Focus on Women Physiotherapy - Gold Coast

International Continence Society

ICS = International Continence Society, meeting in Florence September 2017. Researchers are Jenny Nucifora, Helen Edwards and Janelle Greitschus. 

Photos from the conference and researches standing on the Ponte de Vecchio in Florence.
Research topic also presented at the APA, Australian Physiotherapy Association conference in Sydney.

International Continence Society Abstract

Gynaecology Physiotherapy Screening Clinics Improve Access to Care and Health Outcomes for Women on Gynaecology Outpatient Waiting Lists 

Hypothesis / aims of study

The aim of this study was to determine if a physiotherapy led gynaecology physiotherapy screening clinic (GPSC) can improve access to care and health outcomes in women with incontinence and / or pelvic organ prolapse (POP) referred for gynaecology / urogynaecology outpatient services and wait listed as category 3. Many healthcare systems are currently facing multiple challenges with increasing costs of providing healthcare, ageing populations as well as an increase in chronic diseases. Urinary incontinence and pelvic organ prolapse affect many women across all ages and have a significant impact on women’s quality of life. Treatment involves conservative and / or surgical management. With increasing waiting lists for gynaecology review a different model of care was a priority for both the patient and the health service.

It was hypothesized that implementation of a GPSC:

• Reduces the waiting time to initiation of care for women on gynaecology / urogynaecology department outpatient waiting lists - these women can access the GPSC much earlier than waiting for an initial gynaecology / urogynaecology consultation

• Reduces the number of category 3 patients requiring gynaecology / urogynaecology appointments - women who experience a resolution of their symptoms with GPSC management can be removed from the Gynaecology Outpatient Department (GOPD) waiting list

• Reduces the number of specialist appointments (gynaecology / urogynaecology) required or provides a more efficient pathway to surgical management, for women who remain on the GOPD waiting list after discharge from the GPSC.  These women can receive intensive physiotherapy treatment prior to their specialist consultation.

It was also hypothesized that the majority of women who complete a course of treatment and are discharged from GPSC will have a reduction in the severity of their incontinence and / or prolapse symptoms, have an improvement in their overall quality of life and will have a high level of satisfaction with the GPSC service.

Study design, materials and methods

The study involved a service evaluation comparing patient outcomes before and after the introduction of the GPSC service at two hospital sites.

GPSC admission and discharge data were collated on women completing a course of treatment for incontinence and / or pelvic organ prolapse from January 2015-March 2016. 

Following initial assessment, management options available included conservative management comprising a course of physiotherapy +/- continence nurse advisor review, gynaecology / urogynaecology review, or if clinically indicated referral expediated for specialist review. For patients appropriate for conservative management discharge options included discharge from GPSC with no gynaecology / urogynaecology review indicated or continued on for specialist review in GOPD – again this may have been upgraded for earlier review if clinically indicated. Percentage of women with clinical improvement on clinical outcome measures (Australian pelvic Floor Questionnaire (APFQ) and the AQOL-6D), between initial and discharge were reviewed. Global rating of change scale which was completed on discharge from GPSC was also reviewed.

Data were retrieved from a historical comparator group of women attending an initial gynaecology or urogynaecology appointment between 1st July 2013 -31st December 2013. Medical records were searched to ensure primary diagnosis at initial consultation, follow up appointments or surgery performed was for incontinence and / or POP. For both groups wait time to initiation of care (days), number of specialist appointments required before discharge or surgery were recorded. The data collected was quantitative, non-identifiable and grouped for analysis and reporting.

Results

A total of 380 patients were discharged from GPSC across the two sites from January 2015 to March 2016, with 202 female patients (average age 52 years – range 16-84) conservatively managed. Women completing a course of treatment demonstrated significant clinical symptom reduction as measured on the APFQ across all domains following treatment (p <0.001). 80% of patients reported positive improvement on the GRC scale (n=167). There was no difference in the total AQOL-6D between pre and post treatment however there was a statistically significant reduction in the dimensions for coping and pain (p=0.031 and 0.023 respectively) however numbers were low (n=44). Of the 178 patients who did not complete treatment in GPSC 43% were failed to attend, 30% requested discharge, 13% declined the offer of an appointment and 14% did not respond to the initial offer of an appointment.

Wait time to initiation of care was significantly reduced from a mean 133 days (SD 120) to mean 87 (SD 75) post commencement of the GPSC. Of those that completed a course of treatment 33% of women no longer required a gynaecology / urogynaecology appointment and were removed from the GOPD waiting list. Patients who needed specialist review (66%), both surgical and non surgical, required an average of 1 (SD 1.1 and 0.96 respectively) less gynaecology / urogynaecology appointments per patient. For those 178 patients who didn’t complete a course of treatment 14% were able to be removed from the GOPD waiting list. Earlier specialist review was facilitated in 5% of the patient cohort.

Satisfaction surveys were completed by 121 discharged patients. All participants expressed satisfaction with the service and would recommend it to others.  Over 73% were very satisfied that their main problem was identified and treated by a physiotherapist as well as with the outcome of their management through GPSC.

Interpretation of results

Early intervention in a GPSC can provide patient benefits by providing earlier access to care and significantly reducing patient symptoms. Additionally the GPSC had a positive effect on the health service by reducing the number of patients requiring gynaecology / urogynaecology review, resulting in increased availability of specialist appointments reducing specialist waiting list time. 

Irrespective of whether patients were discharged from GPSC with no specialist follow up required or continued on for gynaecology / urogynaecology review there were still significant improvements in their clinical symptoms following treatment in the GPSC. The GPSC service has improved the patient flow with the patient completing a course of physiotherapy treatment prior to seeing the gynaecologist / urogynaecologist which is in line with current international guidelines (1). It has also allowed for the facilitation of earlier review for patients with severe symptoms.  

Concluding message

Early physiotherapy intervention in a GPSC prior to gynaecology appointment for women with incontinence and or POP can significantly decrease waiting times for initial care, reduce the number of gynaecology appointments required, improve patient outcomes as well as improve patient flow to the gynaecologist.