INTUIT-PC SD: A Practice-Based Intervention To Improve Care for a Diverse Population Of Women With Urinary Incontinence

Sponsor
University of California, San Diego (Other)
Overall Status
Not yet recruiting
CT.gov ID
NCT05534412
Collaborator
Agency for Healthcare Research and Quality (AHRQ) (U.S. Fed), Cedars-Sinai Medical Center (Other), University of California, Los Angeles (Other), Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (Other)
1,600
2
24

Study Details

Study Description

Brief Summary

The burden of urinary incontinence (UI) on American women is immense in human and financial terms, and continues to rise with the growing population of older adults. The goal of this proposal is to improve the care for UI provided to women and, in doing so, decrease the utilization of specialty care while improving patient outcomes. Specific Aim 1 seeks to improve the quality of incontinence care provided to an ethnically diverse population of women through a controlled practice-based intervention involving primary care providers. The intervention involves the implementation of PCOR measures. Four Southern California medical groups will participate in a cluster randomized controlled trial in which 60 offices (15 per site) will be randomized to undergo a practice-based incontinence intervention led by a "clinical champion dyad" comprised of a primary care provider and urologist/urogynecologist, both of whom are members of that specific medical group. The intervention will include physician education, individual performance feedback, electronic decision support, patient education using dedicated advanced practice providers (APPs), and the implementation of an electronic referral service. The quality of patient care, as evidenced by compliance with primary care UI quality indicators the investigators developed and pilot-tested, will be measured across the two randomized arms after implementation of the intervention. Compliance with these quality indicators will be the key means to implement PCOR evidence, while, at the same time, measure quality. In Specific Aim 2, utilization of specialists will be compared before and after the intervention. The investigators hypothesize that improved care at the level of the primary care physician will reduce the number of specialty referrals. Specific Aim 3 will seek to measure the effect of the intervention on patient outcomes. Under the hypothesis that a practice-based intervention will improve disease-specific outcomes, symptom severity, quality of life, and patient knowledge will be measured at baseline using validated questionnaires. After implementation of the intervention, these questionnaires will be given a second time six months later and outcomes will be compared between control and intervention groups. The investigators expect that this intervention will also reduce disparities in care for underrepresented minorities.

Condition or Disease Intervention/Treatment Phase
  • Other: Academic Detailing
  • Other: Electronic Clinical Decision Support
  • Other: APP Co-management
  • Other: Electronic Referral
N/A

Study Design

Study Type:
Interventional
Anticipated Enrollment :
1600 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Intervention Model Description:
Four Southern California medical groups will participate in a cluster randomized controlled trial in which 60 offices (15 per site) will be randomized to undergo a practice-based incontinence intervention or control for 6 months. After the study trial, the control offices will then undergo the intervention as part of a "validation phase" of the study.Four Southern California medical groups will participate in a cluster randomized controlled trial in which 60 offices (15 per site) will be randomized to undergo a practice-based incontinence intervention or control for 6 months. After the study trial, the control offices will then undergo the intervention as part of a "validation phase" of the study.
Masking:
Single (Participant)
Masking Description:
Patients will be aware that their primary care physician is participating in the study. However, they will not be informed of which arm the physician belongs to. Primary care physicians will be aware of which arm their office was assigned to based on whether or not they receive the intervention.
Primary Purpose:
Health Services Research
Official Title:
A Practice-Based Intervention To Improve Care for a Diverse Population Of Women With Urinary Incontinence
Anticipated Study Start Date :
Feb 1, 2023
Anticipated Primary Completion Date :
Feb 1, 2025
Anticipated Study Completion Date :
Feb 1, 2025

Arms and Interventions

Arm Intervention/Treatment
Experimental: Practice-Based Intervention

The intervention will include physician education, electronic decision support, implementation of an electronic referral system, and patient education/co-management by an advance practice provider.

Other: Academic Detailing
Provider Assessment. Physicians and advance practice providers will complete questionnaires before the intervention that assess their knowledge about the treatment for UI in women. Mealtime Lecture. A group meeting will take place for the physicians in the intervention groups. All aspects of incontinence care will be addressed-including elements of the history and physical examination, initiation of conservative treatment, as well as when to refer for second-line therapies performed by specialists-utilizing the the principles of Academic Detailing. Monthly individual feedback. Physicians and their clinical champion specialist will meet for individual coaching one month after the mealtime lecture to discuss and review the physician's previous performance as measured by the baseline chart abstraction. Physicians will have monthly check-ins with their clinical champion via a combination of quarterly synchronous Zooms and monthly asynchronous emails.

Other: Electronic Clinical Decision Support
Intervention physicians will have access to electronic clinical decision support consisting of note templates, order sets, interruptive alerts, and a notification of patients who screen positive for UI.

