Major Finding: Older women received a growing proportion of inpatient surgeries for stress urinary incontinence between 1993 and 2006.
Data Source: Nationwide Inpatient Sample.
Disclosures: Dr. Weidner, Dr. Wu, and their associates said they did not have any relevant disclosures.
HOLLYWOOD, FLA. — Women 65 years and older account for a growing proportion of surgeries for stress urinary incontinence in the United States, based on a study of inpatient trends from 1993 to 2006.
“Providers are not shying away from procedures in the elderly,” Dr. Alison Catherine Weidner said at the annual meeting of the American Urogynecologic Society.
This study of the Nationwide Inpatient Sample (NIS) also reveals a dramatic increase in stress urinary incontinence procedures around 2002. This spike in numbers coincides with the 2001 publication supporting the efficacy of midurethral slings, Dr. Weidner said (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001;12[suppl. 2]:S5-8).
The promotion of new tension-free vaginal tape systems for midurethral slings may account for some of the increase, a meeting attendee commented.
“It was increased clinical use in response to marketing, but also to good data,” replied Dr. Weidner, chief of the division of urogynecology in the department of obstetrics and gynecology at Duke University Medical Center, Durham, N.C.
The database tracks the number of procedures by ICD-9 coding. Another meeting attendee asked if any coding changes could account for the jump.
“Coding practices were actually quite stable,” Dr. Weidner said. “We compared ICD-9 coding books from year to year, and the wording did not change much.” She added, “While it's a bit of a leap, it's safe to assume it's from change in clinical practice.”
The total number of stress urinary incontinence (SUI) inpatient surgeries increased over time. The number was approximately 18,500 in 1993. Then there was a dramatic increase up to 114,600 in 2002, and a slight decrease down to about 95,600 in 2006, the last year of the study.
Dr. Weidner, lead author Dr. Jennifer M. Wu, and their associates assessed both urinary incontinence ICD-9 diagnosis code and ICD-9 SUI procedure codes to calculate the total number of such surgeries per year in women aged 20 and older. The NIS database includes about 5 million to 8 million random discharges per year from community hospitals.
The rates of SUI procedures in elderly versus nonelderly patients (defined as those younger than age 65 years) changed over time as well. “In 1993, rates were fairly similar,” Dr. Weidner said. But rates were significantly different in 2006: 124/100,000 elderly vs. 76/100,000 among nonelderly patients that year. Age-adjusted rates were calculated using 2000 U.S. census data.
“Since 1997, the introduction of the midurethral sling [has] changed practice patterns,” Dr. Weidner said. For example, in 1993, “other repair” of SUI accounted for 34% of procedures. “There was a dramatic shift in 2006 to other repair of SUI being most common at 72%,” Dr. Weidner said. Retropubic suspensions made up 45% of procedures in 1993 but only 17% in 2006. At the same time, significant decreases in “less effective” procedures such as Kelly plication and needle suspensions were observed, with rates dropping below 2% for each in 2006.
The use of a national database on hospital discharges is a strength of the study. However, the NIS only represents inpatient procedures, a potential limitation. “As you know, many stress urinary incontinence surgeries are performed on an outpatient basis,” Dr. Weidner said. In addition, the NIS uses only ICD-9 codes, not CPT codes, she said.
A meeting attendee commented that most slings are placed on an outpatient basis. “Unfortunately, there really is no great outpatient database for surgeries in the United States,” Dr. Weidner said.