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Branche C, Sakowitz S, Porter G, Cho NY, Chervu N, Mallick S, Bakhtiyar SS, Benharash P. Utilization of minimally invasive colectomy at safety-net hospitals in the United States. Surgery 2024; 176:172-179. [PMID: 38729887 DOI: 10.1016/j.surg.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs. METHODS All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes. RESULTS Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (β+0.26 days, confidence interval 0.17-0.35) and costs (β+$2,510, confidence interval 2,020-3,000). CONCLUSION Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.
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Affiliation(s)
- Corynn Branche
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Stanford University, Palo Alto, CA. https://twitter.com/CoreLabUCLA
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Temporary vs. permanent stoma: factors associated with the development of complications and costs for rectal cancer patients. Int J Colorectal Dis 2022; 37:823-833. [PMID: 35201413 DOI: 10.1007/s00384-022-04116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare in-hospital complication rates and treatment costs between rectal cancer patients receiving permanent and temporary stomas. Surgical complications and costs associated with permanent stoma formation are still poorly understood. While choosing between the two stoma options is usually based on clinical and technical factors, disparities exist. METHODS Patients with rectal cancer, stoma formation, complications, and cost of care were identified from the Florida Agency for Health Care Administration Discharge Database. Rectal cancer patients who underwent elective surgery and received a permanent or temporary stoma were identified using ICD-10 codes. Patients who underwent colostomy with resection were included in the "Permanent stoma" group, and those who underwent "resection with ileostomy" were included in the "temporary stoma" group. Multivariable models compared patients receiving temporary vs. permanent stomas. RESULTS Regression models revealed no difference in the odds of having a complication between patients who obtained permanent versus temporary stoma (OR 0.96, 95% CI: 0.70-1.32). Further, after adjusting for the number of surgeries, demographic variables, socioeconomic and regional factors, comorbidities, and type of surgery, there was a significant difference between permanent and temporary stomas for rectal cancer (ß - 0.05, p = 0.03) in the log cost of creating a permanent stoma. CONCLUSION Our findings suggest there are no differences associated with complications, and reduced cost for permanent compared to temporary stomas. Increased costs are also associated with receiving minimally invasive surgery. As a result, disparities associated with receipt of MIS could ultimately influence the type of stoma received.
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Zmijewski P, Rivera Perla K, Leila Paul G, Mazzaglia PJ. Surgical Disparities Among Patients with Primary Hyperparathyroidism: A National Inpatient Sample Database Study. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Akram WM, Vohra N, Irish W, Zervos EE, Wong J. Racial Disparity in the Surgical Management of Diverticular Disease. Am Surg 2021; 88:929-935. [PMID: 34964694 DOI: 10.1177/00031348211058623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race. METHODS Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race. RESULTS Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001. CONCLUSION There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.
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Affiliation(s)
- Warqaa M Akram
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nasreen Vohra
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - William Irish
- Division of Surgical Research, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Emmanuel E Zervos
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Jan Wong
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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Lemini R, Jabbal IS, Stanek K, Borkar SR, Spaulding AC, Kelley SR, Colibaseanu DT. Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay. BMC Surg 2021; 21:163. [PMID: 33765978 PMCID: PMC7993534 DOI: 10.1186/s12893-021-01166-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/17/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility. METHODS Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients. RESULTS Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001). CONCLUSIONS Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.
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Affiliation(s)
- Riccardo Lemini
- Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Iktej S Jabbal
- Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Krystof Stanek
- Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Shalmali R Borkar
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Osagiede O, Haehn DA, Spaulding AC, Otto N, Cochuyt JJ, Lemini R, Merchea A, Kelley S, Colibaseanu DT. Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review. Surg Endosc 2020; 35:5480-5488. [PMID: 32989545 DOI: 10.1007/s00464-020-08039-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/22/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.
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Affiliation(s)
- Osayande Osagiede
- Department of Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, USA
| | | | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA. .,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.
| | - Nolan Otto
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA
| | - Riccardo Lemini
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Scott Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
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Hospital robotic use for colorectal cancer care. J Robot Surg 2020; 15:561-569. [PMID: 32876922 DOI: 10.1007/s11701-020-01142-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.
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Lemini R, Attwood K, Almerey T, Gunn J, Yeager TE, Elias AW, Partain K, Jorgensen MS, Ji W, Gabriel EM, Colibaseanu DT. Is metastasectomy a worthy option?-the role of surgery in metastatic colon cancer to liver and lungs. J Gastrointest Oncol 2019; 10:1032-1048. [PMID: 31949921 DOI: 10.21037/jgo.2019.09.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The role of surgery and metastasectomy is controversial in the treatment of stage IV colon cancer (CC). The aim of this study was to investigate the relationship between primary tumor resection (PTR) with metastasectomy and survival in patients diagnosed with metastatic CC. Methods The National Cancer Data Base (NCDB) was retrospectively queried for patients diagnosed with colon adenocarcinoma from 2004 to 2013. Patient demographics, clinical characteristics, and short-term outcomes were collected. Groups were generated based on if surgery was performed and, if so, was metastasectomy involved. Associations between groups were evaluated using Kruskal-Wallis and Pearson Chi-square tests. Overall survival (OS) was summarized using standard Kaplan-Meier methods. The association between surgical group and OS was evaluated using the log-rank test. Results Of 31,172 patients, 13,214 (42.4%) had surgery while 17,958 (57.6%) did not. Among these, 81.3% of patients had liver metastases only, while 18.7% of patients had both liver and lung metastases. Median OS was 15.1 months (95% CI: 14.8 to 15.5 months) for the entire cohort. However, median OS was significantly better for those who had surgery (either PTR alone or PTR with metastasectomy) compared to those who did not (21.8 vs. 7.5 months, P<0.001). Patients who received PTR with metastasectomy had worse median OS (20.5 vs. 21.8 months, P=0.035) compared to those who only received PTR (P=0.211). Conclusions PTR in select patients diagnosed with metastatic CC provides a remarkable improvement to survival rate. The role of metastasectomy remains controversial as no difference in survival outcomes exists between patients who received it and who did not.
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Affiliation(s)
- Riccardo Lemini
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Tariq Almerey
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jinny Gunn
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | | | - Wenyan Ji
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Emmanuel M Gabriel
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Dorin T Colibaseanu
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
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