Clinician Use and Payments by Medical Specialty for Audiometric and Vestibular Testing among US Medicare Beneficiaries

Importance: Variations in diagnostic test use may indicate that there are opportunities for quality improvement in vestibular health care. To date, the extent to which clinician acquisition of tests varies nationwide by region and specialty of the clinician is unknown. Objective: To quantify variation in clinician use and payments for audiograms and vestibular tests across all geographic regions of the United States and by specialty of practice. Design, Setting, and Participants: This cross-sectional study used a population-based sample of 1307887 audiovestibular test claims from fee-for-service Medicare beneficiaries aged 65 years or older in the Medicare Provider Utilization and Payment Public Use File from January 1 through December 31, 2014. The analysis was completed from January 2 through June 1, 2019. Exposures: Diagnostic audiograms, caloric testing, and rotary chair testing. Main Outcomes and Measures: Test utilization was analyzed by hospital referral region, medical specialty, and total payments. Results: In 2014, clinicians performed 1213328 audiograms, 317880 caloric tests (ie, single caloric irrigations), and 62779 rotary chair tests, for a total of $38647350.21 in Medicare payments from the Centers for Medicare & Medicaid Services. No patient or clinician demographic characteristics were available. Across health care referral regions, rates of testing per 100000 beneficiaries varied from 166 to 12021 for audiograms, 15 to 4271 for caloric tests, and 13 to 3556 for rotary chair tests between the lowest-use and highest-use regions. Most audiograms and caloric tests were billed by audiologists (797957 audiograms [65.8%]; 112485 caloric tests [35.4%]) and otolaryngologists (376728 audiograms [31.0%]; 70567 caloric tests [22.2%]). In contrast, primary care physicians (18933 [30.2%]) and neurologists (15254 [24.3%]) billed the largest proportion of rotary chair tests compared with other specialists, including audiologists (7253 [11.6%]) and otolaryngologists (6464 [10.3%]). Conclusions and Relevance: Substantial geographic and clinician-level variation may have been observed in use of audiovestibular tests. Quality improvement efforts in vestibular health care may need to target a range of clinicians, including primary care physicians to be successful.