Ambulatory procedures for urinary incontinence in the United States, 1994-1996

Racial Disparities in Sacral Neuromodulation for Idiopathic Fecal Incontinence

IMPORTANCE

Sacral neuromodulation (SNM) is an effective treatment for fecal incontinence (FI). Previous studies found that Black women undergo SNM for urinary incontinence less than White women, but there is less known about racial disparities for FI.

OBJECTIVE

This study assessed differences in Black and White patients' FI treatment; SNM counseling was the primary outcome.

STUDY DESIGN

This was a retrospective cohort study of adult non-Hispanic Black and White patients who received FI treatment at an academic institution from 2011 to 2021. Medical records were queried for treatments, testing, and treating specialties for a 2:1 age-matched cohort of White:Black patients.

RESULTS

Four hundred forty-seven women were included: 149 Black women and 298 age-matched White women. A total of 24.4% (109) of patients had documented SNM counseling, significantly fewer in Black patients (14.8% vs 29.2%, P < 0.001). A total of 5.1% (23) of patients received SNM, less frequent in Black patients (2.7% vs 6.4%, P = 0.003). Among patients with SNM counseling, there was no difference between cohorts. Black patients were less likely to be referred for physical therapy (59.7% vs 77.2%, P < 0.001), sphincter imaging (0.7% vs 5.7%, P = 0.011), and defecography (8.1% vs 17.1%, P = 0.009). Different specialties managed the 2 cohorts. Black patients were less likely to see urogynecology and colorectal surgery (21.5% vs 34.6%, P = 0.004; 9.4% vs 15.4%, P = 0.077). Patients seen by these surgeons were more likely to discuss SNM (48.6% vs 8.5%, P < 0.001).

CONCLUSIONS

There were differences between Black and White patients' FI treatment, including counseling about SNM. Multidisciplinary work is needed to provide equitable education for this life-altering condition.

Applying a Health Equity Lens to Urinary Incontinence

Health equity is attained when everyone has the opportunity achieve the health they envision; however, health disparities are a barrier to health equity. As health disparities specific to urogynecology exist, it is critical to examine and contextualize them in a framework that improves understanding of what factors may drive these disparities to craft effective solutions. This article will review what we currently know about urinary incontinence disparities and provide a framework for evaluation as well as a framework for advancing health equity in the care of diverse patient populations with urinary incontinence.

Characteristics of Providers Performing Urogynecologic Procedures on Medicare Patients 2012-2014

OBJECTIVE

To analyze the characteristics of providers performing stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures in the United States.

METHODS

The Centers for Medicare Services public database, released for years 2012 through 2014, was queried for SUI-related and POP-related Healthcare Common Procedure Coding System. Providers were categorized as Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers and non-FPMRS providers, using a list of FPMRS board-certified providers compiled through the American Board of Medical Subspecialties website. Other physician specialties that submitted SUI and POP procedures claims were tabulated.

RESULTS

Six hundred twenty-nine FPMRS and 833 non-FPMRS providers submitted claims for SUI and POP procedures. The SUI procedures claims had the following provider specialty distribution: obstetrics and gynecology (OB/GYN)-FPMRS, 46.7%; urology, 26.3%; OB/GYN, 12.2%; and urology-FPMRS, 13.9%, with the remaining 0.9% being performed by other specialties. The POP procedures had the following specialty distribution: OB/GYN-FPMRS, 63.4%; OB/GYN, 16.7%; urology, 8.3%; and urology-FPMRS, 7.1%, with the remaining 4.5% being performed by other specialties.Provider distribution was compared between transvaginal mesh and sling insertion procedures to transvaginal mesh and sling removal procedures. The FPMRS providers claimed 63.6% of sling and transvaginal mesh insertion procedures and performed 84.9% of mesh and sling removal procedures.

CONCLUSIONS

Medicare reimbursement data provides a unique insight into the distribution of provider specialties performing SUI-related and POP-related procedures in the Medicare population. The OB/GYN-FPMRS providers submitted the majority of claims for SUI and POP procedures from 2012 to 2014. The FPMRS providers are also performing the majority of mesh removal procedures.

Bladder Symptoms and Attitudes in an Ethnically Diverse Population

OBJECTIVE

The aim of the study was to assess pelvic floor symptoms and attitudes in an ethnically diverse population.

METHODS

We conducted a cross-sectional survey of women presenting to 2 community-based, ethnically diverse gynecology clinics. Before being seen by a provider, participants were asked to complete a questionnaire.

RESULTS

A total of 312 women were included: 32.7% white, 50.3% African American, and 17.0% Hispanic. Other racial/ethnic groups were excluded secondary to small samples size. The median (interquartile range) age was 34.0 (27.0-44.0) years. The groups differed with respect to most demographic characteristics, such as income, education, and nation of origin. Nocturia and urinary frequency were the most commonly reported symptoms. African American respondents were more likely to report nocturia than white respondents (odds ratio, 2.4; 95% confidence interval, 1.2-4.8). Respondents' views of normal urinary function generally did not vary by race/ethnicity. However, Hispanic respondents were less likely than white respondents to agree that it is normal to leak urine after having children (odds ratio, 0.28; 95% confidence interval, 0.11-0.68). Among women who reported at least 1 symptom, 46.7% reported that at least 1 symptom bothered them, and this did not differ with respect to race/ethnicity (P ≥ 0.59). African American respondents were more likely than whites to report their urinary leakage to their doctors (P = 0.006).

