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.

Brief versus Thong Hygiene in Obstetrics and Gynecology (B-THONG): A survey study.

AIM: The aim of this study was to evaluate if thong use is associated with a higher report of urogenital infections, including urinary tract infections, yeast vaginitis and bacterial vaginosis. METHODS: A cross-sectional survey regarding underwear preferences and infectious history was designed and distributed to women via a crowdsourcing service. All survey questions related to the last 12 months. Parametric and nonparametric statistical methods were used to compare responses between thong wearers and nonthong wearers. Thong wearers were defined as women who wore a thong equal to or more than 50 % of the time. RESULTS: Nine hundred and eighty-six respondents met inclusion criteria and completed the survey; 186 (18.9%) were defined as thong wearers and 800 (81.1%) were defined as nonthong wearers in the last 12 months. Reported rates of urogenital infections in the last 12 months were not significantly different for thong wearers versus nonthong wearers. Thong use was not an independent predictor of any urogenital infection in this study. CONCLUSION: In this large cross-sectional study we found that oral sex was the only independent predictor of urinary tract infection and bacterial vaginosis, and that wearing noncotton crotch underwear was associated with yeast vaginitis. Wearing thong underwear was not associated with any urogenital infections. Medical providers should discuss sexual practices and underwear fabric, rather than style, with their patients when there is concern for urogenital infection.

The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035.

BACKGROUND: A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035. METHODS: The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures). RESULTS: In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035. CONCLUSIONS: If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.

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.

The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution.

BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States. METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA). RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering. CONCLUSIONS: This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.

Small bowel surgery for the gynecologist specializing in benign disease.

INTRODUCTION: Adhesions are fibrous bands of scar tissue that are often a result of surgery. Adhesions of the bowel are a common finding during gynecologic procedures, and their presence can lead to injury. METHOD: This video article demonstrates enterolysis and small-bowel surgery in women undergoing surgery for a benign gynecologic condition and found to have severe adhesive disease. CONCLUSION: Small bowel surgery is best carried out using a team approach. Surgeons should be especially vigilant about injury to the bowel in patients undergoing extensive adhesiolysis or enterolysis.

Laparoscopic repair of recurrent lateral enterocele and rectocele.

It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.

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.

Access to Urogynecologic Care in Federally Qualified Health Centers: A Mystery Caller Study.

IMPORTANCE: Federally Qualified Health Centers (FQHCs) play an important role in providing care to underserved populations. However, little is known about the availability of urogynecology services at FQHCs. OBJECTIVES: This study aimed to assess the availability of appointments for urogynecology care and to determine the prevalence of FQHCs offering urogynecologic services. STUDY DESIGN: A total of 362 FQHCs across the United States were randomly selected from the Health Resources and Services Administration website, based on specific inclusion criteria. Researchers called the FQHCs and requested the earliest available appointment for pelvic organ prolapse. The availability of urogynecologic services such as pessary fittings, pelvic floor physical therapy, and urodynamic studies was also inquired. RESULTS: A total of 362 FQHCs located in 46 states and the District of Columbia were called. On average, the 362 FQHCs had been established for 19.9 (SD ±15) years, were located in urban areas, and served a median county population of 24,573. Of the 220 FQHCs successfully contacted, 81% (180/220) reported that they could provide care for a patient with pelvic organ prolapse at an appointment 29.1 business days (SD ±30 days) from the date of the call, on average. However, only a small percentage of these FQHCs offered in-office pessary fittings (11%), complex multichannel urodynamics testing (8.6%), or pelvic floor physical therapy (5%). CONCLUSION: The availability of treatments for pelvic floor disorders at FQHCs is limited. These findings highlight a potential disparity in access to urogynecology services for individuals with public insurance.

Access to general obstetrics and gynecology care among Medicaid beneficiaries and the privately insured: a nationwide mystery caller study in the USA.

