Overactive bladder syndrome (OAB) is a common complaint, known to effect 11.8% of the population and the prevalence increases with age (1). It is characterised by the presence of increased urinary frequency, urinary urgency and nocturia with or without urge urinary incontinence. These symptoms are linked to increased levels of anxiety and depression and have detrimental effects on quality of life. Current treatments for the management of OAB include lifestyle changes, pelvic floor training, medication and surgical interventions. Lifestyle changes are poorly supported in the current literature. Medication has low rates of treatment adherence and invasive options have procedure specific complications. Many sufferers adopt coping mechanisms rather than following the prescribed pathway of care.
Acupuncture does not currently feature in the hierarchy of treatments for OAB, however a recent Cochrane Intervention Review demonstrated that treatment effect is comparable to medication with a lower side effect profile (2). 
Jenks et al (3) studied the cost effectiveness of acupuncture compared to mono and dual medication therapy, and additionally to conservative treatment for OAB. This team demonstrated that acupuncture is an effective treatment, showing significant reductions in day and night time frequency and significantly improved functional bladder capacity. In addition, 74% of participants in this study rated their symptom improvement as clinically useful. This improvement is echoed in later larger cohort studies.  However, acupuncture was more expensive after 6 months of treatment compared to first line treatment options. Acupuncture sessions were delivered on an individual basis and the added cost was largely due to the requirement for maintenance to sustain treatment effect.  
Our study aimed to investigate a multi-bed clinic structure as a novel service model to improve capacity and enhance cost effectiveness of acupuncture as a treatment option for OAB. Referral to treatment time was the primary outcome, with patient satisfaction and clinic capacity as secondary outcomes.

The data was collected between August 2022 and March 2023 at one secondary care NHS Trust in England. Ethical permission was not required as the mode of delivery was the subject of the study, intervention was unchanged. No external funding was required or sourced for the implementation of this model as it was delivered within the existing pelvic health physiotherapy service with all training requirements completed in advance of the study. 
Prior to this study, acupuncture for OAB symptoms was delivered by a senior physiotherapist with appropriate skills and training in acupuncture within general pelvic health physiotherapy clinics on an individual basis.
A quality improvement approach utilising the model for improvement was adopted. The problems with the service delivery model were defined by identifying the primary and secondary drivers and subsequently, a multi-bed clinic format was the primary change idea which was tested by two Plan/Do/Study/Act (PDSA) cycles. See figure 1.

Data was collected on the following:
•	Time in days from referral to first treatment – baseline calculation was compared to the mean and standard deviation during the study period. 9 new patients started treatment during the study period. The baseline comparison was made from 9 randomly selected patients receiving maintenance treatment.
•	The number of vacant appointments per clinic expressed as a run chart.
•	Patient satisfaction with change in delivery mode was conducted by a survey of patients who had experience of both the individual and multi-bed experience.
•	Treatment response was measured using the ICIQ-OAB and ICIQ-OAB QoL for new patients referred for a trial of acupuncture.

Primary outcome
The mean length of time between decision to treat with acupuncture and first treatment with the individual treatment model was 51.3 days (SD 26.2). When the multi-bed clinic was established this figure was 4.7 days (SD 4.3). A reduction of 91%.

Secondary outcomes
Clinic capacity - Figure 2 illustrates the percentage of filled appointments per clinic. This shows the demand for the service but also demonstrates that this service model builds capacity for a more sustainable service.
Patient satisfaction – a survey was conducted with patients who had experienced acupuncture for OAB in both a traditional delivery mode of 1:1 treatment and in a multi-bed clinic. There were 12 respondents. All respondents reported they were satisfied with treatment received. The level of privacy was raised by one respondent as an issue. Appointment times were raised by four respondents, one would have preferred an earlier appointment whilst the other three commented that evening appointments made fitting around work schedules and parking easier. These comments were used to address privacy issues and adapt the clinic times to allow for earlier appointments. 

Symptom PROMs for new patients - 9 new patients commenced treatment during the data collection period. 
•	2 have yet to complete the initial trial. 
•	1 did not experience an improvement in symptoms after 5 treatments and terminated the trial at this point.
•	1 did not experience an improvement in symptoms after 6 treatments and was referred back to the referring clinician. 
•	5 completed ICIQ-OAB and ICIQ-OAB QoL questionnaires at baseline, after 3 treatments, and after 6 treatments. On trial completion, average scores had improved by 53% on the ICIQ-OAB and 47% on the ICIQ-OAB QOL.

Time from decision to use acupuncture to first treatment was reduced by 91%, indicating greater efficiency of the studied service model. Having a dedicated clinic has increased capacity to offer treatment and improved sustainability of the service. PROMs outcomes show a reduction in bothersome symptoms in 71% of patients who completed a treatment trial, however this figure is based on very small sample size. All patients who completed a trial went on to request maintenance treatment.

This small-scale study has demonstrated that implementation of a multi-bed clinic to offer acupuncture for OAB symptoms has benefits in terms of efficiency, patient satisfaction and the effect of treatment. However, the numbers of patients involved is currently very small and the cost implications of a multi-bed clinic model have not been studied. Further data collection is required over an extended time frame to validate or challenge these preliminary findings.

Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, Coyne K, Kelleher C, Hampel C, Artibani W, Abrams P. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol. 2006 Dec;50(6):1306-14; discussion 1314-5. doi: 10.1016/j.eururo.2006.09.019. Epub 2006 Oct 2. PMID: 17049716.
Hargreaves E, Baker K, Barry G, Harding C, Zhang Y, Kandala N-B, Zhang X, Kernohan A, Clarkson CE. Acupuncture for treating overactive bladder in adults. Cochrane Database of Systematic Reviews 2022, Issue 9. Art. No.: CD013519. DOI: 10.1002/14651858.CD013519.pub2. Accessed 09 February 2023.
Jenks, J, Kavia, R, Pakzad, MH, Hamid, R, Ockrim, JL, Greenwell, TJ. Acupuncture is clinically but not yet cost-effective in the treatment of symptomatic idiopathic detrusor overactivity. Int J Urol Nurs. 2018; 12: 71– 75. https://doi.org/10.1111/ijun.12166