Abstract
INTRODUCTION/HYPOTHESIS:
We describe responsiveness and minimally important difference (MID) for the Accidental Bowel Leakage Evaluation (ABLE) questionnaire.
METHODS:
Women with bowel leakage completed ABLE, Patient Global Impression of Improvement, Colorectal Anal Distress Inventory, and Vaizey questionnaires pretreatment and again at 24 weeks post-treatment. Change scores were correlated between questionnaires. Student’s t-tests compared ABLE change scores for improved vs. not improved based on other measures. The MID was determined by anchor- and distribution-based approaches.
RESULTS:
Of 266 women, mean age was 63.75 (SD=11.14) and 79% were white. Mean baseline ABLE scores were 2.32 +/− 0.56 (possible range 1–5) with a reduction of 0.62 (SD=0.79) by 24 weeks. ABLE change scores correlated with related measures change scores (r=0.24 to 0.53) and differed between women who improved and did not improve (all p < 0.001). Standardized response means for participants who improved were large ranging from −0.89 to −1.12. Distribution-based methods suggests a MID of - 0.19 based on criterion of one SEM and −0.28 based on half a standard deviation. Anchor-based MIDs ranged from −0.10 to −0.45. We recommend a MID of −0.20.
CONCLUSIONS:
ABLE is responsive to change, with a suggested MID of −0.20.
Keywords: Fecal Incontinence, accidental bowel leakage, Symptom Questionnaire
Brief Summary:
The Accidental Bowel Leakage Evaluation (ABLE) questionnaire is responsive to change and has a recommended MID of −0.2.
Introduction:
Fecal incontinence (FI) is a common condition with profound impact on the sufferer’s quality of life (QOL)1,2. As the current population ages, the condition will likely become even more prevalent, driving a need for high quality research into evaluation and treatment. There is an unmet need for an assessment of FI that is patient-centered, valid, and responsive to change. Our group recently designed and validated the Accidental Bowel Leakage Evaluation (ABLE), a comprehensive, patient-centered tool for the assessment of accidental bowel leakage (ABL) symptoms. In contrast to other FI assessment scales, the ABLE was developed with focus groups and cognitive interviews, providing a patient-centered, comprehensive assessment of FI symptoms.
Our prior work demonstrated that the ABLE is reliable with good psychometric properties 3,4. However, in order to demonstrate the validity of the instrument for interventional studies, patient reported outcome (PRO) assessment instruments need to appropriately assess change in symptoms over time or demonstrate responsiveness to change. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) group defines responsiveness as “the ability of an instrument to detect change over time in the construct to be measured”3. Responsiveness to change is an important component of a PRO scale which furthers the validity of the instrument and enhances its utility in interventional studies.
Another critical factor in the study of QOL conditions such as FI is determining what amount of change in the scale results in meaningful change to a patient. With large sample sizes, small differences in the scale can be statistically significant. Still, statistical significance may not reflect a clinically relevant improvement in patient QOL. The Minimum Important Difference (MID) is the smallest change in a questionnaire score that correlates with clinically important symptom improvement5. Determination of the MID for a PRO scale is essential, as it allows confirmation that differences which are statistically significant are also clinically meaningful.
Having already demonstrated reliability and validity of the ABLE4, our objective for this study was to demonstrate responsiveness to change and determine the MID for the scale.
Materials and Methods:
The validation study for the ABLE measure was a planned ancillary study to a multi-site randomized controlled trial of primary treatment for women with FI as a part of the Pelvic Floor Disorders Network (PFDN) 6,7. Participants completed the ABLE measure at baseline, and again at 24 weeks following treatment. In addition, a subgroup of participants completed the ABLE measure at approximately two weeks after baseline but before treatment to assess test-retest reliability. Study procedures for all sites were approved by the Institutional Review Board and all participants provided written informed consent. The study included women who were at least 18 years old and had fecal incontinence of liquid or solid stool at least monthly over the past 3 months that was bothersome enough to desire treatment. Women with severe constipation (Bristol Stool Index #7) or loose stools (Bristol Stool Index #1) were excluded, as were women who were currently undergoing physical therapy for anal incontinence or had previously or currently using loperamide. A full description of the exclusion and inclusion criteria are included in the parent trial. 6
The ABLE questionnaire was developed as a comprehensive measure of accidental bowel leakage symptoms in women. The items on the measure reflect a conceptual framework developed based on patient input through focus groups and cognitive interviews 8. The measure includes items on liquid and solid stool, mucus, gas, predictability, awareness, control of symptoms, and ancillary bowel symptoms. Scores on the measure range from 1 to 5 with higher scores indicating more severe symptoms. Evaluation of the reliability of the measure demonstrates good internal consistency (alphas of 0.77–0.90) and test-retest reliability (ICC=0.80) 4.
