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63 (); 8-15
doi:
10.1016/j.jor.2024.10.029

Total knee arthroplasty reimbursement is declining overall and at a marginally faster rate amongst female orthopaedic surgeons: A Medicare analysis

, , , , ,
a Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
b Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA

⁎Corresponding author: Georgia Sullivan. Sullivan.georgia@mayo.edu

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

While the prevalence of total knee arthroplasty (TKA) is increasing, reimbursement is declining. The purpose of this study was to determine how surgeon gender influences procedure volume, reimbursement, practice style, and patient demographics for TKAs nationally and regionally between 2013 and 2021.

The Medicare Physician and Other Practitioners database was queried from 2013 to 2021 for procedure volume, TKA reimbursement, surgeon characteristics, and patient demographics for any surgeon who performed at least ten primary TKAs per year. Statistical tests were conducted to analyze differences based on surgeon gender, geography, and year.

Of the 2,415,802 TKAs performed between 2013 and 2021, 1.5 % were billed by female surgeons. The number of TKAs performed annually increased by 29.1 % for female surgeons and decreased by 2.6 % for male surgeons. Between 2013 and 2021, reimbursement for TKAs decreased by 23.9 % for male surgeons and 26.2 % for female surgeons. In 2021, male surgeons were reimbursed $1017 per TKA while female surgeons were reimbursed $964 (p = 0.049). Male surgeons performed more TKAs annually in 2021 (Male: 39.3, Female: 30.9, p < 0.001), more total billable services (Male: 4148.0, Female: 2719.3, p < 0.001), and more unique billable services (Male: 70.7, Female: 55.3, p < 0.001) than female surgeons.

Female representation among surgeons who perform TKAs is increasing nationally. However, male surgeons treat more patients, perform more total billable services, and perform more unique billable services than female surgeons. TKA reimbursement is decreasing at a faster rate for female surgeons than male surgeons, although this is likely due to geographical differences.

Keywords

Knee arthroplasty
Reimbursement
Surgeon gender
TKA
1

1 Introduction

The number of patients receiving total knee arthroplasty (TKA) has increased over the past several decades, which can likely be attributed to the aging population, favorable surgical outcomes, and improvements in technology.1–3 There was a 42 % increase in TKAs performed annually between 2006 and 2014,1 and it is projected that between 1.2 and 3.5 million TKAs will be performed per year by 2030.2–4 As the orthopaedic surgery workforce expands to accommodate increasing patient volume, improvement in diversity, including gender diversity, within the workforce is warranted.5,6 In 2019, female surgeons accounted for only 6.5 % of the American Academy of Orthopedic Surgeons and 14 % of orthopaedic surgery residents.7,8 In particular, female surgeons comprise 2.4 % of adult reconstruction faculty members.9 Despite their underrepresentation, female patients generally express a preference for female orthopaedic surgeons.10 In terms of outcomes, while both male and female arthroplasty surgeons have similar rates of adverse events,11,12 overall surgeon-patient sex discordance is associated with fewer adverse events.13

Despite the increase in volume of TKAs, reimbursement has been declining, which is consistent with trends throughout orthopaedic surgery.14 Average inflation-adjusted Medicare reimbursement for primary TKAs decreased by 42 %, from $1888 in 2000 to $1097 in 2019.15,16 Available data demonstrates that male orthopaedic surgeons earn more income than their female counterparts and receive more industry payments, even after accounting for confounding variables such as rank, subspecialty, and practice setting.17–20 However, it is unclear what proportion of this discrepancy is due to a salary gap, differences in procedure volume, practice styles, patient populations, or other factors. There remains a paucity in the literature addressing whether decreasing reimbursements for specific procedures such as TKAs impact male and female surgeons equally. A prior study that analyzed Medicare claims among orthopaedic surgeons found that female sex was an independent predictor for lower reimbursement, after adjusting for subspecialty, years in practice, practice setting, and total services and beneficiaries.21 The purpose of the present study was to analyze how surgeon gender affected procedure volume, reimbursement, practice styles, and patient characteristics for TKAs at both national and regional levels from 2013 to 2021.

2

2 Methods

This study was exempt from our institution's Institutional Review Board (IRB) approval due to the use of publicly available de-identified information.

