Perfect. Thank you, Fumi. Well, I want to welcome everybody and good morning to many of you and good afternoon to others, and thanks for joining us today. My name is Austin Blackwell, and I'm the Director of Marketing for Botox Urology at Allergan. I'm absolutely delighted to be joining all of you for today's kickoff to the Augs APP meeting and the program. We're going to have the opportunity to go through together in just a few moments. But first of all, I wanted to thank all of you and extend gratitude on behalf of Allergan, which as of just a couple of weeks ago now, is now an AbbVie company, which we're very excited about, and taking the time to dial into today's meeting, which is going to be kicked off by this educational session with Andrea Barker, who I have the pleasure of introducing today. Sort of a new way that we're connecting this year. I know some of you, we were able to meet last year. Allergan did support the Augs APP meeting last year. We certainly value our partnership with the Augs Society. For those of you that we haven't met before, it's great to meet you over the web and look forward to connecting in person in the future. I also just want to acknowledge our thanks to you as healthcare providers and the sacrifices that all of you make every day to risking your own health to better the health of others, given the current environment and situation that we're in, that has led us to connect over the web for this year's meeting. I have the distinct pleasure to introduce today's presenter, which is Andrea Barker. Andrea is a physician assistant at Princeton Urogynecology in New Jersey, where she's practiced for about 10 years now. Their practice has a true pelvic floor center that is very focused on the patient experience, and I can attest is one of the premier urogynecological practices in the country. We've had the pleasure of working with Andrea now for a couple of years. She was actually a member of our inaugural group of individuals from an APP perspective that joined the Allergan Speaker Bureau in 2019. She's continued on with us this year as well, so we're thrilled to have the opportunity to work with her. She's also participated with us helping to train our sales team at Allergan for our past two national sales meetings. We're all in for a treat today as she's going to deliver some fantastic content. You're actually part of the very first group that is going to hear the presentation she's going to deliver today. We just trained our entire Allergan Speakers Bureau on it literally two weeks ago. We've put the final finishing touches on it, and so you'll be the first group to get a chance to see it, so we look forward to your feedback. We do encourage your questions today as well. Please do leverage the chat feature at the bottom of the screen to ask the Q&A to ask your questions and we'll take those at different parts throughout the presentation. I do also have to acknowledge that this is a promotional program that is being delivered by Allergan, and Andrea is a paid speaker consultant for Allergan. Considering all of the questions and considering that this is a promotional program, we'll make sure that all of the content that you'll be listening to and hearing today will remain consistent with the FDA approved package insert for Botox. As you ask your questions, please can keep that in mind and consider that as we'll be able to provide detail only to those questions that are consistent with the approved package insert for Botox. We appreciate that and look forward to hearing from you. With that, thank you again for joining us, and I will turn it over to Andrea to take us through the presentation. Andrea, the floor is yours. Thank you, Austin, and I also just want to thank Allergan, Abby Lee for this great opportunity to speak to all of you, my colleagues across the country. It's just a great way to be able to connect. I just wish that we were able to meet in person. I miss seeing faces face-to-face in person. That's my thing, but I'm getting a little bit used to this. But I also just wanted to say thank you to Allergan for recognizing nurse practitioners and physician assistants as such a vital role in the patient's journey with OAB. It's nice to have that recognition. You guys are so important in this process. We'll get started on what your role actually is in supporting the patient's journey through Botox. We're going to go over a lot of different topics. I hope that you can take away some really just small clinical pearls and things that can make your life a lot easier and the patient's experience a more pleasurable one with walking them through the process. But one super important thing that made a big difference for us was developing an OAB care team for the Botox journey. There's so much information and so many different things that need to happen along the way. Each individual within your practice, be part of that care team makes a huge difference because it will alleviate some of the burden that is there on the information delivering that. Figuring out how to identify individuals and give them leadership roles in each position through a care team will make a huge difference. Clearly educating the patients about their journey is also something that takes some finesse and learning how to communicate that can take a little bit of practice. Hopefully, this will help you do that. Introducing Botox to the patient and having the patients accept it is a bit of finesse as well and that's, again, along the lines of using the right language and delivering it in the proper way. We want to make sure that we also figure out how to give the patients a really positive experience once they've identified that they're going to go through with it. It's important for their process to be something that they're comfortable with from start to finish, as well as just demystifying some of the misconceptions, understanding what the cost is for the patients. We're going to touch on all of those things right now. We have to get through this first slide, which is basically going through what the indication for Botox is. I think we