Mean (and SD) of change scores from baseline to week 24 were computed for the ABLE scale. Responsiveness to change was evaluated by computing Pearson correlations between change scores at 24 weeks for the ABLE and change scores from related measures, specifically the St. Mark’s (Vaizey) score 8, Pelvic Floor Distress Inventory (PFDI) Colo-Rectal Anal Distress Inventory (CRADI), Pelvic Organ Prolapse Distress Inventory (POPDI), Urogenital/Urinary Distress Inventory (UDI), Colorectal Anal Impact Questionnaire (CRAIQ), Pelvic Organ Prolapse Impact Questionnaire (POPIQ), Urinary Impact Questionnaire (UIQ), Pelvic Floor Impact Questionnaire (PFIQ) 9, and the Fecal Incontinence Adaptation Index10. In addition, we examined the correlation between ABLE change scores and changes in baseline incontinence on bowel diaries, including number of accident-free days per week, average number of leaks per day, and number of pad changes per day. We expected that ABLE should have stronger correlations with measures with similar constructs (e.g., fecal incontinence) and lower correlations with measures of less similar constructs (e.g., urinary incontinence, pelvic organ prolapse).
To further assess responsiveness, we conducted t-tests to compare ABLE change scores for those who improved compared to those did not improve from baseline to week 24 based on their Patient Global Impression of Improvement (PGI-I), CRADI, and Vaizey scores. Participants were classified as having improvement on the PGI-I if they reported that they were ‘very much’, ‘much’, or ‘a little better’. They were classified as having improved on the CRADI and Vaizey if they had change scores equal to at least the minimally important difference (MID) for those scales (≤ −5) 11. In addition, the area under the ROC curve (AUC) was calculated to determine how well ABLE change scores distinguished among participants based on whether their condition improved. Effect sizes and standardized response means were also calculated.
The minimally important difference (MID) for the ABLE was determined using both anchor- and distribution-based approaches as recommended 12. Distribution-based approaches included calculating 0.5 SD and computing one standard error of measurement (SEM). SEM equals the standard deviation of the scores times the square root of one minus the reliability of the measure. SEM represents the variation in “true” scores. For the anchor-based approaches, we computed the MID as the difference in mean ABLE change scores between participants who indicating they were “a little better” based on the PGI-I and those who indicating they had “no change.” Similarly, we computed the difference in mean ABLE change scores for those with minimal change vs. no/less than minimal change on the CRADI and Vaizey measures as defined by the MID.
Results
A total of 296 women completed the ABLE scale at baseline, and 266 at week 24. The sample for these analyses was restricted to the 266 participants who had ABLE scores for both baseline and 24-week follow-up. The demographic characteristics of the 266 study participants are shown in Table 1. Mean age was 63.75 (SD=11.14), over three-quarters (79%) were white, and nearly all (95%) had English as a primary language. More than half reported having private insurance or Medicaid/Medicare.
Table 1.
Study Participant Characteristics(N=266)
| Characteristic | N (%) |
|---|---|
| Age | |
| < 40 | 7 (3) |
| 40–49 | 22 (8) |
| 50–59 | 62 (23) |
| 60–69 | 101 (38) |
| 70–79 | 57 (21) |
| 80+ | 17 (6) |
| Race | |
| Native American/Alaskan Native | 3 (1) |
| Black/African American | 40 (15) |
| White | 211 (79) |
| Other | 7 (3) |
| More than one race | 5 (2) |
| Ethnicity | |
| Hispanic/Latina | 26 (10) |
| Not Hispanic/Latina | 240 (90) |
| Primary Language | |
| English | 254 (95) |
| Spanish | 8 (3) |
| Other | 1 (0) |
| Unknown | 3 (1) |
| Insurance | |
| Private insurance | 160 (60) |
| Medicaid/Medicare | 141 (53) |
| Self-pay (without insurance) | 4 (2) |
| Other | 22 (8) |
| Unknown | 2 (1) |
| Patient Global Impression of Improvement (Week 24) | |
| Improved (Very much/much/a little better) | 206 (77) |
| Did not improve (No change/worse) | 40 (15) |
| Unknown | 20 (8) |
| CRADI* | |
| Improved (Change score ≤ −5) | 176 (66) |
| Did not improve (Change score > −5) | 70 (26) |
| Unknown | 20 (8) |
| St. Mark’s (Vaizey) Score | |
| Improved (Change score ≤ −5) | 137 (52) |
| Did not improve (Change score > −5) | 129 (49) |
Note: Sample restricted to participants with ABLE scores at baseline and week 24. Respondents may have more than one type of insurance.
