Our study has several key findings. First we found that the overall rate of stricture diagnosis decreased from 1.4% to 0.9% from 1992 to 2001. The slight decrease in rates of stricture diagnosis may possibly be due to earlier detection and better treatments of sexually transmitted illnesses known to cause strictures, such as gonorrhea. We also found a higher rate of stricture disease among older men, indicating that age may be a risk factor for stricture disease. The age-related increase in stricture diagnosis we identified may be due to the fact that men who age are more likely to undergo instrumentation, such as cystoscopy, endoscopic procedures, and urethral catheter placement, that may result in later stricture development. In addition, aging urethral tissue may be inherently more susceptible to stricture development. Overall diagnosis and treatment rates were highest among Caucasian men, but rates of treatment and diagnosis per 100,000 Medicare beneficiaries were highest among black and Hispanic men. Whether these racial differences in stricture diagnoses are related to the higher rate of sexually transmitted diseases in the black community14
is unknown to date. It should be noted that 42% of men fit in the “other” category, making it difficult to analyze these data with respect to race.
We also found that, among men diagnosed with a stricture, the most common procedure performed was a urethrotomy, followed by urethral dilation. Given that previous series have shown that the efficacy of urethrotomy is similar to urethral dilation, this finding raises several concerns about the quality of care provided to men with stricture disease. Despite the reported higher success rate of urethroplasty over other modalities, the use of urethroplasty was minimal in the Medicare population. The very low urethroplasty rate identified likely represents significant underuse in this population. A previous cost-effectiveness model by Wright et al. indicated that the most cost-effective management algorithm for a bulbar urethral stricture of < 2cm is a single internal urethrotomy followed by urethroplasty if the urethrotomy fails9
. In that study, effectiveness of urethroplasty and initial urethrotomy were assumed to be 95% and 50%, based on a review of the relevant literature9
. The underutilization of urethroplasty is illustrated as follows: if the estimated 50% success rate for urethrotomy is correct, then there should be no more than two urethrotomies performed for every urethroplasty. As the success rate of urethrotomy decreases, the rates should be more equal (i.e. 20% success rate = 5 urethrotomies for every 4 urethroplasties). Although this estimation is limited by a lack of clinical information provided from claims data, the 50:1 ratio identified in this study certainly represents underutilization of urethroplasty. Urethral stents and steroid injections, procedures that have been abandoned at high volume centers, were performed more often than the definitive urethroplasty. These practice patterns lead us to believe that the quality of care provided to men with urethral stricture disease in the Medicare population is suboptimal.
Although the incidence of urethral stricture is low among this population, the complexity of urethral reconstruction is high and, in general, should be performed by formally trained urethral reconstructionists. The key to providing patients with optimal care for this disease burden is early referral and access to select centers of excellence in urethral reconstruction. There are few such centers in the US, which means that many Americans may have problems accessing specialized centers of care for urethral stricture. This potential access-to-care barrier may decrease the likelihood that patients receive treatment with curative intent (urethroplasty). Instead, they are more likely to receive less effective palliative treatment (repeat urethrotomy or dilation). Another potential barrier to urethroplasty includes a delay in referral to a specialist who performs urethroplasty. Some urologists choose to perform repeated urethrotomy or dilations, rather than referring the patient to a specialist. Repeated endoscopic procedures will not only delay cure, but may also worsen stricture characteristics by increasing the length of the stricture and causing more spongiofibrosis15
. This may ultimately result in the need for a more complex urethroplasty that carries a higher failure rate than a straightforward anastomotic repair. Patient preferences for less invasive endoscopic treatments of urethral stricture may also influence treatment patterns. Despite good results of urethroplasty among elderly men16
, many older men may not wish to undergo an operation. Surgeons may also consider patient age and co-morbidities in the decision-making process.
Medicare claims data allow for the assessment of medical care for a large, heterogeneous, nationwide sample of the population across various clinical settings. However, claims files are designed primarily to provide billing information, not detailed clinical information, and therefore this type of study has inherent limitations. Medicare claims data are limited by their reliance on administrative coding systems such as the ICD-9-CM to identify disease burden. Coding is often incomplete, and therefore not all patients treated for stricture are correctly identified. This can result in both underestimation and overestimation of utilization, depending on the sensitivity and specificity of the diagnosis and procedure codes. Our estimates are not population-based; we cannot include prevalent cases of stricture disease for which an individual has not sought care. We were also unable to determine treatment success with these data, and were unable to follow individual patients over time. Also, our use of Medicare claims restricts our analyses to beneficiaries age 65 and over. Our findings therefore may not be generalizable to younger men with stricture disease.