Insurance Status and Access to Otolaryngology Care: National Mystery Caller Study in the United States.

OBJECTIVE: To investigate potential differences in new patient appointment wait times for otolaryngology care based on insurance types and explore factors influencing these wait times. STUDY DESIGN: A cross-sectional audit study, using a "mystery caller" approach, analyzed with a linear mixed Poisson model to adjust for confounding factors. SETTING: A total of 612 physicians across 49 states and the District of Columbia, representing 6 otolaryngology subspecialties, were included. METHODS: Otolaryngology physicians were contacted by mystery callers via telephone with scripted clinical vignettes as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance. Callers requested next available appointment. Wait times for new patient appointments were recorded and analyzed in R using a generalized linear mixed Poisson model. RESULTS: A total of 1183 of 1224 calls reached a representative. Medicaid patients waited 5.73% longer (P < .001) compared to BCBS patients (IRR: 1.06; confidence interval [CI]: 1.03-1.09; P < .001), with respective mean wait times of 36.8 days (SE ± 1.6) and 32.4 days (SE ± 1.6). Longer waiting times were also associated with physicians affiliated with universities (P = .001) and certain subspecialties, such as pediatric otolaryngology (P < .001) and neurotology (P = .008). Regional differences were also observed, with specific AAO-HNS regions showing shorter wait times. The model achieved a conditional R-squared value of 0.947. CONCLUSION: This study reveals disparities in wait times for otolaryngology care based on insurance type, with extended wait times for Medicaid beneficiaries. The findings highlight a potential access to care disparity, which begets the need for strategies that ensure equitable access to otolaryngology care and further research to understand the underlying reasons for these potential disparities.

Medium-Term Outcomes of Conservative and Surgical Treatments for Stress Urinary Incontinence: A Medicare Claims Analysis: Developed by the AUGS Payment Reform Committee.

OBJECTIVE: This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older. METHODS: This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment. RESULTS: Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons). CONCLUSIONS: In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.

Medicaid coverage and access to obstetrics and gynecology subspecialists: findings from a national mystery caller study in the United States.

BACKGROUND: Previous research suggests that access to healthcare may influence the diagnosis and treatment of obstetrical and gynecologic pathologies. Audit studies, a single-blinded and patient-centered design, have been employed to measure access to care for health services. To date, no study has assessed the dimensions of access to obstetrics and gynecologic subspecialty care based on insurance type (Medicaid vs commercial). OBJECTIVE: This study aimed to evaluate the mean appointment wait time for a new patient visit to female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology and infertility when presenting with Medicaid vs commercial insurance. STUDY DESIGN: Each subspecialty medical society has a patient-facing physician directory of physicians across the United States. Of note, 800 unique physicians were randomly selected from the directories (200 per subspecialty). Of the 800 physicians, each physician was called twice. The caller presented with Medicaid or, in a separate call, with Blue Cross Blue Shield. The order in which the calls were placed was randomized. The caller asked for the soonest appointment available for respective medical conditions based on subspecialty: stress urinary incontinence, new-onset pelvic mass, preconceptual counseling after an autologous kidney transplant, and primary infertility. RESULTS: From 800 physicians initially contacted, 477 responded to at least 1 call in 49 states plus the District of Columbia. The mean appointment wait time was 20.3 business days (standard deviation, ±18.6). A significant difference was found in new patient appointment wait times by type of insurance, with 44% longer wait time for Medicaid (ratio, 1.44; 95% confidence interval, 1.34-1.54; P<.001). When the interaction between insurance type and subspecialty was added to the model, it was also highly significant (P<.01). More specifically, Medicaid patients in female pelvic medicine and reconstructive surgery had a longer wait time than commercially insured patients. Patients seeking care in maternal-fetal medicine had the least difference, but Medicaid-insured patient wait times were still longer than commercial-insured patient wait times. CONCLUSION: Typically, a patient can expect to wait 20.3 days for a new patient appointment with a board-certified obstetrics and gynecology subspecialist. Callers presenting with Medicaid insurance experienced significantly longer new patient appointment wait times than callers with commercial insurance.