2.1

2.1 Data source

Publicly available datasets created by the Centers for Medicare and Medicaid Services (CMS) were utilized.22 The “Medicare Physician and Other Practitioners – by Provider and Service” dataset was filtered by Current Procedural Terminology (CPT) code 27447 (primary total knee arthroplasty). This dataset includes 100 % of services billed to Medicare Part B and is based on data from CMS administrative claims from the CMS Chronic Conditions Data Warehouse. This data was then linked to the “Medicare Physician and Other Practitioners – by Provider” dataset based on physician National Provider Identification (NPI) number. Physicians who billed ten or fewer annual procedures were excluded from these datasets for patient privacy purposes. Billing episodes from non-physicians were also excluded to ensure comparability of all reimbursement data.

2.2

2.2 Data extraction

Self-reported gender was extracted for each surgeon from the “Medicare Physician and Other Practitioners – by Provider” dataset. The following data was also collected for each surgeon, each year: address, number of TKAs billed to Medicare, average Medicare reimbursement per TKA, number of Medicare beneficiaries, total billable services, and the number of unique billable services performed. Unique billable services included each distinct CPT code billed by a surgeon without the use of modifiers. Total billable services included any CPT codes billed by a surgeon, including office visits and other procedures. Surgeon address was utilized to stratify surgeons by region according to United States census guidelines: Northeast, South, Midwest, and West, similar to prior studies.23–27 Similarly, surgeons were stratified by rural-urban commuting area codes (RUCA) including metropolitan, micropolitan, small town, and rural.28

Demographics and characteristics of each surgeon's Medicare beneficiaries were identified; data including average age, gender, race (non-Hispanic White), dual Medicare-Medicaid enrollment status, and average hierarchical condition category (HCC) risk score were extracted for each individual surgeon. The HCC risk score is a validated metric that summarizes patient comorbidities and is normalized to 1.0 for a standard patient.29

2.3

2.3 Data analysis

All monetary data was adjusted for inflation to year 2021 dollars based on the United States Consumer Price Index. Average reimbursement, procedural volume, and Medicare beneficiary characteristics were assessed using descriptive statistics each year. All data analyses were performed at a national, regional, RUCA, and state level. Differences between mean values were assessed using the Welch t-test for unequal variances.21,29–32 Kruskal-Wallis tests were used to compare multiple groups, including the differences between regions, states, and RUCAs for each year. Statistical analyses were performed using R (version 4.2.3; Vienna, Austria), with a P-value less than 0.05 indicating significance. The primary outcome variable was the mean reimbursement per TKA each year. Secondary outcome variables were TKA volume, TKA surgeon geographical distribution, TKA surgeon billing practices, and TKA surgeon patient population demographics. Each outcome was evaluated separately for male and female surgeons.

3

3 Results

3.1

3.1 2013 to 2021 trends

From 2013 to 2021, a total of 2,415,802 primary TKAs were billed to Medicare. 35,782 (1.5 %) of those were billed by female surgeons throughout the entire time period. Between 2013 and 2021, the annual number of TKAs performed by female surgeons increased by 29 %, while the annual number performed by male surgeons decreased by 2.6 %. The total number of female surgeons performing TKAs each year increased by 9.1 %, while the number of male surgeons decreased by 7.8 % (Table 1). The greatest increase in the proportion of female TKA surgeons from 2013 to 2021 was seen in the Northeast (1.8 %–2.8 %), while a decrease was seen in the South (−7.5 %) (Fig. 1). The number of TKAs performed each year per surgeon increased nationally for both male (+5.6 %) and female (+18.4 %) surgeons, with both male and female surgeons having the greatest increase in the Northeast (Male: +11.6 %, Female: +66.2 %). The total number of services performed each year also increased for both male (+16.0 %) and female (+8.7 %) surgeons.

