Understanding Geospatial Trends in Lumbar Fusion Incidence and Technique in Medicare Populations.

STUDY DESIGN: Retrospective study with epidemiologic analysis of public Medicare data. OBJECTIVE: This study seeks to utilize geospatial analysis to identify distinct trends in lumbar fusion incidence and techniques in Medicare populations. SUMMARY OF BACKGROUND DATA: With an aging population and new technologies, lumbar fusion is an increasingly common procedure. There is controversy, however, regarding which indications and techniques achieve optimal outcomes, leading to significant intersurgeon variation and potential national disparities in care. MATERIALS AND METHODS: Medicare billing datasets were supplemented with Census Bureau socioeconomic data from 2013 to 2020. These databases listed lumbar fusions billed to Medicare by location, specialty, and technique. Hotspots and coldspots of lumbar fusion incidence and technique choice were identified with county-level analysis and compared with Mann-Whitney U . A linear regression of fusion incidence and a logistic regression of lumbar fusion hotspots/coldspots were also calculated. RESULTS: Between 2013 and 2020, 624,850 lumbar fusions were billed to Medicare. Lumbar fusion hotspots performed fusions at nearly five times the incidence of coldspots (101.6-21.1 fusions per 100,000 Medicare members) and were located in the Midwest, Colorado, and Virginia while coldspots were in California, Florida, Wisconsin, and the Northeast. Posterior and posterolateral fusion were the most favored techniques, with hotspots in the Northeast. Combined posterior and posterolateral fusion and posterior interbody fusion was the second most favored technique, predominantly in Illinois, Missouri, Arkansas, and Colorado. CONCLUSIONS: The geographic distribution of lumbar fusions correlates with variations in residency training, fellowship, and specialty. The geospatial patterning in both utilization and technique reflects a lack of consensus in the application of lumbar fusion. The strong variance in utilization is a potentially worrying finding that could suggest that the nonstandardization of lumbar fusion indication has led to both overtreatment and undertreatment across the nation. LEVEL OF EVIDENCE: Level 3-retrospective.

Geospatial Distribution of Ambulatory Surgery Center Utilization for Otorhinolaryngologic Surgeries Among Medicare Patients From 2015 to 2019.

Objective: To investigate the geographic clustering of ambulatory surgical center (ASC) utilization in otolaryngology to determine hot spot areas of high utilization and cold spot areas of low utilization and socioeconomic factors that correlate with these hot spots and cold spots. Study Design: To develop a national epidemiologic study of ASC utilization in otolaryngology in the United States. Setting: United States of America. Methods: Multiple county-level national databases were reviewed including Center for Medicare Services (CMS) physician billing data, CMS Medicare demographic data, and US Census socioeconomic data. The analysis was conducted using the average of all Medicare billing information from 2015 to 2019. Whether a procedure was performed in an ASC was extracted from CMS data using the CMS definition of an ASC. The percentage ASC billing was calculated as the fraction of CMS payments that were performed in ASCs for the top ENT procedures. A Python-based script for database building and GeoDa, Moran's I clustering coefficient, and a 1-way analysis of variance was utilized to chart and analyze demographic, geographic, and socioeconomic trends. Results: Hot spots of utilization, with an average ASC billing of 80.13%, were seen in Southern California, Florida, Mid-Atlantic, and clusters throughout the Deep South. Cold spot clusters, with an average ASC billing of 2.21%, were located in large swaths of New England, Ohio, and the Deep South with clusters bisecting the Midwest. Cold spots had a higher percentage of poverty and percent eligible for Medicaid. Conclusion: ASC utilization is best used to improve cost-effectiveness and accessibility of care but what is seen is that ASC use is currently highest in cities in coastal areas which already have high levels of care access and are making the most proportional money compared to their rural counterparts.

Geospatial evaluation of disparities in neurosurgical access in the United States.

When neurosurgical care is needed, the distance to a facility staffed with a neurosurgeon is critical. This work utilizes geospatial analysis to analyze access to neurosurgery in the Medicare population and relevant socioeconomic factors. Medicare billing and demographic data from 2015 to 2019 were combined with national National Provider Identifier (NPI) registry data to identify the average travel distance to reach a neurosurgeon as well as the number of neurosurgeons in each county. This was merged with U.S. Census data to capture 23 socioeconomic attributes. Moran's I statistic was calculated across counties. Socioeconomic variables were compared using ANOVA. Hotspots with the highest neurosurgeon access were predominantly located in the Mid-Atlantic region, central Texas, and southern Montana. Coldspots were found in the Great Plains, Midwest, and Southern Texas. There were statistically significant differences (p < 0.05) between high- and low-access counties, including: stroke prevalence, poverty, median household income, and total population density. There were no statistically significant differences in most races or ethnicities. Overall, there exist statistically significant clusters of decreased neurosurgery access within the United States, with varying sociodemographic characteristics between access hotspots and coldspots.

