Abstract
Objectives:
To investigate the association between pelvic organ prolapse (POP) management and Neighborhood Deprivation Index (NDI), a standardized multi-dimensioned measure of socioeconomic status (SES).
Methods:
This retrospective cohort study included female members of a large integrated healthcare delivery system who were ≥ 18 years old and had ≥ four years of continuous healthcare membership from 1/1/2015 through 12/31/2019. Demographic, POP diagnosis, urogynecology consultation and surgical treatment for POP were obtained from the electronic medical record (EMR). NDI data was extrapolated via zip code and was reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI.
Results:
Of 1,087,567 patients identified, 34,890 (3.2%) had POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented roughly a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. 13,730 (39.4%) patients had urogynecology consultation with rates ranging from 23.6% to 26.4% (p<0.01). 12.8% of patients with POP underwent surgical treatment and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures (p=0.01). When controlling for age, no clinically significant difference was demonstrated.
Conclusion:
Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated healthcare system.
Simply Stated: Pelvic organ prolapse (POP) is a significant condition affecting 3–6% of women in the United States during their lifetime, impacting quality of life. Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there is little data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation. This study examined the referral patterns for and the management of POP within a large, membership-based integrated healthcare system with an attempt to identify if there was equitable access to urogynecology subspecialists and surgical treatment for patients in this single healthcare delivery system by a patient’s Neighborhood Deprivation Index (NDI) ranking. NDI is a multifactor measurement of socioeconomic deprivation that is derived from United States Census data. Findings demonstrated that there was little clinical difference in the access to urogynecology subspecialists and surgical management of POP, no matter the degree of socioeconomic deprivation a patient experienced, suggesting equitable access to the evaluation and management of POP for patients participating in this membership-based healthcare delivery system.
Why This Matters: This is the first study that uses Neighborhood Deprivation Index (NDI), a validated multi-dimension measurement of socioeconomic deprivation status, to evaluate the rate of evaluation and treatment of pelvic organ prolapse (POP) within a large, membership-based integrated healthcare system. This study demonstrated similar rates of subspeciality evaluation, access to and type of surgical management between NDI quartiles in a large cohort of patients who had a prevalence of POP similar to rates reported in the literature and who had four years of longitudinal data. This suggests equitable urogynecology evaluation and treatment of prolapse is possible and demonstrates that the management algorithm of this single healthcare system levels care when socioeconomic disparities exist in this community. This study underscores the importance of developing systems that provide equitable potential for optimizing outcomes regardless of patient socioeconomic standing to ensure patients are not left behind in the care of the prolapse symptoms.
Introduction:
Pelvic organ prolapse (POP) is a significant condition that affects between 3–6% of women during their lifetime.1–8 Although differences in POP prevalence based on race and ethnicity have been described in the literature, little is known about disparities in care delivery in urogynecology.2,9,10 A recent retrospective cohort study based on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database highlighted race-based disparities in surgical treatment and found that, compared to White women, Asian and Native Hawaiian/Pacific Islander women with POP were less likely to undergo mesh augmented reconstructive surgery and of those who did receive mesh augmented repairs, Latina and Native Hawaiian/Pacific Islander women were more likely to undergo an open rather than minimally invasive approach.11 Additionally, Black women were more likely to experience postoperative complications after mesh augmented repairs.11 However, while this study identified differences in the surgical management of POP per race/ethnicity, it did not examine the influence of socioeconomic determinants of health on care delivery and treatment outcomes.
The Neighborhood Deprivation Index (NDI) is a standardized measure that ranks a patient’s socioeconomic disadvantage using indicators of socioeconomic status such as education, employment, income, and quality of housing by geographical location.15 An individual’s “neighborhood” of residence is defined by census tracts that are obtained from United States Census Bureau. Each census tract is designed to be a fairly homogeneous unit with respect to socioeconomic characteristics for residents in the neighborhood and generally consists of 600 to 4000 residents.16,17 Living in neighborhoods with higher NDI, or more deprivation, has been associated with higher rates of morbidity and mortality.13–15, 18, 20, 21 To our knowledge, there are no studies to date evaluating the association between NDI and the prevalence of, subspecialty consultation for, or surgical management of POP.
Our study aims to contribute to our understanding of healthcare disparities in urogynecology by reporting the prevalence of POP, the rate of subspeciality consultation, and surgical treatment for POP by NDI within a capitated managed healthcare organization. In doing so, we aim to identify where disparities in care exist within the care continuum to guide future work aimed at narrowing such disparities.