American Indian and Alaskan Native Access to Obstetrics and Gynecology Subspecialists: Findings From a National Mystery Caller Study in the United States.

Background A significant disparity exists for American Indian and Alaska Native populations in accessing obstetric and gynecology (OBGYN) subspecialty care, as nearly 43% of individuals do not reside in areas where the Indian Health Service (IHS) provides care. Geographical separation from IHS facilities exacerbates healthcare disparities, particularly regarding access to specialized services. This study aims to create a map illustrating the average driving time from an IHS clinic to OBGYN subspecialists (e.g., gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility [REI]) and determine the average wait time for appointments with these specialists. Study design A cross-sectional and mystery caller study was conducted using hospital-level data from the IHS and data on women from the 2010 United States Census provided by the US Census Bureau. All US OBGYN subspecialists were identified and mapped. The local distribution of clinics near IHS hospitals was determined, and the nearest OBGYN subspecialist was mapped to IHS hospitals providing women's care services. Thirty-seven OBGYN subspecialists closest to IHS hospitals were contacted to calculate the mean wait time for subspecialty care appointments. Results The median driving time to the closest gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility OBGYN subspecialist was 214 minutes (interquartile range [IQR] 107-290). The longest drive to see a subspecialist for urogynecology services was over 240 minutes. From the 2010 US Census, we identified 583,574 American Indian and Alaska Native (AI/AN) pediatric, adolescent, and women within a 60-minute drive of an IHS hospital. The mean wait time for a new patient appointment was 13.6 business days (SD ± 2). Conclusions Geographical disparities significantly impact the ability of American Indian and Alaska Native populations to access OBGYN subspecialty care. There was no difference in wait times compared to the national average, though there were significantly longer drive times.

Medicare Patient Referral Networks to Pelvic Floor Physical Therapy Across the United States.

OBJECTIVE: The purpose of this study is to evaluate the distribution of referrals to pelvic floor physical therapy throughout the United States and to identify specialties with the highest and lowest referral rates. Referral networks to pelvic floor physical therapy were identified, and factors associated with referral connections were determined. METHODS: This retrospective network analysis of referrals examined U.S. Centers for Medicare and Medicaid Services data from 2009 to 2017. Pelvic floor physical therapists were identified, and their patient-sharing networks were modeled using social network analytics. RESULTS: There were 18,740 Medicare beneficiaries referred to pelvic floor physical therapists between 2009 and 2017. The mean number of referrals to each physical therapy provider or practice was 82 (SD ±46.3). Half of the referrals were made by a general acute care hospital. The remainder were referred by female pelvic medicine and reconstructive surgeons, nurse practitioners, colorectal surgeons, internal medicine, and obstetrician-gynecologists.The number of individual pelvic floor physical therapists, as well as the referrals, increased each year. The geographic representation of the patient referral networks is illustrated. The map reveals that pelvic floor physical therapists often work in groups and treat patients in their geographic vicinity. In this study, we demonstrate intensely fractured referral networks. CONCLUSION: Our network analysis of pelvic floor physical therapy referrals in Medicare patients across the United States shows fractured networks with dense geographic connections in some areas, whereas sparse in others. Multidisciplinary approaches and early referrals to pelvic floor physical therapy are recommended as some ways to amend these fractured networks.

Medicare Patient Referral Networks to Female Pelvic Medicine and Reconstructive Surgeons Across the United States.

OBJECTIVE: The source of urogynecology patient referrals remains poorly understood. We used novel methods to identify referral networks to female pelvic medicine and reconstructive surgeons (FPMRS) and to determine factors associated with physician connections. METHODS: A retrospective analysis of Centers for Medicare and Medicaid Services data with physician sharing relationships spanning 180 days during 2015 was performed. All patients studied were Medicare beneficiaries. Provider patient-sharing networks were modeled using social network analytics. To visualize the resulting flow of patients from referring providers to FPMRS, we encoded the node and edge data and mapped the data to a map of the United States. RESULTS: We studied 206,568 Medicare beneficiaries who were seen by 618 different board-certified FPMRS. Internal medicine physicians followed by nurse practitioners referred the most patients to FPMRS. Over half of referrals were made locally, with patients traveling less than 5 miles from the referring provider to the female pelvic surgeon. The median number of incoming Medicare patient referrals per FPMRS provider was 15 (interquartile range, 12-20) over a 6-month period. The high modularity of the referral network indicates that most providers refer their patients to a few female pelvic surgeons. CONCLUSIONS: Medicare patient referrals to FPMRS are primarily and proportionally the highest from local internal medicine physicians.