CRADI – Colorectal Anal Distress Inventory
Mean (SD) scores for ABLE and the other measures at baseline and week 24 are shown in Table 2. On average, participants had a mean reduction of 0.62 (SD=0.79) in ABLE scores from baseline to week 24. Overall, mean scores for all scales were lower at week 24 and based on bowel diaries, participants had fewer leaks and pad changes per day and nearly two more accident-free days per week.
Table 2.
Mean (SD) Scores on Accidental Bowel Leakage Evaluation and Related Measures at Baseline, Week 24, and Change from Baseline to Week 24 (N=266)
| Measure | Baseline | Week 24 | Change |
|---|---|---|---|
| Mean (SD) | Mean (SD) | Mean (SD) | |
| Accidental Bowel Leakage Evaluation Scale | 2.32 (0.56) | 1.70 (0.80) | −0.62 (0.79) |
| St. Mark’s (Vaizey) Score | 14.16 (4.07) | 8.73 (5.31) | −5.43 (5.85) |
| Pelvic Floor Distress Inventory (PFDI) | 115.68 (60.10) | 79.23 (56.55) | −38.39 (49.80) |
| Urinary Distress Inventory (UDI) | 39.91 (28.62) | 30.04 (26.98) | −10.19 (22.43) |
| Colorectal Anal Distress Inventory (CRADI) | 50.04 (21.55) | 31.84 (22.41) | −19.04 (22.31) |
| Pelvic Organ Prolapse Distress Inventory (POPDI) | 25.74 (22.08) | 17.35 (18.62) | −9.16 (19.06) |
| Pelvic Floor Impact Questionnaire (PFIQ) | 100.36 (78.40) | 67.82 (73.18) | −34.92 (53.69) |
| Urinary Impact Questionnaire (UIQ) | 32.12 (28.58) | 22.54 (26.49) | −10.80 (20.86) |
| Colorectal Anal Impact Questionnaire (CRAIQ) | 41.98 (28.00) | 27.36 (27.26) | −15.11 (20.16) |
| Pelvic Organ Prolapse Impact Questionnaire (POPIQ) | 26.26 (28.36) | 17.93 (25.28) | −9.01 (21.51) |
| Fecal Incontinence Adaptation index | |||
| Hygiene | 47.03 (21.14) | 38.64 (23.39) | −8.96 (18.24) |
| Avoidance | 34.76 (22.87) | 26.87 (22.84) | −8.71 (17.02) |
| Bowel diary | |||
| Number of accident-free days per week | 2.90 (2.15) | 4.87 (2.30) | 1.94 (2.40) |
| Average number of leaks per day | 1.55 (1.75) | 0.65 (1.18) | −0.89 (1.62) |
| Average number of pad changes per day | 0.60 (0.89) | 0.28 (0.74) | −0.30 (1.01) |
Change scores for the ABLE from baseline to week 24 significantly correlated with change scores on all related measures (Table 3). As hypothesized, higher correlations were observed for closely related measures, such as the CRADI (r=0.53), Vaizey (r=0.53), and Fecal Incontinence Adaptation Index (r=0.46–0.48), and lower correlations for less similar constructs, such as the POPIQ (r=0.23) and UIQ (r=0.24).
Table 3.