Study Design:
This retrospective cohort analysis was conducted within an integrated healthcare delivery system that cares for 4.4 million racially and ethnically diverse patients in Northern California.24, 25 Institutional Review Board exemption was obtained for this study. Inclusion criteria included women aged 18 years and older who were registered members between January 1, 2015 and December 31, 2019, with at least four years of continuous healthcare membership, identified through the electronic medical record (EMR). POP diagnoses during the study period were identified through the EMR via ICD-9 or ICD-10 codes (ICD-9 codes: 618.5, 618.4, 618.00, 618.9, 618.2, 618.84, 618.3, 618.6, 618.81; ICD-10 codes: n99.3, n81.4, n81.9, n81.2, n81.3, n81.5, n81.82). Baseline demographics, urogynecology subspecialty consultation data, and details of surgical intervention were obtained.
As noted, NDI is a calculated national measure created by the United States Census tract database utilizing 13 key variables which measure dimensions of socioeconomic status.15, 22 NDI measures for the study participants were supplied by the integrated healthcare organization’s Geographic Information Sciences Department using the key variables identified from American Community Survey (ACS) data.16 A list of the variables obtained from the Census Bureau’s 5-year ACS data are present in supplemental Appendix 1. The NDI calculation algorithm utilized by the GIS database follows the methods standardized by the National Cancer Institute’s GIS mapping Portal for Cancer Research and the census tract of the patient’s address registered in the EMR, with updates in NDI calculations conducted annually.23,24 NDI data are reported in quartiles (where Q1 is 25th percentile or less, Q2 is 26th through 50th percentile, Q3 is 51st through 75th percentile, and Q4 is 76th percentile and above), with higher quartiles representing greater deprivation.
Urogynecology subspecialty consultation was defined as an appointment with the urogynecology department. In this healthcare system, POP surgery is conducted primarily by board certified urogynecologists, with fewer than 10% of procedures performed by general urologists and gynecologists. Surgical procedures were identified using CPT codes and included native tissue apical repairs, mesh augmented apical repairs, obliterative procedures, and isolated vaginal repairs. Isolated vaginal repairs encompassed surgeries that included site specific repairs without an apical support procedure. A comprehensive list of CPT codes are present in supplemental Appendix 2.
Each healthcare organization member was assigned an index date, defined as the date of the first surgical procedure for POP during the study period. For those who did not undergo a procedure, the beginning of the study period (January 1, 2015) was used as the index date. The member’s NDI score, age, and time-sensitive covariates were assigned based on this index date.
Continuous data were reported as means and standard deviations and compared using the student’s t-test. Categorical data were reported as frequencies and percentages and compared using Pearson’s χ2 test. Analysis of variance was conducted to identify demographic, clinical, and treatment differences across NDI quartiles. Logistic regression modeling was performed after initial evaluation of data revealed differences in rates of obliterative surgery across NDI quartiles to control for age, and results are reported as odds ratios with 95% confidence intervals. All analyses were performed using SAS® 9.4 (SAS Institute, Carey, North Carolina). Statistical significance was set at a p value of 0.05.
Results:
Of the 1,087,567 female patients identified during the study period, 34,890 patients (3.2%) were diagnosed with POP. The mean age of patients diagnosed with POP was 61.6 years (SD ± 14.1) and the mean BMI was 28.2 kg/m2 (SD ± 6.2). Patients in Q1,the least deprived group, were less parous compared to Q4, the most deprived group (p<0.01). The highest number of patients with POP identified as White (57.3%), followed by Latina (19.7%), Asian/Pacific Islander (11.5%), and Other/Unknown (5.8%). White patients comprised approximately one third of the Q1 group (32.2%). Black patients represented one of the smallest ethnic/racial groups diagnosed with POP (5.8%); however, they comprised almost half of patients in the Q4 group (47.2%, p<0.01). Approximately 8.6% of patients with POP had a history of prior hysterectomy, with no significant difference between NDI quartile groups, p=0.63 (Table 1).