Fellow Perceptions of Residency Training in Obstetrics and Gynecology.

OBJECTIVE: To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training. METHODS: A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized. RESULTS: A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident. CONCLUSIONS: The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies.

Industry Payments to Obstetricians and Gynecologists Under the Sunshine Act.

OBJECTIVE: To evaluate financial relationships between obstetrician-gynecologists (ob-gyns) and industry, including the prevalence, magnitude, and the nature of payments. METHODS: We conducted a cross-sectional study in which we obtained a list of industry contributions to U.S. obstetricians and gynecologists through the Centers for Medicare and Medicaid Services Open Payments Database from August 1, 2013, to December 31, 2015. These data were cross-referenced with the entire cohort of practicing obstetricians and gynecologists, who were identified using the National Provider Identification database, because not all practicing ob-gyns received payments. These payments were analyzed with respect to 1) types of payments, 2) demographic attributes of health care providers receiving payments, and 3) comparisons between obstetrician and gynecologist subspecialties. Continuous data were compared using the Mann-Whitney test for variables that were not normally distributed and with the t test for variables that are normally distributed. RESULTS: A total of 517,077 nonresearch payments, totaling $79,965,244, were made to 23,292 ob-gyns. Physicians receiving payments were predominantly female, younger than 65 years old, allopathic physicians who graduated from U.S. medical schools in the late 1990s, and were board-certified subspecialists (P<.001 for all). Half of all ob-gyns received payments of varying amounts from drug manufacturers, device manufacturers, or both, with most of the payments for honoraria, faculty compensation, or consulting. Female pelvic medicine and reconstructive surgery physicians received the largest median dollar amount; maternal-fetal medicine physicians received the smallest. CONCLUSION: Obstetricians and gynecologists receive a substantial amount of payments from industry. Most of these payments were for honoraria, faculty compensation, or consulting and totaled less than $400 per health care provider. Although this total amount is less than typically received by surgical providers, including orthopedic surgeons who account for the highest compensated group in total and mean industry payments, the median payment value for obstetrics and gynecology subspecialists surpasses the median payment to orthopedic surgeons. These financial relationships warrant further exploration with future research.

The Geographic Distribution of Pediatric Anesthesiologists Relative to the US Pediatric Population.

BACKGROUND: The geographic relationship between pediatric anesthesiologists and the pediatric population has potentially important clinical and policy implications. In the current study, we describe the geographic distribution of pediatric anesthesiologists relative to the US pediatric population (0-17 years) and a subset of the pediatric population (0-4 years). METHODS: The percentage of the US pediatric population that lives within different driving distances to the nearest pediatric anesthesiologist (0 to 25 miles, >25 to 50 miles, >50 to 100 miles, >100 to 250 miles, and >250 miles) was determined by creating concentric driving distance service areas surrounding pediatric anesthesiologist practice locations. US Census block groups were used to determine the sum pediatric population in each anesthesiologist driving distance service area. The pediatric anesthesiologist-to-pediatric population ratio was then determined for each of the 306 hospital referral regions (HRRs) in the United States and compared with ratios of other physician groups to the pediatric population. All geographic mapping and analysis was performed using ArcGIS Desktop 10.2.2 mapping software (Redlands, CA). RESULTS: A majority of the pediatric population (71.4%) lives within a 25-mile drive of a pediatric anesthesiologist; however, 10.2 million US children (0-17 years) live greater than 50 miles from the nearest pediatric anesthesiologist. More than 2.7 million children ages 0 to 4 years live greater than 50 miles from the nearest identified pediatric anesthesiologist. The median ratio of pediatric anesthesiologists to 100,000 pediatric population at the HRR level was 2.25 (interquartile range, 0-5.46). Pediatric anesthesiologist geographic distribution relative to the pediatric population by HRR is lower and less uniform than for all anesthesiologists, neonatologists, and pediatricians. CONCLUSIONS: A substantial proportion of the US pediatric population lives greater than 50 miles from the nearest pediatric anesthesiologist, and pediatric anesthesiologist-to-pediatric population ratios by HRR vary widely across the United States. These findings are important given that the new guidelines from the American College of Surgeons Children's Surgery Verification™ Quality Improvement Program state that pediatric anesthesiologists must care for a subset of pediatric patients. Because of the geographic distribution of pediatric anesthesiologists relative to the pediatric population, access to care by a pediatric anesthesiologist may not be feasible for all children, particularly for those with limited resources or in emergent situations.

