Prevalence of pediatric lower urinary tract symptoms in a US population seeking medical care, 2003- 2014

Background: We conducted this study to estimate the prevalence of pediatric lower urinary tract symptoms (pLUTS) in a US privately-insured pediatric population who are 18 years of age or older by age, sex, race/ethnicity from 2003–2014. This has not been previously described in the literature. Methods: We retrospectively reviewed Optum’s de-identifed Clinformatics® Data Mart Database database between 2003–2014. A pLUTS patient was defined by the presence of ≥ 1 pLUTS-related ICD-9 diagnosis code between the age of 6–20 years. Neurogenic bladder, renal transplant and structural urologic disease diagnoses were excluded. Prevalence by year was calculated as a proportion of pLUTS patients among the total population at risk. Variables reviewed included age, sex, race, geographic region, household factors and clinical comorbidities including attention-deficit/hyperactivity disorder (ADHD), constipation, and sleep apnea. Point of service (POS) was calculated as a proportion of pLUTS-related claims associated with a POS compared to the total claims at all POS in the time period. Results: We identified 282,427 unique patients with ≥ 1 claim for pLUTS between the ages of 6–20 years from 2003–2014. Average prevalence during this period was 0.92%, increasing from 0.63% in 2003 to 1.13% in 2014. Mean age was 12.15 years. More patients were female (59.80%), white (65.97%), between 6–10 years old (52.18%) and resided in the Southern US (44.97%). Within a single household, 81.71% reported ≤ 2 children, and 65.53% reported ≥ 3 adults. 16.88% had a diagnosis of ADHD, 19.49% had a diagnosis of constipation and 3.04% had a diagnosis of sleep apnea. 75% of pLUTS-related claims were recorded in an outpatient setting. Conclusions: Families consistently seek medical care in the outpatient setting for pLUTS. The demographic and clinical characteristics of our cohort reflect prior literature. Future studies can help define temporal relationships between household factors and onset of disease as well as characterize pLUTS-related healthcare resource utilization. Additional work is required in publicly-insured populations.


Introduction
Pediatric lower urinary tract symptoms (pLUTS) has remained a common childhood disease in the United States. pLUTS includes a range of presentations in children older than 5 years who have completed potty Page 3/12 training, such as daytime and nighttime incontinence, urgency, frequency, and dysuria. 1 Factors associated with disease presentation include gender, family history of incontinence, constipation and behavioral disorders such as Attention-de cit/hyperactivity disorder (ADHD). [2][3][4] Sequelae of disease includes decrease in quality of life and self-esteem as well as recurrent urinary tract infection. 5,6 An estimated 36-128 million dollars/year are spent on pediatric incontinence using Healthcare Cost and Utilization Project (HCUP) data. 7 Data estimating prevalence of pLUTS has largely relied on crosssectional survey methods. Three large studies found daytime urinary incontinence (DUI) in 10% of children sampled, though differences in study techniques and questionnaires limits direct comparison of ndings. 8-10 pLUTS symptoms within these DUI populations were higher with participants reporting urgency, frequency and voiding postponement behaviors. [8][9][10] The number of children with pLUTS seeking medical care and how they use medical resources has not been well-de ned. Existing HCUP data estimates a rate of approximately 1,000 per 100,000 children ages 3-10 years requiring outpatient care for a diagnoses of pediatric incontinence per year. 7 No data exists on additional drivers of healthcare utilization such as household factors or clinical co-morbidities. In order to understand disease burden, longitudinal risk factors, and design effective population-level treatment strategies, it is necessary to further characterize this patient population.
Optum's de-identifed Clinformatics® Data Mart Database (hereafter, referred to as CDM database) is a US database with pharmaceutical and health claims of commercially insured individuals across all 50 states. Both the pediatric population and outpatient setting are represented. Results may be limited by differences in population characteristics in a commercially insured versus uninsured group, however this dataset still represents a unique opportunity to explore a pLUTS cohort using claims data that can be used for future healthcare resource utilization studies. We aim to de ne the prevalence of individuals with pLUTS who are seeking medical care from 2004-2014 within the CDM database, and characterize point of service, demographic factors and clinical comorbidities of constipation and ADHD within this cohort.

