In most practices, physicians and nurses rely loosely on their clinical judgement to gauge whether satisfactory improvements have been attained, and whether their patients require more aggressive treatment. A number of studies suggest that clinicians differ from patients in their expectations for UI treatment outcomes [ 5 , 7—9 ]. Forty-three per cent of the women responded that they would be satisfied with a good improvement that no longer interfered with their quality of life. Overall, there was found to be poor agreement between clinicians' and patients' attitudes towards the acceptability of symptoms after treatment [ 5 ].
The majority of clinicians thought that small amounts of leakage were generally acceptable, although this was not the case for patients, with less than a third of them considering this to be a satisfactory residual treatment outcome. The discrepancy between clinicians' and patients' expectations regarding UI treatment outcomes may explain differences between clinical impressions of success and patient satisfaction following incontinence surgery.
Taken together, the data from these different studies suggest that patients have higher expectations regarding treatment outcomes and are more frequently disappointed with the results of interventions. Only one comparison of physician and patient assessments of improvement has been reported following pharmacologic treatment of UI [ 10 ].
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To our knowledge, no study has examined whether a dichotomy exists between clinicians' and patients' impression of UI treatment outcomes in non-surgical populations of older incontinent women. Behavioural management of UI, including lifestyle modification, pelvic floor muscle exercises, and bladder re-training, remains the first-line treatment for urge, stress and mixed UI, the most common UI types seen in older women [ 11 , 12 ].
The decision to proceed to more aggressive treatment strategies, such as medication or surgery, should be based on clinician and patient dissatisfaction with these conservative measures. A better understanding of the way older women and their clinicians evaluate treatment outcomes is critical to ensure that the patient's goals are met, and that consensus is achieved prior to proceeding to more aggressive treatment options that may entail greater risk.
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The objective of this study was to determine to what extent older women's perceptions of improvement in UI status following behavioural management for UI correspond with physicians' global ratings of change. We also compared patients' and physicians' ratings of improvement with more objective UI outcome measures, such as voiding diaries and quality-of-life measures to better understand whence their judgements were derived.
Participants were consecutive new female patients seeking care at six UI outpatient tertiary care referral centres in Montreal and Sherbrooke, Quebec, between September and June , along with their treating physicians. Women who were 65 years and older and who had symptoms of UI as defined by one or more episodes of involuntary urinary loss during the past 3 months, were eligible.
Participants were not screened for depression. Patients were recruited from the UI clinic rosters by telephone prior to their initial visit with the UI specialist. A research assistant met with all participants at the time of their first appointment to screen for eligibility and obtain consent. UI-specific quality of life was recorded with the Incontinence Quality of Life I-QOL questionnaire designed for all types of UI [ 15 , 16 ], a validated item questionnaire where higher scores indicate better quality of life.
All participants were instructed on how to keep a h voiding diary to record episodes of leakage. The participants then saw a physician specialised in UI urologist, gynaecologist or geriatrician who documented a presumed clinical diagnosis of UI type—either stress, urge, mixed or other. As urodynamic studies were not performed in all patients, we relied on the clinician's diagnosis as the gold standard for classifying UI type. Treatment was identical for all participants. After the first visit, a clinical nurse specialist instructed the patients on lifestyle modification techniques e.
The clinical nurse specialist performed a physical examination to verify that the patients knew how to isolate their pelvic floor muscle properly. Each participant received a page instructional booklet describing the exercise protocol, lifestyle modification techniques and distraction strategies. To encourage adherence to the exercise protocol, a research assistant conducted two telephone follow-ups at 4-week intervals.
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The patients were asked to complete another h voiding diary immediately prior to their 3-month clinic visit with their physician to objectively record if their incontinence episodes had improved. At the 3-month follow-up visit, the same research assistant met with each patient to re-administer the I-QOL and to determine the Patient's Global Impression of Improvement PGI-I in their UI condition subsequent to completing the conservative management protocol.
The PGI-I is a validated, single-item global rating of change scale that asks the patient to describe how their UI condition is after treatment compared with how it was before treatment [ 17 ]. Seven responses are possible: Afterwards, each patient met with their physician to discuss treatment efficacy, and the clinicians were asked to document their Clinician's Global Impression of Improvement CGI-I. Physicians were blinded to the patient's voiding diaries, quality-of-life scores and global impressions of change at follow-up.