Table 1 Gender differences between male and female TKA surgeons.
2013 2019 2021
Male Female P-value Male Female P-value Male Female P-value
Surgeons 6896 132 n/a 7004 163 n/a 6359 144 n/a
TKA Volume 256,573 3445 n/a 292,856 4940 n/a 249,777 4449 n/a
Reimbursement $1336.64 $1306.68 0.57 $1130.57 $1076.77 0.10 $1016.90 $963.77 0.049
TKAs per Surgeon 37.21 26.10 <0.001 41.81 30.31 <0.001 39.28 30.90 <0.001
Average Beneficiaries per Surgeon 495.42 354.88 <0.001 500.47 365.64 <0.001 461.69 346.47 <0.001
Total Annual Services Per Surgeon 3575.87 2502.36 <0.001 4212.03 2710.75 <0.001 4147.99 2719.27 <0.001
Average Services Per Beneficiary 7.22 7.05 0.73 8.42 7.41 0.09 8.98 7.95 0.33
Unique Services Billed 91.14 76.88 <0.001 77.30 63.43 <0.001 70.71 55.33 <0.001
Beneficiary Average Age 72.92 72.67 0.16 73.37 73.06 0.004 73.72 73.47 0.10
Beneficiary Average HCC 1.16 1.15 0.28 1.18 1.19 0.40 1.08 1.10 0.20
Beneficiary Average % White 86.75 86.90 0.50 86.00 85.19 0.32 86.59 85.94 0.42
Beneficiary Average % Female 63.72 67.09 <0.001 62.48 65.56 <0.001 62.00 64.95 <0.001
Beneficiary Average % Dual Medicare and Medicaid 16.38 17.40 0.32 13.10 14.70 0.08 10.91 12.62 0.06
Proportion of TKA Surgeons That Are Female. The percentage of surgeons who performed at least ten total knee arthroplasty (TKA) procedures per year from 2013 to 2021 who are female, nationally and in the Northeast (NE), South (S), Midwest (MW) and West (W) regions.
Fig. 1 Proportion of TKA Surgeons That Are Female. The percentage of surgeons who performed at least ten total knee arthroplasty (TKA) procedures per year from 2013 to 2021 who are female, nationally and in the Northeast (NE), South (S), Midwest (MW) and West (W) regions.

The average inflation-adjusted Medicare reimbursement per TKA declined by 23.9 % for male surgeons and by 26.2 % for female surgeons between 2013 and 2021 (Fig. 2). The decline for male surgeons was greatest in the Midwest ($1342 to $990, −26.3 %), while the decline for female surgeons was greatest in the West ($1362 to $927; −31.9 %). The decline was smallest for both male and female surgeons in the Northeast (Male: −22.6 %, Female: −21.4 %) (Fig. 3).

Reimbursement Based on Gender. The average inflation-adjusted reimbursement rate for total knee arthroplasty (TKA) procedures per year from 2013 to 2021 for male and female surgeons.
Fig. 2 Reimbursement Based on Gender. The average inflation-adjusted reimbursement rate for total knee arthroplasty (TKA) procedures per year from 2013 to 2021 for male and female surgeons.
Regional Reimbursement for Female Surgeons. The average inflation-adjusted reimbursement rate for total knee arthroplasty (TKA) procedures for female surgeons from 2013 to 2021, nationally and in the Northeast (NE), South (S), Midwest (MW) and West (W) regions.
Fig. 3 Regional Reimbursement for Female Surgeons. The average inflation-adjusted reimbursement rate for total knee arthroplasty (TKA) procedures for female surgeons from 2013 to 2021, nationally and in the Northeast (NE), South (S), Midwest (MW) and West (W) regions.

Between 2013 and 2021, the average number of beneficiaries per surgeon decreased by 6.8 % for male surgeons and by 2.4 % for female surgeons (Table 1). Both male and female surgeons performed fewer unique billable services (Male: −22.4 %, Female: −28.0 %) during this time period. Additionally, both male and female surgeons operated on patients with fewer comorbidities as measured by HCCs (Male: −6.9 %, Female: −4.5 %) and fewer patients with dual Medicare and Medicaid coverage (Male: −33.4 %, Female: −27.5 %).

3.2

3.2 2021 differences

2.2 % of all surgeons who performed at least 10 TKAs within the Medicare population in 2021 were female. The proportion of female surgeons was highest in the West (3.4 %) and lowest in the South (1.3 %) (Figs. 1 and 4). Female surgeons were more likely to practice outside of metropolitan areas than male surgeons (Male: 13.6 %, Female: 18.7 %) (Table 2).

