Treatment trends among nurses with urinary incontinence

In this interview, Giulia I. Lane, MD, MS, highlights the study, “Treatment for urinary incontinence in women older than 65 years,” for which she served as the lead author.¹ Lane is an assistant professor of urology at the University of Michigan in Ann Arbor.

Giulia I. Lane, MD, MS

Could you describe the background for this study?

This was a study that I worked on with one of my mentors, Dr. Julie Bynum. Dr. Bynum is a Professor of Geriatric and Palliative Medicine at the University of Michigan and a health services researcher who has extensively worked with U.S. Medicare data linked to datasets like the Nurses’ Health Study. We [wanted] to see what the treatment rates are of women within the Nurses’ Health Study who have incontinence. As you may know, incontinence is really common among women, especially among older women. It is associated with worse outcomes such as worse quality of life and impaired physical functioning. Despite the fact that we have a lot of treatments to try and decrease incontinence for women, very few women seek care for their incontinence and few women undergo treatment. The goal of this study was to use data from the Nurses’ Health Study and pair that with data from Medicare claims to see how many women with incontinence receive treatment.

What were some of the notable findings? Were any of those surprising to you and your coauthors?

For the survey, one of the great strengths was that it's a very large cohort. There were 15,000 women in the Nurses’ Health Study that had completed the questions on incontinence and had complete data from Medicare. They had linkage to Medicare Part A, B, and D. Of those over 15,000 women, 55% of them said they had incontinence. Most of them, nearly 80% of those women, had long standing incontinence symptoms, meaning they had reported incontinence on prior surveys with the Nurses’ Health Study. Of the 55% of women, only 1 in 9 had any claim for incontinence treatment within 1 year of the survey. So, about 11%, which is a small portion. Then we looked at what kind of treatments those 11% of women were getting. Most, 95% of them, received medication alone, which means they weren't receiving advanced therapies like surgery that would be offered by urologists. We found that less than 5% of people with incontinence had received a surgical intervention for their incontinence within a year of the survey.

The other thing that we looked at was factors associated with women receiving treatment. We really could only look at this for women who received medication therapy, because the numbers were so small for the other treatments for incontinence. What we found was that the most powerful association between whether a woman got treated for incontinence was the severity, type, and duration of her incontinence symptoms, which were all strongly associated with receiving treatment.

Although we know that treatment rates are low, I was surprised to find that they were quite so low, and I was also surprised to find that the use of advanced therapies and surgical interventions for incontinence were so low. And this is among a cohort of nurses, so you would think that this cohort would have high health literacy and high access to specialists, and maybe have some of the least barriers to care seeking and navigating the health care system.

Is any future research on this topic planned? If so, what might that focus on?

Since this research has been published, I have embarked on research through my K12 grant through the [National Institute of Diabetes and Digestive and Kidney Diseases] looking at treatment decisions among patients with overactive bladder. We have conducted a mixed methods project that involves surveys and interviews with patients and clinicians with overactive bladder and urgency incontinence looking at their decision-making and what factors went into choosing a therapy or not choosing a therapy. That was presented at SUFU and AUA last year. We're also using, as part of that same project, an institutional data set that has over 300,000 people with overactive bladder to try and map the trajectory of treatment among people with incontinence to explain why the rates of treatment are so low.

What is the overall take-home message for urologists based on the findings from this work?

The main message for urologists is that incontinence is really prevalent among older women, and yet only a minority, 1 in 9, received treatment for the condition. Most likely what they're getting treated with are medications; very few in the study got advanced therapies that urologists can offer. So, when women come to a urologist’s office with incontinence, [we need to] understand that their decision to seek care was [likely] very hard for them to make. It can be a very difficult process to seek care, and making sure that as urologists, we are evaluating their condition fully and offering them treatments that are appropriate and navigating them through that experience in a patient centered way. We're still figuring out what the barriers are to receiving treatment, but based on our interviews, some of the barriers might be that the patients are not educated or don't have knowledge of what they could be treated with. As urologists, that's something we can easily fix.

Is there anything else that you’d like to add?

I think there's so much that we don't know about incontinence care. There are many opportunities for us to explore this. I'm thankful and excited to have the ability to research this and I'm hoping that some of this research can help improve clinician and patient decision-making, and help make incontinence less of a stigmatized condition and an easier condition for us to provide treatment for.

Reference

1. Lane GI, Erekson E, Austin A, et al. Treatment for urinary incontinence in women older than 65 years. Urogynecology (Phila). 2023;29(8):687-695. doi:10.1097/SPV.0000000000001335