Correlations of Change Scores from Baseline to Week 24 between ABLE and Related Measures (N=266)
| Measure | ABLE |
|---|---|
| r | |
| St. Mark’s (Vaizey) Score | 0.53 |
| Pelvic Floor Distress Inventory (PFDI) | 0.46 |
| Urinary Distress Inventory (UDI) | 0.32 |
| Colorectal Anal Distress Inventory (CRADI) | 0.53 |
| Pelvic Organ Prolapse Distress Inventory (POPDI) | 0.20 |
| Pelvic Floor Impact Questionnaire (PFIQ) | 0.33 |
| Urinary Impact Questionnaire (UIQ) | 0.24 |
| Colorectal Anal Impact Questionnaire (CRAIQ) | 0.40 |
| Pelvic Organ Prolapse Impact Questionnaire (POPIQ) | 0.23 |
| Fecal Incontinence Adaptation index | |
| Hygiene | 0.48 |
| Avoidance | 0.46 |
| Bowel diary | |
| Number of accident-free days per week | −0.40 |
| Average number of leaks per day | 0.26 |
| Average number of pad changes per day | 0.24 |
Note: All Pearson correlations significant at p < 0.001.
Mean ABLE change scores differed significantly between participants who improved and those who did not improve based on the PGI-I, CRADI, and Vaizey (Table 4). The number of women who had no change in the PGI-I was small (n= 37) as well as those who deteriorated (n= 23). As planned, the PGI-I was dichotomized into improved vs did not improve. AUCs were acceptable with values of 0.72 to 0.76. ABLE standardized response means for participants who improved were large (> 0.8) with values of −0.89 to −1.12.
Table 4.
Responsiveness of Accidental Bowel Leakage Evaluation Scale Scores to Changes in Clinical Condition
| Criterion | ABLE Mean (SD) |
ES | SRM | AUC (95% CI) | |||
|---|---|---|---|---|---|---|---|
| Baseline (N=266) |
Week 24 (N=266) |
Change | p-value | ||||
| Patient Global Impression of Improvement | |||||||
| Improved | 2.36 (0.55) | 1.63 (0.82) | −0.72 (0.81) | < 0.001 | −1.31 | −0.89 | 0.76 (0.69, 0.83) |
| Did not improve | 2.23 (0.54) | 2.12 (0.67) | −0.11 (0.47) | −0.20 | −0.23 | ||
| Colorectal Anal Distress Inventory | |||||||
| Improved | 2.37 (0.57) | 1.58 (0.84) | −0.79 (0.81) | < 0.001 | −1.39 | −0.98 | 0.72 (0.65, 0.78) |
| Did not improve | 2.25 (0.49) | 2.03 (0.66) | −0.22 (0.58) | −0.45 | −0.38 | ||
| St. Mark’s (Vaizey) Score | |||||||
| Improved | 2.33 (0.56) | 1.38 (0.81) | −0.95 (0.85) | < 0.001 | −1.70 | −1.12 | 0.75 (0.69, 0.81) |
| Did not improve | 2.31 (0.56) | 2.04 (0.65) | −0.26 (0.51) | −0.46 | −0.51 | ||
Note: ES=Effect size; SRM=standardized response mean; AUC=area under receiver operating characteristic curve.
Use of distribution-based methods suggested a MID of −0.19 based on criterion of one SEM and −0.28 based on the 0.5 SD criterion. The 0.5 SD criterion is generally considered a conservative estimate of MID 12,13,14. Figure 1 displays the mean ABLE change scores by patient responses to the PGI-I. Participants who reported feeling a little better had mean change of −0.25 compared to −0.15 for participants who reported having no change, resulting in an anchor-based MID of −0.10. Similar comparisons for those experiencing minimal vs. no change on the CRADI suggested a MID of −0.14 and on the Vaizey a MID of −0.45. These disparate findings may be due to the narrow focus of the Vaizey content in comparison to the broader focus of the ABLE and the closer alignment of content on the ABLE and CRADI. After reviewing each of these findings and based on clinical input, we recommend a MID of −0.20.
Figure 1:
Mean (95% CI) ABLE Change Scores from Baseline to Week 24 by Patient Global Impression of Improvement
Discussion
The ABLE questionnaire is a novel, validated, patient-centered, comprehensive assessment of ABL symptoms that is responsive to change and can be used to assess outcomes for FI treatment. We recommend that the MID for the measure should be estimated at 0.20. Accidental bowel leakage treatments are aimed at improving patient symptoms and quality of life; therefore, PROs are important measures for assessing treatment effectiveness. Rigorously validated measures are important to ensure we capture symptoms that are relevant to participants. In addition to content and construct validity, the responsiveness of an instrument is an important component of validation, which measures sensitivity to changes in a patient’s health status. A scale’s MID is also essential because it estimates the smallest change in the outcome measure that patients perceive as important. In other words, any amount of change greater than the MID is considered to be clinically meaningful or important 15,16. The ABLE instrument provides such an instrument and may be used to reliably and comprehensively assess outcomes in FI treatment.