all know, obviously, Botox has been approved for the treatment of overactive bladder, which is for symptoms of urgency, frequency, urgent continence with patients who've had either inadequate response or are not tolerant of anticholinergic medication. It's been FDA approved since 2013 for the use in the bladder, but it's actually been around for about 30 years or so. It's a well-studied molecule, but there is a boxed warning and we can briefly talk about that. What that really says, if you've ever read that, is that there's some distant spread of the toxin that's been noted. What we've seen with that is that that's mostly reported in patients' children who've been treated with cervical for dystonia and for spasticity. That's typically where that information is being generated from. What's more important is just to know what the contraindications are for using Botox. There really are just two important ones. Botox is contraindicated in the presence of a urinary tract infection, even with patients just with a positive urine culture who are not necessarily symptomatic, or it's also contraindicated in patients who have retention and are unable to intermittently self-catheterize. Those are really the only two major contraindications. You know, Botox has been well established as having a pivotal role in treating the overactive bladder patient. We as professionals, we follow guidelines and it's reassuring to know that OGGS, ACOG, SUFU, all of these different establishments have supported and used Botox as a standard treatment with post-medication failure. If we look through those, it's important to become familiar with the different guidelines that are placed by each of these organizations. They all define Botox basically as an important position and role in the OAB treatment pathway. The Botox journey can really benefit a patient who has OAB, but there can be many challenges, and I'm sure that all of you have experienced them along the way. Identifying patients and figuring out how do we get those patients who've been on multiple medications, getting the information that they need, you know, counseling the patient and explaining to them why Botox is a good option for them, just using the right words and figuring out how to deliver the message, steering clear of certain buzzwords that are buzzkills for the patient, like self-catheterization or needles, injecting, things like that. And then just the challenge of once they've maybe experienced a positive effect with Botox, making sure that they understand that this is a chronic condition and that it will require retreatment and coming up with good protocols to establish within your practice on how to have best practices going forward with patients who are getting retreatment with Botox. That can be a large obstacle for compliance, and we can lose a lot of patients if we don't have good systems in place to address that. So the importance of the OAB care team, this really has been for me a huge thing that made a big difference when we started to address how is this experience from start to finish for the patient. Once you look at each of you come from different practices, you're either part of a hospital, a clinic, private practice, so it's going to look different for all of you. But I think it's important when you think about the treatment plan for a patient who has OAB and figuring out how to provide Botox as an option that we identify all the different people within your office staff and figure out what roles or things that they could excel at within the puzzle. Because we have to identify the patients, we have to deliver the message to the patient, we have to educate them, someone has to explain what the cost is. That's a lot of information and that can be incredibly time consuming. So figuring out ways to give your practice different roles to take will decrease the burden overall and make for a more efficient process. So clearly the experience from making sure that there's a clear concise message that's being delivered to the patient and that means that from the moment that they walk in the door from check in to the nurse or MA who may be taking them back into the room and giving them patient materials and educating to the provider who's taking care of them, the MP or the PA who's educating them and discussing the condition to the physician who is also doing the same or potentially doing their procedures. Each one of these roles is incredibly important and really can't exist well without the other. So making sure that you sit together periodically with your care team and talk through what that looks like for a patient is really vital and making sure that we sort of deliver a very clear concise message to the patients so that there's consistency is reassuring for them. So in order to define the overactive bladder treatment journey and assessing if your patient's ready for it, we need to kind of think about a few things. We all know that we can make the diagnosis, a patient who comes in who has symptoms of urgency, frequency, overactivity, incontinence. We use bladder diaries as kind of your ticket to the show so to speak and that's really helpful to keeping patients connected to their treatment plan and also just using that as a guideline to where are we meeting our goals and expectations. We all know that sort of the first line things diet, behavior, lifestyle, behavior modification, pelvic floor exercises are kind of our first line treatments. Typically we're starting a patient on a medication by their first visit and that we bring them back in one anywhere from four to six weeks to reassess. So the important information about this is that we want to continue to keep in mind that at every step of the way, every touch point is an opportunity to kind of reassess where we are with the patient's goals and are we meeting those expectations and getting success as we define it for the patient. So it's an opportunity to kind of set that out ahead of time but typically also using the AUA or SIFU guidelines is something that I typically do with my patients at their very first visit and giving them