Referral Patterns for Stress Urinary Incontinence: Does Race Matter?

Objectives: A previous study within a large health maintenance organization (HMO) revealed that racial minority women were less likely to receive treatment for stress urinary incontinence (SUI) than White women. Studies have shown significant differences in referral patterns based on race and ethnicity in subspecialties such as cardiology, hepatology, dermatology, and pediatrics. Our primary aim was to compare specialty referrals and consultation rates for the evaluation of SUI based on race and ethnicity. Our secondary aim was to explore if these rates were associated with primary language, neighborhood deprivation index (NDI), or insurance type.

Methods: This was a secondary analysis of a retrospective cohort study. Patients with a new diagnosis of SUI were identified between 2008 and 2017. Patients who were referred to Urology or Urogynecology were then stratified by self-reported race and ethnicity. Logistic regression models were used to examine the association between race/ethnicity and referral patterns/consultations. We also analyzed logistic regression models for primary language, insurance type, and NDI, controlling for confounding variables including age, parity, body mass index (BMI), diabetes, smoking, and postmenopausal status.

Results: A total of 67,187 patients were identified with a diagnosis of SUI, of which 9,074 (13.5%) were referred to Urogynecology or Urology and 8,214 (12.2%) completed a consultation. Hispanic women had the highest rates of referral and consultations at 55% and 55.8%. Adjusted odds ratios (OR) revealed that Hispanic and Black women were more likely to be referred than White women [OR 1.39 (CI 1.31, 1.48) and 1.14 (CI 1.14, 1.26) respectively]. Unadjusted ratios revealed that Non-Spanish and Non-English speaking women were less likely to receive a referral, however this association was no longer noted after adjusting for confounders [OR 0.88 (CI 0.71, 1.08)]. Similarly, those with highest NDI had a higher likelihood of referral, but this association was no longer noted upon adjusted analyses [OR 1.06 (CI 0.97, 1.17)]. Finally, adjusted analysis revealed patients who had a public insurance plan were more likely to have a consultation [OR 0.88 (0.71, 1.08)], though not more likely to have a referral [OR 0.88 (0.71, 1.08)].

Conclusions: Our study found that Hispanic and Black women were more often referred and had consultations with a specialist for evaluation of SUI than White women. Our study suggests that race and ethnicity alone does not explain the differences in treatment for SUI in a large HMO. Future prospective studies are required to further explore the discrepancy between access to subspecialty care and treatment for SUI.