If We Don't Ask, They Won't Tell

Screening for Urinary and Fecal Incontinence by Primary Care Providers

Heidi W. Brown, MD, MAS; Wen Guan, BA; Nicholas B. Schmuhl, PhD; Paul D. Smith, MD; William E. Whitehead, PhD; Rebecca G. Rogers, MD

Disclosures

J Am Board Fam Med. 2018;31(5):774-782. 

In This Article

Discussion

In this survey of 154 PCPs in a Midwestern academic institution, screening rates for UI (75%) were much higher than FI (35%). PCPs were twice as likely to screen for and felt better informed to manage UI versus FI. Those who screen for UI and those who feel informed to treat FI are more likely to screen for FI, suggesting that interventions to improve PCPs' confidence in treating FI may improve screening rates. Further, there was high reported interest in educational materials targeting both patients and providers for both UI and FI, with particular interest in diagnosis and treatment algorithms for both conditions and provider-directed education for FI specifically. This high interest, coupled with the common belief that screening for UI and FI is important, suggests that PCPs may welcome interventions that facilitate diagnosis and treatment.

While several studies to date have examined rates of and reasons for not seeking care for FI in patient populations,[15,20] this study is the first large survey to provide information about rates of and reasons for not screening for FI from the health care provider's perspective. In the only other study in the English literature that queried physicians about screening for FI, 11/56 physicians responded, 9 of whom potentially provided primary care (8 geriatricians and 1 general internist), and the rate of screening for FI among those 9 physicians was 67%, which is significantly higher than the rate in our study of 35%, but somewhat comparable to the screening rate among geriatricians in our study.[20] While the sample size of the study by Kunduru and colleagues[20] is small, several findings in their study mirror those in ours: nonscreeners perceived screening for FI to be less important than screening for other conditions, 50% noted time constraints as an important barrier to screening, and 100% perceived it to be the patient's responsibility to initiate the conversation.[20] Even among those who screened for FI in that study, 50% reported limited accessibility to subspecialty care and concerns about excessive medical costs as barriers to screening or treatment.[20] Similar to our findings, 75% of those who did not screen for FI in that study perceived the prevalence of FI to be low in the general patient population.[20]

Several of our findings deserve special attention. The association of use of the terms, "accidental bowel leakage" and "bowel control issues," with screening for FI emphasizes the importance of terminology with this condition. In the Mature Women's Health Study, an electronic survey of almost 6000 independent women aged 45 years and older, of whom approximately 1000 had FI, the term, "accidental bowel leakage," was preferred by 71% of women with FI over the terms, "fecal incontinence" (6%) or "bowel incontinence" (23%).[21] Of note, very few PCPs in our survey used the term, "accidental bowel leakage," suggesting that it should be included in clinician education efforts. Because it is impossible to know a given patient's preferred terminology without asking, it may make sense to include multiple synonyms when verbally inquiring about FI symptoms. For example, when asking about dyspnea, a clinician might say, "Any trouble with breathing, shortness of breath, trouble catching your breath?" Similarly, when asking about FI, a clinician might ask, "Any bowel control issues? Accidental bowel leakage? Incontinence of stool? Not making it to the toilet when you want to?" Since the majority (75%) of PCPs in this survey already screen at least some patients for UI, adding inquiries about FI at the same time may be an easy way to incorporate this screening.

It is important to note that this high screening rate for UI is likely related to its inclusion as a Merit-based Incentive Payment System (MIPS) quality metric (https://qpp.cms.gov/mips/quality-measures). The Centers for Medicare and Medicaid Services MIPS quality metric #048, "the percentage of female patients aged 65 years and older who were assessed for the presence or absence of UI within 12 months," is based on the rationale that patients may not disclose incontinence symptoms and thus should be asked by a physician about them. If screening for FI in older men and women were similarly recognized as a quality measure, it might similarly increase screening rates.

The strong association of preference to screen verbally with PCP screening for FI also merits mention, since a prior survey of 124 patients with FI reported that over 70% of patients who had not sought care believed that doctors need to speak directly to patients to improve treatment of FI.[20] Interestingly, almost 60% of patients who had not sought care for their FI in that study agreed with the statement that patients would prefer to use questionnaires or answer routine questions about FI.[20] In prior qualitative studies, women with FI describe written inquiry as a more comfortable way to broach an uncomfortable topic,[15] and women with dual incontinence seeking care are more likely to verbally disclose urinary than fecal symptoms.[22] Similarly, adults in Ireland are more likely to disclose the use of incontinence aids on an anonymous written survey than they are when asked in face-to-face interviews.[23] Use of a previsit electronic pelvic floor health questionnaire, results of which were provided to both patients and their PCPs, improved provider-initiated discussion of incontinence in a randomized trial of women aged 40 years or older presenting to an internal medicine clinic for a well-woman examination.[24] It is thus likely that the optimal screening approach for FI should include both written or electronic and verbal inquiry, and we suggest that further research should explore these approaches.

It is striking that only 20% of physicians in training (residents and fellows) in our survey screened for FI, as compared with 41% of attending physicians and 48% of advanced practitioners. Although this finding may be confounded by level of acuity in patient populations, it is important that provider-oriented educational materials target residents and fellows in addition to attending physicians.

Provider-oriented educational materials should also target the patient preferred description of FI, including the term, "accidental bowel leakage," and misconceptions that patients will bring up FI if bothered and should emphasize the existence of effective, minimally invasive treatment options. The high demand for educational materials coupled with our finding that only 6% of clinicians were aware of the National Institutes of Health's Bowel Control Awareness Campaign,[25] whose Web site offers both patient- and provider-oriented information about FI, suggests that efforts to better disseminate this campaign are warranted. Further, demand for evidence-based diagnosis and treatment algorithms for FI is high and should be added to educational materials targeting PCPs.

Our study is limited by the inclusion of PCPs from a single academic medical center, as well as a relatively low response rate of 27%. Physician populations are notoriously difficult to survey, especially via email and without significant incentive for responders.[26] Response rates below 20% are not uncommon in Internet surveys of physicians.[27] In general, response rates have fallen among health care industry surveys recent years and our experience proved no different.[28] We acknowledge that the attitudes, practices, and experiences of survey respondents may not be generalizable to nonresponders or to providers in other health care systems, though Dykema and colleagues[29] suggest that nonresponse bias may be lower among physician populations than others because they are relatively homogeneous. Further, the proportion of respondents who reported screening most or all patients for UI in this study (27%), is comparable to that found in a recent survey of primary care providers (n = 391) across the country (39%).[19] Given that very little information exists regarding PCP screening for UI, and even less exists about screening for FI, this survey of over 150 clinicians who provide primary care in diverse specialties offers valuable insights into differences between UI and FI that may be used to guide improvements in screening for FI.

Based on our findings, we propose that future research should explore whether screening rates can be improved through educational interventions, as well as which formats of screening are optimal for both patients and primary care providers. We hypothesize that patient- and provider-oriented educational materials tailored to primary care providers, complete with evidence-based algorithms for diagnosis and treatment, will promote better screening for FI. We recognize the need to understand the practices and preferences of primary care providers in other locations, as well as in nonacademic practice settings, to facilitate adaptation and dissemination of interventions likely to improve screening and treatment rates across diverse patient populations.

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