Regional Variation in Penile Prosthesis Utilization Among Medicare Patients with Erectile Dysfunction: Variation in Penile Prosthesis Surgery - Beyond the Abstract
Numerous treatment options exist for ED. Penile prosthesis surgery is the most definitive therapy and is associated with excellent patient and partner satisfaction outcomes. Unfortunately, less than one-fourth of urologists perform this procedure. More importantly, less than 2% have specialized sexual medicine or reconstructive urology fellowship training for performing this surgery. As a result of these limitations, access to a urologist and healthcare facility offering penile prosthesis surgery may be constrained in the United States.
Penile prosthesis surgery is not an acute, life-saving procedure, but for many men, this surgery is a life-altering experience that can restore sexual health, psychological well-being, and intimacy with their significant other. The overall benefits may be particularly pronounced in men who abruptly lose erectile function secondary to trauma or pelvic surgery. Given the importance of this procedure to men’s health and sexual function, we sought to better understand penile prosthesis surgery utilization in the United States.
Using Medicare data from the Dartmouth Atlas of Health Care, we identified all men diagnosed with ED from 2006 through 2014. We then determined the number of Medicare beneficiaries who underwent placement of a semi-rigid or inflatable penile prosthesis device for ED. We then calculated the adjusted rate of penile prosthesis surgery nationally and by hospital referral region (HRRs), a measure similar to the hospital catchment area.
We found that the adjusted national rate of ED diagnoses increased over the study period from 640,000 in 2006 to 1.1 million in 2014. Although the absolute number of penile prosthesis surgeries rose during this same time period, the overall rate of surgery declined by 31%. This was because the number of new ED diagnoses substantially outpaced the number of penile prosthesis surgeries being performed for ED. In addition, the majority of HRR’s performed zero to less than 11 penile prosthesis surgeries per year, demonstrating the infrequency of this surgery overall across the U.S.
In addition, we observed significant variation in penile prosthesis surgery across HRRs. A 26.9-fold difference in penile prosthesis surgery utilization was observed between Miami, Florida (45.4 per 1000 beneficiaries), and Kansas City, Missouri (1.7 per 1000 beneficiaries) specifically for the year 2009. Similar but less extreme differences in utilization rates were observed in the other study years. To the best of our knowledge, this is the highest degree of variation reported for a surgical procedure reported to-date.
We incorporated AUA census data into the analysis and found that a substantial amount of variation was attributable to urology provider density. We thus concluded that penile prosthesis surgery utilization is likely directly linked to greater urologist supply. It is well known, however, that urologist supply (or density) is not equitably distributed across the country. This inequity creates large gaps in access to definitive ED treatment and high-quality sexual health care.
Our findings demonstrate that significant regional variation exists in the utilization of penile prosthesis surgery for the treatment of ED amongst Medicare beneficiaries. This variation is likely due to a series of urologist and patient-specific factors, including urology provider density. Future research is needed to better understand the implications of, and improve, variation in penile prosthesis surgery utilization in the U.S.
Written by: Michael E. Rezaee, MD, MPH, and Martin S. Gross, MD, Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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