Funding for this study was obtained from the Canadian Institutes of Health Research in the form of a 2-year Operating Grant to Cara Tannenbaum from to Perfect concordance was defined as the exact same rating obtained from both the patient and physician on the PGI-I and CGI-I respectively after completion of the behavioural management protocol. Agreement between clinician and patient global ratings of improvement was also calculated using Cohen's kappa weighted Fleiss coefficient , which is a more robust measure than the simple percent agreement calculation between two raters as it takes into account the agreement occurring by chance [ 18 ].
A kappa coefficient of 1 indicates perfect agreement and -1 indicates perfect disagreement. Degree of associations between 3-month changes in incontinence episode frequency and changes in quality-of-life ratings with the patient and clinician's global ratings of improvement were assessed with Spearman's correlation coefficient Rho.
Three-month changes in voiding frequencies were calculated as the percent change in the mean number of incontinence episodes per day recorded in the baseline compared to the follow-up voiding diary. Three-month changes in quality-of-life ratings were calculated as the difference in scores between baseline and follow-up administration of the I-QOL questionnaire.
Complete data from seven physicians and female patients with stress, urge or mixed UI were available for analysis.
Baseline patient characteristics are shown in Table 1. The patient sample was in good health with a mean age of 73 years range 65—86 years. Mixed UI was the most common UI type. At least half the patients experienced several episodes of UI each day for 5 years or more. The physicians comprised one geriatrician, two gynaecologists, and four urologists.
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Sufficient patient loads were not available to stratify the data by individual physician or specialty. The weighted kappa coefficient was 0.
There was insufficient sample size to conduct significance testing for concordance rating according to patient age group, UI type, UI severity or duration of UI. In one-sixth of cases, patients said they had improved significantly, whereas clinicians noted only moderate improvements. In over one-third of discordant cases, clinicians noted no improvement, whereas patients reported a little bit of improvement in their UI condition.
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Patients' ratings of improvement correlated better than clinicians' with reductions in UI episodes recorded objectively in the voiding diary, as well as with subjective improvements in quality of life following treatment Table 3. All correlations were statistically significant, moderate in magnitude, and related to improvement scores e.
Correlation between patient and clinician's ratings of improvement and changes in UI frequency and quality of life. Clinicians concurred with their patients' ratings of improvement in a little over half the cases. When disagreement occurred, patients were 1. In comparison with more objective UI outcome measures, patients' global impressions of improvement correlated better than clinicians' with reductions in incontinence episode frequencies recorded in voiding diaries and with improvements in quality-of-life scores.
Our data regarding behavioural management of UI in older women confirms high treatment efficacy rates, based on subjective ratings and improvements in the voiding diaries and I-QOL scores Table 1 , even in this significantly older sample of patients [ 19 , 20 ]. We also reproduced the moderate concordance rates and correlations previously observed between global ratings of change and more objective outcome measures [ 10 , 21 ]. Our results differ from previous work with regard to patients' propensity to rate the results of their intervention more favourably than their physicians.
One explanation for why patients rated their improvements in UI more favourably than their physicians may be the nature of the intervention. The behavioural management protocol in our study required patients to make dietary changes, such as eliminating caffeinated beverages, performing daily pelvic floor muscle exercises, and employing distraction techniques to prolong voiding intervals. These interventions require strong patient motivation and involvement.
As opposed to pharmacologic and surgical interventions, patients are more involved in behavioural therapies and may perceive deriving a greater benefit. Europe PMC requires Javascript to function effectively. Find all citations in this journal default.
Or filter your current search. Gastroenterologie Clinique et Biologique [01 Jun , 28 Pt 1: The aim of this multicenter study was to validate the French version of the fecal incontinence quality-of-life scale FIQL scale developed in the Unites States of America. The FIQL scale has 29 items in four scales: Each item is scored from 1 to 4, with poorest quality-of-life scored 1.
An average is calculated for each scale. After linguistic validation of the questionnaire, the French version of the FIQL scale was tested twice, at day 0 and day 7, by patients with fecal incontinence FI. Construction validity, internal reliability, clinical validity and reproducibility were analysed. Analysis of convergent validity of the French version of the FIQL scale showed very good correlation between items and the corresponding scale for lifestyle 0.