Urogynecology and the underserved.

It is the observation of this author that a majority of US patients who seek and receive care for urogynecologic disorders are Caucasian and have insurance or other means to pay for their care. There are, of course, many exceptions. However, the impression remains that urogynecologic disorders are largely addressed in women who have the luxury of time to do so, access to urogynecologic services and the ability to pay. Unlike cancer, urinary incontinence and prolapse are usually not life threatening. Unlike Obstetrics, the disorder does not have a self-limited course. Urogynecologic conditions only uncommonly warrant urgent attention. However, these disorders have a significant impact on the quality of life of women of all races and social strata. African American women have been found to have greater rates of detrusor overactivity. Latina women have been found to have higher rates of prolapse. There is little or no data on Native American women. Medical insurance coverage is less common among minorities in the US, but quality of life issues undoubtedly transcend one’s race and socioeconomic status. So what can be done to address yet another disparity in our health care system? It begins with the recognition that our profession selects for a certain type of patient. It continues with the willingness to accept patients in to our practice with limited or no resources. Then, we must advocate for them in their efforts to secure public assistance or other health care coverage including charity care within our hospital systems. National organizations should recognize the issue and advocate for public coverage for patients who are otherwise disabled by the effects of their urogynecologic disorders, just as one might be disabled by her “bad back”. Underserved women also have more difficulty finding qualified physicians to address their problems because we are largely driven to practice in high resource settings. With this in mind, we have developed a model for delivery of urogynecologic services in one hospital on the Navajo reservation. This may be applicable to other underserved populations, especially those with public funding. Native women with federal medical coverage who have urinary incontinence or prolapse often have no access to urogynecologic services. They must either suffer or seek referral to facilities which are sometimes hundreds of miles away. Sometimes their referrals are approved, sometimes not. Most of these women do not have the resources to travel back and forth to the referral institution for an initial evaluation, followup visit, pre-operative visits, surgery etc. Once or twice yearly, we visit the reservation to perform surgery on patients with prolapse and/or incontinence. These patients are prescreened according to strict criteria and confirmed as suitable candidates prior to the procedure. These visits serve to both help individual patients and teach the Indian Health Service physicians new techniques. The Indian hospital saves money on referrals and reimburses us for expenses. Over time, we have developed a trusting and professional relationship with the IHS physicians which ultimately nourishes us all. There are many ways that physicians in urogynecology and related fields can address the needs of the medically underserved. It is incumbent on our specialty to devise innovative ways to care for patients of all races and socioeconomic statuses. We must be tireless advocates for these patients until the time when all patients are able to receive equal, high quality care. Int Urogynecol J (2006) 17:429 DOI 10.1007/s00192-006-0182-y