Ratnapradipa Kendra L, Lian Min, Jeffe Donna B, Davidson Nicholas O, Eberth Jan M, Pruitt Sandi L, Schootman Mario
1 Department of Epidemiology, Saint Louis University, St. Louis, Missouri 2 Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 3 Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri 4 Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina 5 Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina 6 South Carolina Rural Health Research Center, University of South Carolina, Columbia, South Carolina 7 Department of Clinical Sciences and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.
Dis Colon Rectum. 2017 Sep;60(9):905-913. doi: 10.1097/DCR.0000000000000874.
Surgical resection is the primary treatment for colon cancer, but use of laparoscopic approaches varies widely despite demonstrated short- and long-term benefits.
The purpose of this study was to identify characteristics associated with laparoscopic colon cancer resection and to quantify variation based on patient, hospital, and geographic characteristics.
Bayesian cross-classified, multilevel logistic models calculated adjusted ORs and CIs for patient, surgeon, hospital, and geographic characteristics and unexplained variability (predicted vs. observed values) using adjusted median odds ratios for hospitals and counties.
The Surveillance, Epidemiology, and End Results-Medicare claims database (2008-2011) supplemented with county-level American Community Survey (2008-2012) demographic data was used.
A total of 10,618 patients ≥66 years old who underwent colon cancer resection were included.
Nonurgent/nonemergent resections for colon cancer patients ≥66 years old were classified as laparoscopic or open procedures.
Patients resided in 579 counties and used 950 hospitals; 47% of patients underwent laparoscopic surgery. Medicare/Medicaid dual enrollment, age ≥85 years, and higher tumor stage and grade were negatively associated with laparoscopic surgery receipt; proximal tumors and increasing hospital size and surgeon caseload were positively associated. Significant unexplained variability at the hospital (adjusted median OR = 3.31; p < 0.001) and county levels (adjusted median OR = 1.28; p < 0.05) remained after adjustment.
This was an observational study lacking generalizability to younger patients without Medicare or those with Health Maintenance Organization coverage and data set did not reflect national hospital studies or hospital volume. In addition, we were unable to account for specific types of comorbidities, such as obesity, and had broad categories for surgeon caseload.
Determining sources of hospital-level variation among poor insured patients may help increase laparoscopic resection to maximize health outcomes and reduce cost. See Video Abstract at http://links.lww.com/DCR/A363.
手术切除是结肠癌的主要治疗方法，但尽管腹腔镜手术已被证明具有短期和长期益处，其使用差异却很大。
本研究旨在确定与腹腔镜结肠癌切除术相关的特征，并根据患者、医院和地理特征对差异进行量化。
采用贝叶斯交叉分类多级逻辑模型，使用医院和郡县的调整后中位数优势比，计算患者、外科医生、医院和地理特征以及无法解释的变异性（预测值与观察值）的调整后比值比（OR）和可信区间（CI）。
使用监测、流行病学和最终结果-医疗保险索赔数据库（2008 - 2011年），并补充县级美国社区调查（2008 - 2012年）的人口统计数据。
共纳入10618例年龄≥66岁且接受结肠癌切除术的患者。
将年龄≥66岁的结肠癌患者的非紧急/非急诊切除术分类为腹腔镜手术或开放手术。
患者分布在579个郡县，使用950家医院；47%的患者接受了腹腔镜手术。医疗保险/医疗补助双重参保、年龄≥85岁、肿瘤分期和分级较高与接受腹腔镜手术呈负相关；近端肿瘤以及医院规模扩大和外科医生病例量增加与接受腹腔镜手术呈正相关。调整后，医院层面（调整后中位数OR = 3.31；p < 0.001）和郡县层面（调整后中位数OR = 1.28；p < 0.05）仍存在显著的无法解释的变异性。
这是一项观察性研究，对没有医疗保险的年轻患者或有健康维护组织保险的患者缺乏普遍性，且数据集未反映全国性医院研究或医院手术量。此外，我们无法考虑特定类型的合并症，如肥胖症，并且外科医生病例量的分类较宽泛。
确定贫困参保患者中医院层面差异的来源可能有助于增加腹腔镜切除术的应用，以实现最佳健康结果并降低成本。见视频摘要：http://links.lww.com/DCR/A363 。
