Health Care Utilization Prior to Ovarian Cancer Diagnosis in Publicly Insured Individuals in New York State.

Background: Women with early-stage ovarian cancer may be asymptomatic or present with nonspecific symptoms. We examined health care utilization prior to ovarian cancer diagnosis to assess whether women with higher utilization differed in their prognosis and outcomes compared to women with low utilization. Methods: Using Medicaid, Medicare, and New York State Cancer Registry data for ovarian cancer cases diagnosed in 2006-2015, we examined selected health care visits that occurred 1-6 months before ovarian cancer diagnosis. We used multivariable-adjusted logistic regression to estimate odds ratios (ORs) and 95% CIs for associations of sociodemographic factors with number of prediagnostic visits and number of visits with tumor characteristics, and Cox proportional hazards regression to examine differences in survival by number of visits. Results: Women with >5 vs 0 prediagnostic visits were statistically significantly less likely to be diagnosed with distant vs local stage disease (OR, 0.72; 95% CI, 0.54-0.96), and women with 3-5 or >5 vs 0 prediagnostic visits had better overall survival (hazard ratio [HR], 0.88; 95% CI, 0.80-0.96 and HR, 0.90; 95% CI, 0.83-0.98, respectively). In stratified analyses, the association with improved survival was observed only among cases with regional or distant stage disease. Conclusions: Women with high health care utilization prior to ovarian cancer diagnosis may have better prognosis and survival, possibly because of earlier detection or better access to care throughout treatment. Women and their health care providers should not ignore symptoms potentially indicative of ovarian cancer and should be persistent in following up on symptoms that do not resolve.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States.

INTRODUCTION: Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population. METHODS: U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders. RESULTS: Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29). CONCLUSIONS: Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

Geographic diffusion of digital mammography in the United States.

BACKGROUND: Examining temporal and spatial diffusion of a new technology, such as digital mammography, can provide important insights into potential disparities associated with access to new medical technologies and how quickly these technologies are adopted. Although digital mammography is currently a standard technology in the United States for breast cancer screening, its adoption and geographic diffusion, as medical facilities transitioned from film to digital units, has not been explored well. METHODS: This study evaluated the geographic diffusion of digital mammography facilities from 2001 to 2014 in the contiguous United States (excluding Alaska and Hawaii) and estimated the geographic accessibility to this new technology for women aged ≥45 years at the census tract level within a 20-minute drivetime by population density, rural/urban residence, and race/ethnicity. The number of mammography units by technology type (film or digital) and density per 10,000 women were also summarized. RESULTS: The adoption of digital mammography advanced first in densely populated regions and last in remote rural areas. Overall, proportion of digital mammography units increased from 1.4% in 2001 to 94.6% in 2014, but since 2008, there was a decline in density of units from 2.31 per 10,000 women aged ≥45 years to 1.97 in 2014. In 2014, approximately 87% of women aged ≥45 years in the contiguous United States had accessibility to digital mammography, but this proportion was substantially lower for Native American women (67%) and rural residents (32%). CONCLUSION: Understanding the diffusion of and accessibility to digital mammography may help predict future medical technology diffusion and assess its role in geographic differences in cancer diagnosis and treatment.

The geography of Medicare's hospital value-based purchasing in relation to market demographics.

OBJECTIVE: To illustrate the association between the sociodemographic characteristics of hospital markets and the geographic patterns of Medicare hospital value-based purchasing (HVBP) scores. DATA SOURCES AND STUDY SETTING: This is a secondary analysis of United States hospitals with a HVBP Total Performance Score (TPS) for 2019 in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database (4/2021 release) and American Community Survey (ACS) data for 2015-2019. STUDY DESIGN: This is a cross-sectional study using spatial multivariable autoregressive models with HVBP TPS and component domain scores as dependent variables and hospital market demographics as the independent variables. DATA COLLECTION/EXTRACTION METHODS: We calculated hospital market demographics using ZIP code level data from the ACS, weighted the 2019 CMS inpatient Hospital Service Area file. PRINCIPAL FINDINGS: Spatial autoregressive models using eight nearest neighbors with diversity index, race and ethnicity distribution, families in poverty, unemployment, and lack of health insurance among residents ages 19-64 years provided the best model fit. Diversity index had the highest statistically significant contribution to lower TPS (ß = -12.79, p < 0.0001), followed by the percent of the population coded to "non-Hispanic, some other race" (ß = -2.59, p < 0.0023), and the percent of families in poverty (ß = -0.26, p < 0.0001). Percent of the population was non-Hispanic American Indian/Alaskan Native (ß = 0.35, p < 0.0001) and percent non-Hispanic Asian (ß = 0.12, p < 0.02071) were associated with higher TPS. Lower predicted TPS was observed in large urban cities throughout the US as well as in states throughout the Southeastern US. Similar geographic patterns were observed for the predicted Patient Safety, Person and Community Engagement, and Efficiency and Cost Reduction domain scores but are not for predicted Clinical Outcomes scores. CONCLUSIONS: The lower predicted scores seen in cities and in the Southeastern region potentially reflect an inherent-that is, structural-association between market sociodemographics and HVBP scores.