Heat Map of Female Surgeons. The number of female surgeons who performed at least ten total knee arthroplasty (TKA) procedures in 2021 in each state. ∗Grey = 0 Female Surgeons.
Fig. 4 Heat Map of Female Surgeons. The number of female surgeons who performed at least ten total knee arthroplasty (TKA) procedures in 2021 in each state. ∗Grey = 0 Female Surgeons.
Table 2 Geographic practice distribution of male and female TKA surgeons.
Region 2013 2019 2021
Male Female Male Female Male Female
Metropolitan (%) 83.5 71.2 85.3 80.4 86.4 81.3
Micropolitan (%) 13.1 19.7 11.7 12.3 11.0 13.2
Small Towns (%) 2.8 7.6 2.5 4.9 2.2 3.5
Rural (%) 0.6 1.5 0.5 2.5 0.4 2.1

In 2021, female surgeons were reimbursed an average of $53 less per TKA than male surgeons (Male: $1,017, Female: $964, p = 0.049). There were also fewer annual total TKAs performed by female surgeons (Male: 39.3, Female: 30.9, p < 0.001) and fewer average beneficiaries per surgeon for females (Male: 461.7, Female: 346.5, p < 0.001). Males performed a greater number of total billable services per surgeon than females (Male: 4148.0, Female: 2719.3, p < 0.001), and they billed for a greater number of unique services (Male: 70.7, Female: 55.3, p < 0.001). Female surgeons had a higher percentage of female beneficiaries than male surgeons (Male: 62.0 %, Female: 65.0 %, p < 0.001).

3.3

3.3 2019 differences (Pre-COVID)

In 2019, female surgeons represented 2.3 % of all surgeons who performed at least 10 TKAs among Medicare patients. The proportion of female surgeons was highest in the West (3.1 %) and lowest in the South (1.6 %) (Fig. 1). Like in 2021, female surgeons were more likely to serve patients in micropolitan areas, small towns, or rural locations than male surgeons (Male: 14.7 %, Female: 19.6 %) (Table 2).

In 2019, male surgeons were reimbursed $1131 per TKA compared to $1077 for female surgeons, but a statistically significant difference was not detected (p = 0.10). Similarly to 2021, in 2019 female surgeons performed fewer TKAs per surgeon (Male: 41.8, Female: 30.3, p < 0.001), had fewer average beneficiaries per surgeon (Male: 500.5, Female: 365.6, p < 0.001), and performed fewer total billable services than male surgeons (Male: 4212.0, Female: 2710.8, p < 0.001).

4

4 Discussion

While more female surgeons are performing primary TKAs today and reimbursement for primary TKAs for both male and female surgeons is decreasing overall, reimbursement for female surgeons is decreasing at a greater rate. With regards to geographic differences, the Northeast experienced the greatest increase in both the proportion of female surgeons and the number of TKAs performed per surgeon per year. In terms of reimbursement, the gap between male and female surgeons increased between 2013 and 2021, and by 2021 this difference reached significance. While the proportion of TKAs performed by female surgeons is increasing, statistically significant differences in practice between male and female surgeons exist in the Medicare patient population; when compared to their female counterparts, male surgeons perform more TKAs, treat more patients, perform more total billable services annually, and bill for more unique services. Finally, while patient demographics are similar between male and female surgeons, female surgeons treat a greater proportion of female patients.

The total TKA volume among Medicare patients decreased by 2.2 % from 2013 to 2021 (2013: 260,018; 2021: 254,226). This finding contradicts previous trends and predictions of an increasing number of TKAs in coming years as the population ages.1–3 It should be considered that the decrease in TKAs observed in the Medicare population may not reflect the total number of TKAs performed because patients who used private insurance or self-pay were excluded, although Medicare recipients make up the largest cohort of TKA patients.33,34 The decrease could also be attributed to the COVID-19 pandemic, when elective joint replacement surgeries were postponed in many hospital systems.35–37 This conclusion is supported by the finding that TKA volume increased by 14.5 % between 2013 and 2019 before decreasing by 14.6 % between 2019 and 2021.

Our findings are consistent with prior research regarding the geographic distribution of female orthopaedic surgeons. A study from 2020 found that New England and the Pacific region have the highest prevalence of female orthopaedic surgeons and the South Atlantic and East South Central regions have the fewest female surgeons.38 Another study also found that the West has the highest proportion of female orthopaedic surgeons and the Midwest and South have the lowest.39 Contributing to these differences, adult reconstruction is one of the orthopaedic subspecialties with the least representation of female surgeons.9,40,41 These discrepancies may be due to an unequal distribution of medical school graduates and residency positions, differences in preferred practice setting, or differences in the availability of open positions.

