Knowledge, Attitudes, and Practices of Physicians Regarding Urinary
Incontinence in Persons Aged greater than or equal to 65 Years --
Massachusetts and Oklahoma, 1993
Urinary incontinence (UI) -- the involuntary loss of urine
sufficient to
be a problem for the patient or caregivers (1) -- affects an
estimated
15%-30% of persons aged greater than or equal to 60 years in the
United States
and is a major cause of admittance to nursing homes (2). UI may be
associated with a variety of medical (e.g., rashes, skin
infections, pressure
sores, urinary tract infections, and falls) and psychosocial
problems (e.g.,
depression, embarrassment, restricted social interaction, reduced
activities
outside the home, reduced sexual activity, and sleep disturbances)
(2-5).
Despite the dissemination of clinical practice guidelines for UI by
the
Agency for Health Care Policy and Research (AHCPR) (1), many
physicians do
not know how to diagnose or treat UI. Beginning in 1992, CDC and
AHCPR funded
demonstration projects in Massachusetts and Oklahoma to educate the
public,
patients, and health-care professionals about UI. In both projects,
physicians were assessed regarding baseline attitudes toward UI,
knowledge of
the causes and treatment of UI, preparedness to evaluate and treat
UI, and
current practices regarding UI. This report summarizes findings
from the two
projects during 1993.
Massachusetts. During March-May 1993, the Massachusetts
Department of
Public Health conducted a telephone survey of 350 eligible
physicians who
were sampled randomly in Essex and Norfolk counties; 163 (47%)
participated.
Of the 163 participants, 124 (76%) were primary-care physicians; 23
(14%),
gynecologists; and 16 (10%), urologists. Overall, 34% reported that
they had
asked at least three fourths of their elderly patients about UI
during the
previous month; urologists (75%) and gynecologists (74%) were more
likely to
report asking than primary-care physicians (21%) (p less than
0.01).
Seventy-two percent of physicians indicated that less than 10% of
their
patients aged greater than or equal to 65 years mentioned
experiencing UI,
and 68% that less than 10% of patients aged greater than or equal
to 65 years
who were asked about UI reported having this condition. The most
common
reasons that prevented physicians from asking patients about UI
included lack
of time (36%), lack of available and effective treatments (28%),
and patient
embarrassment (26%). A total of 73% underestimated the correct
proportion
(two thirds) of elderly patients with UI who could benefit from
therapy. Most
urologists (97%) and gynecologists (91%) and 46% of primary-care
physicians
rated themselves as prepared to treat UI.
Oklahoma. During May-September 1993, the Oklahoma State
Department of
Health mailed a survey to 194 eligible physicians who were randomly
selected
in four counties (Canadian, Cleveland, Logan, and Oklahoma) in the
vicinity
of Oklahoma City; 155 (80%) participated. Of the 155 participants,
120 (78%)
were primary-care physicians; 26 (15%), gynecologists; and nine
(6%),
urologists. Overall, one third (33%) reported always asking all new
patients
about UI; urologists (89%) and gynecologists (58%) were more likely
than
primary-care physicians (23%) to always ask (p less than 0.01). Of
all
respondents, 16% reported they were "fully prepared" and 13%
reported they
were "poorly prepared" to evaluate UI; 62% of the primary-care
physicians
rated themselves as "somewhat prepared" or "poorly prepared" to
evaluate UI.
Nearly one third (32%) of respondents reported incorrectly that
elderly
persons with chronic UI were unlikely to improve. Most (90%)
believed that
physicians should be more active in asking the patient about
problems with
bladder control, and 78% believed that physicians should emphasize
behavioral
treatments (e.g., bladder training and pelvic muscle exercises) for
UI.
Reported by: L Branch, PhD, ABT Associates Inc; N Resnick, MD, C
DuBeau, MD,
Harvard Medical School; A Balsam, PhD, C Bottum, MPH, D Siegal,
MPA,
Massachusetts Dept of Public Health, Boston. A Yerkes, MPH,
Oklahoma State
Dept of Health; S McFall, PhD, College of Public Health, Univ of
Oklahoma
Health Sciences Center, Oklahoma City. Health Interventions and
Translation
Br, and Aging Studies Br, Div of Chronic Disease Control and
Community
Intervention, National Center for Chronic Disease Prevention and
Health
Promotion, CDC.
Editorial Note
Editorial Note: In addition to its clinical effects, UI results in
substantial health-care costs: in 1987, the annual direct costs for
care of
patients with UI were estimated to exceed $10.3 billion (2).
Although
existing therapies can improve two thirds of UI cases, the findings
in this
report suggest that most primary-care physicians neither routinely
ask their
elderly patients about UI nor believe they are adequately prepared
to
evaluate and treat UI. Previous studies have indicated that
approximately
half of patients with UI reported their physicians had never asked
about UI,
treated the condition, or referred them for treatment (6-9).
One of the national health objectives for the year 2000 is to
increase
to 60% the proportion of primary-care providers (i.e., physicians,
physicians' assistants, nurses, and physical and occupational
therapists) who
routinely evaluate their patients aged greater than or equal to 65
years for
UI (objective 17.17) (10). In both Massachusetts and Oklahoma,
interventions
were conducted after the surveys to prepare physicians to evaluate
and treat
UI. In Massachusetts, these interventions included a local
conference about
UI for urologists and chiefs of gynecology, organization of a
series of
hospital grand rounds presentations about UI by urologists, and a
statewide
mailing of program materials and information about the AHCPR
guidelines to
primary-care physicians. In Oklahoma, some physicians at area
hospitals
received briefings at department or general medical staff meetings
to
reinforce the importance of asking patients about UI; in addition,
the
Oklahoma Geriatric Education Center conducted an education session
about
treatment options for UI.
The health-care impact of UI is likely to increase because of
the
changing demographic composition of the U.S. population. As a
consequence,
clinical providers and public health programs will need to
strengthen
capacities to prevent UI and to ensure that patients with this
condition can
receive appropriate treatment. Health-care providers should
routinely ask
elderly patients about this condition and associated problems,
educate
patients about noninvasive behavioral interventions for UI, and if
necessary,
refer patients for appropriate treatment.
References
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Urinary
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