Evaluating the Implementation of Standardized UI Screening in Primary Care

Objectives: to describe results from first-wave implementation of a plan-do-study-act process of urinary incontinence (UI) screening in primary care.

Methods: This was a retrospective chart review of patients having annual preventive care visits in primary care who screened positive (through an automated pre-visit questionnaire) for untreated, bothersome urinary incontinence and were directed to an online shared decision-making module (SDM) to learn about and weigh treatment options. PCPs were informed to expect and review the results available in the electronic health record. Patients who completed the SDM module between April 2023 and January 2024 (first-wave implementation) were included in this cohort. Chart reviews collected patient treatment preferences from the SDM, PCP actions taken and congruence between patient preferences and PCP action. Treatments were categorized as those that could be offered by the PCP versus those requiring subspecialty referral. Congruence was defined as the PCP taking any action supported by the patient’s treatment preferences even if a patient was interested in 2 or more treatments.

Results: 126 patients screened positive for bothersome, untreated UI and completed the SDM. The table describes reported treatment preferences (median 2, IQR 2-3). Of these 126 patients, 92 (73%) completed SDM before the PCP visit and of those 92, the PCP looked at the result before or on the day of the visit in 50 (54%) cases. Despite seeing the positive result of UI, UI was mentioned in the PCP note only 29 times and added to the diagnoses or problem list for the visit only 22 times. There were 32 additional patients whose PCP did not review the SDM result prior to the visit but documented spontaneous discussion of UI in the note.

Overall, in these 126 patients with UI presenting for a preventive exam, 0 were prescribed UI medications, 15 received pelvic floor therapy referrals and 4 received patient education handouts. 66 patients (52%) desired a treatment that requires subspecialty referral; 28 received urogynecology referrals and 3 received urology referrals. Seven of these 31 specialist referrals were made for patients who stated they were not interested in subspecialty treatments on their SDM.

In the overall cohort, 52 encounters were deemed "congruent" between patient preferences and provider action and 74 were deemed "incongruent." There was no difference in congruent treatment in patients whose PCP saw their SDM result prior to the appointment vs not (45% congruence vs 39% congruence, p=0.5).

Conclusions: Despite high rates of patients completing UI SDM before their preventive health visit, we found that PCPs only reviewed the results half the time and did not act in accordance with SDM results. These data will help target interventions to improve PCP use of this information for our second wave of implementation.