title: Hospital variation in sphincter preservation for elderly rectal cancer patients.
abstract: BACKGROUND
  The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients.
  
  
  METHODS
  Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference.
  
  
  RESULTS
  The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation.
  
  
  CONCLUSIONS
  Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Dodgion
authors.affiliation: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Bridget A
authors.initials: BA
authors.lastname: Neville
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.affiliation: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Deborah
authors.initials: D
authors.lastname: Schrag
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Breen
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Zinner
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin. Electronic address: greenberg@surgery.wisc.edu.
authors.forename: Caprice C
authors.initials: CC
authors.lastname: Greenberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D015897:Comorbidity; D013505:Digestive System Surgical Procedures / Q000379:methods; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009367:Neoplasm Staging; D059351:Organ Sparing Treatments / Q000706:statistics & numerical data*; D010502:Perineum / Q000601:surgery; D011237:Predictive Value of Tests; D044469:Racial Groups / Q000706:statistics & numerical data; D012004:Rectal Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D018426:SEER Program / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors
keywords: Elderly; Hospital variation; Rectal cancer; Sphincter sparing surgery
references.citation: World J Surg. 2013 Mar;37(3):639-45
references.pmid: 23224073
references.citation: Surg Oncol. 2007 Dec;16 Suppl 1:S117-20
references.pmid: 18023571
references.citation: Br J Surg. 2004 May;91(5):610-7
references.pmid: 15122614
references.citation: Dis Colon Rectum. 2005 Feb;48(2):270-84
references.pmid: 15711865
references.citation: J Clin Oncol. 2004 Jan 1;22(1):166-74
references.pmid: 14701779
references.citation: Ann Surg. 2007 Aug;246(2):215-21
references.pmid: 17667499
references.citation: Health Serv Res. 2008 Aug;43(4):1145-63
references.pmid: 18248404
references.citation: N Engl J Med. 2002 Apr 11;346(15):1128-37
references.pmid: 11948273
references.citation: Am Surg. 2006 Oct;72(10):906-8
references.pmid: 17058732
references.citation: Med Care. 2002 Aug;40(8 Suppl):IV-26-35
references.pmid: 12187165
references.citation: J Natl Cancer Inst. 2003 May 21;95(10):708-16
references.pmid: 12759388
references.citation: Arch Surg. 2004 Feb;139(2):151-5; discussion 156
references.pmid: 14769572
references.citation: Dis Colon Rectum. 2004 Aug;47(8):1341-9
references.pmid: 15484348
references.citation: Ann Surg. 2005 Mar;241(3):465-9
references.pmid: 15729069
references.citation: Acta Gastroenterol Belg. 2007 Oct-Dec;70(4):374-80
references.pmid: 18330097
references.citation: Pediatr Blood Cancer. 2010 Oct;55(4):621-8
references.pmid: 20806361
references.citation: Ann Surg. 2007 Jan;245(1):88-93
references.pmid: 17197970
references.citation: World J Gastroenterol. 2006 May 28;12(20):3186-95
references.pmid: 16718838
references.citation: Cancer. 1998 Dec 1;83(11):2408-18
references.pmid: 9840542
references.citation: Ann Surg. 1998 Feb;227(2):157-67
references.pmid: 9488510
references.citation: Int J Colorectal Dis. 2010 Dec;25(12):1389-96
references.pmid: 20661600
references.citation: J Clin Epidemiol. 1992 Jun;45(6):613-9
references.pmid: 1607900
references.citation: JAMA. 2002 Oct 23-30;288(16):1987-93
references.pmid: 12387650
references.citation: Ann Surg. 2002 Nov;236(5):583-92
references.pmid: 12409664
references.citation: Ann Surg Oncol. 2008 Nov;15(11):3036-47
references.pmid: 18712449
references.citation: N Engl J Med. 1989 Dec 21;321(25):1720-5
references.pmid: 2594031
references.citation: Dis Colon Rectum. 2012 Dec;55(12):1229-35
references.pmid: 23135580
references.citation: Int J Colorectal Dis. 2013 Apr;28(4):493-501
references.pmid: 23053680
references.citation: Br J Surg. 2009 May;96(5):462-72
references.pmid: 19358171
references.citation: J Natl Compr Canc Netw. 2009 Sep;7(8):838-81
references.pmid: 19755047
references.citation: Clin Colorectal Cancer. 2003 Nov;3(3):165-71
references.pmid: 14706175
references.citation: J Am Coll Surg. 2010 Sep;211(3):325-30
references.pmid: 20800188
references.citation: J Natl Compr Canc Netw. 2005 Jul;3(4):531-9
references.pmid: 16038644
references.citation: Surg Oncol. 2004 Dec;13(4):223-34
references.pmid: 15615660
references.citation: Dis Colon Rectum. 2010 Feb;53(2):115-20
references.pmid: 20087084
references.citation: Health Serv Res. 2003 Jun;38(3):923-45
references.pmid: 12822919
references.citation: Semin Ultrasound CT MR. 2005 Aug;26(4):259-68
references.pmid: 16152740
references.citation: JAMA. 2006 Oct 25;296(16):1973-80
references.pmid: 17062860
references.citation: J Clin Epidemiol. 2000 Dec;53(12):1258-67
references.pmid: 11146273
references.citation: J Surg Res. 2003 Sep;114(1):50-6
references.pmid: 13678698
references.citation: World J Gastroenterol. 2011 Mar 21;17(11):1475-9
references.pmid: 21472107
references.citation: Ann Surg. 2009 Feb;249(2):236-42
references.pmid: 19212176
references.citation: Arch Surg. 2009 Feb;144(2):113-20; discussion 121
references.pmid: 19221321
references.citation: Dis Colon Rectum. 2013 Oct;56(10):1134-42
references.pmid: 24022530
references.citation: Lancet Oncol. 2012 Dec;13(12):e525-36
references.pmid: 23182193
references.citation: World J Gastroenterol. 2011 Feb 21;17(7):855-61
references.pmid: 21412495
references.citation: Colorectal Dis. 2008 May;10(4):314-27; discussion 327-9
references.pmid: 18190614
references.citation: Surg Innov. 2007 Sep;14(3):192-8
references.pmid: 17928618
references.citation: J Surg Res. 2013 Jul;183(1):238-45
references.pmid: 23298948
references.citation: Dis Colon Rectum. 2005 Feb;48(2):195-202; discussion 202-4
references.pmid: 15812583
references.citation: Ann Surg Oncol. 2008 Nov;15(11):3101-8
references.pmid: 18719965
references.citation: Med Care. 2013 Jan;51(1):60-7
references.pmid: 23047124
references.citation: Eur J Surg Oncol. 2008 Jan;34(1):42-8
references.pmid: 17905562
references.citation: Dis Colon Rectum. 2007 Aug;50(8):1119-27; discussion 1126-7
references.pmid: 17573548
references.citation: Ann Surg. 2009 Aug;250(2):260-7
references.pmid: 19638922
references.citation: Colorectal Dis. 2013 Jun;15(6):e309-16
references.pmid: 23586660
references.citation: Ann Surg Oncol. 2001 Mar;8(2):163-9
references.pmid: 11258782
references.citation: Med Care. 2002 Aug;40(8 Suppl):IV-96-103
references.pmid: 12187174
references.citation: Surgery. 2006 Sep;140(3):367-71
references.pmid: 16934597
references.citation: JAMA. 1997 Aug 13;278(6):485-90
references.pmid: 9256223