Estimating uncertainty in a socioeconomic index derived from the American community survey.

Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.

Racial Disparities in Children, Adolescents, and Young Adults with Hodgkin Lymphoma Enrolled in the New York State Medicaid Program.

Background: We examined the impact of race/ethnicity and age on survival in a publicly insured cohort of children and adolescent/young adults (AYA; 15-39 years) with Hodgkin lymphoma, adjusting for chemotherapy using linked Medicaid claims. Materials and Methods: We identified 1231 Medicaid-insured patients <1-39 years diagnosed with classical Hodgkin lymphoma between 2005 and 2015, in the New York State Cancer Registry. Chemotherapy regimens were based on contemporary therapeutic regimens. Cox proportional hazards regression models quantified associations of patient, disease, and treatment variables with overall survival (OS) and disease-specific survival (DSS), and are presented as hazard ratios (HR) with confidence intervals (95% CIs). Results: At median follow-up of 6.6 years, N = 1108 (90%) patients were alive; 5-year OS was 92% in children <15 years. In multivariable models, Black (vs. White) patients had 1.6-fold increased risk of death (HR: 1.58, 95% CI: 1.02-2.46; p = 0.042). Stage III/IV (vs. I/II) was associated with 1.9-fold increased risk of death (HR: 1.86, 95% CI: 1.25-2.78; p = 0.002) and treatment at a non-National Cancer Institute (NCI) affiliate was associated with worse DSS (HR: 2.71, 95% CI: 1.47-4.98; p = 0.001). Conclusions: In this Medicaid-insured cohort of children and AYAs with Hodgkin lymphoma, Black race/ethnicity remained associated with inferior OS in multivariable models adjusted for disease, demographic, and treatment data. Further work is needed to identify dimensions of health care access not mediated by insurance, as findings suggest additional factors are contributing to observed cancer disparities in vulnerable pediatric and AYA populations.

Endometrial Sampling for Preoperative Diagnosis of Uterine Leiomyosarcoma.

STUDY OBJECTIVES: To examine the effectiveness of endometrial sampling for preoperative detection of uterine leiomyosarcoma in women undergoing hysterectomy, identify factors associated with missed diagnosis, and compare the outcomes of patients who had a preoperative diagnosis with those of patients who had a missed diagnosis. DESIGN: Retrospective cohort study using linked data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry from 2003 to 2015. SETTING: Inpatient and outpatient encounters at civilian hospitals and ambulatory surgery centers in New York State. PATIENTS: Women with uterine leiomyosarcoma who underwent a hysterectomy and a preoperative endometrial sampling within 90 days before the hysterectomy. INTERVENTIONS: Endometrial sampling. MEASUREMENTS AND MAIN RESULTS: A total of 79 patients with uterine leiomyosarcoma met the sample eligibility criteria. Of these patients, 46 (58.2%) were diagnosed preoperatively, and 33 (41.8%) were diagnosed postoperatively. Patients in the 2 groups did not differ significantly in age, race/ethnicity, bleeding symptoms, or comorbidities assessed. In multivariable regression analysis, women who had endometrial sampling performed with hysteroscopy (compared with women who had endeometrial sampling performed without hysteroscopy) had a higher likelihood of preoperative diagnosis (adjusted risk ratio [aRR] 3.03; 95% confidence interval [CI], 1.43-6.42). Patients with localized stage (vs distant stage) or tumor size >11 cm (vs <8 cm) were less likely to be diagnosed preoperatively (aRR 0.50; 95% CI, 0.28-0.89, and aRR 0.54; 95% CI, 0.30-0.99, respectively). Supracervical hysterectomy was not performed in any of the patients whose leiomyosarcoma was diagnosed preoperatively compared with 21.2% of the patients who were diagnosed postoperatively (p = .002). CONCLUSION: Endometrial sampling detected leiomyosarcoma preoperatively in 58.2% of the patients. The use of hysteroscopy with endometrial sampling improved preoperative detection of leiomyosarcoma by threefold. Patients with a missed diagnosis had a higher risk of undergoing suboptimal surgical management at the time of their index surgery.

A comparison of two neighborhood-level socioeconomic indexes in the United States.

socioeconomic indexes that capture information about wealth, education, employment, and housing are in wide use in public health. Here we compare the widely used Area Deprivation Index (ADI) to the Yost index. Though they are derived largely from the same data, there are substantial differences between the two. Examination of the geographic areas where the two indexes are most dissimilar suggest that the Yost index has greater face validity and that the ADI is highly sensitive to locations with incomplete census data and with census data containing outliers.

Association between preexisting mental illnesses and mortality among medicaid-insured women diagnosed with breast cancer.

