Evidence-based pelvic floor disorder care pathways optimize shared decision making between patients and surgeons

Abstract

Introduction and hypothesis: Evidence-based care pathways improve care standardization and patient outcomes. We created pelvic organ prolapse (POP) and stress urinary incontinence (SUI) care pathways as decision aids for our multidisciplinary team to use when counseling patients.

Methods: Using a modified Delphi process, an expert team reviewed existing guidelines and literature to reach consensus on pathway definitions and components.

Results: Entry to the care pathways occurs via an advanced practice provider visit. Symptom and quality-of-life questionnaires as well as open-ended patient goals are used to guide patient-provider shared decision making. All treatment choices, including surgical and nonsurgical management, are presented to patients by advanced practice providers. Patients electing nonsurgical management follow-up by telehealth (preferred) or in-person visits as determined by the care pathway. Surgeon consultations are scheduled for patients desiring surgery. Surgical patients undergo urodynamics, simple cystometrics or deferred bladder testing according to the urodynamics clinical pathway. Postoperative follow-up includes telehealth visits and minimizes in-person visits for women with uncomplicated postoperative courses. Patients with resolution of symptoms are graduated from clinic and return to their referring physician. The pathways are revised following publication of new compelling evidence.

Conclusions: We developed POP and SUI care pathways to standardize care across a diverse provider group. Advanced practice providers use care pathways with patients as shared decision-making tools for initial evaluation of patients with prolapse and incontinence. These pathways serve as components of value-based care and encourage team members to function independently while utilizing the full scope of their training.

Keywords: Advanced practice provider; Care pathway; Patient-reported outcomes; Pelvic organ prolapse; Pessary; Shared decision making; Stress urinary incontinence; Value-based care.

Fig. 1

Pelvic organ prolapse clinical pathway. APP advanced practice provider, MA medical assistant, PFPT pelvic floor physical therapy, POD postoperative day, POP-Q Pelvic Organ Prolapse Quantification, PROs patient-reported outcomes, PVR postvoid residual, UDS urodynamics

Fig. 2

Urodynamics clinical pathway. MUI mixed urinary incontinence, SUI stress urinary incontinence, UI urinary incontinence, UUI urgency urinary incontinence

Fig. 3

Stress urinary incontinence clinical pathway. APP advanced practice provider, MA medical assistant, PFPT pelvic floor physical therapy, POD postoperative day, POP-Q Pelvic Organ Prolapse Quantification, PROs patient-reported outcomes, PVR postvoid residual, UDS urodynamics