Disparities in the use of minimally invasive surgery for colorectal disease.
ABSTRACT Morbidity and mortality rates for major surgical procedures are decreased in high-volume hospitals (HVH). Additionally, HVH are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS). Although HVH often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at HVH.
Laparoscopic and open colectomies performed at HVH were identified using the 2008 Nationwide Inpatient Sample database. ICD-9 codes were used to identify MIS colorectal resections. Multiple logistic regression including ethnic and socioeconomic variables were used to identify independent predictive factors for undergoing MIS.
A total of 211,862 colorectal resections were performed at HVH in 2008. Only 16,637 (7.3%) colorectal resections were performed using MIS. When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo MIS than those in the lowest income groups. In addition, patients with Medicaid and uninsured patients were significantly less likely to undergo MIS compared to patients with private insurance. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH.
There are significant socioeconomic disparities in the use of MIS for colorectal disease at HVH. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.
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ABSTRACT: We have recently shown that the majority of patients undergoing fundoplication in the United States are women. Based on these findings, we hypothesized that nonbiological factors contribute to the decisions on surgical reflux therapy. Using State Inpatient Databases of the Agency for Healthcare Research and Quality, we extracted annual fundoplication rates, sex distribution, age cohorts, racial background, and insurance coverage. To account for potential differences in state populations, the results were normalized and correlated with Census data, adult obesity rates, median income, poverty rates, and physician workforce within the state. Fundoplication rates varied fivefold between states, ranging from 4.1 ± 0.1 per 100 000 in New Jersey to 21.8 ± 0.4 per 100 000 in Oregon. Higher poverty rates and a higher fraction of Caucasians within a state independently predicted higher fundoplication rates. While the majority of operations were performed laparoscopically, surgical approaches also differed between states with rates of laparoscopic ranging from 52.3 ± 1.8% in Oklahoma to 87.4 ± 1.7% in Hawaii. A lower number of pediatric and Medicaid-insured patient and a higher fraction of privately insured patients best predicted higher rates of laparoscopic surgery. Our study shows significant regional variation in surgical reflux management, which cannot be explained by differences in disease mechanisms. Insurance coverage and racial background influenced the likelihood of surgery, suggesting a role of financial incentives.Diseases of the Esophagus 10/2013; 27(8). DOI:10.1111/dote.12150 · 2.06 Impact Factor
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ABSTRACT: After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.World Journal of Gastroenterology 02/2014; 20(7):1777-1789. DOI:10.3748/wjg.v20.i7.1777 · 2.43 Impact Factor
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ABSTRACT: Background. The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. Methods. We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparosccrpy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. Results. A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). Conclusion. During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.Surgery 07/2014; 156(3). DOI:10.1016/j.surg.2014.03.046 · 3.11 Impact Factor