Travel Time and Treatment Choice in Pelvic Organ Prolapse Care

INTRODUCTION: Older adults living in rural areas face many unique barriers to seeking urogynecologic care for pelvic organ prolapse (POP). As a rural tertiary care medical center, we wished to explore how travel time impacts patients’ treatment choice and pessary care continuation. We hypothesized that women who experience longer travel times will be more likely to choose surgical management over pessary management compared with women with shorter travel times. OBJECTIVE: Our objective was to assess whether travel time differs between women who chose conservative treatment versus surgical treatment for their pelvic organ prolapse, as well as among those who initially opted for pessary treatment but later transitioned to surgery. METHODS: This was a retrospective cohort study of patients with pelvic organ prolapse who were seen at a single institution between October 2015 and December 2023. We examined initial treatment choice at baseline for the full patient cohort, and subsequent conversion to surgical management for those who initially chose pessary care. Inclusion criteria included a diagnosis of stage 2 or greater POP at new patient visit and available accurate address within a census tract, leading to a sample size of 1521 patients (Figure 1). We collected demographic (including Rural Urban Commuting Code), clinical and treatment data, for the cohort. Travel time to our medical center was calculated with geospatial mapping to the patient census tract. Univariate analysis was performed with two-sample t-tests, one-way ANOVA, or Kruskal–Wallis tests for continuous variables and with Pearson chi-squared tests or Fisher exact tests for categorical variables. Multivariate logistic regression was used to examine the relationship between categorical travel time and treatment selection (pessary versus surgery) with adjustment for a priori-determined demographic factors (Figure 1). RESULTS: Of the 1521 women included in this analysis, 601 (40%) opted for no treatment, 369 (24%) chose to use a pessary device, and 551 (36%) selected surgical management at their initial visit (Figure 2). Median RUCA code was 7 across all groups. Among the 368 women who initially chose pessary management, 96 (26%) converted to surgical management during the follow-up period. Travel time did not differ among women who chose to treat their pelvic organ prolapse versus those who did not (p value 0.82). However, for women who proceeded with treatment at their initial visit, longer travel times were associated with higher odds of selecting surgical treatment over pessary care (p-trend less than 0.0001; Table 1), which remained statistically significant with multivariable adjustment. When results were divided by quartile (N=380), travel time was less than 36, 36–66, 66–86, and greater than 86 minutes, respectively. Travel time was not associated with conversion to surgical management among women who initially selected pessary care (p value 0.84; Figure 2). CONCLUSIONS: In a rural population with pelvic organ prolapse, increased travel time to care was associated with surgical management as initial treatment choice. However, travel time was not associated with continuation of pessary treatment. This finding adds to the small, but important, body of work examining provision of urogynecological care to rural patients.