a either tear off sheet that helps them to kind of see what their journey might look like with that first tier being behavior, you know talking about medications and then potentially if we're not getting that success in their by their next visit making sure they're aware of what those next steps third line therapies may be including obviously Botox and neuromodulation and PTNS. So this slide kind of was depressing when I saw it but it's so true. OAB patients often fail medications but continue receiving them and 71% of patients have a failure within the first six months. So those aren't great numbers but what's even more depressing is that we as clinicians as clinicians somehow are continuing just to cycle patients on these medications. So I think it's really important that when we think about the patient we need to understand what treatment failure looks like. It can be for a number of reasons but the common ones obviously are the patient can't tolerate the medications. You know there's a number of side effects associated with the anticholinergics, dry mouth, constipation. We have to be conscious of high blood pressure with the beta 3s but even more so now the safety concern with the cognitive impact that anticholinergics have on with the associated impact on dementia and Alzheimer's. So that's a lot to just review in that of itself at the visit making sure that we're having a patient who's tolerating it but the lack of response is really important to kind of set out each visit. It may be that we have an improvement to symptoms and they may have a reduction in their number of voids or even number of episodes of incontinence but that might not necessarily make a difference on their them achieving their goals or their quality of life measures. So you know failure can we can't really define failure until we know what their goals and success looks like. So I like to set that out at early on when they're coming in and we're talking through what how this is impacting them and what do we want to get out of this. So just to review again this actually made a huge difference that the information that's come out since I think AUGS put out their guidelines on anticholinergics with overactive bladder patients. This quite honestly was a game changer for our practice and in some ways made things so much easier for me and for everyone else because it takes some of the burden away from feeling that we had to sort of offer more medications to patients. Now with the risk of you know again the cognitive impairment, the dementia, Alzheimer's all associated with anticholinergics we're trying to either get patients who are on an anticholinergic off of it even if they're having success based on some of these risks or I don't necessarily offer them to patients unless it's something that we are obligated to do because of insurances that that's the only medication that may be covered. So this has kind of helped streamline the process in not having as many options to offer the patients and so that's made a big difference. So I think it's important to think how that may impact your patients and making sure that if they're on an anticholinergic that you're revisiting that new data which I'm sure all of you already are. So this I was actually quite surprised by this slide when I first saw it and by the this is a web survey that was conducted in the UK on patients who had overactive bladder and were on a medication that 80 percent of patients were willing to try a procedure. That surprised me. I didn't realize when I thought about that I thought oh my gosh I didn't necessarily feel like that many patients were as willing but you know in the polls the patients want success and I don't think they're getting it from their medications so it's something that we need to be mindful of and there's you know a lot of misconceptions and one of those for me was that we used to a while back think that we needed to have multiple medications failure before they would even qualify for Botox. That was the case in our area years ago. A lot of the insurances may have required a patient to fail two three medications. That's changed. Most insurers do not require anything more than a failure with one anticholinergic before they would approve Botox. So it's important for you all to have a good understanding of what the demographic is in your area as far as the insurances and get a sense as to what obstacles you may run into with that. But when I started to dig a little bit deeper on this information, I realized that we were able to get insurances to cover this much more easily with just one medication failure. And that helps not delay the patient's care from a timing perspective. So getting specific to assess the true impact of OAB. I feel like this is where you as advanced practitioners excel. We take pride in getting to know our patients and personally developing relationships with them. And I know myself, I love to educate them on their conditions and their options being an educator. So we just need to sometimes think about, you know, digging just a little bit deeper with the right questions to get the patients to open up. If you ask the right questions and you listen carefully, you'll realize that the patients are suffering and they want desperately to have an improvement to their quality of life. And so many times, you know, we may have patients every 15 minutes, you know, and you don't necessarily have that time built in. But if you kind of carve out some very specific questions that you like to ask your overactive bladder patients, just to really have them open up about how it's impacting them, as well as just getting them to realize that it's a valid reason to go forward with treatments. You know, this is something that can have an impact on their sleep, which can cause depression. They may be isolated. It impacts their relationships, their travel time, so many aspects of their life. So it's really important to keep that in mind. And it's a privilege to take care of these patients. We need to understand, you know, how the condition is actually affecting them. So that just takes