the future. The healthcare provider can help shape the individuals positive behavioral history for the future by assisting to overcome barriers, promoting increased efficacy and providing a positive experience. 13

21 W As mentioned previously, personal factors can be categorized as biologic, psychologic and sociocultural. In individuals with urinary incontinence it is of particular importance to note personal factors such as age, menopausal status, body mass, self-motivation, perceived health status, education and socioeconomic status. For example a women's educational level directly influences behavior-specific cognitions as well as health-promoting behavior. Behavior-specific cognitions and affect influence an individuals motivational level significantly. This category of variables constitute a center for intervention. Providers have the greatest ability to modify behavior at this level. Individuals decisions about engaging in particular health behaviors are influenced by the perception of what the benefit and/or outcome of the action will be. Beliefs in the benefits or positive outcomes is important for the individual to have in order to engage in a specific health behavior. A woman must believe that improved continence is a benefit and positive outcome in order to engage in healthcare visits and interventions. For example an intrinsic benefit would include improved skin integrity or pelvic floor strength. Perceived extrinsic benefits may include increased social interactions or self-esteem. According to Penter (1996), initially, extrinsic benefits 14

22 may be more motivational but intrinsic benefits may be more motivation for the long haul. Individuals will engage in health promoting behaviors if positive results are anticipated. I. I E. l E! Perceived barriers, imagined or real, affect an individuals ability to engage in health promoting behaviors. If a woman with incontinence is ready to act but perceives that care is not available, treatment options are limited, or the problem isn't significant, the probability of action is low. Conversely, if readiness to act is high and these types of perceived barriers are low, the probability of action is increased. MW As discussed earlier, self-efficacy is a central construct of the HPM. It involves the individuals ability to organize and execute a particular course of action. Self-efficacy involves the ability to judge ones own competence to accomplish a desired Outcome. E l' 'l -E J l 3 EEE! Pender describes activity-related affect as subjective feelings an individual experiences prior to, during, and following a behavior. These feelings become memories and are associated with subsequent behaviors. The affect associated with the behavior can be positive or negative. (Pender, 1996). Examples of negative feelings are anxiety, fear and depression and positive feeling states as joy, 15

23 calm, and elation. These feeling are likely to affect whether an individual will repeat the behavior or maintain the behavior long term. Based on social cognitive theory, there is a relationship between self-efficacy and activityrelated affect. For example, if a woman experiences feelings of empowerment during and following bladder drilling, this positive affective response influences selfefficacy and the behavior is likely to be repeated. Conversely, if a woman experiences unpleasant feelings during and after bladder drilling due to incontinent accidents, the behavior is not likely to be repeated. MW There are many sources of interpersonal influences on health promoting behaviors. Primary sources include family, friends, peers, and health care providers. Interpersonal influences include norms, social support, and modeling. Individuals like to behave in a way that is consistent with interpersonal influences. For example, if women in a female incontinence support group discussed the benefits of seeking health care for this problem an individual may be influence to adopting this health promotion behavior. 5.!!' ] I E] Situational influences are perceptions that individuals have of a given situation. For example, an individual is likely to engage in health promoting behavior if one perceives the environment that it is occurring in safe and reassuring as opposed to threatening and unsafe. Location 16

24 of a provider's office, available parking and /or friendly, accommodating staff are examples of situational influences. Behavioral Outcomes : 'l l l E] E E!' Commitment to an action plan is the first step in generating a behavioral event. According to Penner (1996), this commitment implies two underlying cognitive processes: 1) commitment to carry out a specific action at a given time and place and with specified persons or alone, irrespective of competing preferences; and 2) identification of definitive strategies for eliciting, carrying out, and reinforcing the behavior. As these processes imply one must not only have commitment but have strategies as well. Providers can assist the individual in planning to assure successful implementation. For example, if incontinence is noted on health screening interaction the provider can begin the initial educational process and return visit schedule. WW Competing demands and preferences is when an individual chooses an alternative behavior instead of the planned health-promoting behavior. This differs from what is considered barriers to action in that are last minute decisions based on one's preferences that stops the plan for a positive health action or course of action. Selfregulation/control is required to avoid the dilemma to competing demands and preferences. Health care providers can encourage strong commitments to the plan of action. 17