Data source:
After obtaining institutional review board approval, we analyzed data derived from the CDM database between the years 2003-2014. Clinformatics® Data Mart Database is a de-identi ed database is derived from a large adjudicated claims data warehouse. The database includes deidenti ed administrative health claims for members of large commercial and Medicare Advantage health plans, approximately 15-20 million annual covered lives. Enrollment, demographic and healthcare claims data related to outpatient services and emergency room visits are available. Diagnoses were coded using the International Classi cation of Diseases, ninth revision (ICD-9), procedures using Current Procedural Terminology (CPT).

Study population:
We conducted a retrospective population-based cohort study. Our cohort included all patients ages 6-20 years old at any time between 2003-2014 with an ICD-9 code for pLUTS (Appendix 1) similar to prior HCUP data. 7 A patient was considered to have pLUTS if they had ≥ 1 diagnosis associated with any point of service claim (i.e. POS claim associated with an inpatient, outpatient, or emergency room visit). We excluded patients with an ICD-9 diagnosis or CPT surgical code related to neurogenic bladder, renal transplant, and structural urologic disease that increases risk for pLUTS -hypospadias, vesicoureteral re ux, posterior urethral valves, urethral stricture disease and ureterocele. The total population at risk per Statistical analysis: Prevalence of pLUTS by year was calculated as a proportion of pLUTS patients among the total population at risk within a 6-20 year age group per each one-year period. Each pLUTS patient was counted once per year and could be counted the following year until they reached 20 years of age or left the database. Descriptive analysis of demographic characteristics and clinical comorbidities within the total pLUTS population were calculated as percentages over the total time period. All analysis was conducted using Excel, and descriptive summaries were obtained within Redivis.

