Introduction

Since the early 1930s, the number of people aged over 65 has more than doubled, and today, a fifth of the population is over 60. It is projected that between 1995 and 2025 the number of people over the age of 80 will increase by almost a half and the number of people over 90 will double [1]. Approximately 35% of women experience some degree of urinary incontinence [2] and the prevalence increases with age [3]. Therefore, urinary incontinence poses a significant health problem. Furthermore, it is a sizeable public health and primary healthcare issue as people who were incontinent have a significantly lower health status than people who were continent [4]. Currently, the National Health Service spends nearly half of its annual budget on the over 65 age group, and with the increase in this age group, it is estimated that the cost of incontinence could reach £2 billion by the year 2020 [5, 6].

Increasing waiting time for hospital appointments and treatment is a major health and political issue. In the United Kingdom, the Department of Health highlighted the need for service redesigning to reduce patient waiting times. The NHS Improvement Plan set out an ambitious new aim: “By 2008 no one will wait longer than 18 weeks from GP referral to hospital treatment” [7]. The above shortage of resources in the healthcare system applies to the United Kingdom and may not be universal.

Care providers in the NHS have a contractual and legal onus to provide services in line with the Department of Health's recommendations for good continence care [8]. The guidance lays emphasis on developing integrated continence services, bringing together primary, secondary, and tertiary care under agreed protocols. A recent Department of Health document has recommended that people with long-term conditions are to be offered personalized care plans with community-centered care [9]. Therefore, there is a need to look at how services can be improved to meet the above recommendations. One way to help achieve this is for patients to be seen in a nurse-led triage clinic. The benefits of one-stop nurse-led clinic have been well-explored and well-documented [10, 11]. McGhee et al. [12], in Glasgow, concluded that a dedicated nurse-led continence service allowed improved management, a greater level of awareness, and resource savings in correct and appropriate product use.

Based on the above, we commenced a nurse-led urogynecology triage clinic (UTC). We developed a central district referral point using a nurse-led service aiming to reduce waiting time for clinic appointments, investigations, and treatment for women referred with urogynecological problems.

The aim of this study was to establish whether a nurse-led UTC is effective in delivering appropriate patient care in terms of patient journey (from primary referral to first hospital contact until discharge), diagnosis, management, and outcomes. The above parameters were measured and compared before and after the introduction of the UTC.

Materials and methods

Three hundred case notes of patients attending the UTC between 1 January 2006 and 30 November 2007 were selected randomly for review. The 300 case notes formed 27% of the 1,096 patients seen in the UTC during this time period. Patients were referred to the UTC by the general practitioner (GP) and also by other hospital health professionals. The choice of whether to refer to the UTC or to another hospital specialist was exercised by the GP. The criteria for referral and acceptance to the UTC were lower urinary tract symptoms. If the patient had any other associated symptoms, they were seen in appropriate specialist clinics, e.g., hematuria clinic, pelvic floor clinic. Prior to the visit, the patient was asked to complete a 3-day bladder diary and a symptom-specific questionnaire. The UTC framework was set up as a twice weekly nurse-led clinic and approximately 30 patients were seen monthly. Each patient was seen in 30-min slots and symptom profiles, urinalysis, ultrasound, examinations to measure post void residual urine volume, and pelvic floor assessments were carried out. Drug therapy as well as lifestyle interventions (e.g., weight loss, decreased caffeine intake, dietary interventions) and behavioral therapy (e.g., bladder training, pelvic muscle exercises) were initiated as necessary. The pelvic floor therapy and bladder retraining sessions were done individually at the first visit. Subsequent visits were held as a group therapy. Each patient's management was tailored according to their progress. The patient was discharged when symptoms were either no longer bothersome or she was satisfied with the outcome and wished no further interventions. Patients who remained symptomatic were referred on for further investigations if necessary and to the appropriate specialist consultant clinics.

The following time intervals of primary referral to first hospital contact and first hospital contact to outcome (decision) were analyzed. The referral pattern, median number of visits, and the types of treatment offered were also analyzed. The final outcome was defined as either discharge from the clinic back to the GP or onward referral to a consultant-led specialist clinic. The intervals between referral to first hospital contact, hospital contact to outcome, referral pattern, number of visits, and treatments offered were compared with the time intervals prior to starting the UTC.

