Table 1_Geospatial analysis of hearing-related services utilization among Medicare beneficiaries, 2017–2021.docx

The four cluster groupings were compared across 50 socioeconomic variables using one-way ANOVA. Per-capita utilization, used for descriptive mapping, was calculated using total county population from the American Community Survey; the rationale and implications of this denominator choice are detailed in the Methods.</p>Results<p>1,340 contiguous-US counties, with Medicare billing activity, were included in the spatial analysis (290.7 million residents).

Over 5 years, 15,136,056 hearing-related procedures were billed at a total Medicare payment of $428.3 million (Global Moran's I = 0.49, p < 0.01). Sixty-eight counties were classified as hot-spot clusters. Concentrated in Southern California, Florida, Texas, and the Mid-Atlantic and encompassing 75.5 million residents, 4.9 million procedures, and $159.0 million in spending.

One hundred twenty-five counties were classified as cold-spot clusters, primarily across the Midwest and Deep South, encompassing 5.2 million residents, 316,177 procedures, and $7.3 million in spending. Cold spots had substantially higher poverty rates (14.7% vs. 11.3%), lower median household incomes ($56,239 vs. $86,972), and lower educational attainment than hot spots; hot spots showed greater racial and ethnic diversity.</p>Conclusion<p>Hearing-related Medicare service utilization exhibits substantial geographic clustering, with rural and economically disadvantaged regions showing systematic underutilization.

These findings priority regions for workforce expansion and policy intervention.</p>