Preparedness of Obstetrics and Gynecology Residents for Fellowship Training.

OBJECTIVE: To evaluate the perceptions of fellowship program directors of incoming clinical fellows for subspecialty training. METHODS: A validated survey by the American College of Surgeons was modified and distributed to all fellowship program directors in four subspecialties within obstetrics and gynecology: female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology-infertility. The 59-item survey explored five domains concerning preparedness for fellowship: professionalism, independent practice, psychomotor ability, clinical evaluation, and academic scholarship. A Likert scale with five responses was used and tailored to each subspecialty. Standard statistical methods were used to compare responses between subspecialties and to analyze data within each subspecialty individually. RESULTS: One hundred thirty directors completed the survey, for a response rate of 60%. In the domain of professionalism, more than 88% of participants stated that incoming fellows had appropriate interactions with faculty and staff. Scores in this domain were lower for gynecologic oncology respondents (P=.046). Responses concerning independent practice of surgical procedures (hysterectomy, pelvic reconstruction, and minimally invasive) were overwhelmingly negative. Only 20% of first-year fellows were able to independently perform a vaginal hysterectomy, 46% an abdominal hysterectomy, and 34% basic hysteroscopic procedures. Appropriate postoperative care (63%) and management of the critically ill patient (71%) were rated adequate for all subspecialties. CONCLUSION: Graduating residents may be underprepared for advanced subspecialty training, necessitating an evaluation of the current structure of resident and fellow curriculum. LEVEL OF EVIDENCE: III.

Residency training in pediatric and adolescent gynecology across obstetrics and gynecology residency programs: a cross-sectional study.

STUDY OBJECTIVE: To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. DESIGN: Prospective, anonymous, cross-sectional study. PARTICIPANTS: United States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%). RESULTS: 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03). CONCLUSIONS: Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.

Nomogram to predict successful placement in surgical subspecialty fellowships using applicant characteristics.

PURPOSE: The purpose of the study was to develop a model that predicts an individual applicant's probability of successful placement into a surgical subspecialty fellowship program. METHODS: Candidates who applied to surgical fellowships during a 3-year period were identified in a set of databases that included the electronic application materials. RESULTS: Of the 1281 applicants who were available for analysis, 951 applicants (74%) successfully placed into a colon and rectal surgery, thoracic surgery, vascular surgery, or pediatric surgery fellowship. The optimal final prediction model, which was based on a logistic regression, included 14 variables. This model, with a c statistic of 0.74, allowed for the determination of a useful estimate of the probability of placement for an individual candidate. CONCLUSIONS: Of the factors that are available at the time of fellowship application, 14 were used to predict accurately the proportion of applicants who will successfully gain a fellowship position.

Assessment of four tissue models on knot tensile strength.