Prior to starting the UTC, the clinical pathway consisted of the GP's referring the patients to the consultant teams in the hospital. The patient would be reviewed in the hospital clinic and referred for appropriate investigations. After completing the investigations, the patient would be reviewed back in the clinic and either referred for bladder retraining, pelvic floor exercises, or started on medications. After a suitable interval to assess the efficacy of the treatment modalities started, the patient would be reviewed back again in the clinic and would be either discharged or further management plans made. Thus, the pre-UTC pathways had multiple consultant visits and waiting times at all levels for appropriate investigations to be performed or treatment to be started. The final outcomes measured were similar pre-UTC and post-UTC.

Results

Patient demographics

The mean age at referral was 55 years (range = 13–96 years, SD = 16.9). One hundred and forty-eight (49.3%) patients had previous pelvic surgery; 46 (15.3%) had hysterectomy alone, ten (3.3%) had pelvic floor repair alone, and 14 (4.7%) had a combination of hysterectomy and pelvic floor repair. Eleven (3.7%) patients had previous continence surgery and 67 (22.3%) had other gynecological surgery.

One hundred and seventy-three (57.7%) patients were postmenopausal, and 15 (5%) were on hormone replacement therapy.

Referral pattern

One hundred and eighteen (39.3%) patients were referred by GPs. Ninety-five (31.7%) patients were referred by the urogynecology team and 87 (29%) by other specialist teams including the urologists.

Time intervals before and after the UTC

The mean number of visits were 2.1 (range = 1–9, SD = 1.3). The mean time interval from referral to first visit was 4.6 weeks (range = 1–11 weeks, SD = 1.9) compared to pre-UTC when it was 15.6 weeks (range = 12–32 weeks).

The mean number of weeks from first visit to final outcome was 8.8 weeks (range = 1–60 weeks, SD = 11.2) compared to pre-UTC when it was 11 months (range = 3.0–23.0 months).

The symptom profile, duration of treatment, and management is shown in Tables 1, 2, and 3.

Table 1 Symptomatology
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Table 2 Duration of symptoms
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Table 3 Management modalities
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Urodynamic investigation and outcome

Urodynamics was performed in 70 (23.3%) patients who did not respond to conservative management. The investigation was normal in 25 (35.7%) patients, while 22 (31.4%) had urodynamically proven stress incontinence, 14 (20%) had detrusor overactivity, and 9 (12.9%) had mixed incontinence.

Outcomes

Of the 300 patients, 72 (24%) patients were referred onward to a consultant clinic, 60 (83.3%) were referred to the consultant urogynecology clinic, one (1.4%) to the pessary clinic, five (6.9%) to the pelvic floor clinic, and six (8.3%) to the urology clinic. Fifty-one (17%) patients were being followed up, and 177 (59%) have been discharged from the clinic.

Of the 72 patients referred to the consultant clinics, 49 (68%) had surgery of which eight (16.3%) had pelvic floor repairs, 15 (30.6%) had incontinence procedures, two (2.8%) patients had botulinum toxin injections, and the remaining 24 (48%) had cystoscopic examination as an investigation to rule out intravesical pathology. Three patients (4.2%) were being followed up and two (2.8%) were referred to tertiary pediatric units for further assessment. Eighteen patients (25%) were discharged back to primary care as there was improvement following conservative management. A flow chart of the patients' journey through the UTC is shown in Fig. 1.

Fig. 1
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Flow of patients through the UTC

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Discussion

This study assessed the effectiveness of a nurse-led clinic in terms of patient journey (from primary referral to first hospital contact until discharge), diagnosis, management, and outcomes. The above parameters were measured and compared before and after the introduction of the UTC.

