SU103 - Examining Racial Disparities in Sacral Neuromodulation for Male and Female Patients with Fecal Incontinence

Purpose/Background: Sacral Neuromodulation (SNM) is treatment that can greatly improve quality of life in patients with urinary (UI) and fecal incontinence (FI). Prior research has shown that Black patients undergo SNM for UI less frequently than White patients; however, there is less known about racial disparities in FI. We hypothesized that Black male and female patients with FI would be offered SNM less frequently than White patients.

Methods/Interventions: This was a retrospective cohort study of adult male and female patients who presented to an academic health system for treatment of idiopathic FI from 2011 to 2021. The two cohorts were patients who identified as non-Hispanic Black or non-Hispanic White. Medical records were queried to collect clinical variables including surgical and non-surgical treatments offered, diagnostic tests ordered, and referring provider specialties. A 2:1 age-matched cohort of White patients per Black patient was planned to detect a 10% absolute difference in our primary outcome with 80% power at an alpha of 0.05. The primary outcome was documentation of discussion of SNM as a potential therapy.

Results/Outcomes: 180 Black patients met inclusion criteria (149 women, 61 men) and 360 age-matched White patients were identified (298 women, 62 men). In total, 21.7% (117) of patients with FI had documented counseling about SNM which was significantly less frequent in Black patients (12.8% vs 26.1%, p< 0.001). 4.4% of all patients underwent SNM which also was less common in Black patients (2.2% vs 5.6%, p=0.002). However, among only patients with a documented discussion about SNM, there was no difference based on race (17.4% vs 21.3%, p=0.679). Black patients were less likely to be referred for pelvic floor physical therapy (52.2% vs 72.2%, p< 0.001), anorectal manometry (41.1% vs 51.9%, p=0.018), sphincter imaging (1.1% vs 5.3%, p=0.018), and defecography (7.2% vs 16.1%, p=0.004). Black patients were also less likely to be offered medication management (78.3% vs 88.3%, p=0.002) and dietary counseling (69.4% vs 81.4%, p=0.002). Importantly, we found no difference in Black and White patients’ follow-up after initial diagnosis (78.3% vs 77.2%, p=0.77).
There were differences in the specialties managing the two groups’ FI. Black patients were more likely to see Internal Medicine (IM) (33.3% vs 18.1%, p< 0.001), and less likely to see Colorectal Surgery (CORS), one of the specialists who perform SNM for FI (10.0% vs 17.2%, p=0.026). There was no difference in the percentage of Black versus White patients evaluated by GI (65.6% vs 63.9%, p=0.703) and Urology (7.2% vs 6.4%, p=0.714). Of those seen by CORS or Urology, Black patients were less likely to be offered SNM (3.9% vs 8.3%, p=0.069 and 2.8% vs 5.3%, p=0.021, respectively). Patients seen by CORS and Urology were more likely to be educated about SNM (p < 0.001 and p< 0.001). Alternatively, Black patients and those seen by Gastroenterology (GI) were less likely to be educated about SNM (p < 0.001 and p< 0.001). Patient age was not a predictor of SNM education (p=0.248).

Conclusion/Discussion: There are differences in SNM referrals to treat FI between Black and White patients. This may be due to differences in discussions about this therapy, referral patterns, and specialty-specific counseling. Multidisciplinary work is needed to provide equitable education about SNM for this life-altering condition.