Variation in urgency urinary incontinence treatment by social determinants of health

Objectives: The objective of this study was to assess if provision of treatments for urgency urinary incontinence (UUI) is affected by social determinants of health (SDOH), including race, ethnicity, primary language, residence geographic area type, and estimated median household income (EMHI).

Methods: This was a retrospective cohort study using electronic medical records of a large health system from 2017 to 2022. All adult female patients with the diagnosis of UUI were identified using International Classification of Disease-9 and 10 codes. The following demographics data were extracted: age, BMI, self-identified race and ethnicity, primary language, marital status, tobacco use, EMHI, insurance payor and type, and rural-area commuting area codes describing residence geographic area type. High disease burden was defined as having ten or more items on a patient’s problem list. Provision of the following treatments were extracted: anticholinergic and beta agonist prescriptions, intradetrusor onabotulinumA injection, percutaneous tibial nerve stimulation, and sacral neuromodulation. Specialists were defined as urologists or urogynecologists, while primary care providers (PCPs) included internal medicine, family medicine, and general gynecology providers. The primary outcome was provision of any treatment of UUI. Secondary outcomes included: specific types of UUI treatment and whether treatments were prescribed by a specialist. Univariable comparison and multivariable logistic regression were performed.

Results: Among 33,002 patients with UUI captured, 5,100 patients (15.4%) received a treatment. Those who received treatment for UUI had a mean age of 65.6 years, mostly identified as White race (66.2%) and non-Latina ethnicity (97.9%), lived within the metropolitan area core (96.1%), had Medicare insurance (42.0%), and had EMHI over $100,000 (41.9%). Univariate comparison of patients who received UUI treatment and those who did not are presented in Table 1. Multivariable logistic regression (Table 2) found that the following factors were associated with receiving any UUI treatment: older age, not having a partner/spouse, higher BMI, and having Medicare insurance. Receiving anticholinergic medication was associated with older age, Black or African American race, elevated BMI, current tobacco use, high disease burden, having no partner, Medicare or no insurance, and lower EMHI. Factors associated with beta agonist treatment were older age, White race, high BMI, and Medicare insurance. Receiving any advanced therapy was associated with older age, White race, higher BMI, Medicare insurance, and EMHI in the medium range from over $40,000 to $100,000. Having an anticholinergic medication prescribed by a PCP rather than a specialist was associated with older age, lower BMI, current tobacco use, high disease burden, having no partner or insurance.

Conclusions: Patients who identified as Black or African American race and had lower EMHI were more likely to receive anticholinergic treatment and less likely to have received advanced UUI therapies. This suggests that SDOH contribute significantly to provision of UUI treatments and highlights potential disparities.