This study used three anchor-based approaches and two distribution-based approaches to estimate MID. A reasonable MID estimate based on our findings for ABLE is −0.20 points. One limitation was the small proportion of women reporting “no change” on the PGI-I, which was one measure used for the anchor-based approach. However, there was good correlation in responsiveness between the ABLE questionnaire and the other questionnaires assessing bowel leakage. This is further strengthened by including objective clinical measures using the bowel diary.
There are MID estimates for other existing scales assessing symptom severity and quality of life for FI 11. Jelovsek et al performed a study estimating the MID estimates for four bowel symptom questionnaires including the Fecal Incontinence Severity Index (FISI), the Modified Manchester Health Questionnaire, and two subscales from the PFDI including the CRADI and the CRAIQ. Ancillary analyses were conducted based on a study population of women receiving a variety of fecal incontinence treatments ranging from behavioral techniques to surgery to determine MID estimates for these four scales. The ABLE questionnaire is specifically focused on patient important outcomes and is now an additional questionnaire that can be used in research studies on this condition.
Strengths of our study include using multiple approaches to estimate the MID and that we were able to enroll subjects receiving FI treatment in a large clinical trial. In addition, the ABLE questionnaire was developed based directly on patient input into the symptoms that are most important to women seeking treatment of FI. Limitations to our study include that our study population included only women undergoing non-surgical treatment of FI, and the majority of our population was White and English-speaking. It is possible that the ABLE questionnaire may have different properties in women of different ethnicities, with more severe FI or other concomitant bowel symptoms, or who speak other languages. Future research should focus on confirming validity properties in different FI populations. In addition, we have not determined the impact of missing individual item responses and how this might affect responsiveness. Finally, men may have different threshold for responsiveness. We only included women with normal stool consistency, responsiveness of ABLE may change with different stool consistency.
In conclusion, the ABLE questionnaire has good psychometric properties and is responsive to change. The MID estimate of 0.20 may be used for estimating sample sizes for future clinical trials. The MID is also important for the clinical care of women with ABL and may help guide treatment decision making and when interpreting clinical trial results.
Acknowledgements:
Cleveland Clinic J. Eric Jelovsek, Principal Investigator, Marie Fidela R. Paraiso, Co-Investigator, Mark D. Walters, Co-Investigator, Beri Ridgeway, Co-Investigator, Brooke Gurland, Co-Investigator, Massarat Zutshi, Co-Investigator, Geetha Krishnan, Research Nurse, Ly Pung, Research Nurse, Annette Graham, Research Nurse
Alpert Medical School of Brown University-Women & Infant’s Hospital of Rhode Island Deborah L. Myers, Co-Investigator, Charles R. Rardin, Co-Investigator, Cassandra Carberry, Co-Investigator, B. Star Hampton, Co-Investigator, Kyle Wohlrab, Co-Investigator, Ann S. Meers, BS, RN, Research Supervisor, Kathryn Rhodes, BA, Senior Research Assistant, Erika Spearin, BS, Research Assistant
Duke University Anthony Visco, Principal Investigator, Cindy Amundsen, Co-Investigator, Alison Weidner, Co-Investigator, Amie Kawasaski, Co-Investigator, Shantae McLean, Clinical Site Coordinator, Ingrid Harm-Ernandes, Interventionist, Jennifer Maddocks, Interventionist, Amy Pannullo, Interventionist, Akira Hayes, clinical research coordinator, Acacia Harris, clinical research coordinator, Robin Gilliam, clinical research coordinator
University of Alabama at Birmingham Holly E. Richter, Principal Investigator, R. Edward Varner, Co-Investigator, Robert Holley, Co-Investigator, L. Keith Lloyd, Co-Investigator, Tracy S. Wilson, Co-Investigator, Alicia Ballard, Co-Investigator, Jeannine McCormick, Interventionist, Velria Willis, Research Nurse , Nancy Saxon, Research Nurse , Kathy Carter, Research Nurse , Julie Burge, Research Coordinator
Northwest Texas Physicians Group Susan Meikle, Co-Investigator