communication. And I know that you guys slammed this one out of the park, I'm sure. But so it's, you know, it's a good time to pause and think, you know, about how you can identify the patients in your practice, and the way that you go about educating them, and the specific questions you may ask to see if they are really ready to go forward. Patient identification is key in kind of getting them moving forward with it. So now we're going to talk about Botox and the clinical profile. So we're going to talk data. This, when an anticholinergic fails, we want to kind of be able to start talking about the next third light options, Botox being one of them. This slide is, the important parts about this slide, I think, that are the take-home messages are that by two weeks, we see about a 50% reduction in daily leakage episodes. And that's significant. You know, there are, as we know, medications take four to six weeks to even start to work. Sometimes a lot of the therapies, we are not able to get this fast of a response. And this particular study, we had patients that had a mean baseline of urge incontinence episodes of up to five a day. So they were, you know, significant in in their nature of what this condition was. And I think this is kind of the take-home message when you're delivering it to the patients and they say, well, is it going to work? You can confidently say that they're going to have at least a 50% reduction, but quite honestly, in many other patients, they have reduction in symptoms and in about 25% of patients, they may be dry. This next slide is interesting. So if you know much about placebo, I thought this was interesting that, you know, many of the things that we offer patients, whether it's diets, behavior modification, even medications, they're as good as a placebo effect. This slide shows us that Botox is at least three times better than placebos. And that makes a difference when we're talking in the world of overactive bladder. And this was meaningful because what this particularly, you know, talking about those quality of life measures is, for me, something that is one of the most validating things in giving this treatment, you know, putting this treatment in the forefront for patients. They looked at psychosocial impact, the social embarrassment, avoiding, you know, avoidance of physical activity and things like that. And this obviously shows, you know, just the threshold for clinically meaningful difference is quite low. So that's based on kind of what the FDA's guidelines were. So this far exceeds that. It's important to know what the safety profile is for Botox. And the two main areas that we need to educate and explain to patients are understanding that there is an increase in urinary tract infections in about 18% of patients. That definition based on the clinical trials was defined as a positive urine culture, not necessarily based on symptoms. And as well as then urinary retention. So urinary retention in this clinical trial was basically not defined as the inability to completely empty, but it was an arbitrary number with using PVR thresholds of 200 or greater. So that's, you know, 6% of patients will experience some type of retention, and that can look different for many of them. Another important thing to know is that in an extended trial, the open label three-year extension trial, there was no change in the overall safety profile with Botox retreatment. So a lot of patients wind up asking, you know, will I become immune to this if I keep using it? And you can reassure them that there's been no change in its safety profile as well as its impact on symptoms going forward. So introducing Botox to foster treatment acceptance. So this is really about kind of the finesse in how we deliver the message. So, you know, I think this will help guide your conversations. I actually learned quite a bit from my training through Allergan on how to communicate information effectively, maybe some life lessons even, you know, what we say and how we say matters. So when we start to think about what the patients are actually hearing, we realize that we need to make sure that we're presenting the information in a way that they can accept it accept it and be open-minded to what it is. So a lot of times we think patients are not interested in Botox because they have a misperception about it. But we know that the way that we say it and how we say it will make all the difference for your patient. You as their provider, if you make a clear and concise recommendation with confidence, they're going to follow your lead. So it's really important to get comfortable kind of with this process. And it takes practice and it takes some time to and it takes experience in doing it. So you need to sort of test it out. But this ease, the efficacy, administration, safety, and expense, sort of keeping it in that model will help guide you with the conversation. Because I think, you know, one is identifying the patients. But once we've done that, it's getting the information to them so that they can actually understand it in a clear and concise way. So we start off with efficacy. And I think, you know, the last couple slides back, we'll kind of touch on those points that we want to start off the patients in explaining how much of an impact this is going to have on their quality of life measures. So if we say to them, Botox cuts leakage episodes in half and will have a positive impact on your quality of life, you know, by the 12-week mark, that's significant. We always want to make sure that we're setting kind of realistic expectations for the patients with their goals and that they understand that this is a chronic condition and that will require continued treatment. So there is important for them to know that they need to be retreated. So the next step is kind of, okay, what is that going to look like? What is the administration of Botox going to look like for the patient? So this is super important. This is where you need to spend time yourself on delivering the message to the patient and get comfortable with saying it. So we, you know, we want to