CONCLUSIONS

Our study demonstrates that with few exceptions, bladder symptoms and attitudes are similar among reproductive-age women of various racial/ethnic groups in a community setting.

Changing trends in surgery for stress urinary incontinence

PURPOSE OF REVIEW

Currently, a number of different stress urinary incontinence (SUI) procedures exist. The relatively recent adoption of the midurethral sling into clinical practice has changed the surgical management of SUI. This critical evaluation of the trends in SUI surgery emphasizes the public health burden of SUI surgery, provides insight into modern clinical practice, determines whether these trends reflect evidence-based data, and highlights potential areas for future research.

RECENT FINDINGS

Trends in SUI surgery have shown a rise in the use of midurethral mesh slings with a concomitant decrease in retropubic procedures. The rates of other types of SUI surgery remain quite low. Although the overall rate of slings has increased dramatically, limited population-based data exist regarding specific types of midurethral slings, such as retropubic vs. transobturator vs. mini-slings. There is a need for continued evaluation of these trends in response to heightened public awareness of the potential risks of synthetic mesh.

SUMMARY

The midurethral sling has become the gold standard surgery for SUI. It will be important to evaluate future trends in SUI surgery given the dynamic changes in new techniques for midurethral slings and long-term evidence regarding the effectiveness and risks of specific sling types.

Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data

INTRODUCTION AND HYPOTHESIS

The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California.

METHODS

We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD).

RESULTS

In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6%) and 9,016 (44.3%) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4%). The use of mesh to augment prolapse repairs was similar (22.3% inpatient vs 19.3% outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8%, respectively).

CONCLUSIONS

In California, 16% of POP and 44% of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

Ambulatory procedures for female pelvic floor disorders in the United States

OBJECTIVE

The aim of this study was to estimate the number of women undergoing ambulatory surgical procedures for female pelvic floor disorders (PFDs) in the United States and to compare age-adjusted ambulatory surgical case rates between 1996 and 2006.

STUDY DESIGN

We analyzed data from the 1996 and 2006 National Survey of Ambulatory Surgery, a federal public access de-identified database. Procedures for PFDs were identified using International Classification of Diseases-9th revision Clinical Modification procedure codes for urinary incontinence, fecal incontinence, and pelvic organ prolapse.

RESULTS

The number of women undergoing ambulatory surgical procedures for urinary incontinence increased from 34,968 (95% confidence interval, 25,583-44,353) in 1996 to 105,656 (95% confidence interval, 79,033-132,279) in 2006. The age-adjusted ambulatory surgical case rates for all PFDs increased from 7.91 per 10,000 in 1996 to 12.10 per 10,000 in 2006 (P = .0006).

CONCLUSION

Ambulatory procedures for urinary incontinence increased between 1996 and 2006, as well as the age-adjusted ambulatory case rate for all PFDs.

Ambulatory care related to female pelvic floor disorders in the United States, 1995-2006

OBJECTIVE

The purpose of this study was to describe trends for pelvic floor disorder (PFD)-related ambulatory visits.

STUDY DESIGN

Data were derived from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey. PFD-related visits were based on ICD-9 codes. We collapsed 12 survey years into 3 study periods (1995-1998, 1999-2002, 2003-2006) to evaluate numbers, rates, and trends for PFD-related visits.

RESULTS

The average annual number of PFD-related visits was 3.9 million (95% confidence interval, 3.1-4.7). The annual rate of PFD-related visits per 1000 women was 35.2% in 1995-1998, 40.6% in 1999-2002, and 36.3% in 2003-2006. PFD visits represent 0.9% of all ambulatory visits for adult women in the United States. Women > or =60 years old had higher rates of PFD-related visits compared with women <60 years old.

CONCLUSION

The annual number of PFD-related visits is significant and represents 0.9% of all ambulatory visits made by adult women in the United States.

Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004

OBJECTIVE

The purpose of this study was to describe national trends in surgery for female stress urinary incontinence (SUI).

STUDY DESIGN

We used data from the National Hospital Discharge Survey, a federal dataset sampling patient discharges from US inpatient hospitals. We analyzed patient and hospital demographics and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnostic and procedures codes for 1979-2004. Age-adjusted rates per 1000 women were calculated with 1990 US Census population data.

RESULTS

The number of women who have undergone SUI surgery each year increased from 48,345 in 1979 to 103,467 in 2004. In women > or = 52 years old, the age-adjusted rate more than doubled from 0.64-1.60 procedures per 1000 women; in women < 52 years old, the age-adjusted rate fell from 0.57-0.47. Age-adjusted rates for retropubic urethral suspension (ICD-9-CM, 59.5) fell from 0.37 in 1979 to 0.14 in 2004. For suprapubic sling procedures (ICD-9-CM, 59.4), the age-adjusted rates rose from 0.02 in 1979 to a peak of 0.10 in 1997 and then fell to 0.03 in 2004. Age-adjusted rates for other repair of urinary stress incontinence (ICD-9-CM, 59.79) rose from 0.06 in 1979 to 0.64 in 2004.