BACKGROUND: The mean wait time for new patient appointments has been growing across specialties, including obstetrics and gynecology, in recent years. This study aimed to assess the impact of insurance type (Medicaid versus commercial insurance) on new patient appointment wait times in general obstetrics and gynecology practices. METHODS: A cross-sectional study used covert mystery calls to general obstetrician gynecologists. Physicians were selected from the American College of Obstetricians and Gynecologists directory and stratified by districts to ensure nationwide representation. Wait times for new patient appointments were collected and analyzed. RESULTS: Regardless of insurance type, the mean wait time for all obstetrician gynecologists was 29.9 business days. Medicaid patients experienced a marginally longer wait time of 4.8% (Ratio: 1.048). While no statistically significant difference in wait times based on insurance type was observed (P=0.39), the data revealed other impactful factors. Younger physicians and those in university-based practices had longer wait times. The gender of the physician also influenced wait times, with female physicians having a mean wait time of 34.7 days compared to 22.7 days for male physicians (P=0.03). Additionally, geographical variations were noted, with physicians in American College of Obstetricians and Gynecologists District I (Atlantic Provinces, CT, ME, MA, NH, RI, VT) having the longest mean wait times and those in District III (DE, NJ, PA) the shortest. CONCLUSIONS: While the type of insurance did not significantly influence the wait times for general obstetrics and gynecology appointments, physician demographic and geographic factors did.

Common postoperative pulmonary complications after hysterectomy for benign indications.

OBJECTIVE: The purpose of this study was to estimate the incidence of postoperative pulmonary complications after hysterectomy for benign indications. STUDY DESIGN: This was a retrospective cohort study of all women who underwent hysterectomy for benign indications at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009. Exclusion criteria incorporated patients who underwent hysterectomy for premalignant or malignant conditions. Pulmonary complications were defined as postoperative pneumonia, respiratory failure, atelectasis, and pneumothorax based on International classification of diseases, ninth revision, codes. RESULTS: In the 9-year study period, 3226 women underwent hysterectomy for benign indications (abdominal, 38.4%; vaginal, 39.3%; laparoscopic, 22.3%). Ten of the 3226 women (0.3%; 95% confidence interval, 0.17-0.57%) who underwent hysterectomy were identified with postoperative pulmonary complications. Among the different types of hysterectomy, the incidence of pulmonary complications was not different (total abdominal hysterectomy, 0.9%; vaginal hysterectomy, 0.12%; laparoscopic hysterectomy, 0.9%; P = .8). CONCLUSION: The incidence of postoperative pulmonary complications after hysterectomy for benign indications is low.

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.

Subspecialty Faculty in Obstetrics and Gynecology: Distribution, Demographics, and Implications for Training and Clinical Practice.

OBJECTIVE: The objective of this study was to quantify the subspecialist workforce involved in the clinical education of Obstetrics and Gynecology (OBGYN) residents and to provide an overview of the subspecialist faculty workforce geographic distribution and demographics. METHODS: This cross-sectional, observational study used public data collected from July 1, 2022, through August 31, 2022. A list of Obstetrics and Gynecology residency programs, their sponsoring institutions/locations, and affiliated locations was compiled from the American Medical Association's Fellowship and Residency Electronic Interactive Database. Faculty subspecialists' names were collected by manually searching each program's website. Demographics were collected from the National Plan and Provider Enumeration System. Subspecialty faculty who had completed an Obstetrics and Gynecology residency, were fellowship trained, and/or had board certification in the subspecialty were included in the study. RESULTS: A total of 4,659 subspecialist faculty were identified from 278 residency programs, representing 81.5% of the total subspecialist workforce in Obstetrics and Gynecology (n=5,716). Of the subspecialists identified, 2,838 were faculty at sponsoring institutions, representing 49.7% of the entire subspecialist workforce; the remainder worked with residents at affiliate locations. Our results showed 59.9% of subspecialists were female and 40.1% were male; 97.0% were allopathic subspecialists. The largest proportion of subspecialists were in the age group of 40-49 years (36.6%). Subspecialists were present in 45 states, with the exception of Alaska, Idaho, Montana, North Dakota, South Dakota, and Wyoming. CONCLUSION: Most of the Obstetrics and Gynecology subspecialty workforce is involved in the clinical education of OBGYN residents, with half of the workforce on faculty at the residency program sponsor site. The subspecialty faculty workforce is primarily female, has an allopathic degree, is mid-career, and is geographically diverse.

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.

Small bowel obstruction after hysterectomy to treat benign disease.

