ArticleUrology2026
Clinician- and Geographic-level Variation in Utilization of Sacral Neuromodulation and OnabotulinumtoxinA Injections Among Medicare Beneficiaries With Overactive Bladder.
Article in Urology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectiveTo 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.
methodsThis 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.
resultsOverall, 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.
conclusionAmong 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.
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