Variation in Overactive Bladder Treatment Type by Social Determinants of Health

Overactive bladder (OAB) affects an estimated 9% to 43% of women, with just over a third also experiencing urgency urinary incontinence (UUI). Both of these conditions have a significantly detrimental impact on quality of life; other impacts to quality of life such as social determinants of health (SDOH) have also been associated with differences in the impact and severity of OAB and UUI symptoms, treatment, and access to care. Previous literature has characterized racial and ethnic disparities surrounding care for OAB and UUI, but there is little evidence for the impact or disparities in other SDOH such as language, income, insurance, and geography. This study was designed to evaluate whether the type of OAB or UUI treatment is related to insurance and estimated median household income (EMHI). This was a cross-sectional study conducted within the University of Pennsylvania Health System between January 2017 and January 2022. Inclusion criteria were women 18 years of age or older with a diagnosis of neurogenic OAB or UUI. The primary outcome for this study was provision of any treatment for OAB or UUI, defined as any anticholinergic or β 3 -agonist prescription or advanced therapy. Secondary outcomes were specific types of treatment and specialist care. SDOH data collected included race and ethnicity, primary language, insurance type, EMHI, residence area type, and comorbidities. Final analysis included 32, 396 patients with a mean age of 58. The majority of patients were White or Black/African American. Treatment for OAB or UUI was provided for 5100 patients, with 2914 receiving an anticholinergic drug, 2345 receiving a β 3 -agonist, 842 receiving advanced therapy, and 957 receiving more than one of these. A majority of the population received specialist care. Multivariate analysis showed that treatment of OAB or UUI was associated with living outside the metropolitan area adjusted odds ratio (aOR): 1. 16, 95% CI: 1. 00-1. 34, having Medicaid (aOR: 1. 38, 95% CI: 1. 21-1. 58), low-income Medicare (aOR: 1. 34, 95% CI: 1. 03-1. 76), or Medicare Advantage insurance (aOR: 1. 23, 95% CI: 1. 10-1. 38), being American Indian/Alaska Native (aOR: 1. 85, 95% CI: 1. 20-2. 85) or Black/African American (aOR: 1. 26, 95% CI: 1. 17-1. 35), and EMHI. Patients were more likely to have an anticholinergic prescription if they were Black/African American, had Medicaid insurance, were uninsured, or were in an EMHI category between the federal poverty level (FPL) and 80, 000 annually. These same categories were associated with a reduced likelihood of a β 3 -agonist prescription. Similar trends were seen with slight variation for individual advanced therapies and with receiving specialist care. These results indicate that low-income Medicare, Medicare Advantage, and Medicaid insurance types as well as American Indian/Alaska Native or Black/African American race were associated with higher odds of treatment for OAB or UUI. There were significant disparities in which type of treatment was prescribed by race, including a reduced likelihood of potentially more effective and less dangerous treatment. This highlights concerning gaps in treatment provision by race, supporting previous literature that has brought attention to these disparities. Future studies should focus on prospective designs to more adequately control for confounders and assessing indications for specific treatments for OAB or UUI. In addition, future research should standardize the assessment of estimated household income and strive for as much accuracy as possible to characterize this association more fully. (Abstracted from Urogynecology (Phila). 2025 Oct 1;31 (10): 929-941. doi: 10. 1097/SPV. 0000000000001582)