STUDY OBJECTIVE: To estimate the incidence of small bowel obstruction (SBO) after hysterectomy performed because of benign indications and to compare the incidence of SBO after laparoscopic, vaginal, and abdominal hysterectomy. DESIGN: Single-center retrospective analysis of all hysterectomies performed to treat benign disease over 9 years (Canadian Task Force classification II-2). SETTING: University-affiliated tertiary medical center. PATIENTS: The study included 3229 women who underwent hysterectomy performed because of benign indications. INTERVENTIONS: International Classification of Diseases, 9th revision, codes were applied to eligible patients' medical records to identify those who potentially had an SBO. Again, the electronic medical record was reviewed to confirm the occurrence of SBO. The Fisher exact test was used to evaluate the relationship between SBO and categorical variables, and the Wilcoxon rank sum test was performed to evaluate the relationship between SBO and continuous variables. MEASUREMENTS AND MAIN RESULTS: During the 9-year study, 3229 women with benign disease underwent hysterectomy: 38.3% abdominal, 39.3% vaginal, and 22.3% laparoscopic. Seventeen of 3229 women (0.53%; 95% confidence interval, 0.32-0.86) who underwent hysterectomy were identified as having an SBO. Among hysterectomy types, the incidence of SBO was not statistically significant for abdominal hysterectomy (9 of 17), vaginal hysterectomy (5 of 17), or laparoscopic hysterectomy (3 of 17) (p = .58). There were no differences in demographic data between patients with and without SBO. Incidence rates for SBO were calculated on the basis of hysterectomy route. CONCLUSION: The incidence of SBO after hysterectomy performed because of benign indications is low. The hysterectomy route does not seem to affect risk of SBO.

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.

Appointment Wait Times in Female Pelvic Medicine and Reconstructive Surgery: A Mystery Caller Study.

OBJECTIVE: The aim of the study was to evaluate the mean appointment wait time for a new patient visit at outpatient female pelvic medicine and reconstructive surgery (FPMRS) offices for U.S. women with the common and nonemergent concern of uterine prolapse. METHODS: The American Urogynecologic Society "Find a Provider" tool was used to generate a list of FPMRS offices across the United States. Each of the 427 unique listed offices was called. The caller asked for the soonest appointment available for her mother, in whom uterine prolapse was recently diagnosed. Data for each office were collected, including date of the earliest appointment, FPMRS physician demographics, and office demographics. Mean appointment wait time was calculated. RESULTS: Four hundred twenty-seven FPMRS offices were called in 46 states plus the District of Columbia. The mean appointment wait time was 23.1 business days for an appointment (standard deviation, 19 business days). The appointment wait time was 6 days longer when seeing a female FPMRS physician compared with a male FPMRS physician (mean, 26 business days vs 20 business days, P < 0.02). There was no difference in wait time by day of the week called. CONCLUSIONS: Wait times are a measure of access to care within the health care system. Shorter wait times are associated with increased patient satisfaction. Typically, a woman with uterine prolapse can expect to wait at least 4 weeks for a new patient appointment with an FPMRS board-certified physician listed on the American Urogynecologic Society website. The first available appointment is more often with a male physician. A patient can expect to wait 6 days longer to see a female FPMRS physician. As mean wait times across outpatient specialties continue to increase, FPMRS offices should strive to keep wait times at a minimum to allow women timely access to care.

Hysterectomy Volume Among Recent Obstetrics and Gynecology Residency Graduates.

OBJECTIVE: Although guidelines recommend hysterectomy be performed vaginally whenever possible, recent trainees have decreased exposure to vaginal hysterectomy given the availability of laparoscopic hysterectomy, nonsurgical management, and falling volume nationwide. We sought to estimate hysterectomy volume in the 5 years after residency. Our secondary objective was to compare vaginal hysterectomy utilization between recent graduates and senior surgeons. METHODS: Retrospective, statewide data from 2005 to 2014 was obtained from the Massachusetts Center for Health Information Analysis. All hysterectomies performed in Massachusetts, regardless of payer type, were included. Surgeon identifiers were cross-referenced to another data set with provider demographics. Hysterectomies performed in the first 5 years after graduation were compared with a group 21 to 25 years after residency. RESULTS: Data from inpatient and outpatient databases revealed 87,846 hysterectomies performed by 1967 physicians, including 3146 simple hysterectomies by 192 recent graduates. Recent graduates chose abdominal hysterectomy (44.2%) most commonly, followed by laparoscopic (29.4%), vaginal (16.1%), and laparoscopically assisted vaginal (10.4%). Recent graduates performed a median of 3 to 4 hysterectomies in each of the first 5 years with no increase over time (P = 1). The median number of vaginal or laparoscopic hysterectomies was 0 in these 5 years (interquartile ranges, 0-1 and 0-2, respectively). Members of the senior cohort performed a median of 8 to 9 hysterectomies annually, completing them vaginally more often (24.7% vs 16.1%, P < 0.01). When controlling for patient age and hysterectomy indication, this effect dissipated. CONCLUSIONS: Recent graduates perform 3 to 4 (interquartile range, 1-7) hysterectomies annually, predominantly by laparotomy. Although senior surgeons perform vaginal hysterectomy more often, this is explained by patient characteristics.

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.