At the 2017 American Urological Association Annual Meeting, Dena Moskowitz from the Virginia Mason Center asked the question, “Use of third line therapy for overactive bladder in a practice with multiple subspecialty providers: are we doing enough?“
The AUA has recognized three advanced therapies for OAB that can help when drugs do not – posterior tibial nerve simulation (PTNS), intradetrusor injection of onabotulinumtoxinA, and sacral nerve stimulation. All three therapies offer documented treatment success with varying degrees of risks and side-effects. The guideline specifies that 3rd line therapies should be done at the specialist level.
Despite the variety of options, use of 3rd line options has been reported as less than 5%. This wouldn’t be so startling if OAB patients found success with earlier treatment such as bladder medications. Sadly, that’s not the case.
Despite Advances, Bladder Medications Still Don’t Fill Need
One-year persistence rates for anticholinergics are incredibly low – 12-39% in a recent meta-analysis by Veenboer and Bosch which also notes that “Despite the potential for better adherence with some anticholinergic agents, these analyses suggest that such benefits have not yet been realized, and many patients end up without effective pharmacotherapy.”
While early results of a Canadian study showed superior 12-month adherence to a β3-agonist (30% for naïve; 39% for experienced) compared to antimuscarinics (14-21% for naïve; 14 -35% for experienced), the fact remains that up to 70% dropped off before one year. In other words, even β3-agonists are not a long-term solution for the majority of patients.
Increasing Use of 3rd Line Therapies
The information Dr. Moskowitz shared during her presentation demonstrates the power of specialty and subspecialty groups in expanding treatment for refractory OAB patients. The poster compared treatment rates for drug and 3rd line therapy at Virginia Mason Medical Center as a whole, within Urology, and within Female Pelvic Medicine and Reconstructive (FPMRS) Urology. What the authors found was that as the scope of care became more granular, use of 3rd line therapy for OAB patients increased – 4.5% overall, 11.7% in Urology and 15.8% in FPRMS Urology. Moskowitz also noted that the institution employs a care pathway that emphasizes early patient education on available options should they fail 1st and 2nd line options.
OAB navigators are another way some providers are driving use of 3rd line therapy. For example, across the 12 offices of Urology Associates, P.C., a team of five is responsible for navigating patients for various urologic conditions including OAB, stress urinary incontinence and prostate issues. Beth Rutledge, Chief Nursing Officer, sees these patient navigators as a “service line” to help provide education about treatment options and personalized support throughout the treatment continuum.
However, Rutledge believes that the responsibility for patient navigation is something shared by all staff members. “Healthcare is not a scientific problem, it’s an information problem,” said Rutledge. “When it comes to the care pathway, we need to provide the entire menu up front instead of just the appetizer menu.”
For Urology Associates, the ultimate goal is standardized care for every patient. “It shouldn’t be like winning the lottery. Everyone should have the same options,” said Rutledge who also acknowledges that this can be challenging since individual providers may instinctively want to own the totality of a patient’s care and might not suggest treatments beyond what they offer. As a result, patients aren’t allowed to consider the treatments that make the most sense for them. “The patient is the most underutilized resource in medicine today,” Rutledge said. Patient navigation makes sure patients have the support they need to ensure they receive the best possible care.
OAB Navigation within your Practice
For Urology Associates, it’s been a 2-year journey to integrate and fully appreciate the role of Navigators within their practice. During that time, Rutledge and her team have developed processes and tools to move patients through the OAB treatment pathway. Don’t have 2 years or a designated OAB Navigator? We can help. In her role as consultant for Cogentix Medical, Rutledge provides guidance and support to Urgent PC practices trying to implement navigation best practices to drive increased penetration of 3rd line therapies within their accounts. If you’re interested in learning from Rutledge’s experience, please contact your territory manager or complete this form.
Urgent PC is indicated for the treatment of Overactive Bladder and associated symptoms of urinary urgency, urinary frequency and urge incontinence. Treatment with Urgent PC is contraindicated for patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function or patients who are pregnant or planning to become pregnant during the duration of the treatment. Most patients don't experience side-effects. If side-effects occur, they are typically temporary and include mild pain and skin inflammation at or near the stimulation site. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For complete instructions for use, storage, warnings, indications, contraindications, precautions, adverse reactions and disclaimer of warranties, please refer to the insert accompanying each product or online at www.cogentixmedical.com. Models are for illustrative purposes. Urgent is a registered trademark. © 2017 Cogentix Medical. All rights reserved.