make sure that we stay away and avoid certain trigger words that might scare patients away. So we start, you know, definitely with, we place Botox in your bladder during the procedure, done here in our office, and we make you as comfortable as possible. I think one of the selling points for me, for a lot of my patients who are busy working moms, to be able to say that you can come in on your lunch hour and, you know, be in and out of the office in less than an hour with no downtime is a really huge selling piece for so many patients. So I think it's important to kind of make sure that they understand that this is something that we can do in a very easy and safe way right in the office that doesn't take a lot of time. And again, just touching on the point that, you know, patients will have success and then they'll forget that this does wear off. So they'll say, oh my gosh, it just stopped working, or, you know, they'll forget. So it's just important to kind of continue to re-educate them that this is typically, it lasts, you know, on average about six months. So we do have the patients schedule their repeat Botox at the same time of their procedure in six months so that we kind of keep them on track and we don't lose patients. Of course, we want to always touch on the safety aspect of things and start with the positive. You know, this is where we also lose patients. If we, you know, of course, when we think about having to self-catheterize, that's where we lose most of our patients. So we want to deliver the message in a way that we are explaining to them 94 out of 100 patients who are using Botox do not need to self-catheterize. So if it does happen to you, it's only temporary. And we're here for you. We're going to walk you through what that's going to look like, and we're going to figure it out. So a lot of times when I find a patient who I start to talk about Botox, and before I get anywhere, they say, oh, no, I don't want to do that. That's, you know, yeah, I don't want to catheterize myself. I say, okay, well, let's talk about that. You know, first of all, let me put this in perspective. These are the numbers. The numbers are that, you know, 94% of patients do not need to catheterize. So yes, there is a risk of that, but it's low. You know, they also are scared from this idea of retention. They don't know what that means. So retention, you know, can look a lot of different ways. But most of the time, all that means is that you may have some difficulty in emptying your bladder. That doesn't mean that you can't empty. It just may be a little bit more difficult in you emptying fully, and to remind them that that is temporary. It's going to be a challenge, and it may be a little bit of an obstacle, but it won't last for that long. And then, of course, just explaining to them about the catheter, if we are able to get to that point and talking to them about what, you know, what does that look like? What if I have to use a catheter? What does that mean? So it's really helpful sometimes. I may have a patient that I say, do you think it would help you if I showed you what that looks like? You know, if you're one of those people who wants to know all the details, we can even have you come in, and I can walk you through worst case scenario. If you are that patient, and you're not able to, and you have retention where you can't empty your bladder, let me show you what that's going to look like. I'm confident that we can figure it out together. And that just reassures the patient, so it takes away a lot of those kind of mysteries and misconceptions about what they might be thinking. The expense piece of things, that's also a misperception, and even on my part, I don't think I understood this very well until fairly recently even, that for Medicare, it covers Botox. Almost, you know, where we are, it's 100% coverage. We're very little or out-of-pocket cost for the patients. So cost is really important in my area. I mean, that drives a lot of our decisions for the patients. So I may have patients who are doing well on a medication, but the medicine's so expensive that I say, hey, we might want to just, let's revisit kind of what that's costing you and take a look at if Botox may be a cheaper option for you. And most commercial insurance plans cover Botox. They may be zero or very little out-of-pocket, but there's a fantastic Botox savings program that, if you are not aware of it, it is really important to designate someone in your office to become savvy with it and be able to deliver that information to the patient. So that's, again, where our nurse navigator is huge in helping kind of the patients along with what the cost looks like and checking their eligibility and making sure that we're getting the prior authorization appropriately. So I urge all of you to go back to your practice and to ask the right questions to the people who know, whether it's in billing or if you're, you know, the nurse's navigator in our practice, what insurance is, what's our majority of insurance in our area, what is the coverage like, and, you know, how much of an obstacle is this from a financial standpoint, and how can we help get that information to the patient so that they can understand what the cost really is? Because I believe that if you find out, you'll find that it's actually quite cost effective. So counseling the patient, you know, this is a good, what would you do? This may be a good opportunity to pause for a moment if there are any questions. Austin, I'll defer to you if there's anyone who has any questions at this point that we may want to answer. Sorry, Andrea, I was getting myself off mute there really quickly. Thanks for pausing as we all navigate through the technology here. Yeah, we've gotten a few questions, and I'll sort of take, there's a couple that have come up that are sort of insurance related, so I'll answer those, and then you can add your color commentary too based on your experience. So one of the questions was, will Medicare cover it more than once per year? The answer is yes, Medicare will cover it more than once per year. There