Race and Weight Class Influence Use of Toileting Programs for Incontinence in Nursing Homes

Objectives: Behavioral interventions are a low-risk therapy for urinary/fecal incontinence (UI/FI) and can successfully reduce wetness, accidents, and incontinence sequelae such as pressure ulcers, infections, and caregiver burden. Given the demonstrated influence of race and obesity on nursing home (NH) quality of care, we hypothesized that race- and weight-related disparities exist with the use of behavior-based toileting programs (TPs) in female residents and that minority race and obese residents would be less likely to undergo TP trials.

Methods: We performed a cross-sectional analysis using the 2019 Minimum Data Set 3.0, which includes data from all residents residing in Medicare/Medicaid-certified NHs in the United States. We excluded men, comatose residents, and those with a life expectancy < 6 months. Weight categories were underweight ( < 18.5kg/m²), normal/overweight (18.5 - < 30kg/m²), class 1 obesity (30 - < 35kg/m²), and class 2+ obesity (≥35 kg/m²). Race was defined by resident/family self-report and categorized as White, Black, and Other for analyses. TPs are individualized, offered to incontinent residents without a permanent catheter or ostomy, and may include bladder retraining, scheduled voiding/evacuation, and dietary changes. Response to urinary TPs was documented, and current use of TP was determined by use for four or more days in the past week. Multivariable logistic regression models were developed to examine the association of weight class and race with trial, response, and current use of TPs, while controlling for age, Hispanic ethnicity, stroke, neurogenic bladder, dementia, delirium, activity of daily living (ADL) deficiency score, short-term stay status, and facility-level TP usage.

Results: The study cohort included 580,669 female residents with a mean (standard deviation (SD)) age 78.7 (12.1) years and a mean body mass index (BMI) of 27.8 (SD 16.0). Most residents were White (77.2%) or Black (11.8%), and 4.4% were of Hispanic ethnicity. The prevalence of UI was 38.6%, FI was 36.9%, and dual incontinence (DI) was 29.3%. Black residents had the greatest prevalence of UI, FI, and DI. Only 6.2% of incontinent female residents underwent a urinary TP trial, with 35% having a positive response, and 2.3% reported the current use of a bowel TP. Despite similar responsiveness to TPs, Black female residents had a 41% lower odds of undergoing a urinary TP trial (95% confidence interval (CI) 0.52 – 0.67) and a 45% lower odds of using a bowel TP (95%CI 0.45 – 0.68) compared to White residents. Underweight residents were less likely to have a urinary TP trial (adjusted odds ratio (aOR) 0.85, 95%CI 0.78 – 0.93) compared to normal/overweight residents.

Conclusions: Race- and weight-related disparities exist in implementing behavior-based TPs in NHs. Addressing these disparities is crucial for improving patient outcomes and ensuring that all appropriate NH residents with UI/FI have equitable access to this low-risk intervention.