Other: APP Co-management
To reduce additional burden of care on the PCPs, the investigators will incorporate Advanced Practices Providers into the patient education and self-management portion of care. The APPs will be trained together with the intervention physicians, but they will also undergo additional standardized training on patient education, UI knowledge, providing instruction on Kegel exercises, shared decision making, and self management. Patients will then be scheduled for a UI education and self-management session with the APP by telemedicine (video visit or telephone visit) within one month of their initial visit. For patients in need of an annual pelvic examination, and if the patient's PCP prefers to have the APP conduct the pelvic exam, a separate visit will be scheduled with the APP. A followup televisit will then be scheduled within three months of the initial APP visit, in order to assess the outcome of non-surgical treatment and determine if a specialist referral is indicated.

Other: Electronic Referral
In implementing the electronic consultation system in the private sector, the investigators will model the Expected Practice developed by the Los Angeles County Specialty-Primary Care Work Group. This eConsult system utilizes a "kickback" mechanism by which a specialist, who reviews the referral, can return it if it has not met certain baseline criteria (e.g. for a woman with OAB/urinary urgency: document negative UA, scheduled voids, titrate fluids to thirst, Kegels, antimuscarinics, optimize diuretic control, adjust any diuretics).

No Intervention: Control

Offices in this group will not receive the four-pronged intervention. However, after the study trial, there will be a "validation phase" in which the initial control group will then receive the intervention. This cross-over deign will then allow all 60 offices to receive the intervention. Data from the cross-over intervention group will be analyzed as a separate cohort to confirm improvements in patient care and outcomes as measured in the intervention group under the study trial can be duplicated.

Outcome Measures

Primary Outcome Measures

  1. Adherence to evidence-based quality-of-care indicators [Baseline, 3 months, 6 months]

    Adherence to the QIs for patients who screen positive for UI will be compared across the two randomized arms at baseline and again at 3 and 6 months after intervention implementation.

Secondary Outcome Measures

  1. Referral rates to a specialist [Baseline, 6 months]

    The number of referrals to a specialist over the intervention period (urologist or gynecologist) will be quantified and compared between intervention and control groups. For patients screened as positive for new or worsening UI at their primary care physician office from Specific Aim 1, the investigators will record if and when the patient was referred to a specialist for treatment. Dates of each level of care provided will be incorporated into each chart abstraction so that the timing can be calculated. Investigators will also record the baseline rate of specialty referrals for each office during the baseline chart review.

  2. ICIQ-SF [Baseline, 3 months, 6 months]

    Four-item questionnaire that evaluates frequency, severity and impact on quality of life of UI.

  3. UDI-6 [Baseline, 3 months, 6 months]

    Six-item questionnaire that measures quality of life and symptom distress for UI in women.

  4. PGI-I [3 months, 6 months]

    Global index (transition scale) that measures symptom improvement.

  5. PFAKS [Baseline, 6 months]

    Thirty-one-item questionnaire assessing patient knowledge in three domains: POP (11 items), SUI (10 items) and OAB (10 items) with questions on condition pathophysiology, management, and quality of life.

  6. SDM-Q-9 [6 months]

    Nine-item questionnaire that measures the extent to which patients are involved in the process of decision-making.

Eligibility Criteria

Criteria

Ages Eligible for Study:
18 Years and Older
Sexes Eligible for Study:
All
Accepts Healthy Volunteers:
Yes
Inclusion Criteria of Primary Care Physicians:
  • Primary care physician belonging to a recruited office among one of four participating sites: Cedars-Sinai, Harbor-UCLA, UCLA, UCSD

Inclusion Criteria of Patients

  • Age >18 y/o

  • English or Spanish fluency

  • Female

  • Answers "yes" to incontinence screening tool and agrees to participate

Exclusion Criteria of Primary Care Physicians:
  • Non-primary care specialty

  • Does not belong to one of the participating offices

Exclusion Criteria of Patients

  • Age <18 y/o

  • Answers "no" to incontinence screening tool and/or does not agree to participate

  • Primary care provider (who reviews a list of patients that screen positive) deems patient ineligible due to pregnant, severe memory impairment, or psychiatric history preventing participation

Contacts and Locations

Locations

No locations specified.

Sponsors and Collaborators

  • University of California, San Diego
  • Agency for Healthcare Research and Quality (AHRQ)
  • Cedars-Sinai Medical Center
  • University of California, Los Angeles
  • Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center

Investigators

None specified.

Study Documents (Full-Text)

None provided.

More Information

Additional Information:

Publications

Responsible Party:
Jennifer Anger, Professor of Urology, Vice Chair of Research, University of California, San Diego
ClinicalTrials.gov Identifier:
NCT05534412
Other Study ID Numbers:
  • 802004
First Posted:
Sep 9, 2022
Last Update Posted:
Sep 9, 2022
Last Verified:
Sep 1, 2022
Individual Participant Data (IPD) Sharing Statement:
Yes
Plan to Share IPD:
Yes
Studies a U.S. FDA-regulated Drug Product:
No
Studies a U.S. FDA-regulated Device Product:
No
Keywords provided by Jennifer Anger, Professor of Urology, Vice Chair of Research, University of California, San Diego
Additional relevant MeSH terms:

Study Results

No Results Posted as of Sep 9, 2022