25 H 1!] E!' E I. Health-promotion behavior is the last step in the process, it is the action outcome. The outcome measure is improved well-being. Since most health-promoting behaviors in a healthy lifestyle are continuing activities integral to daily living, the health care provider must promote acquisition of health-enhancing behaviors and assist individuals in sustaining these behaviors throughout life. In summary, Pender's Health Promotion Model (figure 1) represents cyclical, dynamic interactions between its components especially between decision making and action. This model synthesizes research findings from nursing, psychology and public health into an explanatory model of health behavior. This model guides the APN in holistic clinical decision making. This holistic approach focuses on the individual and involves a myriad of variables. The Health Promotion Model has application to a wide variety of health-related actions. There is predictive potential that is useful for developing preventive behaviors and intervention plans with women and urinary incontinence. Screening for urinary incontinence and early detection of risk factors are examples of the health promotion model applied to clinical practice. This model enables the APN to exert control in a situation by manipulating or influencing the major variables that are a part of the theory. These factors influenced the 18

26 decision to use the Health Promotion Model as the framework for this project. LITERATURE REVIEW WWW It is estimated that at least 13 million adult Americans have a problem with urinary incontinence, including approximately 30 percent of community-dwelling persons over 60 years of age (Diokno, Brock, Brown, & Herzog, 1986). For the purpose of this project, literature evaluating community-based women will be reviewed. The Medical, Epidemiologic, and Social Aspects of Aging (MESA) survey conducted by Diokno et al. (1986) reported the prevalence of urinary incontinence in women 60 years and older to be 38%. In this survey, mixed incontinence was most prevalent, at 55.3%, stress incontinence at 26.7%, urge incontinence at 9.1%, and the lother' category at 8.9%. Although urinary incontinence is a common problem, estimates of exact prevalence obtained by epidemiological studies vary considerably. These variations are influenced by several factors, including the way incontinence is defined and the population being investigated. For example, many studies investigate a single urinary symptom such as urinary leakage but do not take into account other symptoms, such as urgency. This produces varied prevalence estimates compared to studies that distinguish between the different types of urinary incontinence, such as in Diokno (1986). 19

27 Another factor influencing accurate prevalence statistics is the under reporting of urinary incontinence by women to their healthcare provider. Many women think it is an inevitable and/or untreatable problem. Many women feel that it is a normal part of the aging process and have low expectations of benefits in reporting due to perceived limited information regarding treatment options. Many believe nothing can be done (Knapp, 1998). A 1994 study of 104 ambulatory older adults concluded that the majority of adults with urinary incontinence do not report their condition to their healthcare provider (Burgio, Ives, Locher, Arena, & Kuller, 1994). Currently there is a small body of literature that indicates consistently that many of the individuals who experience incontinence do not seek treatment. A 1991 study completed by Burgio et al., evaluated 541 community based, healthy middle aged women 42 to 50 years old and studied the women twice at three-year intervals. The women were administered a structured incontinence questionnaire by a nurse. Fifty-eight percent of these women reported occasional urine loss and 30.7% reported regular urinary incontinence. This study also concluded that few women seek treatment. Only 25.5% of the women reporting incontinence sought treatment. There was a strong relationship between frequency of urine loss and seeking treatment (chisquare=40.9, p<o.001), however, only 54.5% of women who reported daily urinary incontinence sought treatment. There 20

