Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH), a chronic and often progressive condition, affects nearly three in four men by the seventh decade of life. Recognizing its clinical and public health significance, UDA investigators used a variety of data sources, including administrative data sets, large national health surveys, and community-based studies, to characterize the demographic burden of illness attributable to BPH and its associated medical care.

For an increasing number of men with BPH, the outpatient physician office represents the portal of entry into the health care system. Illustrating this trend with data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey, an increase in the number of outpatient visits for BPH from 10,116 per 100,000 in 1994 to 14,473 per 100,000 in 2000 was observed ( Table 3 ). During the same period, BPH-related emergency room visits decreased from 330 per 100,000 in 1994 to 218 per 100,000 in 2000. Follow-up visits for imaging, prescriptions, and office-based surgical interventions are likely to be contributing factors to this trend.

Other UDA data sources allowed characterization of the clinical evaluations, medical therapies, and procedural interventions that accompany these outpatient visits. For instance, most urologists recommend medical therapy with α-blockers or 5-α-reductase inhibitors as first-line treatment for men with symptomatic BPH. NAMCS data provide empiric support for this practice pattern. Specifically, in 2000, 23% of prescriptions written at BPH-related outpatient visits were for the α-blockers, doxazosin and tamsulosin. That year, only 7.3% of BPH-related outpatient visits culminated in a prescription for the 5-α-reductase inhibitor, finasteride. The widespread use of these pharmacologic agents is supported by a broad clinical literature including the landmark National Institute of Diabetes and Digestive and Kidney Diseases–funded Medical Therapy of Prostatic Symptoms study, which demonstrated that combination therapy (α-blocker and 5-α-reductase inhibitor) was nearly twice as effective as monotherapy for decreasing the risk of clinical progression (66% risk reduction for the combination, 39% for doxazosin, and 34% for finasteride).

UDA analyses also described the use of emerging, minimally invasive surgical therapies for BPH, including laser ablation, transurethral needle ablation, transurethral microwave therapy, high-energy focused ultrasound, and hot water thermotherapy. According to data from the Health care Cost and Use Project, inpatient admissions for certain minimally invasive BPH surgeries (transurethral needle ablation and microwave therapy) increased from 1990 through 2000. It is interesting to note that, although these procedures are typically described as “office-based,” at least at the beginning of their adoption curve a portion were being performed as inpatient procedures.

BPH procedures in the ambulatory surgery setting increased concurrently. For instance, population-based incidence rates for minimally invasive surgical therapies increased from 264 per 100,000 in 1998 to 357 per 100,000 in 2000. Concurrent with data supporting effective medical therapy for BPH and the introduction of minimally invasive treatment options, national rates of transurethral resection of the prostate decreased steadily in the 1990s.

Urinary Incontinence in Women

Because women may be reluctant to discuss urinary incontinence (UI) with their physicians or believe it is part of normal aging, using physician office visits to describe the prevalence of UI may substantially underestimate its true burden. Population-based data, in contrast, are derived from surveys of individuals who are not necessarily seeking care, and have greater sensitivity for capturing the true burden of UI among American women.

Analyses of population-based data from the National Health and Nutrition Examination Survey (NHANES) estimated a 38% prevalence of UI among women greater than or equal to 60 years old surveyed from 1999 to 2000. When stratified by frequency of episodes, 13.7% of all women in NHANES reported daily incontinence, whereas an additional 10.3% reported weekly incontinence. The prevalence of daily incontinence increased with age, ranging from 12.2% in all women 60 to 64 years old to 19.4% in those greater than or equal to 85 years old. Women with less than a high school education reported incontinence less often than did those with at least a high school education. Prevalence was higher in non-Hispanic white women (41%) than in non-Hispanic black (20%) or Mexican American (36%) women ( Table 4 ). These data are consistent with other large, population-based studies that estimate a higher prevalence of UI in non-Hispanic white women than in other ethnic or racial groups. The annual rate of hospitalizations for a primary diagnosis of UI, most of which are presumably for incontinence surgery, remained stable at 51 to 54 per 100,000 between 1994 and 1998. The rate decreased to 44 per 100,000 in 2000, consistent with a shift to ambulatory surgery and hospital outpatient treatment of women with incontinence. The annual hospitalization rate was highest for women between the ages of 65 and 74 years (108 per 100,000) and for women residing in the South and West. Urban dwellers had a higher rate of hospitalizations than did rural dwellers. Hospital stays were longer for older women.

