Improving the Quality of Care for Women With Urinary Incontinence

“Even when patients were very bothered by incontinence, neither they nor the provider brought it up during healthcare appointments. There is a missing link, and my AHRQ-funded study is helping to fill the gap.”

From a young age, Jennifer Anger, M.D., M.P.H.’s life’s goal was helping people, and she knew at an early age that she wanted to be a doctor. Today, she is an AHRQ-funded expert in female pelvic medicine and reconstructive surgery. 

Dr. Anger, professor and vice chair of research in the Department of Urology at the University of California San Diego Health, has dedicated her career to improving the safety and quality of care for underserved patients, particularly those with pelvic floor disorders—conditions that occur when the muscles, ligaments, or connective tissues that support the pelvic organs weaken over time. This can cause the pelvic organs to sag and lead to problems with bladder and bowel control. Some common types of pelvic floor disorders include urinary incontinence (UI), fecal incontinence, and urinary frequency and urgency. Her AHRQ-funded projects focus on providing the highest quality of evidence-based care to patients. 

“UI is common with aging, but it’s not a part of normal aging,” said Dr. Anger. “Many women are hesitant to bring it up to their provider. Embarrassment is likely the biggest factor that prevents the condition from being addressed.”

Over 25 million American adults experience UI, a condition that is two times more common in women than men. Various factors drive the development of UI, including the stresses of pregnancy and childbirth and the hormonal changes of menopause. Depending on the cause and the severity of the condition, both surgical and nonsurgical treatment options are available to patients. 

Dr. Anger was awarded a 4-year AHRQ grant in 2022 to improve the quality of care for women who have developed a temporary or chronic loss of bladder control resulting in involuntary urine leakage or UI. Her project aims to improve UI care provided to women by primary care physicians, thereby reducing the number of referrals to specialists. Working with one’s primary care provider may contribute to higher quality, more person-centered care, according to Dr. Anger. Her study entails the intervention of a broad mix of primary care physicians who treat patients with UI at one of four Southern California health systems. The intervention includes physician education, individual performance feedback, electronic decision support, and patient education using dedicated advanced practice providers, such as nurse practitioners and physician assistants, trained in specialty areas. Her study encompasses an ethnically diverse population of women who are fluent in either English or Spanish. This project is expected to end January 31, 2026.

With a continued focus on enhancing patient care, Dr. Anger received a 5-year AHRQ-funded Patient Safety Learning Laboratory grant in 2023. She collaborated with a multidisciplinary research team on the project “TRANS-SAFE Patient Safety Learning Lab: Systems Improvement for Psychosocial Safety in Transgender Care,” which focuses on generating evidence to improve patient safety, healthcare quality, and accessibility for transgender patients. Through partnership with the World Professional Association for Transgender Health (WPATH), the evidence generated through this research will be translated into a TRANS-SAFE certification program for healthcare organizations, ensuring that the evidence is widely understood and used. The project ends January 31, 2027.

These grants build on Dr. Anger’s earlier AHRQ-funded work in which she served as a co-principal investigator on a 5-year AHRQ grant with Ken Catchpole, Ph.D., to improve the safety and efficiency of robotic-assisted surgery (RAS) in 2018.

Robotic technology is used to expand and extend a surgeon’s reach while performing delicate surgical procedures that would otherwise be too complex. Surgical technologies, such as RAS, provide benefits to both patients and surgeons. However, they can introduce new challenges and errors related to communication, workflow, and coordination into an already complex arena. 

Dr. Anger and her colleagues were interested in how best to integrate innovative surgical technologies within complex clinical work systems without compromising safety. Applying a human factors research approach, they tested various new methods of teamwork training, task design, and workspace management. The study identified evidence-based opportunities to improve performance, reduce errors, and shorten the surgical learning curve. The team developed a “robotic Olympics,” led by human factors researcher Tara Cohen, Ph.D., which applied a game-based educational competition to improve team skills needed to successfully perform RAS. Insights gained from this research will help hospitals safely use technologies and improve patient outcomes. 

Dr. Anger is a dual fellowship-trained reconstructive urologist. She is also a member of the American Urological Association and WPATH. She serves as a mentor to young physicians and believes that there is a real need for more women in the field. “Even now, only 10 percent of urologists are women, while women make up about 30 percent of urologic patients,” Dr. Anger said. “That’s a serious representation gap.”

Principal Investigator: Jennifer Anger, M.D., M.P.H.
Institutions: UC San Diego Health 
Grantee Since: 2018
Type of Grant: Various

AHRQ Resources

• AHRQ Safety Program for Improving Surgical Care and Recovery
• Effective Health Care Program: Urinary Incontinence
• EvidenceNow: Managing Urinary Incontinence
• Nonsurgical Treatments for Urinary Incontinence in Adult Women: A Systematic Review Update
• Surgery