Neurourology and Urodynamics 35:102–107 (2016)
Prevalence of Urinary Incontinence and Associated Factors in Nursing Home Residents 1
Javier Jerez-Roig,1,2* Marquiony M. Santos,1 Dyego L.B. Souza,1 Fabienne Louise J.S. Amaral,1 and Kenio C. Lima1 Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Lagoa Nova, Natal-RN, Brazil 2 Rehabilitation Service, Hospital Can Misses, Ibiza, Balearic Islands, Spain
Aims: To determine the prevalence of urinary incontinence (UI) and associated factors in the institutionalized elderly. Methods: A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes in the city of Natal (Northeast Brazil). Individuals over the age of 60, who reside in institutions, were included. Hospitalized individuals and those at end of life were excluded. Data collection included sociodemographic information, UI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity, and Pfeiffer test for cognitive status). UI was verified through the Minimum Data Set (MDS) version 3.0, which was also used to assess urinary devices and UI toileting programs. The Chi-square test (or Fisher’s exact test), the linear Chi-square test, and logistic regression were utilized to model associations. Results: The final sample consisted of 321 elderly, mostly females, with a mean age of 81.5 years. The prevalence of UI was 58.88% (CI 95%: 53.42–64.13) and the final model revealed a statistically significant association between UI and white race, physical inactivity, stroke, mobility impairment, and cognitive decline. The most frequent UI type was functional UI and toileting programs (prompted voiding) were only applied to approximately 8% of residents. Conclusions: It is concluded that UI is a health issue that affects more than half of the institutionalized elderly, and is associated with white race, physical inactivity, stroke, and other geriatric syndromes such as immobility and cognitive disability. Neurourol. Urodynam. 35:102–107, 2016. # 2014 Wiley Periodicals, Inc. Key words: ageing; elderly; nursing homes; urinary incontinence
INTRODUCTION
Urinary incontinence (UI) is a geriatric syndrome that causes economic and social impacts derived from high treatment costs and caregiver burden, as well as physical consequences to the health of the elderly.1 This condition is related to other health problems such as dementia, urinary tract infection, being bedridden, cognitive or physical impairment, among others.2,3 Furthermore, incontinence causes hygienic and skin problems, as well as a negative impact on quality of life, which may result in reduced self-esteem, depression, and social isolation.2–4 Admission to a nursing home (NH) can influence continence among new residents and UI in this setting tends to be more severe and costly. Thus, this problem leads to a high burden of health care costs, and occasionally staff morbidity and even burnout.3 Despite the impact of UI, this is an under-diagnosed and under-treated health problem, due to patient embarrassment and the misconception that incontinence is a natural part of the aging process, and also due to the lack of motivation of health professionals to investigate this condition.4 In Brazil, the range of UI rates in the institutionalized elderly in the scientific literature is broad, varying between 22% and 100%, due to different survey methods and sample characteristics. Besides, the studies carried out regarding this condition in Brazilian NH residents are limited, contain serious methodological biases, and have not applied internationally recognized evaluation methods, such as the Minimum Data Set (MDS), which can enable comparison between studies.5 Therefore, new research including the study of incontinence and associated factors is necessary to deepen knowledge on the issue and help plan prevention and treatment measures for UI. The targets are the improvement in quality of life of the institutionalized elderly, #
