Nonsurgical Options for Treating Incontinence.

INTERVIEW WITH DEBBIE FOLKERTS, ARNP-C 

When residents arrive at nursing homes, it is often because of an incontinence problem, and a facility's response can affect its reputation. Anything short of adequate leads to resident embarrassment, possible skin disorders and poor state survey results. Even before that, social stigma often paralyzes incontinent seniors from contacting healthcare providers about their condition. Couple that with fears that surgery might be required, and it's no wonder many people don't seek professional help until they're admitted to a nursing home. Nonsurgical therapies such as biofeedback and pelvic floor stimulation aim to change all that, and Medicare reimbursement might be available to help. Debbie Folkerts, ARNP-C, a nurse practitioner for 15 years with a background in urology and a co-owner of the consulting firm First Choice for Continence, Inc., detailed how these therapies apply to long-term care in an interview with Nursing Homes/Long Term Care Management Assistant Editor Douglas J. Edwards.

Edwards: What is involved in using biofeedback to treat incontinence?

Folkerts: Biofeedback involves the monitoring of the pelvic floor muscle with either an electromyographic (EMG) sensor, which monitors the electrical activity of the muscle, or with a manometry sensor, which monitors pressure or strength exerted by the muscle. The patient looks at a monitor and, when instructed to contract the muscle, can actually see if he/she has found the right one and is contracting it correctly. Many people fail Kegel exercises aimed at limiting incontinence because they never identify the correct muscle. Women are often not given good instructions on Kegel exercises and, in fact, studies have found that 80% of nurses couldn't perform them properly.

Edwards: What is involved with pelvic floor stimulation?

Folkerts: With pelvic floor stimulation, a sensor is used to apply stimulation to the pelvic floor muscle. This can be done rectally, vaginally or with surface stimulation. Pelvic floor stimulation does two things: (1) it strengthens the muscle to enhance faster rehabilitation; (2) it helps to suppress unwanted bladder contractions, which can cause urinary urgency, frequency and incontinence, so that the bladder is not as irritable. We don't understand exactly all the mechanisms involved and why it works so well, but patients do very well with this treatment.

Edwards: How often do these therapies need to be administered?

Folkerts: The protocols that clinicians use vary widely. Some see patients twice a week; some want to see a patient four to six times; others determine the number of visits based on a patient's response, which is my approach.

Edwards: How effective are these therapies?

Folkerts: The literature has reported these therapies to be 60 to 100% effective. In my practice, 80% of my patients get at least 80% better, or even cured, with these types of therapies.

Edwards: Do these therapies have any side effects worth noting?

Folkerts: That's the beauty of these therapies: There are really no side effects with them. How often can we say that with any other treatment modality in medicine? The most commonly observed adverse effect occurs with pelvic floor stimulation; i.e., a patient might fatigue his/her pelvic floor muscle and for 24 hours might have a little less control. After that, it's back to where it should be.

Edwards: Is there any pain associated with pelvic floor stimulation?

Folkerts: No. A patient might feel it's a little strange to have the muscle contracting without telling it to, but it is not uncomfortable.

Edwards: Which nursing home residents benefit the most from these therapies?

Folkerts: A wide variety: those with urinary frequency (i.e., who turn on the call light every 20 to 30 minutes to use the restroom); residents with urge incontinence (i.e., all of a sudden they feel the need to void and must use the restroom immediately or they will have an incontinent episode); residents with stress incontinence (i.e., they leak when they cough, sneeze or laugh); those with mixed urinary incontinence (both urge and stress); and those with pelvic pain that is gynecologic in origin. The patient must be cognizant and have the ability to follow instructions.

Edwards: Are there any residents who tend not to respond as well?

Folkerts: A radical prostatectomy patient is much slower to respond, and the response is contingent on how long it has been since his surgery.

Edwards: How might a skilled nursing facility track the results of these therapies?

Folkerts: The facilities I have visited usually look at two things: (1) the laundry costs of the residents undergoing these treatments--it's not unusual for them to realize a 45% reduction in laundry costs; (2) the type of pads used by the residents. Using differing types of pad to gauge results is difficult because many facilities stock only one type of pad--the diaper. If a facility is going to use pads to track progress, caregivers need to use the appropriate-sized pads for residents and adjust them as residents' needs change.

Facilities can also consider personnel costs. In many situations, facilities have noticed a decrease in personnel time and the associated costs when using these therapies. Facilities can also look at incidence of secondary factors, such as hip fractures from falls because of slippery floors, occurrence of skin conditions, etc.

Edwards: How much do these therapies typically cost a facility to incorporate?

Folkerts: First, the facility needs a staff member (e.g., nurse practitioner, physician assistant or physical therapist) to specialize in these therapies, because they are very clinician-dependent. This person needs to have knowledge of the bladder and be able to identify when a secondary condition arises, such as a urinary tract infection, or whether other pathologies might be involved.

Second, the facility needs to invest in the equipment. There is a vast array of equipment available. To perform basic biofeedback, a facility will probably spend $6,000 to 7,000, which includes two channels of EMG (a channel is a wire from the equipment with a sensor on the end to monitor a muscle group), a stimulation unit and computer to operate the equipment. A more complex piece of equipment--which has two channels of EMG, two channels of manometry and pelvic floor stimulation and can be used to perform a variety of incontinence testing--costs $11,750 to 18,000.

Edwards: What's the outlook for Medicare reimbursement for these therapies?

Folkerts: On October 6, 2000, HCFA issued a policy decision saying biofeedback therapy would be covered for the treatment of patients with stress and/or urge incontinence who failed a documented trial of pelvic floor exercise training or who are unable to perform pelvic floor exercises. They also stated in that decision that the individual contractors or fiscal intermediaries (FIs) may decide whether to cover biofeedback as an initial treatment modality.

HCFA also said that pelvic floor stimulators inserted into the vaginal canal or the rectum would be covered as reasonable and necessary for the treatment of stress and urge urinary incontinence. However, pelvic floor stimulation is not covered as an initial treatment modality; a patient must have first undergone and failed a documented trial of pelvic muscle exercise training before qualifying for reimbursement. Also, implanted stimulators are still not covered.

Edwards: What does the future hold for these therapies?

Folkerts: Although we know these therapies are effective, unfortunately healthcare is driven by what's reimbursed, and that's why it has taken them awhile to take hold. With HCFA's decision, the rest of the insurance industry will have to follow suit and recognize that these are very efficacious, cost-effective forms of treatment that do not limit use of any other treatment modalities, if they're indicated. Eventually you might see approval of nonsurgical treatment before surgical treatment, and that would be a turnaround.