When adjusting for inflation, reimbursement for TKAs decreased by 23.9 % for male surgeons and 26.2 % for female surgeons between 2013 and 2021. This finding is consistent with prior research demonstrating decreasing inflation-adjusted reimbursement over time for TKAs and other orthopaedic procedures.14–16 Additionally, TKA was removed from the CMS inpatient-only list in 2018, and the subsequent increase in outpatient procedures resulted in a decrease in reimbursement.42 In 2013, male surgeons were reimbursed $30 more than female surgeons per TKA on average, but in 2021 this difference increased to $53. The reimbursement gap was not significant in 2013, but the difference approached significance in 2019 and reached significance in 2021. Findings from Holliday et al. support the lack of a reimbursement gap that we observed in 2013, although their study did not include more recent data.43 This current study's identification of a reimbursement gap is consistent with data reported by Avila et al. which demonstrated that female sex is a predictor of lower yearly Medicare reimbursement for orthopaedic surgeons after accounting for individual and practice-specific factors.21 Similar trends have been noted in other specialties including cardiology, radiation oncology, ophthalmology, urology, and otolaryngology, although these studies did not differentiate by procedure code.30,44–47

The gender difference in reimbursement may be driven by geographical differences in where female surgeons choose to practice. Medicare reimbursement is calculated using the resource-based relative value scale, which accounts for the work of the provider, practice expenses, and liability insurance for a given type of provider. The relative value units (RVUs) are multiplied by the Geographic Practice Cost Index (GPCI), which adjusts for regional differences in expenses. Significant variation still exists between cost of living and practice expenses within each region, as there are only 112 regions recognized, of which 34 comprise an entire state.48 Notably, surgeon gender is not a factor in the formula.49 Female surgeons may disproportionally work in areas with lower costs of living, which conversely have lower reimbursement rates. These differences could also be due to job availability, preferred patient population, lifestyle preference, family, affordability, or a number of other factors. Other hypotheses to explain lower reimbursement include differences in the proportions of men and women operating at ambulatory surgical centers and academic medical centers or differences in the use of billing modifiers for cases with increased complexity. Information on billing modifiers was not available in this dataset. The gender difference in reimbursement may be due to a combination of these factors. Notably, our study divided the United States into four regions based on the United States Census boundaries, in accordance with prior literature, which did not allow for the granular comparison of reimbursement within GPCI regions.27,39,50 Future research should aim to determine whether female orthopaedic surgeons are more likely to work in areas with a lower GPCI, and if so, why that is. Additionally, while the 5.3 % gender difference in reimbursement may be marginal, the overall decline in TKA reimbursement between 2013 and 2021 (Male: −23.9 %, Female: −26.2 %) highlights a concerning trend.

While patient populations were similar, male and female surgeons exhibited differences in practice style with regards to procedure types and volume. Female surgeons performed fewer TKAs than male surgeons (30.9 compared to 39.3 in 2021, p < 0.001), which was a consistent trend from 2013 to 2021. Male surgeons also had more beneficiaries, performed more billable services annually, and billed for more unique services than female surgeons. These observations are consistent with findings from Avila et al. demonstrating that male orthopaedic surgeons perform more total procedures and more unique procedures than female orthopaedic surgeons. This trend has also been noted in radiation oncology, ophthalmology, and otolaryngology.21,44,45,47 Given the recent increase in female surgeons in practice, male surgeons included in this study may have more years of practice than female surgeons. The proportion of females entering the field of orthopaedic surgery is increasing, so these women might be at earlier stages of their careers and thus still building their practices. However, information about surgeon subspecialty was not available, so the observed differences in procedure types and volume may be because male and female orthopaedic surgeons favor different subspecialties or have different billing practices.41,51 Subspecializing is becoming increasingly popular among orthopaedic surgeons, so given that greater proportions of orthopaedic residency graduates are female, women may be more subspecialized.52,53

