Socioeconomic, Demographic, and Surgeon Factors Associated With Staged Versus Concomitant Surgery for Pelvic Organ Prolapse and Stress Urinary Incontinence

INTRODUCTION: Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) frequently coexist, and de novo SUI following POP treatment is commonly taken into consideration during surgical planning. While concomitant surgery for POP and SUI may benefit patients, literature suggests a variety of treatment algorithms and clinical application of this data often differs amongst providers. Therefore, it is possible that shared decision making for these complex options may be impacted by language, educational, or other socioeconomic factors. OBJECTIVE: This study examines patient-, location-, and surgeon-level factors associated with staged versus concomitant stress urinary incontinence surgery among U.S. female Medicare patients undergoing surgery for POP. METHODS: The 100% Medicare Standard Analytical Files were used to identify female patients treated surgically for POP between 2016 and 2020. The study included patients who had concomitant midurethral sling (MUS) procedure and those who had a staged procedure defined as MUS within 24 months following POP procedure. Multivariable logistic regression was used to assess the association between patient, location, and surgeon-level factors and the likelihood of staged versus concomitant procedures. Patient-level factors included race, region, and urbanization. Location-level factors were county-level characteristics from the Agency for Healthcare Research and Quality Social Determinants of Health Database 2019, including per capita income, proportion of foreign-born, and proportion of limited English-speaking households. The specialty of the surgeon who performed the POP procedure (urology, obstetrics/gynecology (OBGYN), or other) was used to characterize surgeon-level factors. RESULTS: Among 40,842 patients who had POP procedures between 2016 and 2020, 96.7% (39,440) had a concomitant procedure and 3.4% (1,402) had a staged procedure. Caucasian patients (3.5% vs. 1.2% for Asian, p=0.036), patients living in urban areas (3.5% vs. 3.2% for rural areas, p=0.05) and in the Southern region of the US (3.9% vs. 2.5% Northeastern, p<0.001) were more likely to undergo staged procedures. Patients from counties with lower per-capita income (p=0.001), a lower proportion of foreign-born (p=0.003), and a lower proportion of limited English-speaking households (p=0.002) were more likely to receive staged procedures. Patients whose POP procedure was performed by OBGYNs were more likely to receive staged procedures than those performed by urologists. CONCLUSIONS: Our analysis identified both socioeconomic and surgeon factors associated with staged versus concomitant MUS procedures among patients undergoing surgical treatment for POP. It is not clear if these differences are attributable to inequities in care or other factors. Future studies should endeavor to understand how these socioeconomic and surgeon characteristics impact the decision to undergo a concomitant vs. staged MUS procedure.