28 I was also a strong relationship between volume of urine loss and those that sought treatment (chi-square=14.6, p<o.001). Women who experienced large volumes of urine loss sought treatment more often (60%) compared to 15% of those who experienced slight incontinence. Conclusions included that the type of incontinence did not influence seeking treatment as well as level of education, employment status, or number of children. This study is important to the current body of literature because of its' prevalence and incidence measurements and it underscores the importance for primary care providers to ask all women about incontinence as part of routine health care. A classic study completed by Jolley (1988) questioned 833 women age 25 and older. The overall prevalence of urinary incontinence was found to be 41%. Few (6%) reported the problem to the healthcare provider. perceived by many of the women as common, Incontinence was not serious and therefore did not often report it to the health care provider. Again, according to the Herzog and Flutz (1990) study, prevalence of urinary incontinence across the lifespan was found in approximately 20% of women between the ages of 25 and 64. In a recent study, Brocklehurst (1997) evaluated the prevalence in a random sample of 4,007 community dwelling adults over 30 years of age. Results showed that 14% of the women and 6.6% of the men studied were currently incontinent or had been incontinent. In addition, 9.3% of the women and 21

29 3.8% of the men had been incontinent in the previous year, 7.5% and 2.8% respectively, in the last 2 months, and 5.7% and 2.2% in the week before the interview. The results of this survey also showed that a substantial proportion of the individuals did not consult a primary care provider about the incontinence. When the individuals realized that their incontinence was a problem only 52% consulted their provider. Several additional factors associated with ' prevalence statistics include increased incidence of urinary incontinence with age and with the onset of estrogen loss during the perimenopausal period (Burio, Matthews, & Engel, 1991). Another issue influencing underreporting and prevalence rates involves the wide availability of absorbent products. These products allow women to continue with their activities of daily living without addressing the problem of incontinence. In a 1992 study of 1,299 women age 35 to 79, 344 had urinary incontinence and half of them used protective sanitary pads (Rekers, Drogendijk, Valkenburg, & Riphagen, 1992). These preceding results underscore the fact that urinary incontinence is prevalent and under-reported problem. Urinary incontinence is a common problem among those seen in a primary care setting and its presence is often not know to the health care provider. 22

30 A : 1.! E I'E Quality of life encompasses objectives and subjective evaluations of multiple dimensions, including physical health, personal adjustment, and social interaction. There are many social and medical implications for women who experience urinary incontinence. To understand the true impact of urinary incontinence, quality of life must be considered. Many women experience significant adverse effects on their health, psychological well being, and social activity. The social stigma and embarrassment as well as medical implications such as skin breakdown, decubitus ulcer formation and infection associated with bladder dysfunction effect quality of life. Embarrassment and social stigma contribute greatly to the underreporting of this problem. According to a 1992 study fewer than one half of women with urinary incontinence sought medical help for the problem because of this (Walter & Realini, 1992). Many women experience distress, depression, isolation, and social withdrawal. Incontinence can effect the individual's subjective perception of health. They may experience fear associated with this perception, thinking this change in physical health will interfere with their level of independence. Many women experience self-imposed isolation in order to avoid being in a social setting when incontinence occurs. They limit their social activities rather than risk the embarrassment of an incontinent situation. 23

31 Since severe mortality and morbidity are not associated with this problem, the need to capture impact of health status and health-related quality of life for women is a priority. It is important when evaluating such problems as urinary incontinence to have uniform, instruments to measure these issues. reproducible Several measurements of quality of life of women with urinary incontinence have been tested. In 1994, Schumaker et al. identified that traditional measures of symptoms did not adequately capture the impact that urinary incontinence had on women (Schumaker et al., 1994). Two self-administered, condition-specific instruments were designed to assess this, the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). These two measures provide detailed information on how urinary incontinence affects lives of women by assessing various activities, roles and emotional states (IIQ), as well as data about symptoms associated with urinary incontinence that are troubling to women (UDI). Data on the reliability, validity, and sensitivity conclude that these instruments are psychometrically strong. These tools were modified and retested by Robinson et al. (1998). The original IIQ and UDI were shortened. 384 community dwelling incontinent women, age 60 and older, were tested. Responses to incontinence symptom questions were correlated with the standardized measures. The results were similar in that the woman's symptoms that best correlated with both quality of life measurements and the report of bothersome 24

