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- Title
Physiotherapy first -- improving urogynaecology patient flow and clinical outcomes.
- Authors
Nucifora, J.; Bongers, M.; Howard, Z.; Jackman, A.; Corcoran, K.; Weir, K.; Briffa, K.
- Abstract
Introduction: Allied health first contact models of care have been shown to be effective in providing diagnostic evaluation and management of many patient conditions, improved access to care and reduction in specialist outpatient waiting lists. A new physiotherapy-led pelvic health clinic (PLPHC) commenced at Gold Coast Hospital and Health Service in January 2017. Referrals to the PLPHC were triaged from the urogynecology waiting list and comprised of Category 3 (low priority) patients who had been referred with conditions responsive to physiotherapy intervention, including urinary frequency and urgency, incontinence, and prolapse (Figure 1). The primary aim of this audit was to document the patient journey and clinical outcomes of women attending the PLPHC for management of urinary incontinence (UI) and pelvic organ prolapse (POP). Materials and methods: A post-inception audit of the PLPHC was conducted in October 2017. Participants were asked to complete symptom (Australian Pelvic Floor Questionnaire [APFQ]) and quality of life (Assessment of Quality of Life -- 6 D [AQOL-6D]) questionnaires at initial and discharge appointments, and satisfaction and Global Rating of Change (GROC) questionnaires at discharge. This study was approved by the Gold Coast Hospital and Health Service Human Research Ethics Committee (HREC/17/QGC/129) and Curtin University Human Research Ethics Committee (13545). Results: Between January and September, 158 women completed treatment at the PLPHC, of whom 105 provided consent for their data to be used. Primary diagnoses were stress urinary incontinence (n=21), overactive bladder (n=23) pelvic organ prolapse (n=53) and other (n=8). Women referred to the PLPHC were assessed within a mean (SD) of 16 (9) days of triage and discharged 0 to 251 days following initial assessment (mean=88; SD=57). Number of occasions of service ranged from one to nine (Mean 3.9; SD 2.9). Time from referral received in the urogynaecology clinic to first appointment for comparable patients reduced 59%, from a median 372 days in 2016 to 154 days in the same period of 2017. Patient-reported clinical symptoms, APFQ overall dysfunction scores, were significantly improved from baseline (33/40) to discharge (20/40) (p<0.001). There were significant improvements in the individual bladder, bowel and prolapse domains of the APFQ (p<0.001). Quality of life patient-reported symptoms, AQOL-6D mean utility scores, improved significantly from 0.80 (SD 0.21) to 0.85 (SD 0.19) with a mean (95% CI) change of 0.05 (0.01 to 0.09) (p=0.02). Improvements in the individual AQOL- 6D dimensions of quality of life were not significant except for relationships (p=0.03). Of the participants who completed a GROC, 91% rated an improvement (15 reported +1-2 points, 53 reported +3-5 points). Fifty-three participants were discharged from the PLPHC without requiring specialist medical consultation. Urogynaecologist review was recommended for 35 patients and requested by two patients. Treatment was discontinued for nine patients due to failure to attend and six patients were discharged at their request. During management at the PLPHC, 24 patients were referred back to their GP, predominantly for prescription of topical vaginal oestrogen, and 27 were referred for further investigations such as pelvic ultrasound, urodynamic studies or urinalysis. At the time of discharge from the PLPHC, 19 patients were referred to the nurse-led pessary clinic for ongoing pessary management. High patient satisfaction (94mm on 100mm VAS) was reported with the physiotherapy-led model of care and physiotherapy service provision. Only one of 70 respondents reported being less than satisfied to see a physiotherapist rather than a doctor at her initial appointment. Conclusion: A pelvic health clinic led by advanced practice physiotherapists is an effective model of care for management of UI and POP, regardless of group or individual initial contact. It is successful in providing good clinical and service outcomes that are well accepted by patients and staff. The PLPHC streamlined urogynaecology Category 3 patient flow by: reducing wait time to initial appointment, discharging patients who responded to physiotherapy intervention, escalating patients who required more urgent review, and better preparing patients through completion of all conservative management and investigations prior to their initial urogynaecologist consultation. This model of care should be considered as a viable alternative to traditional medical models of care for appropriately triaged, non-urgent urogynaecological patients. Future research to assess the economic benefit and cost-effectiveness of this model of clinic would be beneficial. Competing interest statement: Zara Howard received funding for two weeks allied health research backfill from Gold Coast Hospital and Health Service to complete the data quality and analysis for this study. Jennifer Nucifora and Zara Howard work as clinical lead and senior physiotherapists respectively within the physiotherapy led pelvic health clinic.
- Subjects
TREATMENT of urinary stress incontinence; URINATION disorders; PELVIC organ prolapse treatment; MEDICAL care; EVALUATION of medical care; PATIENT satisfaction; PHYSICAL therapy; QUALITY of life; QUESTIONNAIRES; RESEARCH funding; WOMEN'S health; DISCHARGE planning; OVERACTIVE bladder; THERAPEUTICS
- Publication
Australian & New Zealand Continence Journal, 2018, Vol 24, Issue 3, p90
- ISSN
1448-0131
- Publication type
Article