1. Study Design

This study was a retrospective descriptive study. The purpose of this study was to investigate the adherence to CIC following a CIEP and influencing factors on compliance.

2. Study Participants

We retrospectively reviewed the data in November 2016. The inclusion criteria were as follows: (1) patients aged over 15 years with emptying failure. Emptying failure patients were defined as those who couldn't void at all or could partially void with a large amount (>100 cc) of residual urine. (2) All patients who revisited the CIC clinic for follow up between January 2012 and July 2014. This study was undertaken in a tertiary referral center, and all patients in need of CIC were referred to the CIC clinic in the hospital.

3. Study Protocol

The CIEP on CIC was created at the research hospital in 2011. Since then, all patients who were prescribed CIC have learnt the procedure through the program. It was based on previous protocol [16]. Some of the protocol has been modified on the basis of many research findings. It was made up of theoretical knowledges and hands-on practice. Total education time was approximately one hour, and the education was provided one-on-one in a separate space.

The nurse in charge of education completed a Ph.D. program and had more than 15 years of clinical experience. She has attended a conference with peer group and of physicians every month; and lectured as an expert in the urology academic society every year.

The program consisted of watching video, customized theoretical knowledges instruction, and hands-on practice (Table 1). Before education, the nurse checked a medical record such as results of urodynamic study, ultrasonography, and underlying disease or surgery record.

Table 1 Contents of Customized Intensive Education Program Click for larger image

At first, a patient watched a video for an overview of CIC. The video lasted for 7 minutes.

After watching the video, customized theoretical knowledges instruction was provided based on the disease states and test results individually. The nurse explained the patient's underlying disease and how the underlying disease cause the emptying failure in detail. In addition, the nurse stressed the advantage of CIC and disadvantage of other methods including the mechanism which complications occur. The patient was educated about the CIC thoroughly.

The next course was a hands-on practice. Before practice education, the nurse checked the patient's physical condition and the structure of the toilet of the patient's house. The nurse explained the process as simply as possible in order not to make it strike the patients as a cumbersome technique. They were taught differently depending on the sex: man in the standing position and a woman in the sitting position on a toilet, respectively. The nurse found the most appropriate posture for the catheterization with the patient and taught various ways to locate the urethra. If the patient had poor vision, she taught the ways to locate the urethra by touch. Except for the patients who were bed-ridden and quadriplegic, she encouraged them to catheterize themselves. The practice session continued until the trainee was able to master the technique.

When the education was over, each patient received a questionnaire about the degree of understanding, satisfaction with the education, and degree of confidence that he/she could catheterize alone; and the most inconvenient procedures. Additionally, the nurse asked the patient about the process of catheterization and what he/she needs to know using short answer questions; if the patient answered incorrectly, the nurse explained it again. At the end of the program, the nurse encouraged the patient to express his/her feelings freely and consulted. If the patient wanted additional counselling after returning home, the patient could call the nurse during office hours.

To check the patients' voiding conditions and compliance, the urologist advised them to revisit the urology clinic no later than one month after the completion of the education. When they revisited, the interview was done via a questionnaire. It included questions about who performed the catheterization, how it was done, or what made the subjects compliant or noncompliant. If the CIC method was not correct, re-education was provided.

4. Data Collection

We collected clinical characteristics of patients such as age, sex, income, education level, occupation, hand dexterity, performance status, primary reasons for emptying failure and voiding status. Among the primary reasons for emptying failure, hysterectomy and low anterior resection was categorized as peripheral nerve injury, and diabetes and peripheral neuropathy were categorized as systemic disease. The voiding status was divided into partial emptying failure and complete emptying failure.

For the short-term adherence rate, answers to the questionnaire and voiding diary in medical records on the second visit were analyzed. The question of questionnaire was “Did you perform CIC as the doctor ordered?” Of the 6 scale answer to the question, ‘somewhat yes’, ‘almost yes’, ‘completely yes’ were categorized as adherent. The medical records and voiding diary in medical record on the last follow-up day were analyzed for the long-term adherence rate. We reviewed the medical record in November 2016. The case that self-voiding was restored and regular catheterizing was performed until the last visit were categorized as adherent. If the last follow-up day was over 6 months, they are categorized follow-up loss and non-adherent.

The level of understanding, satisfaction, and confidence after first education and barrier to CIC were also collected. Finally, we investigated the influencing factor on adherence.

We obtained approval from institutional review board of Seoul National University Hospital (No: H-1408-002-596). This study was exempted from receiving consent because it is unlikely to cause harm to subjects

5. Data Analysis

Descriptive analysis was conducted for description. For the difference in urologic anatomy and urination process by sex, we classified the subjects into male and female groups. Chi-sure or Fisher's exact test for categorical variable and student's t-test for continuous variable were used to compare differences between groups. We evaluated potential influencing factors on the adherence: adherent and non-adherent. These variables were sex, age, the level of education, income, occupation, primary reason for emptying failure, the level of understanding, the level of satisfaction, the level of confidence. Statistical analyses were done with the SPSS software (Statistical Package for the Social Sciences, version 21.0, SPSS Inc.), and a p-value of < 0.05 with a 95% confidence level was considered statistically significant.

1. Characteristics of Patients

The average age was 65.25±14.18 years and the man was older (p=.002). 62.4 % of patients were men. Unemployment (51.1%) in male and housewives (68.2%) in female were the most common. About 72% of the male and 64.7% of the female patients had a good dexterity of the hand. 56.6 % of patients could walk without help. 77.0% of patients could perform self-catheterization after the first session of education. The most common primary reasons for emptying failure were urologic disease (32.6%) in male and spinal cord lesions (30.6%) in female. Most of the patients with unknown etiologies were in a bedridden state. Demographic and clinical characteristics of the patients are presented in Table 2.

Table 2 Characteristics of Patients (N=226) Click for larger image

2. Response to Initial CIC Education

Most of the patients showed a high level of understanding, satisfaction, and confidence. The level of confidence of male was higher than female (p=.014). The most uncomfortable process was significantly different depending on the gender (p<.001). The male patients thought cleaning the perineum caused the most discomfort while the female patients thought identifying the urethra caused the most discomfort. The male patients complained about a sense of discomfort during the insertion of the catheter much more than the female patients (Table 3).

Table 3 Patient's Response to Initial CIC Education (N=226) Click for larger image

3. Adherence Rate and Barrier

At the second visit, the median duration was 22days, adherence rate was 87.6%(198 of the 226). 28 patients were non-adherent and 16 of 28 did not performed CIC at all. The degree of short term adherence was different by gender (p=.031). The major barrier was time management (44.7%), followed by none (24.8%). Although the number decreased, male still had difficulty inserting the catheter and female patients had difficulty identifying the urethra. The number of people who said there was no difficulty has grown from 23 to 56.

The long-term, the median time was 112 days, adherence rate was 50.4%. Ten of the 30 patients who stopped catheterization on their own authority were too seriously ill to perform CIC and had to switch to indwelling catheterization. And nine of the 51 follow-up loss patients were stable, so referred to the primary clinic where the patient lived (Table 4).

Table 4 Patient's Adherence and Barrier Click for larger image

4. The Influencing Factor on Compliance

According to univariate logistic regression analysis, only income variable was associated with adherence (OR: 3.08 [95% CI=1.58~5.99], p=.001), so we couldn't perform multivariable logistic regression analysis. The other variable did not show any significant difference between the two groups (Table 5).

Table 5 The Influencing Factor on Compliance Click for larger image