32 incontinence were frequent episodes, greater amounts of urine loss, and more frequent voids. In 1996, Wagner et al. tested another instrument to measure quality of life specific to urinary incontinence (Wagner et al., 1996). Twenty-eight questions ranging from worry and embarrassment, to issues of self-confidence and avoidance were tested. For validity, severity of incontinence (P<0.0001) and number of medical appointments in the past year to treat incontinence (P<0.0001) significantly predicted the quality of life scores. The quality of life scores were significantly worse as severity classification (mild, moderate, and severe), self-perceived severity (mild, moderate, and severe), and number of medical appointments to treat incontinence in the past year, increased. Women comprised 68% of the sample and the average age was 64 years old. -The tool is internally consistent (alpha 0.95) and highly reproducible (r=0.93, SD 4). In 1997, Kellehler et al. decided to create a quality of life questionnaire for the rapid assessment of urinary incontinence in women (Kellehler et al., 1997) (see appendix B). The initial study of 285 women confirmed that bladder problems are a major impediment on quality of life. The questionnaire was shown to be a reliable and valid instrument to measure these quality of life issues. It is apparent from the literature that urinary incontinence affects-women's quality of life and highly 25

33 reliable and valid self-administered questionnaires exists to measure this. Symptom inventories are an accurate, efficient measure of distress for symptoms associated with urinary incontinence. These inventories complement objective measures, are inexpensive, noninvasive and can be self-administered. In order to overcome the problems of poor sensitivity associated with generic questionnaires, it is necessary to use a disease or condition specific instrument as in the studies previously discussed. It continues to be important to proceed with randomized clinical trials to measure objective data but it is equally important to assess the improvement in the woman's quality of life. It will be important in future nursing research to learn more about women's attitudes toward urine loss. These quality of life assessments contribute to making treatment decisions, and evaluating treatment success, as there is growing recognition of the need to consider life impact in evaluating therapeutic efficacy In addition to social and medical complications one must consider the health-care costs associated with urinary incontinence. There are direct and indirect monetary costs associated with this problem. Direct costs include diagnosis, treatment, direct care, rehabilitation, and management of the consequences of urinary incontinence, such as skin breakdown. Indirect cost includes such factors as 26

34 loss of productivity to society and increased caregiver burden. It is estimated that urinary incontinence costs 11.2 billion dollars annually for persons of both sexes and all ages in the community at large and 52 billion annually for those in nursing homes (based on 1994 dollars) (Hu, 1996). U1 is the second-leading cause of nursing home admissions in the United States, (Haefner & Morley, 1998). The costs associated with these admissions include nursing/labor costs, supplies and laundry. Residential institutions use a whole range of management techniques including incontinence pads, waterproof bedding and chair pads, indwelling catheters, scheduled toileting, and medications. As mentioned previously, the direct costs of urinary incontinence are associated with costs of initial diagnosis/evaluation, costs of treatment, routine care, and rehabilitation and/or therapy. Diagnostic/evaluation costs include provider consultation and examination, laboratory test, and other diagnostic procedures, which are usually done on an outpatient basis. Treatment costs of urinary incontinence could include medication, pessaries or surgery. Pelvic muscle exercises, biofeedback, toileting assistance programs, dietary and fluid management and other behavioral interventions are included in the treatment costs. With the growth of the elderly population, it is important to consider the magnitude of these costs to our society when 27

