良性息肉和结直肠癌的结肠切除术率的变化。
Variation in colectomy rates for benign polyp and colorectal cancer.
机构信息
Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.
Department of Gastroenterology, University of Michigan, Ann Arbor, MI, 48103, USA.
出版信息
Surg Endosc. 2021 Feb;35(2):802-808. doi: 10.1007/s00464-020-07451-5. Epub 2020 Feb 19.
BACKGROUND
Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp.
METHODS
We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race.
RESULTS
Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp.
CONCLUSIONS
The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.
背景
在筛查性结肠镜检查中切除癌前息肉是结直肠癌（CRC）预防的主要方法。复杂的息肉可能需要通过结肠切除术进行外科切除，这种手术的发病率为 17%，死亡率为 1.5%。最近，先进的内镜技术使一些患有复杂息肉的患者能够避免结肠切除术带来的发病率。然而，目前尚不清楚美国因良性息肉而行结肠切除术的比率，而且这种比率在不同地理区域之间的差异尚未得到研究。我们比较了结直肠癌与良性息肉的结肠切除术率的区域差异。
方法
我们对 2010 年至 2015 年期间接受结直肠癌或良性息肉结肠切除术的 Medicare 受益人的 100% Medicare 提供者分析和审查文件进行了回顾性基于人群的研究。我们使用多变量线性回归方法，在医院转诊区域（HRR）水平上获得 CRC 和良性息肉的基于人群的结肠切除术率，同时调整了年龄、性别和种族因素。
结果
在 280815 名患者中，有 157802 名（65.8%）因 CRC 而行结肠切除术，81937 名（34.2%）因良性息肉而行结肠切除术。在各 HRR 中，CRC 的结肠切除术率差异为 5.8 倍（每 1000 名受益人中有 0.32-1.84 例）。然而，良性息肉的差异为 69 倍（0.01-0.69）。虽然 CRC 的结肠切除术率与良性息肉的结肠切除术率相关（斜率=0.61，95%置信区间 0.48-0.75），但 CRC 的结肠切除术率最低或最高的 HRR 不一定也有同样低或高的良性息肉的结肠切除术率。
结论
与 CRC 相比，良性息肉的结肠切除术的使用差异要大得多，这表明在某些地区过度使用了结肠切除术来治疗良性息肉。这种差异可能源于提供者层面的差异，例如内镜医生的转诊实践或技能，或外科医生决定进行结肠切除术，或者由于获得先进内镜医生的机会有限。增加良性息肉内镜切除的干预措施可能会使一些患者免受手术的发病率和费用。
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