Abstract
Importance:
Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them.
Objectives:
To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system.
Study Design:
Electronic health records were queried to identify a cohort of adult women patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. UI referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates.
Results:
In the year following primary care UI diagnosis, 37.2% of patients in the overall cohort (n=4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n=2,398) or mixed UI (n=552), 17.1% were prescribed medication. Women with stress (Odds Ratio 3.10, 95% CI 2.53-3.79) and mixed UI (OR 6.17, 95% CI 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely (OR 0.39, 95% CI 0.29, 0.48).
Conclusion:
Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within one year, suggesting missed opportunities for timely care.
Introduction:
Approximately 50% of women report at least one episode of urinary incontinence (UI) during their adult lives.1,2 UI can be grouped into several categories including stress (leakage of urine due to physical exertion), urgency (leakage of urine due to sudden, compelling desire to void), and mixed (both stress and urgency).3 UI may interfere with work and social functions, negatively affecting independence and quality of life.4-6
Behavioral modifications and pelvic floor exercises are effective first-line nonpharmacological interventions for mild or early UI symptoms for over half of women.7,8 Proper fluid management, timed voiding, and pelvic floor strengthening techniques can be taught during individual appointments or group classes.9 Patients who need additional support engaging pelvic musculature can be referred to pelvic floor physical therapy (PFPT).10 Women with continued stress UI despite conservative treatments may undergo surgical procedures such as urethral bulking, urethral suspension, or sling placement. Therapies for those with ongoing urgency UI include antimuscarinics and B-3 agonists medications, bladder chemo denervation (e.g. botulinum toxin injections), and neurostimulation.10
Despite evidence-based strategies to manage UI, most patients never receive adequate treatment. Several studies have shown as few as 25% of affected patients seek care. 11,12 For those women who do seek care, management is often begun by primary care providers (PCPs).11 However, little is known about how PCPs and patients complete the multiple steps in the evaluation and management of UI, including initiation of conservative treatments, prescription medication use, referrals for specialty care, and patient follow-through with appointments.8 To better characterize UI treatment patterns in PCP clinics, and potential opportunities to improve care, we examined clinical data from electronic health records for prescriptions and referrals to therapy (PFPT) and specialists (urology, and urogynecology) within a large Midwestern academic health system.
Materials and Methods:
Overview
We examined processes of care for women with newly diagnosed UI in a large Midwestern healthcare system. We examined written medication prescriptions and referrals to specialists (PFPT, urology, or urogynecology) during the year after diagnosis and completion of referrals. We also examined factors that may promote or inhibit the care processes. All study procedures were approved by the Medical College of Wisconsin institutional review board.
Setting
The study was conducted in a regional health network with 3 hospitals and 38 satellite clinics providing care across 9 counties in southeastern Wisconsin. The network has over 900,000 outpatient visits annually.
Study Cohort and Variables
Electronic health records (EHR) were queried to identify a cohort of 18 to 89-year-old female patients first diagnosed with UI during primary care (family or general internal medicine) outpatient visits between January 2016 and December 2020. We classified a patient as having a new UI diagnosis if they did not have a UI diagnosis or medication prescription in the 12 months preceding the index outpatient visit. UI diagnosis was defined as the presence of one or more visit diagnoses from a list of ICD-10 codes which encompasses UI, overactive bladder, and urgency of urination (Appendix Table 1).11,12 Inclusion of specific ICD-9 codes has varied in prior research. In addition, ICD-10 codes (which do not have perfect 1:1 matches with ICD-9 codes) were introduced in the time following much of the prior research. Thus, with oversight from three clinicians specializing in the management of UI (ED, JMN, RCO) we developed a primary list that included all relevant ICD-10 codes analogous to ICD-9 codes used in previous publications.11,12
We also used structured EHR fields to collect patient covariates during the year prior to UI diagnosis including demographic information and comorbid diagnoses measured based on all EHR diagnosis using an algorithm developed by Elixhauser and adapted to ICD-10 codes.13,14 EHR referral fields were also utilized to ascertain specialist (urology/urogynecology) and PFPT referral dates, types, and associated diagnoses. EHR prescription fields were used to ascertain medication class, name, and prescription dates for UI medications. Subjects were excluded if there was EHR evidence of urinary tract infection at diagnosis or presence of conditions in the prior year for which UI management might differ substantially (e.g. pregnancy, primary neurologic pathology).
