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	Project Overview: The Optimizing Primary Care Tools for Incontinence Management (OPTIMA) project, led by University of California San Diego, is implementing a four-pronged intervention to improve the quality of care for women with urinary incontinence (UI). This intervention included academic detailing, clinical decision support, Advanced Practice Provider (APP) co-management, and electronic referral. OPTIMA is working with four large Southern California health systems, including a safety-net system with a large number of Spanish-speaking women. For more information on OPTIMA, read their project’s executive summary (PDF, 208 KB).
Jennifer Tash Anger, M.D., M.P.H., UC San Diego Department of Urology, and OPTIMA project PI and Maxwell Moore, M.S., Project Coordinator for the OPTIMA project responded to interview questions on behalf of the team.

At a 30,000-foot view, what is most notable about your team’s approach to UI screening and treatment implementation within primary care? What strategies were central to your project?

Rather than condensing the needs of every woman into a narrow clinical approach, primary care providers often have to be flexible, adjusting to meet the range of needs for the individuals and populations they serve. We aim to be just as versatile, developing an intervention that can be applied in a variety of settings - from academic hospitals to rural clinics. In doing so, we seek to address the significant deficits in quality UI care. We are also interested in reducing disparities in care, so we seek to examine different intersections within primary care’s clinical landscape.

 For example, technological differences exist at both the patient level (i.e., internet access, technological fluency) and at the provider level (i.e., electronic vs. analogue medical records, role of technology in the clinic). We were especially invested in implementing an intervention that overcame these differences to equalize care across practices. Further, since factors such as race, ethnicity, income, and urban/rural geographies are often associated with disparities in the quality of UI care received, we worked with practices that serve a diverse demography of women. Although the major aspects of the intervention are uniform across sites, our approach prioritizes developing specific ways to incorporate our intervention’s clinical tools so they are effective and accessible throughout a range of healthcare settings.

UI is often broached by the patient rather than the provider. How has your project been responsive to patient-driven needs?

Recognizing that UI is highly stigmatized and the burden of initiating a UI conversation often falls to the patient, our intervention aims to enable the patient to bring up their symptoms before the visit from the comfort of home. For those who screened positive prior to their visit, a Best Practice Alert (BPA) lets the provider know that the patient is experiencing bothersome UI, prompting a conversation to occur. We hope that the simplicity of the screening tool increases its generalization to multiple clinical settings (e.g., it could be sent as an email prior to visit, screened by staff in person/over phone, or included as simple line item in intake). Our preliminary results show that, though there are differences between the different alert/screening mechanisms, BPAs effectively encourage the initiation of UI conversations between patients and their providers.

What successes are you celebrating to date? 

A notable success of our project is the development of multiple iterations of the BPA across clinical settings. For the rural clinics participating in our study that do not have the same IT infrastructure as high-volume offices in urban areas, we were able to measure how often “interruptive” alerts (in the form of a pop-up on the EMR) vs. “non-interruptive” alerts (in the form of an EHR “sticky note”) prompted a conversation between provider and patient addressing UI. This approach allowed us to incorporate a pivotal aspect of our intervention, the BPA, in a manner that is both effective and meaningful for providers and their patients across vastly different clinical settings.

How did you address provider education on the topic of UI? Were there any surprises or key takeaways from the training your team did with primary care providers?

Each provider brought their own prior knowledge of UI, comfort with treatments, and management approaches. To make the academic detailing (i.e., provider education) as pragmatic as possible, much of it was built around individualized baseline chart assessment with customized feedback for each provider. Though this method did receive positive feedback, we had some difficulty juggling multiple busy clinician schedules, which in some cases led to prolonged lags between academic detailing and patient recruitment. To help primary care providers put into practice what they learned, we developed a pocket guide with medication details and moved from lectures to one-on-one conversations to support both understanding and confidence among providers with these medications.

After initial implementation, what changes did you make to adapt to the needs of providers and patients?

The initial scaffolding for the intervention was designed in high-tech, high-volume clinical environments such as UCSD. However, we wanted to make sure our intervention could provide versatile solutions and would not be pinned on the assumption that “if it works in our system, it will work for every system.” We invested time working with our rural clinical sites to find analogous mechanisms for both the intervention tools and aspects of study protocol, such as recruitment, that would work for their contexts. For instance, many study patients served by the rural clinics are Spanish-speaking and do not have the same level of internet utility and/or accessibility compared to their urban counterparts. To accommodate for this, we incorporated extensive phone screening options and hired bilingual research personnel to facilitate the study. The change was near-instant; our recruitment rates nearly doubled, with our research site championing the rural clinics going from nearly 0% to over 50% recruitment within 6 months (for reference, the only other research site to reach that milestone is UCSD itself). 

What has been your biggest lesson learned to-date?

Our biggest learning has been ways to overcome the post-COVID primary care physician burnout. From a research perspective, the burnout made it challenging to convince a physician who is already overworked to take on yet more responsibility by participating in a clinical study. 

Aside from the usual battery of provider buy-in methods (i.e., payment, MOC credit, in-office recruitment meals, etc.), we also decided to incorporate increasingly individualized clinical support and education as aspects of our study intervention. We added clinical champions who could work with providers one-on-one at their own pace and according to their needs. Listening to providers and learning about the daily challenges that prevent them from operating to their fullest capacity provided us insights into how we could best structure our multimodal intervention. Much of this information shaped the non-burdensome, time-saving clinical decision support tools that are part of our intervention. 

What advice would you have for primary care practices that may consider adopting interventions to screen and treat UI?

The most important thing practices can do to treat UI is to start off by gaining confidence in any single facet of UI care. Managing UI can seem daunting at first, but providers can start to familiarize themselves with two to three aspects of UI care to confidently treat their patients. For example, many providers are comfortable with diagnosing UI and recommending pelvic floor exercises, but medication prescribing can be daunting. Providers can start with just one medication they feel confident prescribing. Then, as providers address UI in more patients, they will naturally gain exposure to more clinical support and educational resources, developing a nuanced understanding of the different medication regimens and overall aspects of UI care. Doing something new in one’s practice can be difficult, but know that the expectation is not to be an expert instantaneously. Just starting can still make a huge difference in patient care along the way.