Frailty impacts on treatment trends and perioperative urologic morbidity among older women undergoing procedure-based treatment for urinary incontinence

Abstract

Frailty increases with aging and may be a predictor of urologic complications after procedures for urinary incontinence (UI) treatment. We aim to explore the association between frailty and treatment trends and perioperative urologic morbidity among older women after procedure-based UI treatments. We analyzed claims data from a 5% national random sample of Medicare beneficiaries provided by the Centers for Medicare and Medicaid Services to include women undergoing a procedure-based intervention for UI between 2011-2018. Procedures included were midurethral/fascial slings, periurethral bulking, and Burch colposuspension for stress urinary incontinence (SUI); and sacral neuromodulation, intravesical Botox, and posterior tibial nerve stimulation for urgency urinary incontinence (UUI) and the overactive bladder (OAB) syndrome. A Claims-based Frailty Index (CFI) was applied to identify frailty within the 12 months prior to the date of the intervention. The CFI score was dichotomized: ‘Frail’ defined by CFI score ≥0.25 and ‘Non-Frail’ by CFI score <0.25. Demographic and clinical characteristics were abstracted from the analytical file on the date of the intervention. Post-procedure urologic and surgical outcomes that occurred within the 12-month period after the index procedure were also abstracted. Univariate and bivariate analyses stratified by frailty status evaluated differences in demographic and clinical characteristics. Trends of UI interventions performed were compared based on frailty status. Multivariable analyses were performed to identify the relationship of frailty on post-intervention urologic/surgical outcomes and the independent effects of age, race, and region. 21,783 women had a CFI-score and underwent a UI intervention between 2011-2018. The mean age was 72±11 years. The majority of women were White (90.5%). 3,826 had CFI ≥ 0.25 and thus classified as ‘Frail’; 17,957 had CFI<0.25 and was classified as ‘Non-frail’. Slings were the most common procedure performed in this cohort (44%). Frail women with stress urinary incontinence have 2.5 higher odds of having periurethral bulking compared to other SUI interventions. Frail women with UUI/OAB have 1.2 higher odds of having sacral neuromodulation in comparison to other inventions. Urologic complications within 1 year of surgery were identified in 18,198 (83.5%) of subjects. Frail women had 1.63 higher odds of having a urologic complication, 95% CI [1.47, 1.82], p<0.0001. The significant impact of frailty on presence of urology complications of UI procedures did not change after considering age, race, or region. Frailty pre-existed procedure-based treatments for urinary incontinence in 17% of older women. While minimally invasive procedures were most commonly performed, pre-existing frailty resulted in higher rates of urologic complications.