Results
We identi ed the total population at risk during this time period to be 9,263,933. NE. 9 Lower urinary tract dysfunction (LUTD) was found in 9.3% of Turkish schoolchildren ages 6-15 years old and 10 21.8% of Brazilian children. 11 Differences in prevalence can be attributed to differences in study population, age groups, and type of survey administered (validated vs non-validated) along respondent bias. Our use of a claims database relies on clinical assessment with rates less likely to be affected by factors such as likeliness to self-report, survey response rates, and recall bias.
An overall prevalence of 0.92% in the CDM database represents the percentage of privately insured pediatric patients seeking treatment for pLUTS. This prevalence is similar to rates seen in HCUP data of approximately 1,000 out of every 100,000 families seeking care for pediatric incontinence in age groups 3-10 years old within a year. 7 As expected, this number is lower than overall community prevalence estimates, as only 10-16% of families may seek medical care. 12 While severity and frequency may be related to this decision, in a sub-group of children who experienced wetting daily, 40% had not received medical care. 12 13 Additional drivers such as lack of access to care, lack of knowledge regarding treatment options, or social norms that pLUTS is a condition to be outgrown, may play a role in treatmentseeking behaviors. 13 Of the total claims associated with a pLUTS diagnosis, 77.13% were performed in an outpatient setting. This is in contrast to the low numbers of patients requiring inpatient care (3.5%) for incontinence diagnoses, which re ect previously reported data for this point of service. 7 Our study found higher proportion of females (59%) and patients ages 6-10 years old (52.18%). While some studies have found a higher prevalence of LUTD and DUI in girls 13,14 , this has not been consistently demonstrated in other large studies. 15 Data from longitudinal studies of children with DUI found the highest prevalence of disease in early childhood with a spontaneous remission rate of 15.4% per year. 16 Yuksel et al. found that the rates of LUTD stabilized around the ages of 10 in girl and 11 in boys, potentially representing pubertal changes. 10 While the prevalence of disease in the community may drop in older children, we found that the next largest group of patients with pLUTS seeking medical care was 16 years or older (27%). This may re ect increased duration and/or severity of disease that prompts medical care or increasing independence in social activities that increases degree of bother.
Treatment of pLUTS consists of behavioral and lifestyle modi cations to improve voiding, stooling and hydration habits. Effective application and adherence to these changes may be in uenced by social determinants of health including availability of healthy foods, housing factors, and access to healthcare and education. Low levels of parental education, double-income families and household factors such as increased number of siblings or family members, increased number of people sleeping in the child's room, were more likely to have pLUTS, however direct associations between low-income households, presence, or absence of insurance have not been observed. 9,10,17,18 Housing factors such as number of people per room or number of siblings may play a role in NE, potentially re ecting crowding at home that limits bathroom access. Families with fewer children and > 3 adults in the family had higher proportion of pLUTS diagnoses. This could represent lack of knowledge of pLUTS with fewer children, and household crowding factors, though this population generally fell above the federal poverty line.
Prevalence of constipation in the general population varies from 0.7-29.6%. 19 It is higher within the pLUTS population, 34% of children with constipation experience NE and 29% experience DUI 20 . The bladder and rectum are situated next to each other in the pelvis, sharing similar innervation for urethral and anal sphincter control and higher pelvic oor tone leading to symptoms. 21 Children who have a large stool burden may develop a distended rectum that stimulates detrusor muscle contractions, experienced as pain, urgency,incontinence, 21 and fear of painful elimination. We found that 19.49% of children in our pLUTS population had a diagnosis of constipation and a higher proportion of children with pLUTS were found in Southern US regions, where higher rates of constipation are observed 22 . This may re ect factors that link both presentations together, such as diet or water consumption versus the above internal factors.
Behavioral problems, such as ADHD, are also comorbid with pLUTS presentations. Following a systematic review, an overall pooled estimate of ADHD prevalence in the community is 7.20%. 23 A study of > 8000 children found a nearly double rate of externalizing problems related to attention and activity problems, oppositional behavior and conduct disorders in children with DUI versus those without DUI. 24 In our cohort of children with pLUTS, 16.88% had a diagnosis of ADHD. This may be related to the secondary effects of wetting on the development of behavioral symptoms or psychological problems. 24 The rates of comorbid constipation and ADHD are important to note due to the potential for these patients to experience lower compliance and less successful outcomes with treatment outcomes.
Speci c outreach and education programs may be required to address additional needs within these children.
Our description of patients seeking medical care for their symptoms has limitations in its application to a national population. Claims databases are subject to inaccurate and/or missing data. 25 Our choice of pLUTS ICD codes is based on prior literature, however, sensitivity and speci city in the accuracy of coding has not been investigated for these diagnoses. In order to obtain a picture of healthy children seeking medical care for these diagnoses we excluded clinical conditions such as transplant and neurogenic bladder, however, the role of additional conditions such as developmental delay and presence of absence of urinary tract infection were not investigated.
The CDM database is a national sample of patients who are privately insured. It therefore represents a subset of a much larger population, speci cally families who may be overall healthier and able to seek medical care. In this regard, our research question bene ts from this cohort since we assume this is closer to the maximum number of patients who would seek care as opposed to an underestimate due to poor access to education or healthcare resources.

Conclusion
In conclusion, a rate of approximately 1% annual prevalence of pLUTS in the CDM database points to a large and consistent burden to the healthcare system that would bene t from further studies. An improved understanding of clinical and demographic risk factors for pLUTS using longitudinal study methods in insured and those with limited access to insurance populations will help to inform effective treatment and prevention strategies. Further investigation into healthcare resource utilization using claims data will allow these programs to target areas of improvement to reduce healthcare spending and prompt investment into preventative programs. . This protocol includes a waiver of consent, a waiver assent and a waiver of HIPAA authorization. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Consent for publication
Not applicable.

Availability of data and materials
The datasets generated and/or analyzed during the current study are not publicly available due to institutional restrictions on data licensing such that this data cannot be made available but the data can be made available upon reasonable request from the corresponding author because our institution prevents us from further access to the Optum data due to change in licensing status across the institution.  Appendix1updated4.14.23.docx