S. R. Thumma1, J. R. Thumma1, A. Ibrahim1, J. B. Dimick1 1University Of MIchigan, Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA
Introduction: Racial disparities in the use of minimally invasive technology, such as laparoscopic colectomy, are well documented. However, the underlying reasons for these disparities are not well understood. One potential explanation is that minorities receive care in hospitals that are less likely to use minimally invasive approaches. We sought to examine racial disparities in the use of laparoscopic technology for colectomy and explore the contributing factors, including whether the differences in the use of the minimally invasive approach can be explained by the hospitals where minorities receive their care.
Methods: We studied all patients with colon cancer who underwent colectomy (N=112,183, N=1,901 hospitals) in the national Medicare population over 3 years (2010-2012). Univariate and multivariate logistic regression models were used to examine the relationship between race and the use of the laparoscopic approach. In our analyses, we controlled for patient factors (age, gender, race and Elixhauser comorbidities), neighborhood socioeconomic status (SES), and the year of procedure. We present our results stratified by the degree of hospital segregation (i.e., quintiles of the concentration/proportion of blacks in the hospital). Moreover, we assessed the impact of hospitals on the use of laparoscopy by adjusting directly for them using fixed effects models.
Results: In the national Medicare population, 37% of patients received a laparoscopic approach to colectomy. When examining the racial composition of the hospitals where these patients received care, there appeared to be a large degree of racial segregation. For example, the proportion of black patients in a hospital ranged from 0% in the bottom 20th percentile to 49.2% in the top 20th percentile. Black patients were 23% less likely to receive laparoscopic colectomy when compared to non-black patients (OR, 0.77; 95% CI, 0.74-0.80). When each contributing factor was assessed independently using univariate analysis, 36% of the observed disparity in receiving laparoscopic colectomy was explained by the hospitals in which they received care (OR, 0.85; 95% CI, 0.82-0.89) and 39% was explained by SES (OR, 0.86; 95% CI, 0.83-0.89). After adjusting for differences in the hospitals where they received care, SES, and patient factors in a single model, we were able to explain 63% of the observed disparity, leaving 37% of the remaining disparity unexplained. However, even after adjusting for all these factors, black patients were still found to be 9% less likely to receive a laparoscopic colectomy compared to their non-black counterparts (OR, 0.91; 95% CI, 0.87-0.96).
Conclusion: Black patients are less likely than non-black patients to have access to laparoscopic procedures for colon cancer. These disparities are explained in large part by black patients receiving care in hospitals that are less likely to use the minimally invasive approach.