The role of socioeconomic factors in voiding/elimination/intake diary adherence in pediatric lower urinary tract dysfunction evaluation
Ethan Samet, BA, Amanda Berry, PhD, Stephen Zderic, MD, Jason P. Van Batavia, MD, MSTR.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
BACKGROUND: The etiology of a pediatric lower urinary tract dysfunction (LUTD) can be difficult to identify at a first encounter, as patients and families are often unsure of specific voiding/elimination and fluid intake patterns and habits. For this reason, after the initial office visit, patients are sent home with voiding/elimination/intake diaries to fill out prior to follow up visit. Voiding diaries provide detailed information on patients’ urinary void volumes, micturition and stooling frequency, water intake, and medication adherence. Despite the important information gleaned from these diaries, completing the diaries is demanding, requiring collaboration between patients, families, and schools, and many assigned diaries are never returned. In this study, we assess the proportion of voiding/elimination diaries that are never returned, and the effect of demographic and socioeconomic factors on their completion. We hypothesized that lower household income would be associated with lower voiding diary completion rates.
METHODS: We retrospectively reviewed our IRB-approved registry of 665 consecutive patients initially seen between 5/2014-1/2016 who were assigned at least one paper voiding diary for LUTS management. Median household income by zip code was determined by the US Census American FactFinder website.
RESULTS: 830 voiding diaries were assigned to 665 unique patients. Of patients who returned for follow-up visit, 38.1% brought a diary while 61.9% did not. Neither age nor gender were associated with diary completion. The strongest demographic predictor was median household income by zip code, with 18% of families living in zip codes earning <$45,000/year returning a diary compared to 45% of families living in zip codes earning >$90,000/year (Fisher exact = 0.0012). See Table 1 for breakdown of voiding diary adherence by household income levels.
CONCLUSIONS:
When assigning voiding diaries to patients, providers should consider socioeconomic circumstances that may impede diary use and scaffold their implementation accordingly. We found that patients living in areas of median household incomes <$45,000 were less likely to return voiding diaries than those living in areas with higher median household incomes. Socioeconomic disparities in access to and utilization of healthcare, particularly in pediatrics, are being recognized more and more as possible factors in disparities in outcomes. Given the importance information obtained by voiding diaries, the lower rate of return of the diaries in those with lower household incomes may lead to delays in accurate diagnosis and treatment implementation. Future studies will need to focus on the effect of these findings on patient outcomes and any potential disparities in outcomes that may exist. 
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