title: Outcome comparison following colorectal cancer surgery in an equal access system.
abstract: BACKGROUND
  Previous reports suggest outcome differences following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to compare community and tertiary centers in an equal access system.
  
  
  METHODS
  Patients treated for CRC at Department of Defense medical facilities were stratified by care at tertiary (MEDCEN) versus community (MEDDAC) medical centers. Disease-free and overall survival outcomes were calculated, including Cox multivariate analysis.
  
  
  RESULTS
  A total of 6438 patients met inclusion criteria. Overall, 3347 operations were performed at MEDCENs and 3091 operations at MEDDACs. By stage, 25.6% were stage 1, 27.1% stage 2, 29.1% stage 3, and 18.2% stage 4. Mean number of lymph nodes harvested were 11.3 ± 10.2, with no difference between facilities. Disease-free survival at 5 y was similar between the two cohorts (mean 88.1%). Overall 5-y survival was 52.7% (MEDDAC) versus 46.8% (MEDCEN), P < 0.001, due to significant differences in stage 2 patients. Cox regression and logistic regression analysis identified stage 2 patients as independently associated with significantly increased 5-y mortality risk at MEDCEN.
  
  
  CONCLUSIONS
  Outcomes following surgery for CRC in an equal access system are improved in stage 2 patients treated at MEDDACs compared to high-volume, specialist-centered MEDCENs. Further evaluation into factors impacting improved overall survival at MEDDACs, including adjuvant therapy utilization, is warranted to optimize outcomes.
authors.affiliation: Department of Surgery, Madigan Army Medical Center, Fort Lewis, Washington 98431, USA.
authors.forename: Mia
authors.initials: M
authors.lastname: DeBarros
authors.forename: Marlin W
authors.initials: MW
authors.lastname: Causey
authors.forename: Eric K
authors.initials: EK
authors.lastname: Johnson
authors.forename: Justin A
authors.initials: JA
authors.lastname: Maykel
authors.forename: Scott R
authors.initials: SR
authors.lastname: Steele
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000401:mortality; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D012307:Risk Factors; D063128:Tertiary Health Care / Q000706:statistics & numerical data*; D014481:United States; D059030:United States Department of Defense / Q000706:statistics & numerical data
keywords: Colorectal cancer; Community care; Equal access system; Outcomes; Tertiary care