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Diane Newman: Welcome to Uro Today's Bladder Health Center of Excellence. I am Diane Newman, the center's editor. I would like to welcome Dr. Jill Huppert, an obstetrician gynecologist who is currently the medical officer at AHRQ, Agency for Healthcare Research and Quality. She is also the scientific lead officer of the EvidenceNow Initiative on Managing Urinary Incontinence, and she's going to present an overview of this initiative. Thank you very much for joining us.

Jill Huppert: Sure. Thank you for having me today. As Diane mentioned, I'm the overall manager for this initiative, but I have a very important team supporting me, and I don't have time to give a shout out to everyone, but it's a great team of people at AHRQ. So the Managing Urinary Incontinence Initiative grew out of initially a systematic review that we did. One of AHRQ's flagship products is to do systematic reviews in our evidence based practice center, and one of them that we produced for PCORI was on nonsurgical treatments for urinary incontinence in women. And at that time AHRQ was also committed to try to do some dissemination and implementation of effective interventions, and we found that this review actually fit as we worked it through our nomination process because there was good evidence for effective interventions and we thought it was ready for action. So we had a stakeholder meeting, and some of you may have attended that, that was in June of 2019, because we really wanted to get from the stakeholders what was the best way to move forward with this problem.

So just to highlight some of the things that came out of the systematic review in 2018 were that there were several non-surgical treatments to improve UI, both symptoms and cure. And these differed by type of UI, of course, either stress or urgency or mixed. And almost everything that was studied was more effective than no treatment at all, although there were some exceptions, such as periurethral bulking agencies and hormones. In the review, it mentioned high rates of patient satisfaction with the treatment and that these were safe even in the elderly. And most of these were rated as a moderate strength of evidence, so pretty strong evidence.

So as I said, we put this through our AHRQ evaluation process, what should AHRQ invest money into, and we recognized that there was a significant public health burden with about 40% of women reporting any UI, and about 30% of older women reporting moderate to severe UI. The non-surgical interventions that were listed in that systematic review included behavioral medication, neuromodulation, and combinations of those treatments. There were important patient-centered outcomes such as symptoms, quality of life, especially the high social impact of urinary incontinence that was important to women. We recognized that there was an evidence to practice gap with few women who were actually screened in primary care, less than half of women who had symptoms actually seeking care, and of those who had symptoms who sought care, again, a minority of those women actually received and affective treatment. And we thought that this fit very well with AHRQ's interest in improving the care in primary care, because it was something that's amenable to early identification and treatment, and could help with efficient use of specialty and community resources.

So I don't know about you. I've been both a patient and a provider going to primary care, and it basically feels like this to me. I can't remember, as a patient, all the things I'm supposed to ask about, definitely been guilty of the, "Oh, by the way," as the doctor's trying to leave. And the provider's trying to figure out immunization schedules, routine screenings, the complete review of system, and then charting, of course, which isn't even shown here. So how do you throw urinary incontinence into that already complex system? So this is why we decided to use this EvidenceNow model, which is something that AHRQ had developed for use with heart health was their initial EvidenceNow, and that initiative takes the form of a suite of products, some grants, a resource center, and an evaluation built right in to see what's working.

So the components are, first of all, we wrote a U18 grant, which is a cooperative agreement so that there would be substantial AHRQ involvement. It wasn't like an RO1 where each individual applicant gets to pretty much decide what they're doing and then we sit back and watch them from afar. This is really trying to coordinate the grantees. We made five awards at 3 million a piece for a three year project length. And then we also funded a contract that had two parts, a resource center and an evaluation contract, and that total was 3 million with four years because we're hoping that they take the fourth year to complete the evaluation part, the evaluation of the initiative and collaborating on the different outcomes. So the main purpose of the grants is to make non-surgical treatments for women available in primary care, and then secondarily to learn which strategies work best to improve primary care. So there's lots of different ways to try to get practices to change, and we're trying to learn as we're improving.

The contractor is charged with developing a resource center with an environmental scan of what's working, what tools and options are out there for our grantees, to provide technical assistance and facilitate learning among the grantees. So they did compete to become a grantee, but now that they're in the program, they're cooperating with each other. And then the contractor also has to conduct the outcome evaluation for the overall performance and impact of the grantees and the initiative as a whole. And this is where we funded our grantees. So we have a pretty broad geographic reach, a grantee in California, Wisconsin, Illinois, Ohio, and then one in the Southeast, a VA network that's covering three states in the Southeast. And our contractor is bi-located on both coasts with a office in San Francisco as well as an office in DC.