The cohort was divided into subgroups based on ICD-10 codes for the type of UI (stress, urgency, mixed, other) diagnosed at the initial PCP visit (Appendix Table 1). If a patient had two UI codes that fell into different categories she was classified as having mixed UI.
Analysis
UI medication prescriptions and referrals to specialist physicians (urology/urogynecology) and PFPT were examined in the year after the index PCP visit. Logistic regression models were used to examine the association between a referral (to either PFPT or specialist) and patient demographics, comorbidity, type of UI, and diagnosis dates (pre- vs during COVID-19) for all patients. For patients with urgency or mixed UI, we modeled the associations of UI with medication prescriptions and demographics, comorbidities, and diagnosis dates. We also examined models with a composite “any guideline-recommended treatment” variable that included PFPT or specialist referrals to for stress UI, and PFPT or specialists referrals or medication prescriptions for urgency or mixed UI.
In sensitivity analyses, we examined the impact on our results of using a more limited UI-specific group of ICD-10 codes for the urgency UI subgroup. In addition, because antimuscarinic and B3-agonist UI medications are not generally recommended treatments for stress UI, we performed individual electronic chart reviews of all patients assigned to the stress UI cohort who had been prescribed these medications (n=50). We found half had mixed UI described in notes despite only having a stress UI diagnosis. As relatively few patients’ diagnoses were affected, overall results were unchanged, and results are therefore not presented.
Results:
Of the 6,419 female patients age 18-89 diagnosed with UI, 4,382 were included in our analysis. Reasons for exclusion are shown in Appendix Figure 1. Demographics for the overall cohort overall and by UI subtype are shown in Table 1.
Table 1.
Baseline Cohort Demographics
| Total (n=4382) |
Urgency (n=2348) |
Stress (n=869) |
Mixed (n=552) |
Other (n=563) |
|
|---|---|---|---|---|---|
| N, % | N, % | N, % | N, % | N, % | |
| Race | |||||
| White | 3477 (79.3) | 1880 (78.4) | 716 (82.4) | 451 (81.7) | 430 (76.4) |
| Black | 694 (15.8) | 412 (17.2) | 100 (11.5) | 85 (15.4) | 97 (17.2) |
| Other | 211 (4.8) | 106 (4.4) | 53 (6.1) | 16 (2.9) | 36 (6.4) |
| Hispanic | 147 (3.4) | 79 (3.3) | 33 (3.8) | 12 (2.2) | 23 (4.1) |
| Age | |||||
| 18-49 | 1196 (27.3) | 716 (29.9) | 247 (28.4) | 87 (15.8) | 146 (25.9) |
| 50-59 | 735 (16.8) | 376 (15.7) | 192 (22.1) | 84 (15.2) | 83 (14.7) |
| 60-69 | 1018 (23.2) | 531 (22.1) | 198 (22.8) | 161 (29.2) | 128 (22.7) |
| 70-79 | 917 (20.9) | 509 (21.2) | 153 (17.6) | 136 (24.6) | 119 (21.1) |
| 80-89 | 516 (11.8) | 266 (11.1) | 79 (9.1) | 84 (15.2) | 87 (15.5) |
| BMI | |||||
| 1: Underweight | 69 (1.6) | 39 (1.6) | 7 (0.8) | 11 (2.0) | 12 (2.1) |
| 2: Healthy | 996 (22.7) | 573 (23.9) | 193 (22.2) | 90 (16.3) | 140 (24.9) |
| 3: Overweight | 1118 (25.5) | 625 (26.1) | 229 (26.4) | 132 (23.9) | 132 (23.4) |
| 4: Obese | 2185 (49.9) | 1155 (48.2) | 438 (50.4) | 318 (57.6) | 274 (48.7) |
| Elixhauser Comorbidity Index | |||||
| 0 | 1732 (39.5) | 913 (38.1) | 395 (45.5) | 227 (41.1) | 197 (35.0) |
| 1 | 1117 (25.5) | 641 (26.7) | 220 (25.3) | 119 (21.6) | 137 (24.3) |
| 2 | 690 (15.7) | 386 (16.1) | 127 (14.6) | 81 (14.7) | 96 (17.1) |
| 3+ | 843 (19.2) | 458 (19.1) | 127 (14.6) | 125 (22.6) | 133 (23.6) |
| Insurance | |||||
| Commercial (including PPO Managed Care) | 1342 (30.6) | 761 (31.7) | 343 (39.5) | 117 (21.2) | 121 (21.5) |
