Impact of Social Determinants of Health on Fecal Incontinence Treatment In Older Women.

Abstract

OBJECTIVE Many women with fecal incontinence (FI) do not seek care despite the availability of effective treatments. Factors influencing care-seeking for FI are not well elucidated, and the role of social determinants of health (SDOHs) in FI treatment utilization is unknown. Our primary aim was to determine the association between SDOHs and treatment utilization among Medicare beneficiaries with FI. We secondarily aimed to determine the baseline treatment utilization rate and to determine factors associated with FI treatment utilization. STUDY DESIGN We conducted a retrospective cohort study of Medicare beneficiaries with FI based on 2010-2018 claims data from a 5% national sample. Women with FI were identified by diagnosis codes, and those receiving treatment were identified by Current Procedural Terminology codes for pelvic floor physical therapy with biofeedback, sacral neuromodulation, anal sphincteroplasty, percutaneous tibial nerve stimulation, and anal procedures. Comorbidity was assessed via the Charlson comorbidity index. SDOHs were defined by the Social Vulnerability Index (SVI), a census-based score accounting for factors such as socioeconomic status, disability, ethnicity, language, housing type, and transportation by county. SVI is reported as a percentile rank, with higher percentiles reflecting greater vulnerability. Additional SDOH variables analyzed included Medicaid dual eligibility status, per capita income, and proportion of the population below poverty level. The association between SDOHs and treatment for FI was evaluated using Cox proportional hazards models. RESULTS We identified 33,010 women with a diagnosis of FI, of whom 3,160 (9.6%) underwent treatment. Treatment modalities included anal procedures (6.5%), sacral neuromodulation (2.4%), percutaneous tibial nerve stimulation (0.9%), anal sphincteroplasty (0.4%), and pelvic floor physical therapy with biofeedback (0.1%). Those who did not undergo treatment were older, more commonly Medicaid dual eligible, had lower per capita incomes, higher poverty rates, and higher Charlson comorbidity index scores (all p<0.01, Table 1). Higher SVI scores (HR 0.88, 95% CI 0.79-0.97), Medicaid dual eligibility (HR 0.45, 95% CI 0.39-0.52), and residence in high poverty counties (HR 0.82, 95% CI 0.74-0.9) were associated with lower likelihood of treatment, whereas higher income was associated with greater likelihood of treatment (HR 1.44, 95% CI 1.3-1.59). The association between treatment and Medicaid dual eligibility (HR 0.91, 95% CI 0.82-1.01), income (HR 1.41, 95% CI 1.27-1.56), and poverty rate (HR 0.86, 95% CI 0.78-0.95) persisted after accounting for patient characteristics; the association between SVI and treatment did not. Increasing age (HR 0.96, 95% CI 0.96-0.97), Black race (HR 0.82, 95% CI 0.7-0.97), higher Charlson comorbidity index (HR 0.65, 95% CI 0.06-0.70), depression (HR 0.66, 95% CI 0.53-0.81), immobility (HR 0.36, 95% CI 0.22-0.61), and loose stools (HR 0.87, 95% CI 0.79-0.94) were associated with lower treatment receipt, whereas urinary incontinence (HR 1.71, 95% CI 1.57-1.85) and constipation (HR 1.29, 95% CI 1.19-1.40) were associated with higher likelihood of treatment. CONCLUSIONS Treatment utilization among women with FI is low even within an insured population. In addition to comorbid conditions, social factors reflecting social disadvantage are associated with lower treatment utilization. Future efforts to increase treatment utilization should target this vulnerable group of women.