2014 Wiley Periodicals, Inc.
reduction of health problems associated with incontinence and also reduction of sanitary costs. The objective of this study is to verify the prevalence of urinary incontinence and its associated factors in institutionalized elderly persons. MATERIALS AND METHODS
A cross-sectional population-based study is presented herein, with data collection carried out between October and December 2013, in 10 of the 14 NH registered by the Sanitary Vigilance in the municipality of Natal (Northeast Brazil). All elderly (60 years of age) were included in the study, according to criteria of the World Health Organization (WHO) for developing countries. Exclusion criteria were hospitalized or palliative care residents. The current work is part of a project entitled ‘‘Human ageing and health in long-term health institutions for the elderly,’’ with approval report no. 308/2012 from the Research Ethics Committee of the Federal University of Rio Grande do Norte (Brazil). Agreement letters from the 10 NH participating in the study were obtained along with signed informed consent forms from the residents and direct caregivers. Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. Correspondence to: Javier Jerez-Roig, Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000, Lagoa Nova, Natal-RN, Brazil. E-mail: [email protected] Received 3 May 2014; Accepted 26 August 2014 Published online 12 October 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22675
Urinary Incontinence in Nursing Home Residents The research team was composed of the first author and students of the undergraduate program in physiotherapy from the Federal University of Rio Grande do Norte (UFRN), who met twice before the study to ensure that questionnaires were adequately designed and that examiners were calibrated. In addition, a pilot study was previously carried out with 24 elderly from the the first institution researched. The dependent variable of the study was the presence of UI as reported by the direct caregiver, according to MDS version 3.0, which was also used to assess fecal incontinence (FI), urinary devices and toileting programs (bladder training, scheduled toileting, or prompted voiding).6 The definition recommended by the International Continence Society (ICS) in 2002 was utilized, which considers any involuntary urine loss.7 Those presenting with a urinary catheter or ostomy were accounted for, but excluded from bivariate analysis.8,9 In addition, the direct caregiver answered questions regarding duration and type of UI, use of diapers and daily amount of urine loss, as well as questions regarding the presence of constipation during the previous 5 days. Types of UI accepted by ICS in 2002 were used: stress urinary incontinence, defined as any ‘‘involuntary loss of urine during coughing, sneezing or with exertion;’’ urgency urinary incontinence, defined as ‘‘involuntary loss of urine accompanied by or immediately proceeded by urgency’’ and finally mixed urinary incontinence, defined as the combination of these symptoms.7 Furthermore, as utilized by other studies in NH settings, functional UI was defined as the loss of urine due to inability or unwillingness to access toilet facilities as a result of physical or cognitive impairment, psychological unwillingness or environmental barriers.9,10 In this type of UI, two sub-types were differentiated: functional UI by physical impairment, mainly due to gait limitations, and functional UI by cognitive impairment, mainly due to cognitive limitations in reaching or using toilet facilities.9 Finally, following Prado Villanueva et al.,9 a variable was added to define the cases that presented a combination of symptoms from two or more of the aforementioned UI types. Sociodemographic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, hobbies/ free time occupations, retirement/pension, administration of finances of the elderly, health plan, and number of elderly per caregiver), along with NH data (type of NH and ratio residents/ caregivers), and information related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzheimer’s disease, stroke, arterial hypertension, kidney insufficiency, stroke, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal-rectal and prostate surgical records, consumption of alcohol, past and current tobacco consumption, urinary infection within the past 30 days, hip fracture within the last 60 days, daily medicines, and number of daily medicines). The mobility status was also considered (independent gait, walks with aid, wheelchair user, and bedridden condition), as well as functional capacity, assessed by the Barthel Index,11 excluding the areas corresponding to continence as described by Prado Villanueva et al.9 Cognitive capacity was evaluated by a temporal orientation question ‘‘What year are we in?,’’ by the capacity of administrating finances, by the ability to answer questionnaires of another parallel research study and by the Pfeiffer Test, except for those with severe hearing deficits or foreigners. Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and linear Chi-square test. The magnitude of association was verified by the prevalence ratio, to a 95% level of significance. The variables with P levels lower than 0.20 were analyzed through logistic regression to build the Neurourology and Urodynamics DOI 10.1002/nau
103
multivariate model, using the Stepwise Forward method. Permanence of variables in multiple analysis depended on the likelihood ratio test, absence of multicollinearity, and also on the capacity of improving the model through the Hosmer and Lemeshow test. Transformation from odds ratio to prevalence ratio followed Miettinen.12 RESULTS
Of the total number of elderly, eight (2.4%) were excluded from the study: six (1.8%) were hospitalized, one (0.3%) was in terminal phase, and one (0.3%) was not over the age of 60. A total of 321 elderly were included in the study, mostly of the female gender (75.4%), with an average age of 81.5 years (standard deviation 9.0). Childless individuals comprised 49.2% of the individuals, 47.4% were single and 25.2% were widows(ers). Most participants (63.3%) resided in a not-for-profit NH, with the majority (46.7%) having been institutionalized due to a lack of caregivers or because they lived by themselves. Average (SD) residence time was 63.2 months (62.0) and the average ratio elderly/caregiver was 8.1 (5.2). The majority of elderly were retired (95.3%) however did not have private health plans (62.6%). UI prevalence (Table I) was 58.88% (CI 95%: 53.42–64.13). Three cases were not classified: two (0.6%) presented with permanent urinary catheters, and one used intermittent catheterisation. Double incontinence was observed in 41.9% of residents. Diapers were utilized by 66.0% of residents, and toileting programs were applied to 7.8% of residents. Among these cases, 12 (48.0%) reported partial improvements and nine (36.0%) reported complete rehabilitation, according to caregivers. The frequencies of the gender and age variables are presented in Table II, along with the variables presenting statistically TABLE I. Incontinent Residents Characteristics (n ¼ 189)
Frequency Occasionally incontinent Frequently incontinent Always incontinent Quantity of urinary leakage Low High Duration of UI Less than 1 month Between 1 month and 1 year Over 1 year DK/N/A Types Stress UI Urgency UI Functional UI (physical impairment) Functional UI (cognitive impairment) Forms Single forms (no combination of types) Combination of types Undetermined Moment Day Night Day and night Toileting program Yes No Response to program (n ¼ 16) No improvement Partial improvement Not able to determine
n
%
19 32 138
10.1 16.9 73
42 147
22.2 77.8
1 31 146 11
0.5 16.4 77.2 5.8
7 26 106 102
3.7 13.8 56.1 54
127 55 7
67.2 29.1 3.7
6 11 172
3.2 5.8 91
16 173
8.5 91.5
2 12 2
12.5 75 12.5
104
Jerez-Roig et al.
TABLE II. Association Between UI and Variables Presenting Statistically Significance, As Well As Gender and Age UI Yes
Type of institution For-profit Not-for-profit Gender Female Male Age 60–80 Over 81 Children Yes No Race Other Caucasian Schooling level Illiterate-primary education I Primary education II-superior Private health plan Yes Not-for-profit Reason for admission: no caretaker No Yes Reason for admission: living alone No Yes Reason for admission: own choice No Yes Physical activity Yes No Occupation Yes No Smoking habit No Yes Alzheimer disease No Yes Stroke No Yes Fecal incontinence No Yes Constipation No Yes Mobility Walks without aid Walks with aid Wheelchair user Bedridden Functional capacity Independency/slight dependency Moderate dependency Severe dependency Capacity to answer surveys Yes No
No
n
%
n
%
81 108
71.1 52.9
33 96
28.9 47.1
0.002a,
1 0.74 (0.63–0.89)
142 47
59.2 60.3
98 31