Adult-Onset IgA Vasculitis Presenting as an Unusual Rash and Pancolitis.

A 47-year-old female presented with complaints of abdominal pain and a history of new-onset maculopapular rash. A workup including laboratory and imaging studies, colonoscopy, and biopsy was performed that led to the diagnosis of adult-onset IgA vasculitis. The patient responded well to intravenous methylprednisolone and was followed up as an outpatient where she continued with oral methylprednisolone and azathioprine. This case is noteworthy for the unusual adult-onset presentation with primarily gastrointestinal symptoms and atypical rash pattern. Furthermore, while very effective in this patient, the use of corticosteroids is a treatment decision that has some controversy in the current literature.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair.

Introduction There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique. Methods Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran's I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001.  Results  There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively). Conclusions Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities.

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran's I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.

Demographic and Geospatial Analysis of Buprenorphine and Methadone Prescription Rates.

Background The medical community continues to seek to understand both the causes and consequences of opioid use disorder (OUD). The recent 2019 public release of the Automation of Reports and Consolidated Orders System (ARCOS) database from the years 2006 to 2012 provides a unique opportunity to analyze a critical period of the opioid epidemic with unprecedented data granularity. Objectives This study aims to use the ARCOS dataset to (1) determine significant contributory variables to opioid overdose death rates, (2) determine significant contributory variables to the relative prescription of buprenorphine and methadone, and (3) evaluate the existence of statistically significant geospatial clusters in buprenorphine and methadone prescription rates. Methods This study utilizes multiple databases, including the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER), the Drug Enforcement Administration (DEA) prescription drug data, and the United States (US) Census demographics, to examine the relationship between the different treatments of OUD. Linear regressions are used to determine significant contributory factors in overdose rate and the buprenorphine-to-methadone ratio. Geospatial analysis is used to identify geographic clusters in opioid overdoses and treatment patterns. Results Methadone prescriptions, racial demographics, and poverty were found to significantly correspond to opioid overdose death rates (p < 0.05). Buprenorphine prescriptions were not found to be significant (p = 0.20). Opioid overdoses, metro character, racial categorization, and education were found to significantly correspond to the ratio of buprenorphine to methadone prescribed (p < 0.05). Cluster analysis demonstrated different geospatial distributions in the prescriptions of buprenorphine and methadone (p < 0.05). Conclusion Historically, methadone prescriptions have been higher in areas with high overdose rates. Buprenorphine and methadone prescribing patterns have historically demonstrated different geographic trends.

Analysis of Rural Disparities in Ultrasound Access.

Purpose This work aims to conduct a geospatial analysis of recent ultrasound access and usage within the United States, with a particular focus on disparities between rural and urban areas. Methods/Materials Multiple public datasets were merged on a county level, including US Department of Agriculture economic metrics and Centers for Medicare Services data using the most recent years available (2015-2019). From these databases, 39 total variables encompassing the socioeconomic, health, and ultrasound characteristics of each county were obtained. Current Procedural Terminology (CPT) codes incorporated included ultrasound-guided procedures and diagnostic exams. Three thousand eleven counties were included. The combined dataset was then exported to GeoDa for network-based analysis and to produce map visualizations. To identify statistically significant (p < 0.05) hotspots and coldspots in point-of-care ultrasound (POCUS) prevalence, Moran's I was used. Choropleth maps were created for visualization. ANOVA was run across the four Moran's I groups for each of 39 variables of interest. Results A total of 30,135,085 ultrasound-related CPT codes were billed to Medicare over 2015-2019, with 26.55% of codes being ultrasound-guided procedures and 73.45% being diagnostic exams. 38.84% of rural counties had access to POC ultrasound compared to 88.56% of metropolitan counties and 74.19% of counties overall. Hotspots of POCUS were in Southern California and the Eastern US (average of 1,441 per 10,000 Medicare members per year). Coldspot areas were seen in the Great Plains and Midwest (average of 7.43 per 10k Medicare members per year). Hotspot clusters, when compared to coldspot clusters, were significantly (p < 0.001) more dense (703.6 to 14.9 people per square mile), more urbanized (3.5 to 7.1 Rural-Urban Continuum (RUC)), more college-educated (25.1% to 20.0%), more likely to have an Emergency Department (ED) visit (725.8 to 616.9 visits per 1,000 Medicare members), more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%), and less Hispanic representation (2.6% to 5.5%). Conclusions Ultrasound access and usage demonstrate significant geospatial trends across the United States. Hotspot and coldspot counties differ on several key sociodemographic and economic variables.