Table 1:
Patient demographic, clinical and treatment characteristics among patients with pelvic organ prolapse (POP) and according to neighborhood deprivation index (NDI)
| Total | NDI quartile | P value | ||||
|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | |||
| Demographic Characteristics, n (%) | 34,890 | 9178 (26.3) | 8656 (24.8) | 8526 (24.4) | 8530 (24.5) | |
| Age in years, mean (SD) | 61.6 (14.1) | 63.3 (14.2) | 61.6 (14.0) | 61.3 (13.8) | 60.1 (14.1) | |
| Parity, n (%) | <0.01 | |||||
| 0 | 1419 | 390 (27.5) | 369 (26.0) | 301 (21.2) | 359 (25.3) | |
| 1 | 3282 (9.4) | 902 (27.5) | 823 (25.1) | 818 (24.9) | 739 (22.5) | |
| 2 | 8828 (25.3) | 2699 (30.8) | 2363 (26.8) | 2072 (23.5) | 1694 (19.2) | |
| ≥3 | 10,043 (28.8) | 2324 (22.9) | 2302 (26.3) | 2641 (27.6) | 2776 (32.5) | |
| Unknown | 11,318 (32.4) | 2863 (25.3) | 2799 (24.7) | 2694 (23.8) | 2962 (26.2) | |
| Race/Ethnicity, n (%) | <0.01 | |||||
| White | 19,980 (57.3) | 6423 (32.2) | 5477 (27.4) | 4734 (23.7) | 3346 (16.8) | |
| Black | 2011 (5.8) | 187 (9.3) | 383 (19.1) | 491 (24.4) | 950 (47.2) | |
| Latina | 6862 (19.7) | 878 (12.8) | 1285 (18.7) | 1759 (25.6) | 2940 (42.8) | |
| Asian/Pacific Islander | 4004 (11.5) | 1184 (29.6) | 1016 (25.4) | 1006 (25.1) | 798 (19.9) | |
| Other/Unknown | 2033 (5.8) | 506 (24.9) | 495 (24.4) | 536 (26.4) | 496 (24.4) | |
| Body mass index, kg/m2, mean (SD) | 28.2 (6.2) | 26.8 (5.5) | 27.8 (5.8) | 28.6 (6.3) | 29.7 (6.7) | |
| History of hysterectomy, n (%) | 2983 (8.6) | 796 (26.7) | 738 (24.7) | 702 (23.5) | 747 (25.1) | 0.63 |
| Treatment characteristics | ||||||
| Surgical management of prolapse, n (%) | 4,451 (12.8) | 1116 (12.2) | 1058 (12.2) | 1135 (13.3) | 1142 (13.4) | 0.01 |
Abbreviations: Neighborhood Deprivation Index, NDI; Quartile, Q; Standard deviation, SD
Within our cohort, 39.4% of patients with POP (n=13,730) had a consultation with a urogynecology subspecialist, with similar rates across the NDI quartiles (Table 2). 12.8% (n=4451) of patients with POP received surgical intervention (Figure 1). 12.1% of Q1 patients (n=1116), 12.2% of Q2 patients (n=1058), 13.3% of Q3 patients (n=1135), and 13.4% of Q4 patients (n=1142) received surgical intervention for POP (p=0.01) (Table 1). Women who consulted a urogynecologist had higher rates of surgical treatment (26.5%, n=3,635) compared to those who did not (3.9%, n=816; p<0.01). Patients who were surgically managed by a non-urogynecologic surgeon had an isolated vaginal repair rate of 16.8% compared to 10.7% among patients who received surgical management from a urogynecologist. There was no trend toward isolated vaginal repair by NDI.
Table 2:
Urogynecology consultation in patients diagnosed with POP by NDI
| Total | NDI quartile | P value | ||||
|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | |||
| Presence of Urogynecology consultation | ||||||
| Yes, n(%) | 13,730 (39.4) | 3619(26.4) | 3237 (23.6) | 3386 (24.7) | 3488 (25.4) | <0.01 |
| No | 21,160 (60.7) | 5559 (26.3) | 5419 (25.6) | 5140 (24.3) | 5042 (23.8) | |
Figure 1:
Patient Diagnoses and Surgical Intervention. POP, pelvic organ prolapse
The most common surgical intervention across all quartiles was vaginal native tissue apical repair (47.6%), followed by mesh-augmented reconstructive surgery (23.7%), obliterative procedures (16.9%) and isolated vaginal repair (11.8%) (Table 3). The rates of these surgeries were similar across quartiles except for obliterative procedures with Q1 patients undergoing obliterative procedures at a higher frequency (21.8%) than other NDI quartiles (p<0.01). Logistic regression modeling adjusting for age and using Q1 as the reference group demonstrated no significant difference in the rate of obliterative surgery in the two most deprived quartiles [Q3 (Adjusted OR (aOR) 0.8, 95% CI 0.6–1.0, p=0.09) and Q4 (aOR 1.0, 95% CI 0.8–1.3, p=0.87)], however, Q2 patients were less likely to obtain obliterative surgery (aOR 0.7, 95% CI 0.6–1.0, p=0.03) (Table 4).