is no prior authorization required for Medicare Part B covered patients, and they will essentially cover it no sooner than 12 weeks. So the treatment sort of cycle that Andrea will be speaking to a little later is typically about every six months, but as per the package insert, it can be administered no sooner than 12 weeks, so they will essentially cover it up to four times per year. So that sort of answers that question. And then the other question that came up earlier that I wanted to acknowledge and then also get your experience on, Andrea, was around myrbitric failure. So does insurance, or do we see limitations on Botox use requiring you to step through myrbitric? And so that's a very good question, and we've done a very extensive analysis, and we've found that only 4% of commercially Medicare and Medicaid covered lives actually require you to step through myrbitric before Botox can be approved. So the lion's share of plans do not require you to step at it through myrbitric before you would use Botox. So hopefully that provides a little insight. But Andrea, from your perspective, have you seen anything in your area specifically to myrbitric requirements for Botox? Not specifically to myrbitric. I mean, I do have a number of patients' plans that require just to have failed a medication. But clearly, even with Medicare, that's not the case. I mean, we can even go to that straightaway for many of those patients. Okay. Yeah, that sounds consistent with what we found. There's not a lot of step at it, and it's very surprising, as you pointed out earlier, a large percentage of the plans do not require you to fail multiple anticholinergics before going to Botox. So that's what we've sort of found, and it sounds like that's consistent with what you've seen in your practice. So there are a couple more questions coming in, but I think we'll just go ahead and move forward, Andrea, and we'll take more questions towards the end of the presentation. Okay, great. So once we've identified the patient and we've convinced them that Botox is the right option for them, providing a positive experience for them in the office, which is predominantly where we do all of our procedures for Botox. Very rarely do we do them at the hospital, 99% of the time we're doing them in office. It's really important to provide a good experience for the patient. I think, again, making sure that they realize when they come in, this is just an office procedure. The actual time it takes to deliver the Botox into the bladder is short and quick. Start to finish, they'll be out in less than an hour. We're just using some local anesthesia. A lot of times we have amazing nurses and MAs who help us with that verbal anesthesia, which is just kind of distracting the patient. Sometimes talking to them throughout the procedure, maybe providing some comfortable music and just making sure that they have a positive, comfortable experience. That's so important. We don't want them to finally get to that point and then have a really negative experience, even if they have good results from the medication or from the Botox. It's unfortunate if they felt as though they were in pain or they had to be there for a really long time or they just were nervous and scared the whole time. You need to kind of think through what those steps look like in your practice. That kind of goes back to a little bit of that care team that we were talking about. A good experience for the patient is something that requires multiple steps, multiple people within your practice for that to be a really seamless effort. Making sure the patients have the correct expectations, of course, before we get started. Obviously, making sure that your equipment and everything that you have is appropriate and in place, that comfort level. Sometimes I like to ask the patients even ahead of time before we even do that, what do you typically like? What would make you feel comfortable during this? Would you like music? Do you like us to talk? Do you want us to not say anything? Just understanding kind of your patient and what works for them is really important. That's something that we want to make sure that there's protocols in place for that. Using retreatment protocol to keep patients on track, this is really valuable. We found when we were really starting to do more and more Botox in our practice, we did not have good systems in place to figure out when do we bring them back? How do we get them rescheduled? There was a lot of loss to follow-up because we did not have a good system in place. What we discovered was at the time that the patients finished with their treatment and they're checking out, we typically make two appointments for them. One will be a quick two-week follow-up just to make sure that we're checking PVRs and checking on them symptom-wise and checking for retention. Then we actually schedule their repeat Botox. We've used the six-month interval as our retreatment interval, and that seems to work. In light of telehealth, I find that there's this kind of four-month window post-Botox that is a really nice touchpoint. If we don't have to bring the patient in the office and we can actually just reach out to them via telehealth just to touch in and talk to them, it's a really nice way to have them stay engaged and connected in their care, as well as just identify some patients. There may be symptoms are returning, and we wouldn't want them to have to have symptoms return and wait for the six months. We want to get them in sooner. So, establishing in your practice good retreatment protocols is extremely important and works for you, but it will make all the difference, for sure. So, again, this is just kind of harping on that six-month interval, but that does seem to be a really magic number in what we're seeing. Six months is the median time for retreatment for Botox in the clinical studies. So, again, making sure that we're pre-scheduling the retreatment on the day of the injection, I think, saves a lot of staff time and headaches in getting this as a seamless event. So, Botox, there's different ways that you can do