35 considering assisting improvement of identification, evaluation and treatment of urinary incontinence. fl 3 3'. Many primary care providers fail to evaluate urinary incontinence, (Newman, 1997; Knapp, 1998, Neuman, 1998). In a 1998 study completed by Jones and Brunner, it was concluded that most primary care providers did not routinely ask about incontinence and when they were aware of a positive assessment, frequently did not diagnose the underlying cause or recommend treatment, (Jones & Brunner, 1998). Another study completed by McFall et el. (1997) reported results of a physician survey, which included 155 physicians in three specialties (family practice, internal medicine, and obstetrics and gynecology), to determine practice patterns related to the evaluation and treatment of incontinence. The results of this survey indicated that they missed opportunities to identify patients with urinary incontinence. About one half of the physicians in this survey reported that it was usually the patient who raised the issue and 40% of the physicians reported that they ask new patients about incontinence sometimes, rarely, or never. Only 17% of physicians Surveyed reported having seen or read the Clinical Practice Guidelines (AHCPR). In 1994, McDowell et al. completed a study of 364 individuals to determine urinary incontinence recognition rates and interventions. It was a multi-site, randomized, controlled study. Geriatric Assessment Units identified more individuals with 28

36 urinary incontinence than community-based practices but the intervention/referral rate were low for both types of sites. The outcome of this study points to the need for increased emphasis in curriculum preparing health care providers as well as the need for continuing education for those already in practice. Lack of a clear understanding of the identification, diagnosis and treatment of urinary incontinence contributes to under-diagnosing this disorder. Curricula preparing healthcare providers requires increased focus. Health care providers need to ask women about urinary incontinence. E.3 E I H 1.. I E l' 3.3 1' Clinical practice guidelines have been created to address needs to decrease healthcare provider practice variation, slow the rise of healthcare costs, monitor inappropriate care, assist clinicians in staying abreast of new clinical information, set research priorities, and promote better healthcare outcomes. As with all guidelines and protocols, barriers exist that limit the effect of these guidelines. Careful analysis of guideline attributes and identified barriers such as organizational barriers, administrative policies that conflict with guideline recommendations and the climate to conform to local systems of care need to be considered. Guideline implementation, evaluation and improvement are most likely to be successful when they are a part of an explicit, evidence-based process for evaluating and improving clinical practice. The 29

37 literature well supports the effectiveness of clinical practice guideline implementation in many situations. Stuart et al. (1997) describes successful implementation of an evidence-based clinical practice guideline in women with acute dysuria. The guideline was based on an evaluation and implementation of the medical literature using the best available evidence. Following these guidelines resulted in a significant decrease in laboratory testing and visits to the office for acute dysuria. Several nurses actively involved in an evidence based "Continence for Women Project" (Sampselle et al., 1997) developed educational strategies to improve incontinence in women. Such practices as pelvic floor exercise, voiding diaries and bladder-training programs were tested. Although a definitive study of the preventive potential of the strategies has not yet been done, this project demonstrated the benefit of these strategies in reducing existing urinary incontinence symptoms. This projects' effectiveness was measured by women reporting a decrease in the amount and severity of reported urinary incontinence, a decrease in the cost of self-managing urinary incontinence, and an increase in the quality of life for those who initially reported a continence problem. The agency for Health Care Policy and Research (AHCPR) released their first updated guidelines for urinary V incontinence in As part of these new guidelines an 30

38 algorithm is provided in the Quick Reference Guide (AHCPR, 1996). Selection of appropriate behavioral, pharmacological, surgical treatments, and supportive devices for use in managing urinary incontinence is reviewed. Several specific interventions including toileting assistance, nighttime voiding, fluid and dietary management, skin care, social and organizational environmental factors are discussed. PROJECT DEVELOPMENT Qverxieu This project was developed in 2000 as an extension of the AHCPR guidelines (1996) to provide a format to assist primary care providers in collecting physical assessment data. The cause of urinary incontinence is often multifactorial and warrants a comprehensive evaluation. Components of the comprehensive evaluation completed by the primary care provider include screening questions (see appendix A) (Sampselle et al., 1997), through history, physical exam, and preliminary diagnostic evaluation and management. AHCPR guidelines provide an algorithm for management of urinary incontinence, (figure 3). The physical exam is considered a component of the basic evaluation. This project format is constructed to follow a logical sequence of information gathering with women experiencing urinary incontinence. This format is easy to implement in the primary care setting. This tool assists the primary care provider in completing the requirements for 31

