Regional Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem

Published:November 26, 2022DOI:



      Hemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period.


      Using Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL.


      1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL.


      While continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sun Z.
        • Migaly J.
        Review of hemorrhoid disease: presentation and management.
        Clin Colon Rectal Surg. 2016; 29: 22-29
        • Riss S.
        • Weiser F.A.
        • Schwameis K.
        • et al.
        The prevalence of hemorrhoids in adults.
        Int J Colorectal Dis. 2012; 27: 215-220
        • Etzioni D.A.
        • Beart Jr., R.W.
        • Madoff R.D.
        • Ault G.T.
        Impact of the aging population on the demand for colorectal procedures.
        Dis Colon Rectum. 2009; 52 (discussion 590-581): 583-590
        • Davis B.R.
        • Lee-Kong S.A.
        • Migaly J.
        • Feingold D.L.
        • Steele S.R.
        The American society of Colon and rectal surgeons clinical practice guidelines for the management of hemorrhoids.
        Dis Colon Rectum. 2018; 61: 284-292
        • Alonso-Coello P.
        • Guyatt G.
        • Heels-Ansdell D.
        • et al.
        Laxatives for the treatment of hemorrhoids.
        Cochrane Database Syst Rev. 2005; 2005: CD004649
        • Rivadeneira D.E.
        • Steele S.R.
        • Ternent C.
        • et al.
        Practice parameters for the management of hemorrhoids (revised 2010).
        Dis Colon Rectum. 2011; 54: 1059-1064
        • Moesgaard F.
        • Nielsen M.L.
        • Hansen J.B.
        • Knudsen J.T.
        High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin.
        Dis Colon Rectum. 1982; 25: 454-456
        • Wilson M.Z.
        • Swarup A.
        • LR T.W.
        • Ivatury S.J.
        The effect of nonoperative management of chronic anal fissure and hemorrhoid disease on bowel function patient-reported outcomes.
        Dis Colon Rectum. 2018; 61: 1223-1227
        • Sandler R.S.
        • Peery A.F.
        Rethinking what we know about hemorrhoids.
        Clin Gastroenterol Hepatol. 2019; 17: 8-15
        • Shanmugam V.
        • Thaha M.A.
        • Rabindranath K.S.
        • Campbell K.L.
        • Steele R.J.
        • Loudon M.A.
        Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids.
        Cochrane Database Syst Rev. 2005; 2005: CD005034
        • Lohsiriwat V.
        Hemorrhoids: from basic pathophysiology to clinical management.
        World J Gastroenterol. 2012; 18: 2009-2017
        • Clark J.D.
        Variation in Michigan hospital use rates: do physician and hospital characteristics provide the explanation?.
        Soc Sci Med. 1990; 30: 67-82
        • McPherson K.
        • Wennberg J.E.
        • Hovind O.B.
        • Clifford P.
        Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway.
        N Engl J Med. 1982; 307: 1310-1314
        • Wennberg J.
        • Gittelsohn
        Small area variations in health care delivery.
        Science. 1973; 182: 1102-1108
        • Wallaert J.B.
        • Nolan B.W.
        • Stone D.H.
        • et al.
        Physician specialty and variation in carotid revascularization technique selected for Medicare patients.
        J Vasc Surg. 2016; 63: 89-97
        • Song Y.
        • Skinner J.
        • Bynum J.
        • Sutherland J.
        • Wennberg J.E.
        • Fisher E.S.
        Regional variations in diagnostic practices.
        N Engl J Med. 2010; 363: 45-53
        • Huber T.S.
        • Seeger J.M.
        Dartmouth Atlas of Vascular Health Care review: impact of hospital volume, surgeon volume, and training on outcome.
        J Vasc Surg. 2001; 34: 751-756
        • Newman L.
        New Dartmouth Atlas: improving US cardiac care?.
        Lancet. 2000; 356: 660
        • Mullner R.M.
        Tracking medicine: a researcher's quest to understand health care.
        Curr Rev Acad Libr. 2011; 48: 1521
        • House S.A.
        • Singh N.
        • Wasserman J.R.
        • Kim Y.
        • Ganduglia-Cazaban C.
        • Goodman D.C.
        Small-area variation in the care of low-risk neonates in Massachusetts and Texas.
        Hosp Pediatr. 2020; 10: 1059-1067
        • CMS. Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)
        Center for Medicare and Medicaid services.
        (Available at:)
        • O'Connor A.M.
        • Llewellyn-Thomas H.A.
        • Flood A.B.
        Modifying unwarranted variations in health care: shared decision making using patient decision aids.
        Health Aff (Millwood). 2004; (Suppl Variation): VAR63-VAR72
        • Sepucha K.R.
        • Fowler Jr., F.J.
        • Mulley Jr., A.G.
        Policy support for patient-centered care: the need for measurable improvements in decision quality.
        Health Aff (Millwood). 2004; (Suppl Variation): VAR54-VAR62
        • Services CfM
        Medicare fee for service payment schedule.
        (Available at:)
        • Vyas D.A.
        • Eisenstein L.G.
        • Jones D.S.
        Hidden in plain sight - reconsidering the use of race correction in clinical algorithms.
        N Engl J Med. 2020; 383: 874-882
        • Ward M.M.
        Regional variation in surgical procedure rates: going beyond description.
        JAMA Surg. 2022; 157: 91-92