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Surgeon, Hospital, and Geographic Variation in Minimally Invasive Colectomy

Aquina, Christopher T., MD, MPH*; Becerra, Adan Z., PhD*; Justiniano, Carla F., MD*; Xu, Zhaomin, MD, MPH*; Boscoe, Francis P., PhD; Schymura, Maria J., PhD; Noyes, Katia, PhD, MPH*; Monson, John R. T., MD*,‡; Temple, Larissa K., MD, MSc*; Fleming, Fergal J., MD*

doi: 10.1097/SLA.0000000000002694

Objective: To identify sources of variation in the use of minimally invasive surgery (MIS) for colectomy.

Background: MIS is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study identified factors explaining variation in MIS use for colectomy.

Methods: The Statewide Planning and Research Cooperative System was queried for scheduled admissions in which a colectomy was performed for neoplastic, diverticular, or inflammatory bowel disease between 2008 and 2015. Mixed-effects analyses were performed assessing surgeon, hospital, and geographic variation and factors associated with an MIS approach.

Results: Among 45,714 colectomies, 68.1% were performed using an MIS approach. Wide variation in the rate of MIS was present across 1253 surgeons (median 50%, interquartile range 10.9%–84.2%, range 0.3%–99.7%). Calculating intraclass correlation coefficients after controlling for case-mix, 62.8% of the total variation in MIS usage was attributable to surgeon variation compared with 28.5% attributable to patient variation, 7% attributable to hospital variation, and 1.6% attributable to geographic variation. Surgeon-years in practice since residency/fellowship completion explained 19.2% of the surgeon variation, surgeon volume explained 5.2%, hospital factors explained 0.1%, and patient factors explained 0%.

Conclusions: Wide surgeon variation exists regarding an MIS approach for colectomy, and most of the total variation is attributable to individual surgeon practices—much of which is related to year of graduation. As increasing surgeon age is inversely proportional to the rate of MIS, patient referral and/or providing tailored training to older surgeons may be constructive targets in increasing the use of MIS and reducing healthcare utilization.

*Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY

New York State Cancer Registry, New York State Department of Health, Albany, NY

Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL.

Reprints: Christopher T. Aquina, MD, MPH, University of Rochester Medical Center, 601 Elmwood Ave., Box SURG, Rochester, NY 14642. E-mail:

Meeting presentation: Surgical Forum Podium Presentation at American College of Surgeons, 2016 Clinical Congress, Washington, DC, October 16 to 20, 2016.

The authors declare no conflict of interests.

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