A Mixed Methods Assessment of Racial Disparities in Fecal Incontinence

Objectives: Previous work from our group identified racial disparities in access to various treatments for fecal incontinence (FI), including dietary counseling, antidiarrheals, pelvic floor physical therapy, and surgical interventions such as sacral neuromodulation (SNM). However, less is known about patient experiences with these barriers.

Methods: This was a retrospective chart review and prospective, mixed-methods survey of adult non-Hispanic Black and White female patients treated for FI from 2011 to 2021. To qualify for this study, women had to meet one of the following criteria: 1) they did not respond to medical therapy and did not proceed with SNM or 2) they did not follow-up after medication prescription. The electronic medical record was queried to collect clinical variables including diagnostic testing and treatments. Area Deprivation Index (ADI) scores were calculated based on patient zip codes. Patients were contacted by phone in a semi-structured interview about the treatments they were offered and utilized, and symptom severity.

Results: 59 adult women (24 Black and 35 White) responded to the study for a total response rate of 52%, not different between groups (50% vs 53%. ADI scores revealed that Black patients had greater socioeconomic disadvantage than White patients (9.0 vs 4.0, p< 0.001).

FI severity scores differed between the two cohorts. Black patients were more likely than White patients to report occasional, weekly, or daily solid stool incontinence (75.0% vs 48.6%, p=0.042) and liquid stool incontinence (87.5% vs 51.4%, p=0.004). Of those prescribed fiber supplements, Black patients were less likely to report symptom improvement (25.0% vs 70.0%, p=0.013) and adhere to their regimen over time (25.0% vs 63.3%, p=0.013). A similar trend was observed with antidiarrheals with symptomatic improvement (57.1% vs 87.5%, p=0.092) and adherence to treatment (28.6% vs 87.5%, p=0.035). There was no difference in SNM counseling between the two cohorts (8.3% vs 11.4%, p=0.451).

Following treatment initiation, Black patients were more likely to report minimal improvement in FI, whereas White patients more often reported a significant improvement (p=0.038). Black patients were more likely to report a significant impairment in daily functioning secondary to FI (83.3% vs 57.1%, p=0.034).

Considering these differences in symptom severity, response to treatment, and lifestyle alterations, Black patients were more likely to seek a follow-up visit with a provider that performs SNM (79.2% vs 28.6%, p< 0.001).

Conclusions: Disparities were observed between Black and White patients regarding adherence to conservative treatments and perceptions of treatment outcomes. Black patients were more likely to have severe symptoms, poorer treatment outcomes, and want future follow-up, highlighting the importance of addressing disparities in FI management including patient-reported barriers.