40.8 39.7
0.865a
1 1.02 (0.83–1.25)
75 114
53.9 63.7
64 65
46.1 36.3
0.08a
1 1.18 (0.98–1.43)
101 82
65.6 52.6
53 74
34.4 47.4
0.020a,
1 0.80 (0.66–0.97)
79 110
53 65.1
70 59
47 34.1
0.029a,
1 1.23 (1.02–1.48)
80 76
52.6 66.1
72 39
47.4 33.9
0.027a,
1 1.26 (1.03–1.53)
79 110
68.1 54.7
37 91
31.9 45.3
0.019a,
1 0.80 (0.67–0.96)
81 98
51.3 65.8
77 51
48.7 34.2
0.010a,
1 1.28 (1.06–1.55)
161 18
60.8 42.9
104 24
39.2 57.1
0.029a,
1 0.70 (0.49–1.01)
177 2
59.4 22.2
121 7
40.6 77.8
0.037b,
1 0.37 (0.11–1.27)
17 172
28.8 66.4
42 87
71.2 33.6
Prevalence of Urinary Incontinence and Associated Factors in Nursing Home Residents 1
Javier Jerez-Roig,1,2* Marquiony M. Santos,1 Dyego L.B. Souza,1 Fabienne Louise J.S. Amaral,1 and Kenio C. Lima1 Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Lagoa Nova, Natal-RN, Brazil 2 Rehabilitation Service, Hospital Can Misses, Ibiza, Balearic Islands, Spain
Aims: To determine the prevalence of urinary incontinence (UI) and associated factors in the institutionalized elderly. Methods: A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes in the city of Natal (Northeast Brazil). Individuals over the age of 60, who reside in institutions, were included. Hospitalized individuals and those at end of life were excluded. Data collection included sociodemographic information, UI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity, and Pfeiffer test for cognitive status). UI was verified through the Minimum Data Set (MDS) version 3.0, which was also used to assess urinary devices and UI toileting programs. The Chi-square test (or Fisher’s exact test), the linear Chi-square test, and logistic regression were utilized to model associations. Results: The final sample consisted of 321 elderly, mostly females, with a mean age of 81.5 years. The prevalence of UI was 58.88% (CI 95%: 53.42–64.13) and the final model revealed a statistically significant association between UI and white race, physical inactivity, stroke, mobility impairment, and cognitive decline. The most frequent UI type was functional UI and toileting programs (prompted voiding) were only applied to approximately 8% of residents. Conclusions: It is concluded that UI is a health issue that affects more than half of the institutionalized elderly, and is associated with white race, physical inactivity, stroke, and other geriatric syndromes such as immobility and cognitive disability. Neurourol. Urodynam. 35:102–107, 2016. # 2014 Wiley Periodicals, Inc. Key words: ageing; elderly; nursing homes; urinary incontinence
INTRODUCTION
Urinary incontinence (UI) is a geriatric syndrome that causes economic and social impacts derived from high treatment costs and caregiver burden, as well as physical consequences to the health of the elderly.1 This condition is related to other health problems such as dementia, urinary tract infection, being bedridden, cognitive or physical impairment, among others.2,3 Furthermore, incontinence causes hygienic and skin problems, as well as a negative impact on quality of life, which may result in reduced self-esteem, depression, and social isolation.2–4 Admission to a nursing home (NH) can influence continence among new residents and UI in this setting tends to be more severe and costly. Thus, this problem leads to a high burden of health care costs, and occasionally staff morbidity and even burnout.3 Despite the impact of UI, this is an under-diagnosed and under-treated health problem, due to patient embarrassment and the misconception that incontinence is a natural part of the aging process, and also due to the lack of motivation of health professionals to investigate this condition.4 In Brazil, the range of UI rates in the institutionalized elderly in the scientific literature is broad, varying between 22% and 100%, due to different survey methods and sample characteristics. Besides, the studies carried out regarding this condition in Brazilian NH residents are limited, contain serious methodological biases, and have not applied internationally recognized evaluation methods, such as the Minimum Data Set (MDS), which can enable comparison between studies.5 Therefore, new research including the study of incontinence and associated factors is necessary to deepen knowledge on the issue and help plan prevention and treatment measures for UI. The targets are the improvement in quality of life of the institutionalized elderly, #