| Medicare | 933 (21.3) | 477 (19.9) | 144 (16.6) | 150 (27.2) | 162 (28.8) |
| Medicare Advantage | 1425 (32.5) | 776 (32.4) | 252 (29.0) | 211 (38.2) | 186 (33.0) |
| Other | 682 (15.6) | 384 (16.0) | 130 (15.0) | 74 (13.4) | 94 (16.7) |
| During COVID-19 Pandemic (2020) | |||||
| Yes | 942 (21.5) | 585 (24.4) | 137 (15.8) | 93 (16.8) | 127 (22.6) |
In the year following a primary care UI diagnosis, 20.6% of women in the overall cohort were referred for further management – 17.7% to urology/urogynecology and 3.2% to PFPT (Figure 1). The mean time to referrals was 13.1 days (S.D. 51.5), with 11.4% of patients receiving a referral on the date of diagnosis. One or more referral visits to urology/urogynecology and PFPT were completed by 71.0% and 57.4% of women, respectively. With regard to patients with urgency or mixed UI, 17% were prescribed an antimuscarinic or B-agonist medication. The mean time to medication initiation was 15.8 days (S.D. 58.7), and 14.3% of all patients begun on medication were begun on the date of diagnosis. Long and short-acting oxybutynin were the most commonly prescribed initial medication (Table 2).
Figure 1.
Referral and Prescription Rates
Table 2.
Type of UI Medication Prescription
| All Mixed and Urgency n=2,950 |
Urgency Incontinence, n=2398 |
Mixed Incontinence, n=552 |
|
|---|---|---|---|
| N, % | N, % | N, % | |
| Any medication | 504 (17.1) | 401 (16.7) | 103 (18.7) |
| Darifenacin | 7 (0.2) | 5 (0.2) | 2 (0.4) |
| Fesoterodine | 8 (0.3) | 7 (0.3) | 1 (0.2) |
| Long-Acting Oxybutynin | 139 (4.7) | 107 (4.5) | 32 (5.8) |
| Mirabegron | 43 (1.5) | 35 (1.5) | 8 (1.4) |
| Short-Acting Oxybutynin | 128 (4.3) | 102 (4.3) | 26 (4.7) |
| Solifenacin | 100 (3.4) | 83 (3.5) | 17 (3.1) |
| Tolterodine | 71 (2.4) | 55 (2.3) | 16 (2.9) |
| Trospium Long-Acting | 3 (0.1) | 3 (0.1) | 0 (0.0) |
| Trospium Short-Acting | 5 (0.2) | 4 (0.2) | 1 (0.2) |
Figure 1 and Table 2 show referrals and prescriptions by UI subtype. Rates of specialist-physician referral were highest for mixed (30.6%) and stress UI (27.3%). Referrals for PFPT were substantially lower than specialty referrals, but highest for stress UI (8.2%). UI medication prescriptions were similar for urgency (16.7%) and mixed (18.7%) UI. A composite outcome of guideline-recommended treatment (i.e. PFPT or specialist referrals for patients with stress UI, referrals or medications for urgency and mixed UI) revealed 37.2% of patients overall, including 44.2% of patients with urgency, 33.9% with stress, and 50.0% with mixed UI received some identifiable treatment. Patients completed their first specialist physician appointment in 66-72% of cases and completed their first PFPT appointment in 56-61% of cases across the UI subtypes.
With an odds ratio of 0.39 (95% CI 0.29-0.48), women diagnosed with UI during the COVID-19 pandemic were less likely to be referred for further care (specialist physician or PFPT) compared to those diagnosed before January 2020 (Table 3). Patients with stress and mixed UI were more likely to be referred to a specialist physician or PFPT compared to women with urgency UI with odds ratios of 3.10 (95% CI 2.53-3.79) and 6.17 (4.03-9.66), respectively. In analyses of the urgency and mixed cohorts (Table 4), younger age and higher comorbidity were associated with lower use of medication. In an analysis using our composite outcome, patterns were similar (Appendix Table 2). UI type was not associated with the likelihood of completing first referral appointments.
Table 3.