39 Management of Urinary Incontinence in Primary Care Basic evaluation.history, including assessment of risk factors (Table I), and bladder record.physical examination.measure post-void residual volume.urinalysis Treat Yes (Table 2) reversible conditions > Reversible conditions identified? (Table 2 Still incontinent? Further evaluation required? (Table 4) Further diagnostic test Options (Table 5) Patient cured or A satisfied Initial management options (Table 3) Yes Incontinence Key V 0 Yes - No Decisions persistent. Patient desires further evaluation and treatment Treatment D Interventions Patient cured or. satisfied Figure 3. Agency for Health Care Policy and Research Clinical Practice Guidelines, I996 32

40 basic evaluation if urinary incontinence is identified following the AHCPR guidelines. The purpose in completing all components are to confirm the presence of urinary incontinence, identify contributing factors, identify a presumptive diagnosis, identify individuals appropriate for initial therapy, and to identify individuals who are appropriate for evaluation and referral. All components of the physical exam format are readily available to an ambulatory health care provider. This includes the urine dipstick, post-void residual testing and cough stress test. These tests can typically be done quickly and inexpensively, with minimal equipment. In addition, they do not require complex Clinical Laboratory Improvement Amendments (CLIA certification). However, more advanced assessment such as complex urodynamic testing should be referred to specialty care providers as they are generally considered outside the scope of primary care practice. There are several recommended areas to evaluate prior to using the physical assessment tool. With initial data collection each woman should be asked the urinary incontinence screening questions. If a woman screens positive for urinary incontinence the provider proceeds with the steps of the basic evaluation according to the AHCPR guidelines. The quality of life inventory (Appendices B and C), history and assessment of risk factors is completed and a bladder record (Appendix D), is given to the woman. Steps 33

41 one through eight of the physical exam checklist (Appendix E) are then implemented. One should reference the AHCPR algorithm for management steps. At any time during the basic evaluation the primary care provider may refer the patient for evaluation by~a specialist. In order to implement the AHCPR guidelines effectively many aspects of urinary incontinence should be reviewed. This includes risk factors associated with urinary incontinence, anatomy and physiology of urinary incontinence, and types of urinary incontinence. This is included in the packet of information for primary care providers (see Appendix F). The physical assessment tool is a single sided sheet that provides a format for data collection. Screening data, history, diagnosis and treatment recommendations require documentation elsewhere within the individuals medical record. Screening.Written or verbal screening questions should be provided routinely by the healthcare provider. During an annual physical exam the provider should discuss voiding behavior with women. Language that destigmatizes the condition should be used. The Continence for Women Project, (Sampselle et al., 1997), tested several screening questions, (see Appendix A, partial list) based on the AHCPR 34

42 guidelines. Asking these key questions can identify individuals who require an evaluation for incontinence. These questions help to differentiate between the two most common types of urinary incontinence in women, stress urinary incontinence and urge urinary incontinence. If screening is positive for urinary incontinence the next step in the AHCPR algorithm is to proceed with the basic evaluation (figure 3). History Evaluation of urinary incontinence requires a detailed history. The history should elicit specific information that allows one to categorize and quantify incontinence to optimize treatment choices. It should include a focused medical, neurologic and genitourinary history (Resnick, 1995) as well as assessmentof risk factors, gynecologic history, obstetric history, past medical and surgical history. Review of medications, including nonprescription drugs is imperative (AHCPR, 1996). Many drugs have a direct effect on bladder function or may affect a person's ability to cope with bladder function. For example, diuretics may cause rapid diuresis. Large volumes of urine are produced and may cause increased frequency and urgency. In an already unstable bladder, incontinence may result. Antidepressants/anticholinergic/anti-Parkinsonian/antihistamine drugs may cause adverse effects on the bladder. These drugs relax the sphincter muscles and reduce smooth 35