University of California, San Diego Charles Nager, Principal Investigator, Michael Albo, Co-Investigator, Emily Lukacz, Co-Investigator, Cindy Furey, Interventionist, Patricia Riley, Interventionist, JoAnn Columbo, Research Coordinator, Sherella Johnson, Research Coordinator
Kaiser Permanente – San Diego Shawn Menefee, Co-Investigator, Karl Luber, Co-Investigator, Keisha Dyer, Co-Investigator, Gouri Diwadkar, Co-Investigator, Jasmine Tan-Kim, Co-Investigator, Giselle Zazueta-Damian, Research Coordinator, Linda Mackinnon, Research Coordinator
University of New Mexico Yuko Komesu, Co-Investigator, Gena Dunivan, Co-Investigator , Peter Jeppson, Co-Investigator , Sara Cichowski, Co-Investigator, Christy Miller, Interventionist, Erin Yane, Interventionist, Julia Middendorf, Research Nurse, Risela Nava, Research Coordinator, Karen Taylor, Research Nurse
RTI International Marie G. Gantz, Principal Investigator, Dennis Wallace, Alternate Principal Investigator, Amanda Shaffer, Research Operations Manager, Poonam Pande, Chemistry, Manufacturing, and Controls Project Leader , Kelly Roney, Regulatory Project Leader, Benjamin Carper, Statistician, Ryan E. Whitworth, Statistician, Lauren Klein Warren, Statistician, Kevin A. Wilson, Clinical Research Informatics Project Leader, Brenda Hair, Clinical Research Informatics Manager, Kendra Glass, Data Manager, Daryl Matthews, Data Manager, James W. Pickett, II, Programmer, Yan Tang, Programmer, Tamara L. Terry, Research Services Manager, Lynda Tatum, Research Services Supervisor, Barbara Bibb, Programmer, Jutta Thornberry, Program Manager, Kristin Zaterka-Baxter, Clinical Study Specialist, Lindsay Morris, Research Coordinator
University of Pennsylvania Heidi Harve, Co-Investigator, Uduak Umoh Andy, Co-Investigator, Michelle Kingslee, Research Coordinator, Lorraine Flick, Research Nurse
University of Pittsburgh Halina M. Zyczynski MD, Principle Investigator, Pam Moalli PhD, MD, Co-Investigator, Gary Sutkin MD, Co-Investigator, Jonathan Shepherd MD, Co-Investigator, Michael Bonidie MD, Co-Investigator, Steven Abo, MD Co-Investigator, Janet Harrison MD, Co-Investigator, Christopher Chermansky MD, Co-Investigator, Lori Geraci, Research Coordinator, Judy Gruss, Research Coordinator, Karen Mislanovich, Research Coordinator, Ellen Eline, Interventionist, Beth Klump, Interventionist, Susan E. George DPT, Interventionist
University of North Carolina at Chapel Hill William E. Whitehead Ph.D., Co-Investigator Sources of Support: U10 HD041261, U10 HD069013, U10 HD054214, U10 HD054215, U10 HD041267, U10 HD069025, U10 HD069010, U10 HD069006, U01 HD069031
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Financial Disclaimers/Conflict of Interest Statement:
RG Rogers – Royalties from Uptodate, DSMB chair for the TRANSFORM Trial sponsored by AMS, ABOG travel and stipend, ACOG travel, IUGA travel and stipend.
Vivian W Sung-None
Emily S Lukacz - Consultant: Axonics; Research support: Boston Scientific, Uroplasty/Cogentix, Pfizer; Royalties: UpToDate.
Pamela Fairchild - None
Lily Arya -None
Matthew Barber - – Royalties, Elsevier and UpToDate
Alayne Markland - None
Nazema Y Siddiqui – Medtronic Inc (Research Grant)
Carla M Bann - None
Presented at the American Urogynecologic Society 40th Annual Scientific Meeting, October 09, 2018 - Saturday, October 13, 2018, Chicago
Contributor Information
Rebecca G Rogers, Dell Medical School, University of Texas, Austin and Professor, University of New Mexico Health Sciences Center, Albuquerque, NM.
Carla M Bann, Division of Statistical and Data Sciences, RTI International, Research Triangle Park, NC.
Matthew D Barber, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC and Obstetrics Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland OH.
Pamela Fairchild, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Women’s Research Institute, Pittsburgh, PA.
Emily S Lukacz, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Diego, San Diego, California.
Lily Arya, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pa..
Alayne D. Markland, Department of Medicine, University of Alabama at Birmingham; Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL.
Nazema Y Siddiqui, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
Vivian W Sung, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI.
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