Likelihood of a Referral in the year after Primary Care Incontinence Diagnosis, Odds Ratio (95% CI)
| Specialist Physician | PFPT | |||
|---|---|---|---|---|
|
Referral placed
n=777 |
Completed First
Appointment n=588 |
Referral placed
n=141 |
Completed First
Appointment n=81 |
|
| Race | ||||
| White | - (comparison) | - (comparison) | - (comparison) | - (comparison) |
| Black | 1.40 (1.12-1.74) | 0.96 (0.63-1.50) | 0.68 (0.36-1.20) | 1.34 (0.37-5.32) |
| Other | 1.09 (0.70-1.69) | 0.86 (0.39-2.02) | 1.32 (0.54-2.83) | 0.05 (0.00-0.34) |
| Age | ||||
| 18-49 | 1.22 (0.92-1.61) | 0.86 (0.50-1.44) | 1.46 (0.81-2.71) | 0.51 (0.13-1.94) |
| 50-59 | 1.00 (0.74-1.34) | 0.87 (0.50-1.52) | 1.11 (0.59-2.11) | 0.87 (0.21-3.63) |
| 60-69 | - (comparison) | - (comparison) | - (comparison) | - (comparison) |
| 70-79 | 0.87 (0.67-1.12) | 1.13 (0.67-1.92) | 1.13 (0.62-2.05) | 1.87 (0.42-8.60) |
| 80-89 | 0.62 (0.45-0.85) | 1.07 (0.56-2.12) | 0.96 (0.45-1.96) | 0.74 (0.14-4.07) |
| Elixhauser Comorbidity Index | ||||
| 0 | - (comparison) | - (comparison) | - (comparison) | - (comparison) |
| 1 | 0.92 (0.75-1.12) | 0.75 (0.51-1.12) | 0.81 (0.52-1.24) | 1.11 (0.43-2.95) |
| 2 | 0.75 (0.58-0.97) | 1.02 (0.61-1.73) | 0.86 (0.49-1.44) | 0.37 (0.09-1.34) |
| 3+ | 0.93 (0.74-1.18) | 0.77 (0.49-1.23) | 0.82 (0.47-1.38) | 0.42 (0.12-1.41) |
| Hispanic | ||||
| No | - (comparison) | - (comparison) | - (comparison) | |
| Yes | 1.26 (0.74-2.11) | 0.82 (0.32-2.18) | 0.65 (0.17-1.93) | |
| Insurance | ||||
| Commercial (including PPO Managed Care) | - (comparison) | - (comparison) | - (comparison) | - (comparison) |
| Medicare | 1.01 (0.75-1.38) | 1.14 (0.64-2.03) | 0.56 (0.28-1.11) | 2.12 (0.46-10.6) |
| Medicare HMO | 0.96 (0.72-1.27) | 1.54 (0.90-2.63) | 0.57 (0.30-1.06) | 1.70 (0.40-7.50) |
| Other | 1.10 (0.85-1.41) | 1.69 (1.04-2.77) | 0.47 (0.25-0.83) | 0.94 (0.24-3.61) |
| COVID | ||||
| No | - (comparison) | - (comparison) | -(comparison) | - (comparison) |
| Yes | 0.37 (0.29-0.48) | 0.86 (0.52-1.47) | 0.67 (0.39-1.09) | 1.60 (0.48-5.73) |
| Type of UI | ||||
| Urge | - (comparison) | - (comparison) | - (comparison) | - (comparison) |
| Stress | 3.10 (2.53-3.79) | 0.85 (0.57-1.26) | 6.17 (4.03-9.66) | 1.37 (0.48-3.92) |
| Mixed | 3.94 (3.13-4.95) | 1.03 (0.66-1.62) | 5.36 (3.22-8.96) | 0.91 (0.30-2.71) |
| Other | 2.41 (1.88-3.07) | 1.41 (0.84-2.42) | 0.90 (0.34-2.04) | 0.53 (0.07-3.74) |
Table 4.
