Patterns of Pessary Care and Outcomes for Medicare Beneficiaries With Pelvic Organ Prolapse

Abstract

Objectives Using a national dataset, we sought to assess patterns of pessary care in older women with pelvic organ prolapse (POP) and subsequent outcomes, including rates of complications and surgical treatment of POP. Methods Public Use Files from the United States Centers for Medicare and Medicaid Services were obtained for a 5% random national sample of beneficiaries from 1999 to 2000. Diagnostic and procedural codes (ICD-9-CM and CPT-4) were used to identify women with pelvic organ prolapse (POP) and those treated with pessary. Individual subjects were followed longitudinally for nine years. Across this duration, patient care and outcomes (e.g., return clinic visits, repeat pessary placements, complications, and rate of surgical treatment of prolapse) were assessed. Results Of 34,782 women diagnosed with POP, 4,019 (11.6%) were treated with a pessary. In the initial three months after pessary placement, 40% underwent a follow-up visit with the provider who had placed the pessary, and through nine years after the initial fitting, 69% had such a visit. During this period, 3% of subjects developed vesicovaginal or rectovaginal fistulas, and 5% had a mechanical genitourinary device complication. Twelve percent of women underwent surgery for POP by one year; with 24% by nine years. Conclusions Pessary can be effectively used for management of POP in older women. Despite this, a low percentage of Medicare beneficiaries undergo pessary fitting. Lack of continuity of care results in a small, but unacceptable rate of vaginal fistulas.

Outcomes of Vaginal Prolapse Surgery Among Female Medicare Beneficiaries

“…Our group has previously addressed coding issues related to pessary use in the Medicare population (12). The observation that pessary use was similar between groups that did and did not have an apical suspension procedure at the time of initial surgery may have been due to a pessary placed for incontinence and not prolapse, or a pessary may have been inserted for more severe symptoms prior to surgery.…”

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

“…This may be due to pessary coding in patients who had been managed chronically with pessaries (prevalent pessary use), and does not identify patients who choose to undergo a pessary fitting as an initial treatment for their prolapse (incident pessary use). A study utilizing the same database looked specifically in women that were managed with pessaries, and we found that by 1 year after fitting, 12% of women underwent prolapse surgery; with 24% by 9 years (Alperin et al, 15 2013).…”

Large rectovaginal fistula due to a cube pessary despite routine follow‐up; but what is ‘routine'?

“…performed a 9‐year longitudinal study on the pattern of pessary use and found that within 3 months of pessary fitting only 40% of patients underwent a follow‐up visit and only 69% of patients had such a visit at any time throughout the 9‐year study period . Proposed protocols for pessary follow‐up often are developed by the pessary manufacturer, with some manufacturers suggesting review every 4–6 weeks which would be costly and burdensome for patients . Regular follow‐up intervals also vary greatly in the published work, from every 3 months to annually for those who are able to perform self‐care, to 1–3 months for those who are not .…”