Patterns of Sacral Nerve Modulation Adoption: Impact of State Licensure, Region, and Urbanicity

Sacral nerve modulation (SNM) is an effective therapy for fecal incontinence (FI), but its national utilization and access remain poorly understood. Regulatory and geographic factors may affect treatment adoption.

In this retrospective cohort study, the IBM MarketScan claims database (2014-2022) was used to identify commercially insured adults aged 18-65 y with persistent FI. Patients were stratified by state fluoroscopy licensing policies, census region, metropolitan residence, and age. Outcomes included SNM and ostomy placement. Fine-Gray competing risk models and Cox regression were used to estimate associations with state fluoroscopy licensing policies, adjusting for age, sex, region, and metro status.

Among 62,167 patients, SNM was placed in 4.1%, while 1.1% underwent ileostomy/colostomy. Large metropolitan residence was associated with reduced SNM use (subdistribution hazard ratio (SHR): 0.70, 95% confidence interval (CI): 0.60-0.82; P < 0.001). Compared to the West, SNM use was significantly higher in only the South (SHR: 1.52, 95% CI: 1.21-1.90; P < 0.001). Fluoroscopy exam requirements, mandated only in California, did not significantly impact patient likelihood to undergo SNM compared to other states without requirements (SHR: 0.77, 95% CI: 0.53-1.12; P = 0.16). Adults aged ≥59 y were more likely to receive SNM than younger patients (SHR: 1.50, 95% CI: 1.32-1.70; P < 0.001).

SNM is underutilized in the United States, with access significantly influenced by geography. Fluoroscopy examination mandates, regional differences in training density, and structural barriers in metropolitan and western areas may limit SNM adoption. Policy standardization and expanded training opportunities may help improve equitable access.