PRIMARY CARE REFERRAL PATTERNS FOR PATIENTS WITH URINARY INCONTINENCE IN AN ACADEMIC HEALTH SYSTEM FROM 2018-2020

ABSTRACT

Introduction: While an estimated 50% of adult women experience urinary incontinence (UI), the majority will never receive treatment. Most studies of incontinence care delivery have been limited to administrative (billing) data following treatment. Much less is known about earlier steps in evaluation, including primary care intentions to refer to specialty care. Objective: To better understand the gaps and barriers to receiving care, we examined referral patterns from primary care providers for patients with new diagnoses of urinary incontinence between 2018-2020 and the extent to which such referrals changed during the COVID-19 pandemic. Methods: Electronic health records (EHR) from 24 primary care practices within a single academic medical system were queried to identify a cohort of adult (18 - 90-year-old) female patients first diagnosed with urinary incontinence during primary care (family or general internal medicine) outpatient visits between January 2018 and December 2020. Demographics were determined from appropriate EHR fields, and diagnoses pulled from problem lists, past medical histories, and office visit diagnosis fields. EHR referral fields were utilized to ascertain referral dates, types, and associated diagnoses. Electronic prescription fields were used to record treatment information including medication class, name, and prescription dates. Subjects were excluded if there was EHR evidence of urinary tract infection at diagnosis, UI in the prior year based on diagnosis or medication usage (anticholinergic, B3 agonists), or presence of conditions for which incontinence management might differ substantially in the prior year (pregnancy, spinal cord injury). Referrals to specialty physicians (urology/urogynecology) and pelvic floor physical therapy (PFPT) were examined for the year after UI diagnosis. Logistic regression was then used to assess for associations between referrals and patient demographics, comorbidity, and diagnosis dates (pre-vs during-COVID-19). Results: The study identified 514 women with a newly diagnosed urinary incontinence diagnosis (Table 1). In the year following UI diagnosis, 31.91% were referred to specialty care for management -29.0% to urology/urogynecology and 3.5% to pelvic floor physical therapists. Women diagnosed with UI during the COVID-19 pandemic, starting January 2020, were less likely to be referred with an odds ratio of 0.29 (95% CI 0.19, 0.45) compared to those diagnosed before (Table 2). There was no association of referrals with patient age, race, or number of comorbidities (Elixhauser Comorbidity Index), but confidence intervals were wide. Patterns were similar for models that examined specialty physician or PFPT referral separately. Conclusions: Less than 1 in 3 women were referred to specialty care for UI by their primary care provider with less than 1 in 25 referred to PFPT. There was a significant decrease in likelihood of referrals during 2020 suggesting that the COVID-19 pandemic interfered with UI patients receiving quality care. Future studies aiming to improve incontinence care should examine other aspects of nonsurgical UI care delivery, including barriers to behavioral self-management, medication use, and completion of specialty referrals.