Geographic Variation In Rates Research Articles

Factors Associated with Psychiatrist Opt-out from US Medicare: an Observational Study.

Concerns exist about availability and access to psychiatric services in the USA. For Medicare beneficiaries, one impediment to psychiatric services is the extent to which psychiatrists have opted out of the Medicare program. This study describes geographic variation in rates that psychiatrists opt out of Medicare, and assesses physician-level and geographic-level predictors of opt-out. Retrospective cross-sectional analysis of data describing psychiatrists' opt-out status as of March 2017 linked to data on psychiatrist location, psychiatrist characteristics (obtained from a comprehensive US physician database), and market area-level characteristics. 27,838 psychiatrists in the USA MAIN MEASURES: Whether a psychiatrist had opted out of Medicare as of March 2017. Overall, 7.0% of psychiatrists (1940/27,838) opted out of Medicare as of March 2017. Opt-out rates varied substantially across states and within states. Physician-level factors independently associated with opt-out included: older age (psychiatrists > 65years were 2.6 percentage points more likely to opt vs. psychiatrists < 35years old, p = 0.03), greater years of experience, female gender (female psychiatrists were 2.6 percentage points more likely to opt out than male psychiatrists, p < 0.001), graduation from a top-20 ranked medical school (1.7 percentage points more likely to opt out of Medicare, p < 0.001), and domestic medical graduate (domestic graduates were 7.3 percentage points more likely to opt out of Medicare vs. foreign graduates, p < 0.001). Adjusting for other individual- and geographic-level factors, psychiatrists who practiced in areas with more psychiatrists per Medicare beneficiary were less likely to opt out (p < 0.001). The overall likelihood that psychiatrists opt out of Medicare is significant and varies considerably across regions and by characteristics of psychiatrists.

Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study

ObjectiveTo examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS).DesignNational cohort study.SettingNHS hospitals.Participants27 997...

Identifying regional characteristics influencing variation in the utilization of rotator cuff repair in the United States

There is a lack of consensus regarding indications for surgical management of rotator cuff disease, which can lead to increased regional variation. The objectives of this study were to describe the geographic variation in rates of rotator cuff repair (RCR) in the United States over timeand to identify regional characteristics associated with utilization. The United States was divided into 306 hospital referral regions. The adjusted per capita RCR rate was calculated using procedural counts derived from the Medicare Part B Carrier File from 2004-2014. Population-weighted multivariable regression was used to identify regional characteristics independently associated with utilization in2014. In 2014, an 8-fold difference in rates of RCR was found between regions. Between 2010 and 2014, the overall rate of RCR grew only 3.6% and regional variation decreased. Higher regional utilization of several other orthopedic procedures (P < .02), as well as the regional supply of orthopedic surgeons (P = .002), was independently associated with significantly increased utilization. The South, Southeast, and Southwest were independently associated with significantly higher utilization (P<.001)compared with the Northeast. A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P < .001). Utilization of RCR has increased substantially over the past decade, but the rate of growth appears to be slowing. RCR remains a procedure with significant regional variation, and increased utilization across regions is associated with higher orthopedic surgeon supply and increased rates of other orthopedic procedures.

Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care. To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation. This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018. Successful community discharge as defined for the Discharge to Community-Post-Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates. Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P < .05). Risk-standardized state rates ranged from 55.9% to 73.3%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%). The observed variation suggests opportunities exist for improving this important, patient-centered national quality measure. Future research is needed to identify the aspects of care delivery and the community services and supports that facilitate successful community discharge. These findings can be used to guide care improvement efforts and further improve the consistency and quality of postacute care.

Geographic and Patient Characteristics Associated With Election of Prophylactic Mastectomy in Young Breast Cancer Patients With Early Disease.

To examine the association between geography and utilization rates of contralateral prophylactic mastectomy (CPM) relative to patient-level factors in patients with early stage breast cancer. Using the Truven Health MarketScan Commercial Database, a descriptive analysis of geographic variation in genetic testing and CPM rates of 38,108 women ages 18 to 64 years treated with surgery for invasive unilateral breast cancer between 2010 and 2012 was conducted. Multivariate hierarchical analysis was used to examine the relationship between CPM likelihood and patient characteristics, with metropolitan statistical area (MSA) serving as a random effect. Patient characteristics included age group, BRCA1/2 carrier status, family history of breast cancer, breast surgery type, radiation therapy, drug therapy, and payer type. All MSAs in the United States were included, with areas outside MSAs within a given state aggregated into a single area for analytical purposes. Descriptive analysis demonstrated significant geographic variation in rates of CPM irrespective of risk inferred from primary malignancy treatment course (P<0.01 to <0.001). Odds of CPM were higher among BRCA1/2 carriers (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.52-2.06), followed by MSA (median OR among all MSAs was 1.61; 95% CI, 1.51-1.73) and family history of breast cancer (OR, 1.49; 95% CI, 1.28-1.53), respectively. Patients who were not tested for BRCA1/2 were less likely (OR, 0.66; 95% CI, 0.61-0.71) to undergo CPM than patients with a negative BRCA test. The large geographic variation we observed in CPM indicate a need to understand and optimize clinical decision-making.

Admissions to intensive cardiac care units in France in 2014

Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.

Paid employment amongst adults with learning disabilities receiving social care in England: trends over time and geographical variation

Purpose The purpose of this paper is to examine trends over time and geographical variation in rates of paid employment amongst working age adults with learning disabilities receiving long-term social care in England. Design/methodology/approach Data were drawn from NHS Digital adult social care statistics examining paid/self-employment for working age (18-64 years) adults with learning disabilities known to social care (2008/2009 to 2013/2014) or receiving long-term social care (2014/2015 to 2016/2017). Findings In 2016/2017, councils reported that 5.7 per cent of working age adults (7,422 people) with learning disabilities receiving long-term social care were in paid/self-employment, with higher employment rates for men than women and most people working less than 16 hours per week. Paid employment rates seem to be slightly declining over time, and there is wide variation across councils in reported paid/self-employment rates. Social implications Despite good evidence for the cost effectiveness of supported employment support, employment rates for adults with learning disabilities receiving long-term social care remain extremely low. Originality/value This paper presents in one place statistics concerning the paid employment of working age adults with learning disabilities in England.

Hepatitis C Virus Infection Among Women Giving Birth — Tennessee and United States, 2009–2014

Hepatitis C virus (HCV) affects an estimated 3.5 million persons in the United States (1), making it the most common bloodborne infection in the country. Recent surveillance data showed increased rates of HCV infection among adolescents and adults who are predominantly white, live in nonurban areas, and have a history of injection drug use.* U.S. birth certificate data were used to analyze trends and geographic variations in rates of HCV infection among women giving birth during 2009-2014. Birth certificates from Tennessee were used to examine individual characteristics and outcomes associated with HCV infection, using a multivariable model to calculate adjusted odds of HCV-related diagnosis in pregnancy among women with live births. During 2009-2014, HCV infection present at the time of delivery among pregnant women from states reporting HCV on the birth certificate increased 89%, from 1.8 to 3.4 per 1,000 live births. The highest infection rate in 2014 (22.6 per 1,000 live births) was in West Virginia; the rate in Tennessee was 10.1. In adjusted analyses of Tennessee births, the odds of HCV infection were approximately threefold higher among women residing in rural counties than among those in large urban counties, 4.5-fold higher among women who smoked cigarettes during pregnancy, and nearly 17-fold higher among women with concurrent hepatitis B virus (HBV) infection. HCV infection among pregnant women is an increasing and potentially modifiable threat to maternal and child health. Clinicians and public health officials should consider individual and population-level opportunities for prevention and risk mitigation.

Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014

The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. To provide updated information about cesarean rates and geographic variation in cesarean use in China. Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. Live births. Annual rate of cesarean deliveries. Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. Between 2008 and 2014, the overall annual rate of cesarean deliveries increased in China, reaching 34.9%. There was major geographic variation in rates and trends over time, with rates declining in some of the largest urban areas.

