16A: Long term clinical outcomes following the Trans‐Obturator Post‐Anal Sling (TOPAS) procedure

Abstract

15 Identifying barriers to third-line therapy: a patient-centered approach to refractory overactive bladder A. Davenport, S. Stark, A. Quian, D. Sheyn, J. Mangel Case Western Reserve University, Cleveland, OH, Obstetrics & Gynecology, MetroHealth Medical Center, Cleveland, OH, Female Pelvic Medicine and Reconstructive Surgery, MetroHealth Medical Center, Cleveland, OH, Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, Vanderbilt University, Nashville, TN OBJECTIVES: To explore the reasons why women do not pursue thirdline therapy for overactive bladder (OAB). MATERIALS AND METHODS: This is a qualitative research project aiming to identify barriers to treatment with intradetrusor onabotulinumtoxinA, sacral neuromodulation, or percutaneous nerve stimulation. Initial data collection included a chart review of English-speaking women aged 18 to 80 with a diagnosis of OAB who attended an office visit in the departments of urogynecology or urology at our institution between January 2017 and March 2018. Of these women, patients counseled for third-line therapy, refractory to two or more medications, or lost to follow up after initiating a second medication were considered study candidates. Previous recipients of third-line therapy were excluded. Potential study candidates were then randomly invited to participate in a semi-structured phone interview using a beta-tested interview guide. Interview topics included medical knowledge and beliefs, quality of life, and treatment experience. The interviews were then transcribed into text. Using grounded theory, three independent researchers with experience in qualitative methodology reviewed the transcriptions and coded participant responses thematically. Interviews continued to be performed until no new themes were identified (theoretical saturation). Each coder reviewed the themes identified by the other members of the research team and any coding discrepancies were discussed amongst the group for internal validation. RESULTS: On chart review, 381 English-speaking women aged 18 to 80 with a diagnosis of OAB were evaluated in the office from January 2017 to March 2018. 66 patients (17.3%) had already received thirdline therapy. 56 women qualified for our study. The average interview length was approximately 30 minutes and theoretical saturation occurred at 30 interviews. Insufficient or deficient in-office education was the most common modifiable barrier identified by the women interviewed. Many participants would have preferred to be educated about third-line options earlier—perhaps beginning at the first office visit. Other modifiable barriers included negative experiences with previous treatments or evaluation techniques, provider sex, and wait times. Non-modifiable barriers included desire for non-invasive interventions, fear of side effects, negative anecdotes from friends, cost, concern about repeat procedures, self-defined readiness, medical co-morbidities, and media portrayal of onabotulinumtoxinA. CONCLUSION: In-office education is of paramount importance to women suffering from refractory OAB. Timing of counseling is of equal importance. Third-line therapy counseling should be incorporated into the initial office visit. This may improve patient compliance and graduation to advanced therapy in women who later go on to develop refractory symptoms.