Likelihood of a UI Medication Prescription among Patients with Urge or Mixed Incontinence in the year after Primary Care Incontinence Diagnosis, n=2950
| Odds Ratio (95% CI) | |
|---|---|
| Race | |
| White | - (comparison) |
| Black | 0.77 (0.57-1.02) |
| Other | 1.64 (0.89-2.90) |
| Age | |
| 18-49 | 0.66 (0.46-0.96) |
| 50-59 | 1.09 (0.75-1.58) |
| 60-69 | - (comparison) |
| 70-79 | 1.19 (0.90-1.58) |
| 80-89 | 1.39 (1.01-1.92) |
| Elixhauser | |
| 0 | - (comparison) |
| 1 | 0.92 (0.72-1.18) |
| 2 | 0.82 (0.61-1.10) |
| 3+ | 0.71 (0.54-0.95) |
| Hispanic | |
| No | - (comparison) |
| Yes | 0.52 (0.23-1.12) |
| Insurance | |
| Managed Care | - (comparison) |
| Medicare | 1.29 (0.88-1.89) |
| Medicare HMO | 1.27 (0.89-1.83) |
| Other | 1.47 (1.05-2.04) |
| COVID | |
| No | - (comparison) |
| Yes | 0.84 (0.66-1.07) |
| Type of UI | |
| Urge | - (comparison) |
| Mixed | 1.03 (0.80-1.31) |
We conducted a sensitivity analysis for “true urgency UI” with a more restrictive set of ICD codes. We removed “Other” UI codes as well as urinary urgency (R3915) and overactive bladder (N3281) from the list of urgency UI ICD codes (Appendix Figure 2). The rates of referral to specialty physicians and PFPT were higher in this subgroup, increasing to 21.9% and 3.7% respectively compared to 10.6% and 1.3% in the larger urgency UI subgroup.
Discussion:
Our study reports care patterns for 4,382 women with a new UI diagnosis by a PCP in a large Midwestern health system. In the year following diagnosis, the majority of patients were not treated with prescription medications or referred to PFPT or specialist physicians. However, most women who were referred to another specialty care provider completed their first appointment. While UI type was associated with different rates of referrals, there were no clear trends by age, race, or insurance status. As expected, we noted a significantly lower rate of specialist physician referrals during the COVID-19 pandemic.
There have been few prior studies of initial UI management in primary care and, to our knowledge, none with detailed information about potential barriers to UI care. Our study demonstrated over one-quarter of women did not complete their referrals to specialists and nearly half did not schedule recommended PFPT visits. Given evidence of patients’ reluctance to address UI due to embarrassment15 and sometimes normalization of UI,16 patient outcomes could be improved by outreach to encourage referral completion by primary care practices, specialty/therapy practices, or health systems. Furthermore, we found over half of patients received oxybutynin for management of urgency of mixed UI. Side effects are higher and adherence rates are lower with oxybutynin compared to other overactive bladder medications.8,17 While costs may play a role, many health plans now have similar copays for agents with more favorable side effect profiles. Decision support and/or assistance with prior authorization by health systems, reductions in cost, prior authorization mandates, or other barriers to long-acting UI medications other than oxybutynin by insurers, could improve patients’ outcomes and reduce primary care burden.
Given the well-established efficacy of pelvic floor strengthening7,8 our study demonstrates surprisingly low rates of referral to PFPT - 8.2% stress, 1.3% urgency, 6.0% mixed, and 3.2% of all UI patients. First-line therapy for UI consists of behavioral modifications including PFPT, which can help reduce both urgency and stress UI by over 50%.18,19 One hypothesis for low rates of PFPT referrals is insurance restrictions, long distances, or long waits for specialized physical therapists. Nationally there is approximately 1 pelvic floor physical therapist per 100,000 people, and estimates are even lower at 1 per 200,000 people in Wisconsin.20 An additional possible explanation is lack of PCP education on the benefits of PFPT for subsets of patients with UI. A survey of PCPs revealed 59% found difficulty differentiating UI types and 69% reported management of UI to be difficult.21 Alternatively, it is possible many PCPs provide instruction in lifestyle modification and Kegel education themselves and determine referral is not necessary. However, PCPs frequently cite “lack of time” and “too many other issues to address” as barriers to providing UI care,22-24 and more intensive UI training is substantially better than basic education, making robust PCP-based bladder training education less likely.
Our study offers complementary information to other recent studies. In a survey of primary care residency program directors, Mazloomdoost and colleagues reported 9.7% of providers would immediately refer newly diagnosed UI patients for specialist care while 70% would only refer patients who had a poor response to PCP-initiated treatment.25 Our results were consistent with this, showing that the majority of phsyicians did not refer immediately. Minassian et al.11 who used similar EHR data, reported higher rates of women with UI receiving care (92.3%) than we did (33-50%). However, unlike our study, that work included patients with either newly diagnosed or longstanding UI enrolled in a cohort study that asked multiple UI questions, perhaps priming subjects to discuss treatment options with their providers. Future work, which could incorporate natural language processing of physician notes or routine patient self-reporting of UI, could provide further insights into barriers to treatment in the primary care setting.
