S2262 The Rise of POEM: Achalasia Treatment Trends, Institutional Disparities, and the Impact of CPT Coding in a Nationwide Cohort (2014-2024)

Introduction: Peroral endoscopic myotomy (POEM) has transformed the management of achalasia over the past decade. While utilization has increased, the impact of procedural coding changes and institutional disparities remains unclear. This study assessed nationwide trends in achalasia treatment, institutional differences in POEM adoption, and the effect of the 2022 CPT code introduction. Methods: We analyzed adults diagnosed with achalasia (2014–2024) using the TriNetX Network, a large, federated database of de-identified electronic health records from academic and community healthcare organizations across the U.S. We calculated annual incidence proportions and prevalence rates for POEM, laparoscopic Heller myotomy (LHM), pneumatic dilation (PD), and botulinum toxin injection (BT), defined per 100,000 patients with achalasia. Interrupted time series (ITS) analysis was used to assess the impact of the dedicated CPT code for POEM introduced in 2022. Procedure utilization trends were compared between academic and non-academic institutions and stratified by age group. Results: Among 47,881 patients (mean age 66 ± 17 years; 53% woman), achalasia diagnoses nearly doubled over the study period. POEM utilization rose sharply from 0.42% in 2014 to 3.21% in 2024, while LHM declined from 1.46% to 0.94%. BT use increased 4-fold, whereas PD rates remained relatively stable. Despite the 2022 CPT code implementation, ITS analysis showed no significant change in POEM utilization slope or level (P > 0.30). In 2024, POEM rates were over 4 times higher in academic centers versus non-academic centers (4,112 vs 989 per 100,000 achalasia patients; P < 0.001). Age-based analysis revealed that younger patients (<40 years) predominantly underwent POEM or LHM, whereas older adults (>60 years) were more likely to receive PD or BT. Conclusion: Over the past decade, POEM has emerged as the leading therapy for achalasia in the U.S., with its adoption driven primarily by clinical efficacy and provider expertise rather than reimbursement or procedural coding changes, as demonstrated by our ITS analysis. However, substantial disparities persist across institutional settings and age groups, with academic centers exhibiting significantly higher and earlier adoption. These findings highlight the need for broader dissemination, enhanced training, and equitable access to advanced endoscopic therapies across all practice environments.