CONCLUSION

The number of women who have undergone SUI surgery increased significantly from 1979-2004. Because the National Hospital Discharge Survey data do not include ambulatory procedures, accurate information on same-day surgeries is unavailable. Currently no ICD-9-CM procedure code exists specifically for midurethral sling procedures. Both missed sampling of same-day procedures and nonspecific or inaccurate coding may explain the surprising decline in suprapubic sling procedures and the rise in rates of other repair of SUI. A national ambulatory surgical database and a specific code for midurethral sling are needed to capture these important data.

Is Burch colposuspension ever cost-effective compared with tension-free vaginal tape for stress incontinence?

OBJECTIVE

This study was undertaken to evaluate the cost-effectiveness of Burch colposuspension compared with tension-free vaginal tape.

STUDY DESIGN

A Markov decision model was developed to compare costs (2005 US dollars) and effectiveness (quality-adjusted life years) of Burch and tension-free vaginal tape for stress urinary incontinence over 10 years from a health care system perspective. After surgery, outcomes included cure, persistent stress urinary incontinence followed by second surgery, and persistent stress urinary incontinence and mesh erosion after tension-free vaginal tape. An incremental cost-effectiveness ratio of less than $50,000 per quality-adjusted life year was considered cost-effective.

RESULTS

For the base-case, the Burch strategy cost more than tension-free vaginal tape ($9320 vs $8081), but was slightly more effective (7.260 vs 7.248 quality-adjusted life years). The incremental cost-effectiveness ratio was $98,755 per quality-adjusted life year. The incremental cost-effectiveness ratio was less than $50,000 per quality-adjusted life year when the relative risk of cure after Burch to tension-free vaginal tape was greater than 1.09.

CONCLUSION

Burch colposuspension was not cost-effective compared with tension-free vaginal tape. However, if the tension-free vaginal tape failure rate was to increase over time, Burch may become cost-effective.

Outpatient laparoscopy for abdominal and pelvic pain in the United States 1994 through 1996

OBJECTIVE

The purpose of this study was to estimate the frequency at which laparoscopic surgery is performed to treat female pelvic pain.

STUDY DESIGN

Using the National Survey of Ambulatory Surgery, we performed a retrospective, cross-sectional study of women who had been diagnosed with abdominal or pelvic pain who underwent outpatient laparoscopic procedures. Rates of procedures were tabulated for all years that were available (1994-1996). A comparison was made across age, ethnicity, and geographic distribution.

RESULTS

The estimated number of women who underwent outpatient laparoscopic surgery for pelvic/abdominal pain was 120,000, 130,400, and 128,600 for the years 1994 through 1996, respectively. Typical additional procedures that were performed included lysis of adhesions, dilation, and hysteroscopy. The women who underwent these procedures were generally of reproductive age (mean, 32.2 +/- 9.6 years old). Most procedures are performed in hospitals with the use of general anesthesia. The southern portion of the country contributes a disproportionate share of the reported procedures.

CONCLUSION

Laparoscopic surgical evaluation of female pelvic or abdominal pain occurs frequently in the US health care system.

Complications following surgical intervention for stress urinary incontinence: A national perspective

AIMS

Stress urinary incontinence (SUI) impacts many women. Treatment is primarily surgical. Post-operative morbidity considerably affects individuals and the health care system. Our objective is to describe complications following surgery for SUI and how they affect resource utilization.

METHODS

Utilizing the Nationwide Inpatient Sample (a nationally representative dataset), 147,473 patients who underwent surgery for SUI from 1988 to 2000 were identified by ICD-9 codes. Comorbid conditions/complications were extracted using ICD-9 codes, including complication rates, length of stay (LOS), hospital charges, and discharge status.

RESULTS

Overall complication rate was 13.0% (not equal to sum of complication sub-types, as each woman may have had = 1 complication), with 2.8% bleeding, 1.4% surgical injury, 4.3% urinary/renal, 4.4% infectious, 0.1% wound, 1.1% pulmonary insufficiency, 0.5% myocardial infarction, 0.2% thromboembolic. The "gold standard" surgical technique for SUI, the pubovaginal sling, had the lowest morbidity at 12.5%. Mean LOS increased with morbidity: from 2.9 to 4.1 to 6.1 days for those with 0, 1, and =2 complications respectively (P < 0.001). Similarly, inflation-adjusted hospital charges increased with morbidity: from 7,918 dollars to 9,828 dollars to 15,181 dollars for those with 0, 1, and =2 complications respectively (P < 0.001). The percentage of patients requiring post-discharge subacute or home care increased with morbidity: from 4.4% to 8.4% to 14.3% for those with 0, 1, and =2 complications (P < 0.001).

CONCLUSIONS

A substantial percentage of women experience complications following surgery for SUI. Post-operative morbidity leads to dramatically increased resource utilization. Prospective studies are needed to identify pre-operative risk factors and intraoperative process measures to optimize the quality of care.