National Variation in Elective Colon Resection for Diverticular Disease.
National Variation in Elective Colon Resection for Diverticular Disease.
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DOI：
10.1097/sla.0000000000004236
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发表时间：
2022-02-01
影响因子：
9
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中科院分区：
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本研究旨在描述憩室炎择期乙状结肠切除术的地理变异程度，并确定与观察到的变异相关的因素。国家指南治疗复发性憩室炎未能提供强有力的建议或反对手术干预。我们假设医疗保健市场因素将与憩室炎结肠切除术（一种酌情手术干预）的地理差异显著相关。我们使用2013年1月至2015年9月的医疗保险服务中心100%住院LDS文件来计算每个医院转诊区域（HRR）的观察到的标准化结肠切除率与预期的标准化结肠切除率。然后，我们分析了患者，医院和市场水平的因素与结肠切除术的变化。对于每一个HRR，赫芬达尔-赫希曼指数（HHI），市场竞争的措施，计算。在研究期间，共有19,557名医疗保险患者在2,462家医院接受了憩室炎的选择性结肠切除术。标准化结肠切除率范围从塔斯卡卢萨HRR的0到密歇根州皇家橡树HRR的3.7。很少有患者因素与变异相关，但许多医院因素（规模、面积、利润状况和关键通路指定）都与变异相关。在对市场因素的分析中，外科医生密度的增加和市场竞争的减少与结肠切除术的预测率较高相关。我们观察到复发性憩室炎的标准化结肠切除率有明显的变化（超过3倍）。外科医生密度和医院水平因素与这种变化密切相关，可能是憩室病结肠切除术的主要驱动因素。需要进一步的调查和更强有力的国家指南来优化结肠切除术的患者选择。
This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation. National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention. We used Center for Medicare Services 100% inpatient LDS files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each Hospital Referral Region (HRR). We then analyzed patient, hospital and market level factors associated with variation of colectomy. For each HRR, Herfindahl-Hirschman index (HHI), a measure of market competition, was calculated. A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2,462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density and decreased market competition were associated with higher predicted rates of colon resection. We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy.