title: Fundoplication for gastroesophageal reflux disease: regional variability and factors predicting operative approach.
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.
authors.affiliation: Division of Digestive Diseases, Department of Medicine, University of Oklahoma Health Science Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Salman
authors.initials: S
authors.lastname: Nusrat
authors.forename: Klaus
authors.initials: K
authors.lastname: Bielefeldt
mesh_terms: D000328:Adult; D002648:Child; D016208:Databases, Factual; D005260:Female; D018662:Fundoplication / Q000191:economics / Q000706:statistics & numerical data*; D005764:Gastroesophageal Reflux / Q000208:ethnology / Q000601:surgery*; D062306:Geography, Medical; D006801:Humans; D007348:Insurance, Health; D010535:Laparoscopy / Q000706:statistics & numerical data; D008297:Male; D010342:Patient Acceptance of Health Care; D012737:Sex Factors; D012959:Socioeconomic Factors; D014481:United States; D044465:White People
keywords: fundoplication rate; incentive; laparoscopic surgery; state difference