Table 3:
Patient treatment characteristics and surgical procedure type by NDI
| Total | NDI quartile | P value | ||||
|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | |||
| Surgical Intervention (%) | 4451 | 1116(25.1) | 1058 (23.8) | 1135 (25.5) | 1142 (25.7) | 0.01 |
| Vaginal Native Tissue Repair, n(%) | 2119 (47.6) | 491 (44.0) | 521 (49.2) | 557 (49.1) | 550 (48.2) | |
| Mesh Augmented Reconstructive Surgery, n(%) | 1056 (23.7) | 258 (23.1) | 248 (22.4) | 267 (23.5) | 283 (24.8) | |
| Obliterative Procedure, n(%) | 750 (16.9) | 243 (21.8) | 154 (14.6) | 180 (15.9) | 173 (15.2) | |
| Isolated Vaginal Repair, n(%) | 526 (11.8) | 124 (11.1) | 135 (12.8) | 131 (11.5) | 136 (11.9) | |
Abbreviations: NDI = Neighborhood Deprivation Index; Q = quartile
Table 4:
Logistic regression model of Obliterative procedure by NDI quartile, controlling for age
| NDI quartile (Q1 reference) | Unadjusted OR(95% CI) | |||
|---|---|---|---|---|
| P value | Adjusted OR (95% CI) | P value | ||
| Total | 2.6 (2.4–2.8) | <0.01 | 2.6 (2.4–2.8) | <0.01 |
| Q2 | 0.6 (0.5–0.8) | <0.01 | 0.7 (0.6–1.0) | <0.01 |
| Q3 | 0.7 (0.5–0.8) | <0.01 | 0.8 (0.6–1.0) | 0.09 |
| Q4 | 0.6 (0.5–0.8) | <0.01 | 1.0 (0.8–1.3) | 0.87 |
Discussion:
Our data, drawn from more than 1 million diverse women, demonstrated a 3.2% incidence of POP, similar to the reported incidence of 3–6% found in the literature.1–8 We found that Q1 (the least deprived quartile) had the highest rate of POP despite having a lower parity, and was comprised of the highest number of White patients. In contrast, Q4 (the most deprived group) had the lowest incidence of POP and was comprised of the largest number of Black patients. It is unlikely that this data reflects a truly lower incidence of POP among women from more deprived neighborhoods; it more likely reflects the presence of social, cultural, or economic barriers that are disproportionately affecting women of lower SES from seeking care for POP symptoms. Most studies evaluating the prevalence of prolapse have populations comprised primarily of White women of higher SES, lending little information for patients of other backgrounds. Socioeconomic barriers to medical care, including inadequate transportation, childcare, sick leave from work, English proficiency, and medical literacy, are well-documented.13,14,18–20,30 In addition, patient perceptions of how their socioeconomic status impacts their access to care have been described in the primary care setting.30 More research is needed to identify how these barriers and perceptions could impact patient care seeking behavior, and reports of the overall prevalence of POP, in urogynecology.
We found that roughly 40% of patients with prolapse had a subspecialty consultation with a urogynecologist, and when comparing subspecialty consultation rates across NDI quartiles there was no clinical difference between NDI quartile groups. Over 60% of women with a diagnosis of POP in our study did not have subspecialty evaluation, which may be related to multiple factors. Patient-reported symptom bother varies greatly across all stages of POP and patient POP stage data was not available for this study, making it unclear whether lack of consultation resulted from a lack of patient bother due to POP symptoms, whether acceptable non-surgical treatment was offered by general gynecologists, or whether it represents a missed opportunity for provision of subspecialty care. Furthermore, our data is predominantly from patients who completed a consultation with a urogynecologist and may not reflect patients who were referred for subspecialty care but did not present for evaluation.