The COVID-19 pandemic has been shown to negatively impact referral rates to specialty services for a variety of medical and surgical conditions.26-29 We believe our study is the first to investigate the impact of COVID-19 on PCP referral rates to specialty providers for UI. While we found no significant reduction in the diagnosis of UI during the pandemic, there was a statistically significant decrease in referrals to specialist physicians. Therefore, our data suggests COVID-19 changed physician treatment patterns and potentially the quality of care for patients with UI. Santiago et al reported bladder training and PFPT can be effective remotely,30 emphasizing the importance of PCPs continuing to provide referrals even in a virtual setting.
Our study has several limitations. We identified patterns of care not previously described for UI patients of all types. However, because of the lack of detail and potential inaccuracies in identifying UI subtypes using EHR-structured fields, our stratified analyses should be considered exploratory. Additionally, we were limited to the records from our system and might have included patients with previous diagnoses at other institutions, and were unable to examine details of referrals completed outside of our system . Also, we had no consistent way to classify patients based on UI severity or bother or to identify use of pessaries for SUI in primary care It is possible some patients declined the offer of a referral or prescription because they were simply not troubled enough by their symptoms.31 However, our health system did not have a consistent UI screening program at the time of our study. Therefore, the women who discussed symptoms enough during their index office visits for physicians to record the diagnosis likely had a significant degree of bother or severity. We were unable to identify all patients with neurologic or other problems that generally require specialist care, so some of these higher-risk patients may be included in our cohort. Although our findings regarding COVID were robust even with adjustment for other measured patient characteristics, it is possible that other unmeasured differences in the patient populations seen during COVID could explain the differences we found; this deserves futher investigation in other cohorts. Lastly, our study data was limited to trends within a single academic institution in Wisconsin and may have limits in generalizability to other communities.
In conclusion, given the non-invasive nature of UI behavioral treatment, and its efficacy in stress, urgency, and mixed subtypes, our study’s findings regarding the low referral rates and high percentage of patients receiving no identifiable care suggest missed opportunities to improve patients’ quality of life. Future work should include additional information regarding UI severity, patient interest in pursuing care, and barriers to treatment within the primary care setting. Innovative health system care pathways that reduce care barriers such as inadequate PFPT supply (eg suppot for group classes), and use of nonclinician supports to encourage followup and referral completion could reduce delays in patient care. Additionally, natural language processing or other techniques which could identify bladder training education in office notes might better identify patients who would benefit from UI interventions.
Supplementary Material
“Simply Stated”:
Although behavioral modifications, medications, and other interventions can improve urinary incontinence, many women never receive them. To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy and specialist physicians within a large Midwestern academic health system. Data was collected from electronic health records to determine a cohort of female patients with a new urinary incontinence diagnosis during outpatient primary care visits from 2016 to 2020. Data analysis looked at the rates of referrals and medication prescriptions for these women based on their subtype of urinary incontinence (stress, urgency, or mixed). Our results showed that in the year following primary care UI diagnosis, overall 20.6% of women were referred for further management: 17.7% to urology/urogynecology and 3.2% to pelvic floor physical therapy. Most women who were referred attended an initial appointment. Among those with urgency or mixed incontinence, only 17.1% were prescribed medication. Overall, roughly 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within one year of diagnosis. This suggests primary care physicians are missing opportunities to provide guideline-based care to their female patients with urinary incontinence.
“Why This Matters?”:
There have been few prior studies of initial UI management in primary care and, to our knowledge, none with detailed information about potential barriers to incontinence care.
A composite outcome of guideline-recommended treatment (i.e. PFPT or specialist referrals for patients with stress incontinence, referrals or medications for urgency and mixed incontinence) revealed 37.2% of patients overall, including 44.2% of patients with urgency, 33.9% with stress, and 50.0% with mixed UI received some identifiable treatment.
Our study demonstrated over one-quarter of women did not complete their referrals to specialists and nearly half did not schedule recommended PFPT visits.
While we found no significant reduction in the diagnosis of UI during the pandemic, there was a statistically significant decrease in referrals to specialist physicians. Therefore, our data suggests COVID-19 changed physician treatment patterns and potentially the quality of care for patients with UI.
Our study’s findings regarding the low referral rates and high percentage of patients receiving no identifiable care suggest missed opportunities to improve patients’ quality of life.
Funding Statement:
Research reported in this article was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, of the National Institutes of Health under award number P20DK127511. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Conflicting and Competing Interests: The authors report no conflict of interests to declare
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