Pre-Operative Urodynamic Evaluation in Female Medicare Patients Undergoing a Stress Urinary Incontinence Procedure: Rates Before and After the Value Trial
Annah J. Vollstedt, MD; Rachel Moses, MD; MPH; E. Ann A. Gormley, MD
Dartmouth Hitchcock Medical Center, Lebanon, NH
BACKGROUND: The American Urologic Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) Guideline outlines the evaluation and treatment of stress urinary incontinence (SUI) and state that urodynamic (UDS) testing may be omitted in healthy females who have not undergone a prior SUI procedure. This recommendation is largely based on the data reported in the seminal Value of Urodynamic Evaluation (ValUE) trial. We sought to investigate the rates of UDS testing in those undergoing a SUI procedure before and after the ValUE trial publication.
METHODS: Using The Dartmouth Institute Atlas Rate Generator exploring a 100% Medicare claims data, we identified females with a diagnosis of SUI by ICD-9 codes and a CPT code for either urethral bulking or urethral sling procedure, within 306 hospital referral regions (HRR). We then identified the proportion of those who also had a CPT code for UDS within one year prior to their SUI procedure.
RESULTS: Complete 2011 and 2013 data was available for 151 of the 306 HHRs. The national percentage of pre-operative UDS evaluation was 53% (16020/30131) in 2011, compared to 55% (11,772/21579) in 2013, after the publication of the ValUE trial (p=0.157). In 2011, the highest percentage of UDS testing in was performed in Monroe, LA at 81% (48/59) and the lowest in Jonesboro, AR at 22% (14/64). In 2013, the highest percentage of UDS testing was performed in Longview, TX at 88% (43/49) and the lowest in Springfield, MO at 22% (22/99). Only 40% (61/151) of HHRs decreased their use of UDS, while 52% (79/151) increased UDS rates, and 8% (11/151) HHRs stayed the same.
CONCLUSIONS: There is significant regional variation in utilization of UDS in those undergoing a SUI procedure. Nationally, the overall rates of UDS, diagnostic testing did not change significantly after the publication of the ValUE trial. When evaluating at the HRR level, a larger proportion of HRRs demonstrated increased or unchanged rates between 2011 and 2013. Further research is needed to investigate the differences in UDS testing after the distribution of the SUI AUA/SUFU guidelines as well the rates of UDS testing in populations other than Medicare beneficiaries.
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