this. We have a really nice portal through our practice that we're able to send patients text messages, and those are really fantastic reminders to patients who have had Botox just to say, hey, you may be due for your upcoming revisit, retreatment, just ways to check in. So, that may be, again, another great point just to figure out what resources you have available to make sure that patients stay connected for their retreatments and how we don't lose them to follow up. Helping the patients understand the Botox cost and coverage, again, I can't say this enough. If I didn't have my nurse navigator to help with some of that information, it would be really time-consuming. So, it's really nice to be able to identify people in the practice and give them sort of those leadership roles. But cost for the patient may be a big concern, and I'm sure it is for many of your patients. So, that usually drives a lot of our decisions in what we're going to offer for the patient or what recommendations that we make. So, making sure that we're being proactive when we're identifying Botox as them, that we say, okay, we're going to get prior authorization, we'll help you understand what this is going to look like for you from a cost perspective. And most of the time, we find that with the Botox savings program, that's been incredibly helpful and it's minimized cost to the patient significantly. Again, we did touch on this, but basically, coverage for Medicare patients is 100%. And so, that's really reassuring, especially in my practice, we have a large percentage of patients that are Medicare. So, it just makes for the conversation once we've identified that they're a candidate, that's their next question. And I said, that's usually never an issue. Clearly, we're going to make sure that that's, you know, we'll find out what the cost will be to you. But most of the time, cost is not an issue at all. And even with the commercial insurance plans, it's covered, you know, almost 99%. But the Botox savings programs, if you don't know about it, I would urge you to look into it, because they can provide your patients great savings, paying as little as $0 out of pocket for Botox treatments. So, you can ask your reps, and they can help you with some of that information. So, I think that's about it. Let's see. So, let's see, ways you can help your patients on the Botox journey. So, I think we've kind of gone over all of those slides, but most important, you know, identifying what your role is in the practice and responsibility as part of the OAB care team. You as nurse practitioners and PAs, you are so vital to this care team. You really, in my mind, are one of the important pieces of the puzzle in getting patient success. Making sure you outline what that journey looks like for the patients in as far as establishing what your goals are for the patient at their very first visit, and making sure that you revisit that every time that they come back for their follow-ups. That will really help you to assess, you know, how is our therapy doing? Are we getting and reaching our goals so that we are really making those quality-of-life differences for the patient? I think if we use those models, you will see that there's a greater readiness to move on to Botox. Don't forget to use that EASE model. EASE will really help when we're kind of having to talk through the information and using your words wisely, knowing sort of what to say and how to say it is really important. As well as just coming up with those protocols within your practice to know what typically we need to do for revisiting it as an every-six-month treatment. You know what? I'm sorry. I kind of skipped over these, but let me just briefly, I think we kind of talked about them, but just want to make sure that I'm not misleading things. For safety information about Botox, clearly we went through the warnings and precautions. There's increased risks associated with patients who have pre-existing conditions. You always want to make sure that we're screening our patients beforehand for Botox. Anyone who has any neuromuscular conditions, ALS, MS, those are patients that are going to be at a much higher risk with this, and I usually caution avoiding Botox in these patients. Clearly, someone who has chronic urinary tract infections, usually two or more urinary tract infections within six months, I work with those patients. We want to make sure that we address the urinary tract infections prior to Botox, and we come up with certain protocols to have them infection-free. That will make a big impact on their success with Botox, but I don't recommend Botox on someone who has chronic infections, because this will typically, they won't get the same type of results. And then again, clearly, as we talked about in the beginning, you know, it is contraindicated in patients who have retention and are unable to intermittently self-cath. So it's important to kind of keep those safety information in your mind before we actually recommend Botox to your patients. Urinary retention in patients treated with bladder, for overactive trials, I think we kind of touched on this before. Another important thing to know is that for some of your patients, this product does contain albumin, which is a derivative of human blood. So you want to, you know, make sure that if there are any of your patients in the practice who this may be a concern for, it's, there's just, you know, a very theoretical risk of transmission within those patients, but it's extremely remote, but it's something that is just important to note. Let's see. Another thing to know, too, is just drug interactions. Co-administration of Botox is something that you need to be really cautious about with patients who are on immunoglycosides. We want to proceed with caution to the effect that the toxin may be potentiating those effects. So an even use of anticholinergic medications after Botox may exacerbate or potentiate anticholinergic effects with Botox. So being cautious in those patient population. Well, I'm super thankful that I had the opportunity to speak with all of you. Thank