Uptake Of New Surgical Treatments For BPH Varies By Provider Age And Population Density Among States In New England
Emma Waddell, BA1, Stephen Schmit, BS1, Borivoj Golijanin, MS2, Joshua R. Tanzer, PhD3, Anna Shlimak, BS Candidate2, Emerson Kopsack, BA Candidate2, Christopher Tucci, MS4, Taylor Braunagel, MS2, Andrew Tompkins, MD4, Elias Hyams, MD4.
1The Warren Alpert Medical School of Brown University, Providence, RI, USA, 2Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI, USA, 3The Lifespan Biostatistics Epidemiology Research Design Core, Providence, RI, USA, 4The Warren Alpert Medical School of Brown University; Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI, USA.
Background: Various surgical modalities exist to treat benign prostatic hyperplasia (BPH), including the historical gold standard transurethral resection of prostate (TURP). As new technologies have emerged, there has been limited research into procedural uptake and diversification. Regional characteristics like providers' age and population density may influence the number and types of procedures available to patients. We evaluated whether surgical practice patterns for BPH varied by provider age and rural composition of states in New England.
Methods: Bladder outlet procedures were identified by CPT code in publicly available Medicare data among New England urologists from 2014-2019. TURP (52601), Greenlight laser vaporization (52648), Urolift (52441), Rezum (53854), and Holmium laser enucleation (52649) were included. Data were analyzed by state. Rural composition obtained from the U.S. census and distribution of provider age were compared to uptake of newer procedures over time. Uptake was defined by increasing rates of Urolift, Rezum, and HoLEP relative to TURP and Greenlight. Generalized linear models assessed whether provider age, rural composition, and their combined interaction were related to uptake of newer procedures.
Results: Table 1 summarizes the average provider age, percentage of rural population, and procedural diversity by state. The combined effects model (Table 2) allowed for comparison between four groups defined by rural vs urban composition and distribution of provider age. Rural areas with less variation in provider age demonstrated slower uptake of newer procedures (Cohen's d = - 0.65, Z = -2.29, p = 0.0220). Urban areas with more variation in provider age demonstrated more rapid uptake of newer procedures (Cohen's d = 1.36, Z = 2.67, p = 0.0076). The two other groups did not have statistically significant results.
Conclusions: A combined-effects model demonstrates that patients needing bladder outlet surgery who live in rural areas of New England with less variation in provider age have fewer surgical treatment options. They may face a significant travel burden to access newer procedures. A remaining unanswered question is whether the lack of procedural diversity and slower uptake is due to provider preference, skill and comfort, poor healthcare infrastructure, or a combination.
| State | Age (M,SD) | Rural Composition (%) | Procedural Diversity, Procedures (Z score) | Procedural Diversity, Providers (Z score) | Procedural Diversity Increase, Procedures (Z score) | Procedural Diversity Increase, Providers (Z score) |
| CT | 54, 11 | 12 | -1.96 | 0.08 | 0.02 | -0.33 |
| MA | 53, 9 | 8 | 0.16 | 0.21 | 0.79 | 0.27 |
| ME | 48, 8 | 61 | 0.25 | 0.03 | 1.00 | -1.01 |
| NH | 42, 9 | 40 | 0.40 | -0.04 | -0.16 | 0.05 |
| RI | 54, 10 | 9 | 0.21 | 0.23 | -1.82 | 1.79 |
| VT | 54, 6 | 61 | 0.93 | -0.30 | 0.17 | -0.77 |
| Overall | 51, 9 | 32 | 0.00 | 0.00 | 0.00 | 0.00 |
| Comparison | Cohen's d | Z | p |
| Procedures (Less Common - More Common) | |||
| Rural area, less spread in provider ages | -0.65 | -2.29 | 0.022 |
| Rural area, more spread in provider ages | 0.77 | 1.35 | 0.1766 |
| Urban area, less spread in provider ages | -0.06 | -0.19 | 0.8481 |
| Urban area, more spread in provider ages | 1.36 | 2.67 | 0.0076 |
| Providers (Less Common - More Common) | |||
| Rural area, less spread in provider ages | -0.74 | -2.28 | 0.0223 |
| Rural area, more spread in provider ages | 0.52 | 0.8 | 0.4243 |
| Urban area, less spread in provider ages | 0.11 | 0.3 | 0.7653 |
| Urban area, more spread in provider ages | 1.38 | 2.36 | 0.0181 |
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