We found no significant clinical differences in surgical treatment rates across NDI quartiles. Our data stands in contrast to previously published reports comparing access to urogynecologic care based on race/ethnicity, socioeconomic status, and insurance coverage.2,8,11,12, 31 This leveling of care may be explained by a number of factors, not the least of which is that membership in a capitated integrated healthcare delivery system removes barriers to care intrinsic to many U.S. healthcare systems, such as poor access to in-network subspecialists, strict pre-authorization requirements, unclear provider reimbursements for procedures, or sizable deductibles and copays. Furthermore, our data shows that rate of surgery for POP is directly affected by presence of a subspecialty consultation, as patients evaluated by a urogynecologist were almost eight times more likely to receive surgery for POP compared to women who did not receive subspecialty consultation (26.5% versus 3.9%, respectively, p<0.01).
When comparing types of surgical intervention, we found no significant differences between NDI quartiles except for obliterative procedures. Q1 patients had a higher rate of obliterative procedures, but this difference was not observed after controlling for age and this may be explained by several factors. Women in Q1 were, on average, older compared to women in other quartiles and obliterative procedures are more frequently performed in older women. The prevalence of sexual activity reported by older female patients declines as patients age32, which can impact the decision to proceed with obliterative procedures. Patients residing in more deprived neighborhoods have broadly been shown to have higher rates of morbidity and mortality in the literature, possibly due to social, cultural or economic barriers to resources and medical care.13–15, 18, 20, 21 The prevalence of prolapse increases with age, and this could explain the higher rate of Q1 patients diagnosed with prolapse.
Disparate surgical care for the treatment of POP and benign gynecologic conditions have been described in the literature, primarily focusing on racial/ethnic differences and socioeconomic status individually.11,13–15,28,29, 35 When comparing route of hysterectomy for benign indications, Black and Latina women and women insured by Medicare were more likely to undergo open abdominal procedures, while White women were more likely to undergo laparoscopic procedures for the same indications.33 However, a study evaluating route of hysterectomy in the same single integrated healthcare system demonstrated similar rates of minimally invasive hysterectomy across racial/ethnic groups.34 This highlights the potential for equitable healthcare management and treatment which could be achieved by restructuring care delivery systems and incentives.
Our study has several strengths. The large sample size, the duration of follow-up, and the ability to identify subspecialty consultation and surgical treatment of POP allowed for the reliable evaluation of differences in evaluation and treatment across NDI quartiles. The use of NDI as a measure of SES allows for a more comprehensive and generalizable study, as NDI uses several indices associated with socioeconomic standing and is a well-validated measure.
Our study is not without limitations. Members of this integrated healthcare system have access to insurance and may represent a less deprived population compared to other areas of the United States, affecting the generalizability of our study results. Descriptive comparisons conducted by Davis et al. demonstrated that members of this integrated healthcare system were older and more likely to be female compared to the general population within the counties in which this healthcare system operates.24 However, these studies found similarities between NDI distribution at this single integrated healthcare system and NDI distribution of the local community.24, 25 The retrospective observational design and reliance on EMR for chart review are additional limitations to this study as there is the potential for errors related to inaccurate member demographic, diagnosis, or treatment entry into the EMR. Additionally, surgical treatment rates could be underestimated by not capturing women who were diagnosed with POP during the study but received surgery outside of the study period. The effects of the COVID-19 pandemic on NDI quartile and access to care for POP were not evaluated in this study, as they fell outside the study period.
Although our study did not identify clinically significant disparities in the POP evaluation and treatment across NDI quartiles, this should not be taken to mean disparities do not exist. Additional studies are needed to better understand the promoters of and barriers to subspecialty care, surgical management, outcomes, and patient satisfaction following POP treatment. For example, future inquiries evaluating the time to surgical intervention for POP from diagnosis could identify potential disparities in care. In addition, studies assessing patient decision-making, physician bias in counseling for POP treatment, postoperative outcomes and complications using NDI would further contribute to our understanding of medical inequities within urogynecology.
No clinically significant difference in the rate of subspecialty consultation for and surgical management of POP by NDI quartiles were observed in our cohort, suggesting an effective application of equitable urogynecologic care within the evaluated integrated health care system. This study demonstrates the potential for achieving equitable access to evaluation of and surgical intervention for POP regardless of the patient’s socioeconomic standing, emphasizing the importance of evaluating and establishing conditions to provide equitable care for all patients with POP.
Supplementary Material
Sources of support and conflict of interest statement:
Dr. Abigail Shatkin-Margolis was supported by grant 1K12DK111028 from the National Institute of Diabetes, Digestive, and Kidney Disorders.
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