OBJECTIVE: To determine whether the tissue model onto which a knot is tied influences the knot's tensile strength. STUDY DESIGN: Zero-gauge, nonexpired, silk, polyglactin 910, polydioxanone, and polypropylene sutures were tied on 4 different mock tissue models. The tissue models were standard metal hex head screw, uncooked chicken breast, a tube of packaged "string" cheese, and a cylinder of bubble wrap. The knots were tied without a surgeon's knot and with 4 additional square knots (1 = 1 = 1 = 1 = 1). The knots were tied by a single obstetrician/gynecologist investigator (J.M.D.) over the period of 1 week to minimize fatigue. We compared the knots when subjected to a tensiometer until the suture broke or untied. A minimum of 20 knots per group were needed to detect a moderate effect size with a power of 85% and a type I error rate of 5%. RESULTS: A total of 407 knots were tied with 4 types of material (silk, polyglactin 910, polydioxanone, and polypropylene), using 4 different models (chicken, bubble wrap, cheese, and metal). Among the knot failures, 113 of 407 untied rather than broke (28%). No differences in the likelihood of knots coming untied between the different models (p = 0.34) or tension at failure (p = 0.81) were noted. A 4 × 4 factorial analysis of variance (ANOVA) was conducted to determine the effects of the suture material and model type on tension at failure and whether there was any interaction between the 2 factors. No significant difference was observed in the interaction between suture material and model type (p = 0.35), and no effect for model type was found (p = 0.22). CONCLUSIONS: Tissue models that use materials more similar to human tissue do not seem to influence knot strength when compared with standard metal models. We propose that it is possible to have an accurate understanding of how knots withstand force and to simulate an in vivo environment by using low-cost, easily accessible natural and synthetic materials for the mechanism onto which the knot is tied.

Factors used by program directors to select obstetrics and gynecology fellows.

OBJECTIVE: To describe the factors and attributes that obstetrics and gynecology fellowship directors use in selecting applicants for interview and ranking. METHODS: Anonymous questionnaires were completed by obstetrics and gynecology fellowship directors using a web-based survey (adapted from a previously published questionnaire) before match day 2011. Fellow selection practices were evaluated and included importance of prematch preparations, screening of applications, interview processes, and recommendations given to applicants. Fellowship directors were asked to grade selection factors based on a 5-point Likert-like scale (ranging from 1 being unimportant to 5 being essential). RESULTS: A total of 187 fellowship directors representing programs accredited by the American Board of Obstetrics and Gynecology, Inc. were surveyed, and 124 completed the survey (66% response rate). The factors in prematch preparations that 99-100% of program directors found in the essential to important range were a high-quality obstetrics and gynecology residency training program and experience with clinical research during residency or with clinical research after residency. Surgical experience was valued more by gynecologic oncologist respondents than by other subspecialty respondents, although this statistic did not reach statistical significance (P=.08). CONCLUSION: Education pedigree and research experience are important factors considered by fellowship directors when selecting fellowship applicants. For applicants, these data will allow for a critical self-analysis before applying or interviewing.

Factors used by female pelvic medicine and reconstructive surgery fellowship directors to select their fellows.

INTRODUCTION AND HYPOTHESIS: We report the attributes of Female Pelvic Medicine and Reconstructive Surgery (FPM&RS) fellowship applicants that are most valued by fellowship program directors during the ranking process. METHODS: Anonymous questionnaires were filled out by FPM&RS fellowship program directors following the 2008 match. The survey was designed to assess the relative importance of various factors in the ranking of fellowship applicants. RESULTS: Surveys were sent to 67 program directors, and 21 completed the survey (31%). Items ranked as the most important in the selection process were a high quality obstetrics and gynecology residency education (8.2+/-1.2), followed by clinical research experience (7.4+/-1.4). Ability to work well with staff and work ethic were considered to be the most important subjective criteria. CONCLUSIONS: Our results support anecdotal evidence that placed emphasis on research experience and interpersonal skills in the selection of FPM&RS fellows.

Income differentials required to make fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral.

We used standard financial techniques and a return-on-educational-investment model to calculate the required annual income necessary to render additional fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral. To explore a range of potential outcomes, we conducted a sensitivity analysis that used various discount rates and retirement ages. Compared to obstetrics/gynecology residents who go directly into private practice, residents who pursue fellowship training in female pelvic medicine and reconstructive pelvic surgery experience a financial loss of more than $400,000 to $600,000, assuming there is no income differential after fellowship. To render the additional training financially neutral requires an annual income that is 16-31% higher than that of general obstetrician/gynecologists. Required additional annual income was on the lower end of this spectrum when modeling later retirement age estimates and using lower discount rates. Fourth year obstetrician/gynecology residents considering female pelvic medicine/reconstructive surgery require higher incomes over the working lifetime to render fellowship training financially neutral.