So each of our grantees, although they all have the same overarching goals, they have unique features. Our Wisconsin team is using a streamlined practice facilitation, as many you know, practice facilitation can get a little old for the practices, and they're also focused on community partnership building. The VA group is working with a mobile health application that they've used before called My Healthy Bladder. They're also providing a data dashboard to physicians so that they can see how their practices are changing. The IT2 team at Northwestern is using automated UI screening at the time of annual visit, and a computerized education module that hopefully will help women to make an informed care about their choice. The Empower program in Cleveland is using a nurse navigation pathway, and they've also got a chat bot for patients, and they're using the ECHO model to educate providers.

The group in San Diego is using practice facilitation dyads, where there's a champion at the site paired with a facilitator, and they have four approaches that they're trying to test: academic detailing, clinical decision support, electronic referral, and advanced practitioner co-management, and they want to test which of those approaches works best. So our hope from all of this is that we move from primary care feeling less like the Cat in the Hat and a little bit more like Snoopy leading Woodstock, or maybe that's the patients leading the doctors or the providers.

And I've got some resources here for you. The initiative that we have on how we prioritize new topics, the MUI initiative itself, the systematic review that was published in 2018. And also, since we've been partnering with PCORI on this, PCORI has developed some evidence updates, one aimed towards clinicians and one aimed towards patients that they've got up on their website. Yeah, and that's about all I have.

Diane Newman: Thank you so much. That was really, really exciting to see what AHRQ is doing. So you should be commended, you and your staff, as well as the agency. Being in this field for a long time, it's evident that, like you say, women are not reporting it, but also providers, whether it's primary care or any other specialty or gynecologists, are really not asking about it. And I've really been involved in models where we actually go into the community and educate about the bladder and then weave in incontinence. I know I've worked with actually two of your sites, Alabama with Elaine Markland and then Heidi Brown up in Wisconsin. I know Wisconsin's trying to go in the community, but I found that even just classes, raising awareness because there's such a lack of knowledge. Do you think that any of them will be actually going into the community as opposed to just going into the practices?

Jill Huppert: Yes. That's a great question, and you're right. I think that the Wisconsin team has definitely had some experience with I believe it's MOM, the community based program for bowel and bladder, and that they are hoping to improve those connections. It is one of the things that we wrote into the FOA, that the grantees should consider how they can make linkages to community and community support. I think, like you said, those are the only two of the five initiatives that have specifically called that out. AHRQ, I don't want to say made a decision, but AHRQ's usual lane is at the practice level and not at the patient. Usually our work is not direct to patient care, so we didn't write it as a patient educational initiative, although I think that even, for example, the Empower, the IT2, they're trying to add a lot more patient teaching to their parts.

The patient is screened, but, for example, in the program from Northwestern, they're being given of an educational computerized tool and trying to be involved in the decision making process, and the UCSD team is trying to measure shared decision making around it. So yeah, I hope that answers your question.

Diane Newman: No, I know it's hard, because, like you say, it's just that women just seem to accept this. And your report was wonderful because it did review what is the evidence out there, and we do have a lot of efficacy in non-surgical treatment. I think that on the provider side, though, there's this belief that those are not very effective. Women don't want to do it. I'm somewhat biased because I've been doing that since I started my practice in the '80s. And there are a subset of women that will follow behavioral interventions, say, and non-surgical treatments, and do very well, especially those that may not have real severe symptoms, and it empowers that woman. You mentioned your funding in PCORI. I know that many researchers will be viewing this. Do you think there'll be further funding in this area? I know there's also a PCORI initiative, but this is such a major issue, especially with the aging woman, but I was wondering where do you see the federal agencies going as far as funding?

Jill Huppert: Well, I think this has helped raise the issue. It was interesting. People were like, "Why is AHRQ going in this direction?" The first was heart health and the second was unhealthy alcohol use, so it's like, "How did you get to the bladder from those two?" But one of the things that AHRQ tries to target is the areas that don't have a real champion. So if there's an NIH area that really is going to do this, then we're not going to take on cancer control, for example. It's just not where we're going to be. But we generally don't fund by topic. That's not AHRQ's thing as well. What I have seen from the EvidenceNow Heart Health Initiative that they became interested in some follow on studies from that, which one of the ones was the cardiac rehab study that we funded afterwards. So I think that establishing this evidence, and really on the dissemination and implementation, and making sure that we get patient-centered outcomes that are measured is really where AHRQ's interest lies.

Diane Newman: Well, you tell anybody who says that to you is that smoking comes up in all epidemiological studies as far as it being a risk factor for incontinence, and alcohol is a trigger for urinary urgency. So I see you as right on with this. So thank you very much for presenting this. I know our viewers are really going to find this informative. Thank you, Dr. Huppert.

Jill Huppert: Great. Thanks very much for inviting me.