Halani Priyanka Kadam, Wilson Lauren, Cadish Lauren A, Routh Jonathan C, Anger Jennifer
Department of OB/GYN, Scripps Clinic Anderson Medical Pavilion, San Diego, CA.
Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
Am J Obstet Gynecol. 2025 Jul 7. doi: 10.1016/j.ajog.2025.07.006.
Many women with fecal incontinence do not seek care despite the availability of effective treatments. Factors influencing care-seeking for fecal incontinence are not well elucidated, and the role of social determinants of health in fecal incontinence treatment utilization is unknown.
Our primary aim was to determine the association between social determinants of health and treatment utilization among Medicare beneficiaries with fecal incontinence. We secondarily aimed to determine the baseline treatment utilization rate and to determine factors associated with fecal incontinence treatment utilization.
We conducted a retrospective cohort study of Medicare beneficiaries with fecal incontinence based on 2010 to 2018 claims data from a 5% national sample. Women with fecal incontinence 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. Social determinants of health were defined by the Social Vulnerability Index, a census-based score accounting for factors such as socioeconomic status, disability, ethnicity, language, housing type, and transportation by county. Social Vulnerability Index is reported as a percentile rank, with higher percentiles reflecting greater vulnerability. Additional social determinant of health variables analyzed included Medicaid dual eligibility status, per capita income, and proportion of the population below poverty level. The association between social determinants of health and treatment for fecal incontinence was evaluated using Cox proportional hazards models.
We identified 33,010 women with a diagnosis of fecal incontinence, of whom 3160 (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<.01, Table 1). Higher Social Vulnerability Index scores (hazard ratio, 0.88; 95% confidence interval, 0.79-0.97), Medicaid dual eligibility (hazard ratio, 0.45; 95% confidence interval, 0.39-0.52), and residence in high-poverty counties (hazard ratio, 0.82; 95% confidence interval, 0.74-0.9) were associated with lower likelihood of treatment, whereas higher income was associated with greater likelihood of treatment (hazard ratio, 1.44; 95% confidence interval, 1.3-1.59). The association between treatment and Medicaid dual eligibility (hazard ratio, 0.91; 95% confidence interval, 0.82-1.01), income (hazard ratio, 1.41; 95% confidence interval, 1.27-1.56), and poverty rate (hazard ratio, 0.86; 95% confidence interval, 0.78-0.95) persisted after accounting for patient characteristics; the association between Social Vulnerability Index and treatment did not. Increasing age (hazard ratio, 0.96; 95% confidence interval, 0.96-0.97), Black race (hazard ratio, 0.82; 95% confidence interval, 0.7-0.97), higher Charlson comorbidity index (hazard ratio, 0.65; 95% confidence interval, 0.06-0.70), depression (hazard ratio, 0.66; 95% confidence interval, 0.53-0.81), immobility (hazard ratio, 0.36; 95% confidence interval, 0.22-0.61), and loose stools (hazard ratio, 0.87; 95% confidence interval, 0.79-0.94) were associated with lower treatment receipt, whereas urinary incontinence (hazard ratio, 1.71; 95% confidence interval, 1.57-1.85) and constipation (hazard ratio, 1.29; 95% confidence interval, 1.19-1.40) were associated with higher likelihood of treatment.
Treatment utilization among women with fecal incontinence 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.
尽管有有效的治疗方法，但许多大便失禁的女性并未寻求治疗。影响大便失禁患者寻求治疗的因素尚未得到充分阐明，健康的社会决定因素在大便失禁治疗利用中的作用尚不清楚。
我们的主要目的是确定大便失禁的医疗保险受益人中健康的社会决定因素与治疗利用之间的关联。其次，我们旨在确定基线治疗利用率，并确定与大便失禁治疗利用相关的因素。
我们基于来自5%全国样本的2010年至2018年索赔数据，对大便失禁的医疗保险受益人进行了一项回顾性队列研究。通过诊断代码识别大便失禁的女性，通过盆底物理治疗（带生物反馈）、骶神经调节、肛门括约肌成形术、经皮胫神经刺激和肛门手术的当前程序术语代码识别接受治疗的女性。通过查尔森合并症指数评估合并症。健康的社会决定因素由社会脆弱性指数定义，这是一个基于人口普查的分数，考虑了诸如社会经济地位、残疾、种族、语言、住房类型和各县交通等因素。社会脆弱性指数以百分位数排名报告，百分位数越高反映脆弱性越大。分析的其他健康社会决定因素变量包括医疗补助双重资格状态、人均收入和贫困线以下人口比例。使用Cox比例风险模型评估健康的社会决定因素与大便失禁治疗之间的关联。
我们确定了33010名诊断为大便失禁的女性，其中3160名（9.6%）接受了治疗。治疗方式包括肛门手术（6.5%）、骶神经调节（2.4%）、经皮胫神经刺激（0.9%）、肛门括约肌成形术（0.4%）和带生物反馈的盆底物理治疗（0.1%）。未接受治疗的患者年龄较大，更常见的是具有医疗补助双重资格，人均收入较低，贫困率较高，查尔森合并症指数得分较高（所有P<0.01，表1）。较高的社会脆弱性指数得分（风险比，0.88；95%置信区间，0.79 - 0.97）、医疗补助双重资格（风险比，0.45；95%置信区间，0.39 - 0.52）以及居住在高贫困县（风险比，0.82；95%置信区间，0.74 - 0.9）与较低的治疗可能性相关，而较高的收入与较高的治疗可能性相关（风险比，1.44；95%置信区间，1.3 - 1.59）。在考虑患者特征后，治疗与医疗补助双重资格（风险比，0.91；95%置信区间，0.82 - 1.01）、收入（风险比，1.41；95%置信区间，1.27 - 1.56）和贫困率（风险比，0.86；95%置信区间，0.78 - 0.95）之间的关联仍然存在；社会脆弱性指数与治疗之间的关联则不存在。年龄增长（风险比，0.96；95%置信区间，0.96 - 0.97）、黑人种族（风险比，0.82；95%置信区间，0.7 - 0.97）、较高的查尔森合并症指数（风险比，0.65；95%置信区间，0.06 - 0.70）、抑郁症（风险比，0.66；95%置信区间，0.53 - 0.81）、行动不便（风险比，0.36；95%置信区间，0.22 - 0.61）和稀便（风险比，0.87；95%置信区间，0.79 - 0.94）与较低的治疗接受率相关，而尿失禁（风险比，1.71；95%置信区间，1.57 - 1.85）和便秘（风险比，1.29；95%置信区间，1.19 - 1.40）与较高的治疗可能性相关。
即使在参保人群中，大便失禁女性的治疗利用率也很低。除了合并症外，反映社会劣势的社会因素与较低的治疗利用率相关。未来提高治疗利用率的努力应针对这一脆弱的女性群体。