As for patient demographics, there were no differences between male and female surgeons in the average number of services performed per beneficiary, beneficiary age, beneficiary comorbidities as measured by HCCs, beneficiary race, or dual Medicare and Medicaid insurance status. However, female surgeons treated a statistically significant higher proportion of female patients than male surgeons. Notably, both male and female surgeons operated on patients with fewer HCCs, which represent chronic health conditions, in 2021 than 2013. This trend is concerning because more complex patients may not be receiving the care they need, potentially due to cost, access, or surgeon discretion. Several studies have shown that across surgical specialties, female surgeons receive fewer procedural referrals than male surgeons,54,55 and one study found that the referrals female surgeons receive are for less complex cases than male surgeons.56 Evidence also suggests that there may be concordance between referring physician gender and surgeon gender.54,55

Another consideration for the future trajectory of TKA reimbursement is the Comprehensive Care for Joint Replacement Model (CJR), a trial of bundled payments for TKA that was implemented in certain regions in 2016 and will conclude in December 2024. The intent of CJR is to incentivize high-value care by increasing profits for providers who spend less than the bundled payment amount. However, early data shows that while CJR may result in improved quality metrics and cost savings for CMS, this comes with increased costs for institutions, financial penalties for physicians, and creates conflicts of interest between payors, hospitals, and physicians.57,58 Future research is necessary to study the efficacy of CJR and to determine how this potential shift in payment framework will impact reimbursement.59

There were several limitations to this study that stemmed from the use of a Medicare database. Besides gender, other surgeon characteristics could not be accounted for including years in practice, age, race, and practice setting. However, controlling for regional differences may help to eliminate some of these confounding factors. Any surgeon who performed fewer than ten TKAs was excluded for patient privacy, which may have excluded individuals with less specialized practices. Given that surgeon subspecialty information was not available, some differences in practice style may be due to male and female surgeons disproportionally representing different subspecialties. As this study only included data from Medicare Part B, it is possible that different trends may exist for commercial payors. A systematic review from 2016 found that the average age of TKA patients ranges from 55 to 68, which is near the beginning of Medicare eligibility at 65.60 The average beneficiary age in this study was about 73, which is likely due to the older age of patients in the Medicare population compared to the general TKA patient population. However, these findings retain clinical significance as Medicare is the largest payor of TKAs, and Medicare reimbursement rates heavily influence payments by private insurers.33,34 Finally, given limits of the database utilized, we do not have access to individual billing episodes where multiple codes or modifiers may have been utilized to increase reimbursement, such as the 22 modifier for increased patient or operative complexity. As such, it is possible that male surgeons may be utilizing modifier codes or billing practices which maximize reimbursement that may not reflect the same billing practices as female surgeons. Future study will be important to determine any such differences and identify any potential gap in billing practices that may be contributing to the reimbursement gap.

5

5 Conclusions

This study revealed that the demand for TKAs increased from 2013 to 2019 and then decreased between 2019 and 2021, likely due to the COVID-19 pandemic. Although the majority of TKAs are performed by male surgeons, the proportion of female surgeons who perform TKAs increased from 2013 to 2021 across the United States, with the most growth seen in the Northeast. Reimbursement for female surgeons who perform TKAs is decreasing at a faster rate than for male surgeons, although the difference in reimbursement is minimal (5.3 % in 2021). This difference in average TKA reimbursement is likely attributed to geographical differences in the practice locations of female and male TKA surgeons, with male surgeons being more likely to practice in areas with higher Medicare Geographic Practice Cost Index reimbursement multipliers. Male surgeons have more lucrative practices than female surgeons in terms of the number of Medicare patients, the number of total procedures, and the number of unique procedures, but patient demographics are fairly similar between genders. This study identified that while women are changing the demographics of orthopaedic surgery, there remains further work to not only increase gender diversity but reimbursement parity in the field. Future work should be done to determine what factors influence women who choose orthopaedic surgery as their specialty and how their preferences for their future practices differ from men.

Potential conflicts of interest and funding sources

None are declared.

CRediT authorship contribution statement

Georgia Sullivan: Writing – original draft. Vikram Gill: Conceptualization, Formal analysis, Writing – review & editing. Eugenia A. Lin: Writing – review & editing. Alexandra Cancio-Bello: Writing – review & editing. Jack Haglin: Conceptualization, Data curation, Writing – review & editing. Joshua S. Bingham: Writing – review & editing, Supervision.

Ethical statement

This manuscript was produced without artificial intelligence software.

This study was exempt from our institution's Institutional Review Board (IRB) approval due to the use of publicly available de-identified information.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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