In contrast to the decreasing hospitalization rate for incontinence between 1992 and 2000, outpatient visits for UI more than doubled during this period. Physician visits linked with a UI diagnosis increased from 845 per 100,000 women in 1992 to 1845 per 100,000 in 2000. Similarly, visits for which UI was the primary diagnosis increased from 468 per 100,000 in 1992 to 1107 per 100,000 in 2000. Office visits for incontinence by female Medicare beneficiaries (≥65 years old) increased from 1371 per 100,000 in 1992 to 2937 per 100,000 in 1998. The rate in white women approximately doubled that in African American, Asian American, or Pacific Islander women, and was 50% higher than that in Hispanic women.

Despite its adverse quality of life effects, fewer than half of women with incontinence seek care for this chronic condition. Although only a small fraction of women with UI seek surgical intervention, the number treated surgically is nonetheless substantial and accounts for a considerable proportion of incontinence-related expenditures. UDA analyses revealed that among women with commercial health insurance the rate of inpatient hospitalizations for incontinence procedures (as the primary or a secondary procedure) ranged from 123 per 100,000 in 1994 to 114 per 100,000 in 2000. Hospitalizations for incontinence surgeries as the primary procedure decreased from 59 per 100,000 women in 1994 to 33 per 100,000 in 2000. Consistent and substantial geographic variation is also noted in rates of incontinence surgery. For instance, between 1994 and 2000 rates of hospitalization for incontinence-related surgery ranged from 74 to 114 per 100,000 women in the Northeast United States to 217 to 306 per 100,000 in the West.

In 1998, collagen injection, pubovaginal sling, and anterior urethropexy were the most commonly performed surgical procedures for female UI. This pattern reflects increased use of pubovaginal slings among incontinent women from 1995 (621 per 100,000 women) to 1998 (2776 per 100,000). Although still common, the number of anterior urethropexies decreased between 1992 (3941 per 100,000) and 1998 (2364 per 100,000). During the same interval, nationwide use of needle suspension procedures (the so-called “Raz” and “Pereyra” procedures) decreased precipitously.

UDA analyses also captured initial trends toward more frequent ambulatory surgical care for female UI. Among commercially insured women less than or equal to age 65, the rate of ambulatory surgery visits for UI increased from 15 per 100,000 in 1994 to 34 per 100,000 in 2000. Likewise, the rate of ambulatory surgical center visits by older (≥65 years) Medicare beneficiaries with UI increased from 60 per 100,000 in 1992 to 142 per 100,000 in 1998. During this interval, the increasing use of ambulatory surgery likely reflected the emergence of injectable periurethral bulking agents for female stress incontinence.

Urinary Incontinence in Female Nursing Home Residents

Identification of incontinence at the time of nursing home admission, typically relying on resident medical records, suggests that only 1% to 2% have a diagnosis of incontinence. Clinical studies reveal, however, that a much larger proportion actually has UI at nursing home admission. To explore this difference, UDA researchers used data from the National Nursing Home Survey to compare administrative and clinical estimates of the prevalence of incontinence within the same vulnerable population.

Among female nursing home residents with an admitting or current diagnosis of incontinence in their medical records 73.8% to 85.4% was identified by the National Nursing Home Survey as having difficulty controlling urination, and 9.5% to 11.7% had an indwelling urethral catheter (or urinary stoma). Moreover, well over half of those with incontinence required personal assistance and almost one fourth required special equipment when using the toilet. Among the entire population of female nursing home residents (regardless of record-based continence status) 56.3% to 58.6% were reported to have difficulty controlling urination. This rate was stable between 1995 and 1999. Fully 56.6% of these patients required personal assistance and 15.2% required special equipment when using the toilet.

Nursing home residents with incontinence were older than those without incontinence. In 1999, 50.7% of incontinent women were greater than or equal to 85 years old, 31.5% were 75 to 84 years old, and 17.8% were less than or equal to 74 years old ( Table 5 ). In contrast, 41.5% of those without incontinence were greater than or equal to 85 years old, 32.2% were 75 to 84 years old, and 26.2% less than or equal to 74 years old. Race and ethnicity did not differ between the incontinent and continent nursing home residents (see Table 5 ).

Table 5

Female nursing home residents with admitting or current diagnosis of urinary incontinence

	1995		1997		1999
	Count	Rate (95% CI)	Count	Rate (95% CI)	Count	Rate (95% CI)
Totals	13,915	1237 (949–1524)	20,679	1789 (1435–2143)	15,979	1366 (1050–1681)
Age
74 or less	2443	1435 (605–2265)	2408	1334 (610–2058)	2827	1389 (588–2190)
75–84	4159	1131 (662–1601)	9029	2428 (1679–3176)	5668	1540 (972–2107)
85 or more	7313	1245 (848–1644)	9242	1531 (1085–1978)	7685	1254 (823–1685)
Race
White	13,397	1340 (1022–1558)	17,962	1779 (1403–2155)	15,075	1509 (1148–1869)
Other	518	421 (0–905)	2717	1969 (858–3080)	904	554 (58–1051)

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