title: Differences in Physician Referral Drive Disparities in Surgical Intervention for Hepatocellular Carcinoma: A Retrospective Cohort Study.
abstract: OBJECTIVE
  To determine whether sociodemographic and geographic factors are associated with referral for surgery and receipt of recommended surgical intervention.
  
  
  BACKGROUND
  Surgical interventions confer survival advantages compared with palliative therapies for hepatocellular carcinoma (HCC), but disparities exist in use of surgical intervention. Few have investigated referral for surgery as a potential barrier to surgical intervention, and little is known about the effects of patient geographic factors, including proximity to surgical centers.
  
  
  METHODS
  Data were abstracted from the Pennsylvania Cancer Registry for patients with a diagnosis of HCC from 2006 to 2011. Using hospital procedure volume data from the Pennsylvania Health Care Cost Containment Council, we calculated proximity to a surgical center. We used multivariable logistic regression to determine whether geographic, racial, socioeconomic, and clinical factors were associated with referral for surgery and receipt of a recommended surgical intervention.
  
  
  RESULTS
  Of 3576 patients with HCC, 41.0% were referred for surgery. Patients who lived closer to a surgical center were less likely to be referred for surgery (adjusted odds ratio = 0.79; 95% confidence interval, 0.68-0.92). Surgical referral was less likely among older, male patients with Medicaid insurance and advanced tumor stage at diagnosis. Of those referred, 1276 (87.0%) underwent surgical intervention. Proximity to a surgical center was not associated with receipt of surgical intervention (P = 0.27). Patients with distant tumor stage at diagnosis were less likely to receive recommended surgical intervention (adjusted odds ratio = 0.27; 95% confidence interval, 0.15-0.50).
  
  
  CONCLUSIONS
  Geographic and sociodemographic disparities in referral for surgery may be major barriers to surgical intervention for patients with HCC.
authors.affiliation: *Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA †VA Pittsburgh Healthcare System, Pittsburgh, PA ‡Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA §Department of Health Policy & Management, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Alexis P
authors.initials: AP
authors.lastname: Chidi
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Bryce
authors.forename: Larissa
authors.initials: L
authors.lastname: Myaskovsky
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
authors.forename: David A
authors.initials: DA
authors.lastname: Geller
authors.forename: Douglas P
authors.initials: DP
authors.lastname: Landsittel
authors.forename: Allan
authors.initials: A
authors.lastname: Tsung
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012042:Registries; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D055815:Young Adult