Geographic Variation in the Rate and Timing of Cataract Surgery Among US Communities.

Previous studies using data from the 1980s found relatively little geographic variation in cataract surgery rates across the United States. We do not know whether similar patterns hold true today, nor do we know the patient- and community-level factors that might explain any recent geographic variations in the rate and timing of cataract surgery. To assess the extent of geographic variation in patient age at initial cataract surgery and the age-standardized cataract surgery rate in a large group of insured US patients with cataracts. Retrospective cross-sectional study of 1 050 815 beneficiaries older than 40 years of age with cataracts who were enrolled in a nationwide managed-care network during the period from 2001 to 2011. The data analysis was started in 2014 and refined in 2015. Median age at initial cataract extraction, age-standardized cataract surgery rate, and time from initial diagnosis to first surgery for patients with cataracts were compared among 306 US communities. Multivariable regression modeling generated hazard ratios (HRs) with 95% CIs identifying factors associated with patients' likelihood of undergoing cataract surgery. A total of 243 104 patients with cataracts (23.1%) underwent 1 or more surgical procedures (55.1% were female patients). Communities with the youngest and oldest patients at initial surgery differed in age by nearly 20 years (59.9-60.1 years in Lansing, Michigan, and Aurora, Illinois, vs 77.0-79.6 years in Marquette, Michigan; Rochester, New York; and Binghamton, New York). The highest age-standardized cataract surgery rate (37.3% in Lake Charles, Louisiana) was 5-fold higher than the lowest (7.5% in Honolulu, Hawaii). The median time from initial cataract diagnosis to date of first surgery ranged from 17 days (Victoria, Texas) to 367 days (Yakima, Washington). Compared with white patients, black patients had a 15% decreased hazard of surgery (HR, 0.85 [95% CI, 0.83-0.87]), while Latino patients (HR, 1.08 [95% CI, 1.05-1.10]) and Asian patients (HR, 1.09 [95% CI, 1.05-1.12]) had an increased hazard. For every 1° higher latitude, the hazard of surgery decreased by 1% (HR, 0.99 [95% CI, 0.98-0.99]). For every additional optometrist per 100 000 enrollees in a community, the hazard of surgery increased 0.1% (HR, 1.001 [95% CI, 1.001-1.001]). In recent years, patient age at first cataract surgery and the age-standardized surgery rate have varied considerably among some US communities. Future research should explore the extent to which such variations may affect patient outcomes.

Geographic Variation in Treatment and Outcomes Among Patients With AMI: Investigating Urban-Rural Differences Among Hospitalized Patients.

The value of early invasive revascularization for patients suffering acute myocardial infarction (AMI) is well known. However, access to revascularization services varies geographically and demographically. Previous studies have not examined the influence of rural residence on revascularization rates and outcomes among patients hospitalized with AMI. Our retrospective cohort study included patients hospitalized in Washington State with a primary diagnosis of AMI from 2009 to 2012. Urban or rural residence was determined using rural-urban commuting area (RUCA) codes. Multivariable models were used to evaluate geographic variation in rates of invasive versus medical management, in-hospital mortality, rehospitalization, and subsequent revascularization procedures. Our study included 25,156 urban dwellers and 2,770 rural residents. Adjusted models found rural patients to be at increased odds of undergoing invasive revascularization during the initial episode of AMI care (OR = 1.11; 95% CI: 1.01-1.21; P = .02) compared to urban dwelling patients. Rural patients were more likely to be transferred for care (OR = 4.28; 95% CI: 3.93-4.66; P < .001) and more likely to undergo coronary artery bypass grafting (CABG) (OR = 1.55; 95% CI: 1.35-1.78; P < .001) compared to the urban cohort. We found no significant geographic cohort differences in in-hospital mortality or subsequent revascularization rates. Our findings suggest that despite limited access to cardiac care facilities, rural patients are accessing revascularization services. However, rural residents are more likely to undergo CABG during their index admission. High transfer rates suggest that rural regions rely on effective transfer networks to access invasive cardiac services.