2014 Wiley Periodicals, Inc.
reduction of health problems associated with incontinence and also reduction of sanitary costs. The objective of this study is to verify the prevalence of urinary incontinence and its associated factors in institutionalized elderly persons. MATERIALS AND METHODS
A cross-sectional population-based study is presented herein, with data collection carried out between October and December 2013, in 10 of the 14 NH registered by the Sanitary Vigilance in the municipality of Natal (Northeast Brazil). All elderly (60 years of age) were included in the study, according to criteria of the World Health Organization (WHO) for developing countries. Exclusion criteria were hospitalized or palliative care residents. The current work is part of a project entitled ‘‘Human ageing and health in long-term health institutions for the elderly,’’ with approval report no. 308/2012 from the Research Ethics Committee of the Federal University of Rio Grande do Norte (Brazil). Agreement letters from the 10 NH participating in the study were obtained along with signed informed consent forms from the residents and direct caregivers. Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. Correspondence to: Javier Jerez-Roig, Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000, Lagoa Nova, Natal-RN, Brazil. E-mail: [email protected] Received 3 May 2014; Accepted 26 August 2014 Published online 12 October 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22675
Urinary Incontinence in Nursing Home Residents The research team was composed of the first author and students of the undergraduate program in physiotherapy from the Federal University of Rio Grande do Norte (UFRN), who met twice before the study to ensure that questionnaires were adequately designed and that examiners were calibrated. In addition, a pilot study was previously carried out with 24 elderly from the the first institution researched. The dependent variable of the study was the presence of UI as reported by the direct caregiver, according to MDS version 3.0, which was also used to assess fecal incontinence (FI), urinary devices and toileting programs (bladder training, scheduled toileting, or prompted voiding).6 The definition recommended by the International Continence Society (ICS) in 2002 was utilized, which considers any involuntary urine loss.7 Those presenting with a urinary catheter or ostomy were accounted for, but excluded from bivariate analysis.8,9 In addition, the direct caregiver answered questions regarding duration and type of UI, use of diapers and daily amount of urine loss, as well as questions regarding the presence of constipation during the previous 5 days. Types of UI accepted by ICS in 2002 were used: stress urinary incontinence, defined as any ‘‘involuntary loss of urine during coughing, sneezing or with exertion;’’ urgency urinary incontinence, defined as ‘‘involuntary loss of urine accompanied by or immediately proceeded by urgency’’ and finally mixed urinary incontinence, defined as the combination of these symptoms.7 Furthermore, as utilized by other studies in NH settings, functional UI was defined as the loss of urine due to inability or unwillingness to access toilet facilities as a result of physical or cognitive impairment, psychological unwillingness or environmental barriers.9,10 In this type of UI, two sub-types were differentiated: functional UI by physical impairment, mainly due to gait limitations, and functional UI by cognitive impairment, mainly due to cognitive limitations in reaching or using toilet facilities.9 Finally, following Prado Villanueva et al.,9 a variable was added to define the cases that presented a combination of symptoms from two or more of the aforementioned UI types. Sociodemographic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, hobbies/ free time occupations, retirement/pension, administration of finances of the elderly, health plan, and number of elderly per caregiver), along with NH data (type of NH and ratio residents/ caregivers), and information related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzheimer’s disease, stroke, arterial hypertension, kidney insufficiency, stroke, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal-rectal and prostate surgical records, consumption of alcohol, past and current tobacco consumption, urinary infection within the past 30 days, hip fracture within the last 60 days, daily medicines, and number of daily medicines). The mobility status was also considered (independent gait, walks with aid, wheelchair user, and bedridden condition), as well as functional capacity, assessed by the Barthel Index,11 excluding the areas corresponding to continence as described by Prado Villanueva et al.9 Cognitive capacity was evaluated by a temporal orientation question ‘‘What year are we in?,’’ by the capacity of administrating finances, by the ability to answer questionnaires of another parallel research study and by the Pfeiffer Test, except for those with severe hearing deficits or foreigners. Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and linear Chi-square test. The magnitude of association was verified by the prevalence ratio, to a 95% level of significance. The variables with P levels lower than 0.20 were analyzed through logistic regression to build the Neurourology and Urodynamics DOI 10.1002/nau
