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Trends in urodynamics study utilization in a Southern California managed care population

      Objective

      We examined trends in overall and preoperative urodynamics utilization among women with stress urinary incontinence (SUI) to determine if practice patterns changed following publication of a 2012 randomized trial questioning the value of preoperative urodynamics in patients with uncomplicated SUI.

      Study Design

      We collected electronic medical record data on the number of female patient visits to Kaiser Permanente Southern California urology and urogynecology clinics with stress or mixed incontinence, urodynamic studies (UDS) performed, surgeries performed for stress incontinence, and the demographic and clinical characteristics of these patients during 2 discrete time periods before and after a potentially practice-changing publication. We used χ2 tests and t tests as appropriate. A multivariate logistic regression model was used to estimate the odds of urodynamics performed during January 2013 through June 2014 (study period 2) compared to urodynamics performed during July 2010 through December 2011 (study period 1) after adjustment for demographic and clinical characteristics.

      Results

      In all, 33,775 women were diagnosed as having SUI or mixed urinary incontinence during study period 1 and 37,238 women were diagnosed with these conditions during study period 2. Among these women 12.8% underwent UDS in study period 1 compared to 8.4% in study period 2 (P < .01). The rate of UDS per patient visit decreased 27.0% between the 2 time periods (P < .01). In women undergoing surgery for stress incontinence, urodynamics were performed 56.5% of the time in study period 1 and 46.5% of the time in study period 2. After controlling for demographic, pelvic organ prolapse, and other bladder diagnoses, the odds of urodynamics performed in study period 2 was 0.54 times the odds of urodynamics performed in study period 1 (95% confidence interval, 0.52–0.57). Among women with only the diagnosis of stress incontinence, 1.78% underwent urodynamics in study period 1 compared with 0.84% in study period 2 (P < .01). Preoperative urodynamics decreased from 39% in study period 1 to 20% in study period 2 (P < .01).

      Conclusion

      Significantly fewer UDS are being performed overall and prior to stress incontinence surgery in this population. This change may be due to recent studies suggesting low utility of urodynamics in patients with uncomplicated, stress-dominant incontinence.

      Key words

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      Linked Article

      • Preoperative voiding dysfunction is a risk factor for operative failure according to the VALUE study!
        American Journal of Obstetrics & GynecologyVol. 215Issue 1
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          We read with interest “Trends in urodynamics study utilization in a Southern California managed care population” by Lippman et al.1
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        American Journal of Obstetrics & GynecologyVol. 215Issue 1
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          Thank you for your request for clarification. Even before the VALUE trial, a lack of correlation among preoperative urodynamics findings and postoperative voiding dysfunction and continence outcomes has been described.1 A secondary analysis of 597 patients from the Trial of Midurethral Slings (in which all patients had preoperative urodynamics before midurethral sling) did not show a correlation of preoperative urinary flow characteristics with postoperative outcome.2 We agree that it is reasonable to obtain noninvasive uroflow data before performing a stress incontinence procedure, particularly in patients who report a slow or hesitating urinary flow, a feeling of incomplete bladder emptying, or other symptoms of voiding dysfunction.
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