GP supply, deprivation and emergency admission to hospital for COPD and diabetes complications in counties across Ireland: an exploratory analysis.

Geographical variation in rates of emergency inpatient admission for chronic disease may be due to variation in health need. However, it may also reflect differences in the provision of services which reduce the risk of inpatient admission for chronic disease, such as primary care. The aim of this paper was to examine the effect of primary care provision [general practitioner (GP) supply] and deprivation on county-specific rates of emergency admission to hospital for diabetes complications and chronic obstructive pulmonary disease (COPD) in Ireland. Data on emergency inpatient discharges were obtained from the hospital inpatient enquiry (HIPE) system. Secondary data on GP supply were obtained from a recently published study, while secondary data on deprivation were obtained from the Small Area Health Research Unit. The effect of county-level GP supply and deprivation on age-standardised rates of discharge for diabetes complications and COPD were examined, adjusting for population density and the proportion of the population who were eligible for free primary care. Greater deprivation and lower GP supply are associated with increased rates of discharge from hospital for COPD and diabetes complications. However, these associations are stronger in counties where a lower proportion of the population are eligible for free primary care. Geographical variation in rates of admission to hospital for chronic disease is associated with both population need and health system factors. These findings suggest that primary care resourcing must be a key consideration in any efforts to tackle acute hospital capacity problems.

P09.13 Impact and cost-effectiveness of point-of-care testing for chlamydia: accounting for geographic variation in infection burden and testing rates, health service configuration, and implementation strategy

Introduction Point-of-care tests (PoCTs) for Chlamydia trachomatis potentially improve control by reducing transmission through reduced treatment delay, reduced loss to follow up, and greater convenience for patients leading to increased testing. However, with ~3–5 fold variation in rates of Chlamydia testing and diagnosis across geographic settings in England, in assessing cost-effectiveness the epidemiological context needs to be considered. Methods We developed a transmission-dynamic model to capture geographic variation in rates of testing and diagnosis using current technology to allow assessment of the impact of implementing PoCTs in different clinical services in different localities. The model incorporates heterogeneity in sexual partner change rates and is stratified by age and sex. It uses behavioural and prevalence data from the Natsal national survey, and Public Health England surveillance data on testing and diagnosis rates. Uncertainty in natural history and behavioural parameters is captured by Monte Carlo methods. Health service reconfiguration using PoCT is considered, including rates of PoCT introduction and reduction in presumptive treatment. Results The model captures observed geographic variation in rates of testing and diagnosis in females and males, which affects the impact and cost-effectiveness of PoCT introduction. In general, whilst PoCTs may reduce incidence by increasing diagnosis and treatment, if sensitivity is lower than conventional testing then there is potentially increased transmission from false-negative patients. The net effect depends upon characteristics of the particular PoCT. Conclusion PoCT sensitivity and specificity are key determinants of whether replacing conventional testing is likely to reduce or increase the incidence of infection. Importantly, if the convenience of PoCT increases testing rates then diagnoses might initially increase even though incidence falls; interpretation of surveillance data needs to account for this. This work is the foundation of a user-friendly web-based tool assessing the (cost-) effectiveness of introducing PoCTs in different local settings. Disclosure of interest statement CED, ESS, NG, EHE, RHJ, YC, CML, and PJW thank Innovate UK for funding. PJW thanks the UK Medical Research Council for Centre funding (grant MR/K010174/1), and also thanks the UK National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Modelling Methodology at Imperial College London in partnership with Public Health England (PHE) for funding (grant HPRU-2012–10080). The funding sources had no involvement in the study design or conduct; the collection, analysis and interpretation of data; the preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health, or Public Health England. CED was employed for part of the project by the National Chlamydia Screening Programme. The other authors declare no competing interests.

Variation in Prenatal Diagnosis of Congenital Heart Disease in Infants.

