A multi-professional UK wide survey of undergraduate continence education.

OBJECTIVES: Findings from national audits and enquiries continue to report that care for patients with continence problems is often substandard and inadequate education is often cited as one of the probable causes. These factors combined with the forecasted increase in the number of people with incontinence prompted us to undertake a survey of all UK Higher Education Institutes (HEIs) to establish the amount of undergraduate continence education within relevant healthcare programs--medical, adult nursing, mental health nursing, learning disabilities nursing, children's nursing, midwifery, physiotherapy, and occupational therapy. DESIGN: An on line questionnaire targeted course program leads (n = 362) in all 86 HEIs in which undergraduate professional healthcare programs were provided (n = 362). MAIN OUTCOME MEASURE: Eighty-six HEIs were approached, 85 agreed to participate in the survey. A response rate of 81% (n = 294/362 programs) was obtained: 14% (n = 42) of respondents reported that there was no continence-related education within their undergraduate program. The mean number of hours was 4.7 (SD 4.3), and ranged from 2.5 (SD 3.5) hr (Occupational Therapy) to 7.3 (SD 4.8) hr (Adult Nursing). CONCLUSION: The survey results indicate that the amount of undergraduate education has changed little. Further research is needed to identify the most appropriate methods of delivering continence education and translate knowledge into improved patient outcomes. Adequate undergraduate continence education directed by the General Medical Council, Royal Colleges and Health Professional Council is required.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence.

OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling. DATA SOURCES: The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database. STUDY SELECTION: The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI. DATA EXTRACTION: Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person. RESULTS: Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions. LIMITATIONS: Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies. CONCLUSIONS: More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Prompted voiding for the management of urinary incontinence in adults.

BACKGROUND: Prompted voiding is a behavioural therapy used mainly in North American nursing homes. It aims to improve bladder control for people with or without dementia using verbal prompts and positive reinforcement. OBJECTIVES: To assess the effects of prompted voiding for the management of urinary incontinence in adults. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (to February 2000) and reference lists of relevant articles. We contacted investigators in the field to locate extra studies. Date of the most recent searches: February 2000. SELECTION CRITERIA: All randomised or quasi-randomised trials which addressed prompted voiding for the management of urinary incontinence. The trials included adult men and women, with or without cognitive impairment, diagnosed as having urinary incontinence as identified by the trialists, either by symptom classification or by urodynamic investigation. DATA COLLECTION AND ANALYSIS: The identified reports were assessed for eligibility. Two reviewers independently reviewed the selected studies for methodological quality. Data describing six pre-specified outcomes were extracted independently by each reviewer and consensus reached when there was disagreement. Trial investigators were consulted when clarification or further detail was required. A third reviewer was recruited to proof read the review at different stages. MAIN RESULTS: Five trials were included in the review. These involved 355 elderly people, most of whom were women. One other trial was excluded because no relevant outcome data were reported, and one trial is awaiting assessment. Prompted voiding was compared with no prompted voiding in four trials. The limited evidence suggested that prompted voiding increased self-initiated voiding and decreased incontinent episodes in the short-term. There was no evidence about long-term effects. A single small trial suggested that adding the muscle relaxant, Oxybutinin, reduced the number of incontinent episodes in the short-term: This study used a cross-over design and so did not address long-term effects. REVIEWER'S CONCLUSIONS: There was insufficient evidence to reach firm conclusions for practice. There was suggestive, although inconclusive, evidence of short-term benefit from prompted voiding and from adding the muscle relaxant, Oxybutinin to prompted voiding.