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

Many women initially present to their primary care doctor with complaints of urinary incontinence before being referred to specialists in urology or gynecology for more advanced treatment. Additionally, many women have an improvement in their symptoms from conservative interventions such as pelvic floor exercises and decreased fluid intake, or from starting pharmacotherapy for overactive bladder. These treatments may prevent women from needing to see a specialist entirely.1,2  Because specialists are limited in number or have long wait times, improving the quality of care before a referral can decrease total cost of care and optimize treatment for incontinence.3,4


In this retrospective review of 200 women who were seen for a new visit by a Female Pelvic Medicine and Reconstructive Surgeon for a complaint of urinary incontinence, we examined the care that they received in the twelve months prior to their referral. We used a set of twelve previously developed quality indicators that were relevant to primary care clinicians to evaluate the quality of care prior to referral to a specialist.5 The quality indicators included questions that should be asked of any woman with incontinence, such as trying to differentiate between stress and urge incontinence, asking about how severe or bothersome the problem is to the patient, and asking about the amount and type of fluid that a patient consumes. Other indicators are more specific to stress incontinence (for example, overweight women should be counseled to lose weight) or urge incontinence (such as recommending to cut back on fluids or start medication).

Of 200 women seen in two distinct academic hospital systems, only 40% of the recommended care was given prior to their referral. Clinicians asked about symptom severity or prior treatments in one third of patients, and performed a urinalysis or pelvic exam in about half. Only one quarter of patients with incontinence was given information about pelvic floor exercises. Quality indicator adherence for women with urgency incontinence was particularly low, with fluid intake history documented only 8% of the time and behavioral therapy recommended 14% of the time. Six of the 74 patients with urgency symptoms (8%) were prescribed a pharmacologic therapy, despite proven efficacy.

We also examined whether the care provided differed by practitioner sex. Previous research has suggested that female providers take better care of patients and have better outcomes, and this may be especially true for diseases that occur predominantly in women.6-8  We found that female clinicians were more likely to have performed these quality measures before referring their patients to a specialist. We also looked at how long clinicians had been in practice and found that those with more years of experience were actually less likely to adhere to the quality indicators. When we examined both gender and years of experience together, we found that female physicians still provided better incontinence care compared to their male counterparts.

Overall, there is significant room for improvement in taking care of women with urinary incontinence. Leveraging the electronic medical record, utilizing mid-level practitioners, and educating primary care practices may help improve the quality of care for women with this common condition.

Written by: Claire S. Burton, MD1 & Jennifer T. Anger, MD MPH2

  1. Department of Urology, Stanford University, Stanford, CA
  2. Department of Urology, University of California San Diego, La Jolla, CA

References:

  1. Anger JT, Weinberg AE, Albo ME, Smith AL, Kim J, Rodríguez L V, et al. Trends in Surgical Management of Stress Urinary Incontinence Among Female Medicare Beneficiaries. Urology [Internet]. Elsevier Inc.; 2009 [cited 2019 Nov 11];74:283–7. Available from: http://dx.doi.org/10.1016/j.urology.2009.02.011
  2. Moskowitz D, Adelstein SA, Lucioni A, Lee UJ, Kobashi KC. Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers—Are We Doing Enough? J Urol [Internet]. Elsevier Ltd; 2018;199:779–84. Available from: https://doi.org/10.1016/j.juro.2017.09.102
  3. Nam CS, Daignault-Newton S, Kraft KH, Herrel LA. Projected US Urology Workforce per Capita, 2020-2060. JAMA Netw Open [Internet]. 2021;4:e2133864. Available from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786183
  4. Franken MG, Corro Ramos I, Los J, Al MJ. The increasing importance of a continence nurse specialist to improve outcomes and save costs of urinary incontinence care: an analysis of future policy scenarios. BMC Fam Pract [Internet]. BioMed Central; 2018 [cited 2019 Jun 3];19:31. Available from: https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-018-0714-9
  5. Anger JT, Scott VCS, Kiyosaki K, Khan AA, Weinberg A, Connor SE, et al. DEVELOPMENT OF QUALITY INDICATORS FOR WOMEN WITH URINARY INCONTINENCE. Neurourol Urodyn. 2013;32.
  6. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women. Does the sex of the physician matter? N Engl J Med [Internet]. 1993 [cited 2019 Oct 24];329:478–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8332153
  7. Cassard SD, Weisman CS, Plichta SB, Johnson TL. Physician gender and women’s preventive services. J Women’s Heal. Mary Ann Liebert Inc.; 1997;6:199–207.
  8. Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: Observational study. BMJ. BMJ Publishing Group; 2017;357.

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