Prenatal diagnosis allows improved perioperative outcomes for fetuses with certain forms of congenital heart disease (CHD). Variability in prenatal diagnosis has been demonstrated in other countries, leading to efforts to improve fetal imaging protocols and access to care, but has not been examined across the United States. The objective was to evaluate national variation in prenatal detection across geographic region and defect type in neonates and infants with CHD undergoing heart surgery. Cardiovascular operations performed in patients ≤6 months of age in the United States and included in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2006-2012) were eligible for inclusion. Centers with >15% missing prenatal diagnosis data were excluded from the study. Prenatal diagnosis rates were compared across geographic location of residence and defect type using the χ(2) test. Overall, the study included 31,374 patients from 91 Society of Thoracic Surgeons Congenital Heart Surgery Database participating centers across the United States. Prenatal detection occurred in 34% and increased every year, from 26% (2006) to 42% (2012). There was significant geographic variation in rates of prenatal diagnosis across states (range 11.8%-53.4%, P < .0001). Significant variability by defect type was also observed, with higher rates for lesions identifiable on 4-chamber view than for those requiring outflow tract visualization (57% vs 32%, P < .0001). Rates of prenatal CHD detection in the United States remain low for patients undergoing surgical intervention, with significant variability between states and across defect type. Additional studies are needed to identify reasons for this variation and the potential impact on patient outcomes.

“Geography of suicide in Hong Kong: Spatial patterning, and socioeconomic correlates and inequalities”

Past urban research on Western nations tends to show high suicide rates in inner city and socioeconomically deprived areas. However, little is known about geographic variations in suicide in non-Western cities. We used Bayesian hierarchical models to estimate smoothed standardised mortality ratios (2005–2010) for suicide in people aged 10 years or above in each geographic unit in Hong Kong at two levels, i.e. large street block (n = 1639; median population = 1860) and small tertiary planning unit group (n = 204; median population = 14,850). We further analysed their associations with a range of area socioeconomic characteristics and a deprivation index. The “city centre” of Hong Kong, a generally non-deprived area, showed mostly below average suicide rates. However, there were high rates concentrating in some socioeconomically deprived, densely populated areas, including some inner city areas, across the city. Males had greater geographic variations in rates than females, except the elderly group. The use of smaller geographic units revealed finer detailed suicide distribution than the use of larger units, and showed that suicide rates were associated with indicators of socioeconomic deprivation (population with non-professional jobs and low median household income), and social fragmentation (proportions of unmarried adults and divorced/separated adults), but not with Gini coefficient. Sex/age groups had different associations with suicide rates. Areas in the most deprived quintile had a suicide rate more than two times higher than the least deprived. The association between suicide and deprivation was stronger in males than females and more marked in the younger populations compared to the elderly. The spatial distribution of suicide in Hong Kong showed distinct patterning and a stronger association with income compared to findings from Western countries. Suicide prevention strategies should consider tackling the marked socioeconomic gradient in suicide and high risk in young and middle-aged males living in deprived areas.

Geographic variation in rates of common surgical procedures in France in 2008–2010, and comparison to the US and Britain

Geographic variation in use of elective surgeries has been widely studied in the US, where over-utilization is incentivized. We wanted to explore recent trends in the geographic variation of common surgical procedures in France – where a global budget, centralized planning process, and compulsory insurance scheme are in place – and to compare measures of variation there to those in the US and Britain. For 2008–2010, we calculated French age- and sex-adjusted per capita utilization rates and four measures of geographic variation for hip fracture admission (which is standard treatment and shows minimal geographic variation across countries) and 14 elective surgical procedures. We found substantial geographic variation in age-sex adjusted per capita admission rates for elective procedures: radical prostatectomy, spine surgery, and CABG showed the greatest variation, while hip fracture, colectomy, and cholecystectomy showed the least. Among older patients, most French admission rates were lower than those seen in the US. In general, measures of geographic variation were lower in France than those reported in the US or Britain. French policymakers could use analyses of geographic variation in service utilization to inform policy, to identify areas for intervention, or to measure the effectiveness of efforts designed to reduce variation in care.