Gender Representation in Orthopaedic Surgery: A Geospatial Analysis From 2015 to 2022.

Introduction The gender disparity in orthopaedic surgery is well-established. According to our analysis, only 7.4% of practicing orthopaedic surgeons in the US are female in 2022. While there are several theories attempting to explain this gender gap, our eight years of data show that limited female representation is a self-perpetuating cycle as areas without female representation almost never improve in that regard. It appears that existing female mentorship is critical to the growth of a female orthopaedic presence in an area. In the present work, we aim to describe how gender diversity in orthopaedic surgery differs across the country, how this diversity is changing over time, and how surgeon gender diversity may be affected by the sociodemographic characteristics making up the counties where orthopaedic surgery is practiced. Methods A retrospective study was conducted using publicly available National Provider Identifier (NPI) data from 2015 to 2022. Orthopaedic surgeons and their genders were identified using the Provider Type and Gender data elements associated with an individual NPI. Rural-urban and metro characters were defined using the USDA Economic Research Reserve's rural-urban continuum codes. Python was used for database building and data cleaning. GeoDa, a statistical map-based graphing software, was used to plot and assess demographic, geographic, and socioeconomic trends. Trends in gender diversity from 2015 to 2019 were analyzed for each individual year as well as the time period as an aggregate. Cluster analysis was performed to assess complex spatial patterns of variables that could not be condensed linearly or logarithmically. Moran's I was used to measure the similarity of a Federal Information Processing System (FIPS) area code to its neighbors. Within the clustering analysis, spatial clusters were broken down into four groups of spatial outliers (High-High, High-Low, Low-High, and Low-Low) referencing a given area's relationship with its neighbors. Factorial ANOVA between each of the four cluster types was performed using the variables provided in the article to identify significant demographic variables within the cluster analysis. Results There are relative hotspots of gender diversity in the Northwest, Northeast, and Southwest with relative coldspots in the Midwest and Southern US. In counties that are considered gender diversity hotspots, the total population of orthopaedic surgeons increases by 0.94 each year while the population of female orthopaedic surgeons increases by 0.2, suggesting that in areas with high gender diversity, 4.7 male orthopaedic surgeons are joining practices for every 1.0 female. In areas with low gender diversity, the population of orthopaedic surgeons increases by 0.11 surgeons each year while the slope for an increase in female orthopaedic surgeons is 0. Conclusions  Orthopaedic surgery lags behind other male-dominated surgical specialties in gender parity. Our analysis demonstrates that certain areas of the country including the Northwest, Northeast, and Arizona have improved gender diversity compared to the rest of the country. We also see that the rate of increase of female orthopaedic surgeons in the past seven years is highest in areas with more preexisting female orthopaedic surgeons, suggesting the importance of a "trailblazer" phenomenon in recruiting female surgeons.

Geospatial distribution of relative cesarean section rates within the USA.

OBJECTIVE: To evaluate the existence of statistically significant clusters of Cesarean section rates at the county level and assess the relationship of such clusters with previously implicated socioeconomic factors. RESULTS: County-level obstetrics data was extracted from March of Dimes, originally sourced from National Center for Health Statistics. County-level demographic data were extracted from the US Census Bureau. Access to obstetricians was extracted from National Provider Identifier records. Rural counties were identified using Rural Urban Commuting Area codes developed by the department of agriculture. The dataset was geospatially analyzed using Moran's I statistic, a metric of local spatial autocorrelation, to identify clusters of increased or decreased Cesarean section rates. The American South, especially the Deep South, is a major cluster of increased Cesarean section rates. As a general but not absolute pattern, the American West and Midwest had lower Cesarean section rates than the Northeast. Focal areas of increased Cesarean section rates included the Kansas-Nebraska border, Michigan's upper peninsula, and the New York City metropolitan area. The gross geospatial differences were not explained by rurality, obstetric access, or ethnic and racial factors alone.