The numbers of women seen and treated in the UTC are large enough to judiciously assess the quality of care provided and the appropriateness of the referrals to secondary care. The referral profile of the patients fits with the demographic highest prevalence in the postmenopausal age group as the mean age of referral was 55 years. Most of the patients referred had long-standing symptoms of more than 5 years. This may be a reflection of women's reluctance to seek help due to embarrassment and the stigma associated with the condition, highlighting the need for public education. Moreover, the government's focus has been to develop continence assessment in all age groups including the elderly to prevent institutionalized age discrimination [13]. A large number of patients referred (49%) had previous pelvic surgery, suggesting the common pathophysiology associated with pelvic floor disorders.

One hundred and eighteen patients (39%) were directly referred from primary care by the GPs, thereby decreasing referrals to specialist consultant clinics and fostering conservative patient management. The management of the patients was in line with national guidelines and recommendations. Interestingly, none of the patients were treated with anticholinergics alone for overactive bladder symptoms following accepted recommendations for first-line treatment of overactive bladder symptoms with conservative methods [14].

Urodynamic investigations were performed in only 23% of the referred patients. This practice is in line with other studies concluding that a specialist-trained continence nurse is able to use basic assessment tools to diagnose patients correctly without first-line resort to invasive and expensive investigations [15].

Our findings indicate that the majority of patients reporting urinary symptoms can be managed effectively by a continence nurse specialist without the need for referral to secondary care or for surgery. Conservative treatments such as lifestyle interventions and behavioral therapies have been shown to be successful with improvement or cure rates between 68% and 74%, respectively [16]. In keeping with this, 59% of patients in this study did not require onward referral and were discharged from the UTC. In contrast to conventional practice, we also introduced the concept of group therapy classes as opposed to `one to one therapy, although it was still available on request. This has proved very effective because it enabled larger numbers of women to be trained in a shorter space of time and the social interactions of the group therapy sessions provided each individual patient with useful perspective on her condition.

The mean time interval from referral to first visit was 4.6 weeks which effectively enables the patient pathway to be completed within the United Kingdom government target of 18 weeks. Additionally, the mean number of visits of 2.1 and the time period from first visit to final outcome of 8.8 weeks falls well within the 18-week pathway target. The UTC reduced the mean time interval from referral to first visit by a third (4.6 weeks compared to pre-UTC of 15.6 weeks). There was a considerable reduction in the number of patient visits from a mean of 44 weeks prior to the UTC to 8.8 weeks. These results can have profound implications on the design of conventional existing services in the NHS that utilize multiple professionals to deliver facets of continence care that are fragmented, thereby increasing the patient journey.

The white paper, “Our Health, Our Care, Our Say,” set a new direction for the health and social care system [17]. The paper proposed a radical and sustained shift in the way in which services are delivered, ensuring that they are more personalized and that they fit into people's busy lives. This will give patients a choice as to where they are seen and care delivered, so that they are the driving force for service improvement. Patients attending the UTC have a choice to how many visits they feel they need to attend and the service set up is flexible. This gives a high degree of choice to the patient and plays a key role in compliance and an ultimate outcome.

Services such as the UTC that are streamlined and designed to deliver all significant aspects of continence care through a single trained individual would decrease the number of visits needed by the patient and thus increase the efficiency of the service. Such integrated care services are advantageous over traditional clinics. They provide a structured framework for evidence-based best practice for identified patient groups, are patient-centered and clinically driven, and act as a tool for systematic action to ensure continuous improvements in patient care. They ensure fewer missed appointments by patients as the number of visits required are fewer and is controlled by the patient to a large extent.

Thus, the UTC serves to highlight the role of the primary healthcare team as crucial in accessing and facilitating secondary care judiciously. The strength of this study is the evaluation of the management of a large number of women with varied urogynecological problems.

The limitation of this study is the retrospective method with its attendant drawbacks of incomplete documentation and noncontemporaneousness. But as this study assesses the effectiveness of a care delivery system, it helps to focus the need for such a service, identify pitfalls, and determine feasibility issues for continuation of the service.

Conclusions

By service redesigning, the UTC has reduced the number of clinic visits, the time interval from first referral to clinic visits, and the time interval from first visit to outcome. The majority of patients were discharged without the need for further referral. The UTC service served to decrease the number of consultant referrals and reduced the waiting list for surgical procedures. There is a real need for such service designing in order to improve the quality of services delivered in an objectively measurable way with appropriate positive outcomes on patient care.