Local geographic variation in chronic liver disease and hepatocellular carcinoma: contributions of socioeconomic deprivation, alcohol retail outlets, and lifestyle

PurposeHepatocellular carcinoma (HCC) incidence rates continue to increase in the United States. Geographic variation in rates suggests a potential contribution of area-based factors, such as neighborhood socioeconomic deprivation, retail alcohol availability, and access to health care. MethodsUsing the National Institutes of Health-American Association of Retired Persons Diet and Health Study, we prospectively examined area socioeconomic variations in HCC incidence (n = 434 cases) and chronic liver disease (CLD) mortality (n = 805 deaths) and assessed contribution of alcohol outlet density, health care infrastructure, diabetes, obesity, and health behaviors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from hierarchical Cox regression models. ResultsArea socioeconomic deprivation was associated with increased risk of HCC incidence and CLD mortality (HR, 1.48; 95% CI, 1.03–2.14 and HR, 2.36; 95% CI, 1.79–3.11, respectively) after accounting for age, sex, and race. After additionally accounting for educational attainment and health risk factors, associations for HCC incidence were no longer significant; associations for CLD mortality remained significant (HR, 1.78; 95% CI, 1.34–2.36). Socioeconomic status differences in alcohol outlet density and health behaviors explained the largest proportion of socioeconomic status-CLD mortality association, 10% and 29%, respectively. No associations with health care infrastructure were observed. ConclusionsOur results suggest a greater effect of area-based factors for CLD than HCC. Personal risk factors accounted for the largest proportion of variance for HCC but not for CLD mortality.

How Understanding Thyroid Cancer in Belgium Can Help Us Mitigate the Problem of Increasing Incidence

There is an epidemic of thyroid cancer in the south of Belgium. Or is there? Van den Bruel et al (1) report that the incidence of thyroid cancer in the north is 4.1 per 100 000 people, and in the south, the rate is twice as high, 8.3 per 100 000 people. Although this could represent an epidemic of disease in one part of the country, it is also possible that the difference is caused by geographic variation leading to overdiagnosis. Van den Bruel et al (1) examined this hypothesis by looking closely at geographic variation in rates of various activities that contribute to the detection of thyroid cancer.Butwhat exactly are the conceptsofoverdiagnosis and geographic variation, why do they matter, and how do they relate in this case? This report is complex, so to examine the concepts, we will focus on just two findings: rates of imaging studies and rates of needle biopsy before surgery. These two rates are of particular interest because they provide clues about what we can do to alleviate the problem of thyroid cancer overdiagnosis.

Understanding the Dissemination of Sacral Neuromodulation

To assess trends in the use of sacral neuromodulation and to measure the magnitude of variation in its use across geographic regions. We used the State Ambulatory Surgery Database (SASD) from 2002 to 2009 from Florida to identify patients implanted with a neuromodulator. Age- and gender-adjusted rates of implantation were calculated by year and by geographic region, defined by the Hospital Service Area. The coefficient of variation was estimated to quantify the magnitude of variation for different time periods. Adjusted rates of sacral neuromodulation increased significantly from 1.1 per 100,000 population in 2002 to 10.4 per 100,000 population in 2009. The majority of cases were performed for overactive bladder. There was a very large amount of geographic variation in rates of these procedures as evidenced by the high coefficients of variation: 1.67 (2002 and 2003), 1.70 (2004 and 2005), 1.49 (2006 and 2007), and 1.05 (2008 and 2009). Rates of sacral neuromodulation have increased dramatically over the past decade. However, these rates of utilization are highly variable across regions, with some regions performing large numbers of these procedures and other regions performing few to no procedures. This range in practice patterns may reflect medical uncertainty surrounding the role of this procedure.

Time trends over five decades, and recent geographical variation, in rates of childhood squint surgery in England

AimsTo study trends in rates of childhood squint surgery in England over five decades, and to study recent geographical variation in England.MethodsUse of routine hospital statistics to analyse trends in...