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Predicting opportunities to increase utilization of laparoscopy for rectal cancer

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Abstract

Background

Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer.

Methods

The Premier™ Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010–6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran–Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy.

Results

3336 patients were included—43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use.

Conclusions

Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

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Acknowledgements

The authors acknowledge the Medtronic Minimally Invasive Therapies Group for access to the data source and assistance with statistical modeling.

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Authors and Affiliations

  1. Division of Colon and Rectal Surgery, Department of Surgery, Baylor University Medical Center, 3500 Gaston Street, R-1013, Dallas, TX, 75246, USA

    Deborah S. Keller

  2. Healthcare Economics and Outcomes Research, Medtronic, Mansfield, MA, USA

    Jiejing Qiu

  3. University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Anthony J. Senagore

Authors
  1. Deborah S. Keller
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  2. Jiejing Qiu
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Corresponding author

Correspondence to Deborah S. Keller.

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Disclosures

Ms. Qiu is employed by Medtronic, which gave access to the data source and assistance with statistical analysis. Drs. Keller and Senagore have no conflicts of interest or financial ties to disclose.

Appendix: Rectal procedures and stoma codes

Appendix: Rectal procedures and stoma codes

46.04 Resection of exteriorized segment of large intestine

48.40 Pull-through resection of rectum, not otherwise specified

48.42 Laparoscopic pull-through resection of rectum

48.43 Open pull-through resection of rectum

48.50 Abdominoperineal resection of the rectum, not otherwise specified

48.51 Laparoscopic abdominoperineal resection of the rectum

48.52 Open abdominoperineal resection of the rectum

48.49 Other pull-through resection of rectum

48.59 Other abdominoperineal resection of the rectum

48.69 Other resection of rectum, (Partial proctectomy, Rectal resection NOS)

48.62 Anterior resection of rectum with synchronous colostomy

48.63 Other anterior resection of rectum

48.64 Posterior resection of rectum

48.65 Duhamel abdominoperineal pull-through

17.36 Laparoscopic Sigmoidectomy

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Keller, D.S., Qiu, J. & Senagore, A.J. Predicting opportunities to increase utilization of laparoscopy for rectal cancer. Surg Endosc 32, 1556–1563 (2018). https://doi.org/10.1007/s00464-017-5844-y

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