Clinician- and Geographic-level Variation in Utilization of Sacral Neuromodulation and OnabotulinumtoxinA Injections Among Medicare Beneficiaries With Overactive Bladder - PubMed (original) (raw)

Clinician- and Geographic-level Variation in Utilization of Sacral Neuromodulation and OnabotulinumtoxinA Injections Among Medicare Beneficiaries With Overactive Bladder

Leo D Dreyfuss et al. Urology. 2026 Feb.

Abstract

Objective: To evaluate clinician- and geographic-level variation in utilization of sacral neuromodulation (SNM) and onabotulinumtoxinA injections as index treatment for overactive bladder (OAB) among United States Medicare beneficiaries.

Methods: This is a cross-sectional study of a 100% sample of fee-for-service Medicare beneficiaries undergoing first-time SNM test procedures or onabotulinumtoxinA injections from 2014-2016. The primary outcomes were clinician- and geographic-level variation in utilization of SNM or onabotulinumtoxinA injections. Secondary outcomes included variation in use of SNM test procedures (percutaneous nerve evaluation [PNE] and stage 1 permanent tined lead placement [stage 1]). Geographic region was defined using hospital referral regions (HRRs). Mixed-effect logistic regression models were used to calculate the median odds ratio (MOR) for clinician and HRR (higher MOR = greater variability between groups) and to identify individual-level predictors of utilization.

Results: Overall, 48,580 Medicare beneficiaries underwent SNM (47.1%) or onabotulinumtoxinA injections (52.9%) during the study period. There was a considerable amount of variation according to clinician and HRR, which were more influential than patient-level characteristics in the type of procedure received. The adjusted MOR for SNM versus onabotulinumtoxinA injections was 33.1 for clinician and 4.24 for HRR. For stage 1 versus PNE, the MOR was 13.12 for clinician and 2.44 for HRR.

Conclusion: Among Medicare beneficiaries undergoing first-time SNM or onabotulinumtoxinA injections, there was considerable variation according to performing clinician and geographic region. These findings suggest that non-clinical variables-who a patient sees and where they live-are significant drivers of minimally invasive OAB therapy utilization in the United States.

Copyright © 2025 Elsevier Inc. All rights reserved.

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Conflict of interest statement

Declaration of Competing Interest The authors have no conflict of interest to declare.

Figures

Figure 1:

Figure 1:

Variation in clinician utilization of minimally invasive therapy for overactive bladder from 2014–2016. Each black dot represents an individual clinician and blue lines represent 95% confidence intervals. Y-axis represents rate of sacral neuromodulation procedures as proportion of total procedures performed (sacral neuromodulation plus onabotulinumtoxinA injections). Model includes clinicians with at least 11 procedures performed during study period, corresponding to ≥75th percentile. Models are adjusted for clinician-level characteristics and beneficiary-level characteristics (age, sex, race, Charlson comorbidity index, claims-based frailty index, and area deprivation index).

Figure 2:

Figure 2:

Variation in hospital referral region utilization of minimally invasive therapies for overactive bladder from 2014–2016. Use of sacral neuromodulation as proportion of total procedures (sacral neuromodulation plus onabotulinumtoxinA) depicted with a color scale, with darker colors indicating greater proportion sacral neuromodulation. Hospital referral region derived from clinician zip code. Models are adjusted for hospital referral region and beneficiary-level characteristics (age, sex, race, Charlson comorbidity index, claims-based frailty index, and area deprivation index).

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