Optimizing surgical choices for older women with pelvic organ prolapse
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PROJECT SUMMARY Pelvic organ prolapse (POP) is a common disorder resulting in the pelvic organs (e.g., uterus, bladder, bowel) bulging into the vagina or outside of the body. POP significantly affects older women’s quality of life, with most experiencing protrusion of tissue from the vagina, urinary and bowel symptoms, or difficulty evacuating urine or stool. Because these symptoms can be so debilitating for older women, many opt for surgery. One in five women will have POP surgery by age 80 and this number is projected to rise as the prevalence of POP will almost double by 2050. POP surgery can be performed in different ways and there are trade-offs with each approach. A standard algorithm for determining the ideal surgical approach does not exist; thus, an older woman may consult three different surgeons and receive three different recommendations. Dr. Shatkin- Margolis’ preliminary data investigating female Medicare beneficiaries who underwent POP surgery showed that nearly 70% of women age > 65 had isolated anterior/posterior repairs, omitting concurrent apical repair (highest point or top of the vagina). Approaches that avoid apical repair, although less invasive and with lower risk of immediate postoperative complications, are known to incur high rates of reoperation (≥20%). Therefore, it remains unclear why patients and surgeons are choosing a surgical approach that subjects older women to high rates of recurrence, retreatment, and repeat surgery. To that end, this proposal seeks to optimize surgical choices for older women with POP by investigating why older women are having non-apical surgeries at such high rates. To do so, Dr. Shatkin-Margolis will (1) identify patient-, surgeon-, and system-level factors associated with non-apical surgical approaches using a large national Medicare database, (2) qualitatively explore patient- and surgeon- perspectives influencing surgical decisions, and (3) engage community and clinician experts in designing a decision support tool for older women and their surgeons to ease the decision process. These aims will provide the necessary preliminary data for an R01 proposal to trial the geriatric- informed decision support tool with the goal of achieving individualized and optimized surgical decisions that ultimately improve the health of older women with POP. Dr. Shatkin-Margolis is Associate Professor of Obstetrics, Gynecology & Reproductive Sciences at the University of California, San Francisco and a high- volume pelvic reconstructive surgeon. Under the direct supervision of a multidisciplinary team of leaders in health services research (Anne Suskind), geriatric informed decisions (Louise Walter), qualitative methodology (Jennifer James), advanced statistics (John Boscardin), and human-centered design (Jan Yeager), Dr. Shatkin- Margolis will execute a detailed career development plan to achieve 3 training goals: (1) develop a foundation of core principles for the research domain of Geriatric Urogynecology, (2) acquire skills to leverage large national databases using advanced statistics, and (3) develop skills in qualitative methods and human- centered design, to create interventions that improve the care of older women with pelvic floor disorders.