you. I would love to hear any questions that you all have. Great, thanks, Andrea. Fantastic presentation. I think one of the things that you said that really resonated with me is that, you know, there are certain buzzwords that could be a buzzkill for patients, and as you mentioned, you know, we've learned a lot over the years that, you know, the words you use and the order in which you introduce Botox really matters. So, you know, we encourage you to really think about that talk track, you know, similar to what Andrea does in her practice to optimize the patient comfort with Botox as you introduce it to them and maximize the probability you'll get a yes when you do. So with that, let's go ahead and take the next few minutes just to go through a few questions. There's a couple quick ones that I think we can hit on. So one of them was, is there a minimum age restriction for Botox injections? And I can go ahead and take that one. As per the FDA approved product label, we included patients that were 18 and older. So most insurance companies and payers are consistent with the product label, which would be 18 and above approved for Botox injections for overactive bladder. Another one that I wanted to get your take on, Andrea, I'll add a little bit to as well. I'd be interested to know if most practices are performing urodynamics prior to administering Botox, or if some find an acceptable PBR is enough. I can tell you that as part of the registration trials for overactive bladder, doing prior urodynamics was not part of the protocol. Per our understanding, most insurance companies for overactive bladder do not require urodynamics prior to approving Botox. Whether that's a common practice amongst different practices, I'll defer to you, Andrea, and based on what you guys do in your practice and your understanding, if that is a common practice. Right. So we do not require our patients to do urodynamics prior to Botox. And even for the diagnosis of overactive bladder or mixed urinary incontinence, the only time that I would maybe recommend doing a urodynamics prior to Botox is if I have somebody that they have a mixed picture of incontinence, it's not necessarily clear if that's their predominant issue is because of incontinence. And we're not 100% clear that it is an intrinsic issue and it may be a structural component going on like intrinsic sphincter deficiency. I may want to do urodynamics prior to Botox, but that's not protocol. We rarely, we don't make patients do that ahead of time. It's just for a few patients. If we're also not clear on someone who has retention and understanding sort of what their detrusor activity is like, we may do a urodynamics procedure, but that's not standard and it's not common that we do that. Got it. Makes sense. Okay. One other quick one. I want to make sure I touch on this just to ensure that we're clear. We talked a lot about insurance and what insurance requires and sort of demystifying when they'll allow you to use Botox per the payer requirement. And so a question came in, just want to make sure I got this right. Does it mean that Botox can be added to the bladder care pathway as the first line management with conservative therapy? So what I can say is that we align to the AUA-SUFU guidelines as well as the AUGUS-ACOG guidelines that Andrea mentioned earlier in the presentation. And so those generally recommend first line management being conservative therapies, including behavioral management and dietary restrictions. Second line would be oral medications. And then third line would be the advanced therapy such as Botox. So that's what we recommend in terms of the bladder care pathway. I think that it's important to note in the second line management, as Andrea spoke to, you do not have to step through multiple medications before you can use Botox. That's consistent with the AUA and SUFU guidelines. And that's consistent with what the majority of the insurance companies will allow you to do before approving Botox. So I want to make sure that we're clear on that. And Andrea, I don't know if you have anything you would add based on how you fit Botox in the bladder care pathway in your own practice. So you laid it out well, Austin. Yes, we usually follow those guidelines. We have that care pathway that typically looks like those first line, just as you described, you know, diet, behavior, physical therapy. Second line being typically using medications and showing them third line. I do like to show them that pathway on their first visit so they understand where they are in the journey, so to speak, and kind of what to potentially expect if we don't get success with some therapies, what our options are. But typically after I have a patient who has a failure of a medication, you know, for sure it's going to be in that conversation as the next step. Yeah, it makes sense. And we've actually found as well, to your point, that introducing that entire care pathway on the first visit and every visit sort of gives the patient hope, gives them understand of what's to come if the management point that they're at currently doesn't work well for them. So agree with that. Well, I know that we're a couple of minutes over, so I want to be respectful of the time for AUGs and thank all of you for joining us today, and thank you, Andrea, for taking us through all the content and providing your expertise. For any of you that do have additional questions, we do have a section, a sponsorship section within the AUGs, the website for this meeting, and there is an email address in there where you can go in and submit any additional questions you have. So sorry for those of you that we weren't able to get to all your questions, but you can feel free to ask questions through that feature. There are also resources available in there as well. So thank you to all of you for joining us today. Have a great rest of the meeting, and we look forward to meeting with you again.

Austin Blackwell

Botox Urology

Allergan

Andrea Barker

physician assistant

Botox treatment

overactive bladder

efficacy

patient experience

insurance coverage