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Dis Colon Rectum. 2017 Sep;60(9):905-913. doi: 10.1097/DCR.0000000000000874.

Patient, Hospital, and Geographic Disparities in Laparoscopic Surgery Use Among Surveillance, Epidemiology, and End Results-Medicare Patients With Colon Cancer.

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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.



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

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