103
multivariate model, using the Stepwise Forward method. Permanence of variables in multiple analysis depended on the likelihood ratio test, absence of multicollinearity, and also on the capacity of improving the model through the Hosmer and Lemeshow test. Transformation from odds ratio to prevalence ratio followed Miettinen.12 RESULTS
Of the total number of elderly, eight (2.4%) were excluded from the study: six (1.8%) were hospitalized, one (0.3%) was in terminal phase, and one (0.3%) was not over the age of 60. A total of 321 elderly were included in the study, mostly of the female gender (75.4%), with an average age of 81.5 years (standard deviation 9.0). Childless individuals comprised 49.2% of the individuals, 47.4% were single and 25.2% were widows(ers). Most participants (63.3%) resided in a not-for-profit NH, with the majority (46.7%) having been institutionalized due to a lack of caregivers or because they lived by themselves. Average (SD) residence time was 63.2 months (62.0) and the average ratio elderly/caregiver was 8.1 (5.2). The majority of elderly were retired (95.3%) however did not have private health plans (62.6%). UI prevalence (Table I) was 58.88% (CI 95%: 53.42–64.13). Three cases were not classified: two (0.6%) presented with permanent urinary catheters, and one used intermittent catheterisation. Double incontinence was observed in 41.9% of residents. Diapers were utilized by 66.0% of residents, and toileting programs were applied to 7.8% of residents. Among these cases, 12 (48.0%) reported partial improvements and nine (36.0%) reported complete rehabilitation, according to caregivers. The frequencies of the gender and age variables are presented in Table II, along with the variables presenting statistically TABLE I. Incontinent Residents Characteristics (n ¼ 189)
Frequency Occasionally incontinent Frequently incontinent Always incontinent Quantity of urinary leakage Low High Duration of UI Less than 1 month Between 1 month and 1 year Over 1 year DK/N/A Types Stress UI Urgency UI Functional UI (physical impairment) Functional UI (cognitive impairment) Forms Single forms (no combination of types) Combination of types Undetermined Moment Day Night Day and night Toileting program Yes No Response to program (n ¼ 16) No improvement Partial improvement Not able to determine
n
%
19 32 138
10.1 16.9 73
42 147
22.2 77.8
1 31 146 11
0.5 16.4 77.2 5.8
7 26 106 102
3.7 13.8 56.1 54
127 55 7
67.2 29.1 3.7
6 11 172
3.2 5.8 91
16 173
8.5 91.5
2 12 2
12.5 75 12.5
104
Jerez-Roig et al.
TABLE II. Association Between UI and Variables Presenting Statistically Significance, As Well As Gender and Age UI Yes
Type of institution For-profit Not-for-profit Gender Female Male Age 60–80 Over 81 Children Yes No Race Other Caucasian Schooling level Illiterate-primary education I Primary education II-superior Private health plan Yes Not-for-profit Reason for admission: no caretaker No Yes Reason for admission: living alone No Yes Reason for admission: own choice No Yes Physical activity Yes No Occupation Yes No Smoking habit No Yes Alzheimer disease No Yes Stroke No Yes Fecal incontinence No Yes Constipation No Yes Mobility Walks without aid Walks with aid Wheelchair user Bedridden Functional capacity Independency/slight dependency Moderate dependency Severe dependency Capacity to answer surveys Yes No
No
n
%
n
%
81 108
71.1 52.9
33 96
28.9 47.1
0.002a,
1 0.74 (0.63–0.89)
142 47
59.2 60.3
98 31
40.8 39.7
0.865a
1 1.02 (0.83–1.25)
75 114
53.9 63.7
64 65
46.1 36.3
0.08a
1 1.18 (0.98–1.43)
101 82
65.6 52.6
53 74
34.4 47.4
0.020a,
1 0.80 (0.66–0.97)
79 110
53 65.1
70 59
47 34.1
0.029a,
1 1.23 (1.02–1.48)
80 76
52.6 66.1
72 39
47.4 33.9
0.027a,
1 1.26 (1.03–1.53)
79 110
68.1 54.7
37 91
31.9 45.3
0.019a,
1 0.80 (0.67–0.96)
81 98
51.3 65.8
77 51
48.7 34.2
0.010a,
1 1.28 (1.06–1.55)
161 18
60.8 42.9
104 24
39.2 57.1
0.029a,
1 0.70 (0.49–1.01)
177 2
59.4 22.2
121 7
40.6 77.8
0.037b,
1 0.37 (0.11–1.27)
17 172
28.8 66.4
42 87
71.2 33.6