BACKGROUND: We investigated the impact of preexisting mental illnesses on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer. METHODS: Data from the New York State Cancer Registry for 10,444 women diagnosed with breast cancer from 2004 to 2016 and aged <65 years at diagnosis were linked with Medicaid claims. Women were categorized as having depression or a severe mental illness (SMI) if they had at least three relevant diagnosis claims with at least one claim within three years prior to breast cancer diagnosis. SMI included schizophrenia, bipolar disorder, and other psychotic disorders. Estimated menopausal status was determined by age (premenopausal age <50; postmenopausal age ≥50). Hazard ratios (HR) and 95% confidence intervals (95%CI) were calculated with Cox proportional hazards regression, adjusting for potential confounders. RESULTS: Preexisting SMI was associated with greater all-cause (HR = 1.36; 95%CI 1.18, 1.57) and cancer-specific (HR = 1.21; 95%CI 1.03, 1.44) mortality compared to those with no mental illnesses. No association was observed between preexisting depression and mortality. Among racial/ethnic subgroups, the association between SMI and all-cause mortality was observed among non-Hispanic white (HR = 1.47; 95%CI 1.19, 1.83) and non-Hispanic Asian/Pacific Islander (HR = 2.59; 95% 1.15, 5.87) women. Additionally, mortality hazards were greatest among women with preexisting SMI that were postmenopausal (HR = 1.49; 95%CI 1.25, 1.78), obese (HR = 1.58; 95%CI 1.26, 1.98), and had documented tobacco use (HR = 1.42; 95%CI 1.13, 1.78). CONCLUSION: Women with preexisting SMI prior to breast cancer diagnosis have an elevated mortality hazard and should be monitored and treated by a coordinated cross-functional clinical team.

Health Care Utilization Prior to Ovarian Cancer Diagnosis in Publicly Insured Individuals in New York State.

BACKGROUND: Women with early-stage ovarian cancer may be asymptomatic or present with nonspecific symptoms. We examined health care utilization prior to ovarian cancer diagnosis to assess whether women with higher utilization differed in their prognosis and outcomes compared to women with low utilization. METHODS: Using Medicaid, Medicare, and New York State Cancer Registry data for ovarian cancer cases diagnosed in 2006-2015, we examined selected health care visits that occurred 1-6 months before ovarian cancer diagnosis. We used multivariable-adjusted logistic regression to estimate odds ratios (ORs) and 95% CIs for associations of sociodemographic factors with number of prediagnostic visits and number of visits with tumor characteristics, and Cox proportional hazards regression to examine differences in survival by number of visits. RESULTS: Women with >5 vs 0 prediagnostic visits were statistically significantly less likely to be diagnosed with distant vs local stage disease (OR, 0.72; 95% CI, 0.54-0.96), and women with 3-5 or >5 vs 0 prediagnostic visits had better overall survival (hazard ratio [HR], 0.88; 95% CI, 0.80-0.96 and HR, 0.90; 95% CI, 0.83-0.98, respectively). In stratified analyses, the association with improved survival was observed only among cases with regional or distant stage disease. CONCLUSIONS: Women with high health care utilization prior to ovarian cancer diagnosis may have better prognosis and survival, possibly because of earlier detection or better access to care throughout treatment. Women and their health care providers should not ignore symptoms potentially indicative of ovarian cancer and should be persistent in following up on symptoms that do not resolve.

Variation in Adequate Lymph Node Yield for Gastric, Lung, and Bladder Cancer: Attributable to the Surgeon, Pathologist, or Hospital?

BACKGROUND: The Commission on Cancer recently released quality-of-care measures regarding adequate lymphadenectomy for colon, gastric, lung, and bladder cancer. There is currently little information regarding variation in adequate lymph node yield (ALNY) for gastric, lung, and bladder cancer. METHODS: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I-III gastric, stage I-II lung, and stage II-III bladder cancer resections from 2004 to 2014. Hierarchical models assessed factors associated with ALNY (gastric ≥ 15; lung ≥ 10; bladder ≥ 2). Additionally, the proportions of variation attributable to surgeons, pathologists, and hospitals were estimated among Medicare patients. RESULTS: Among 3716 gastric, 18,328 lung, and 1512 bladder cancer resections, there were low rates of ALNY (gastric = 53%, lung = 36%, bladder = 67%). When comparing 2004-2006 and 2012-2014, there was significant improvement in ALNY for gastric cancer (39% vs. 68%), but more modest improvement for lung (33% vs. 38%) and bladder (65% vs. 71%) cancer. Large provider-level variation existed for each organ system. After controlling for patient-level factors/variation, the majority of variation was attributable to hospitals (gastric: surgeon = 4%, pathologist = 2.8%, hospital = 40%; lung: surgeon = 13.8%, pathologist = 1.5%, hospital = 18.3%) for gastric and lung cancer. For bladder cancer, most of the variation was attributable to pathologists (surgeon = 3.3%, pathologist = 10.5%, hospital = 6.2%). CONCLUSIONS: ALNY rates are low for gastric, lung, and bladder cancer, with only modest improvement over time for lung and bladder cancer. Given that the proportion of variation attributable to the surgeon, pathologist, and hospital is different for each organ system, future quality improvement initiatives should target the underlying causes, which vary by individual organ system.

Impact of preexisting type 2 diabetes mellitus and antidiabetic drugs on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer.

BACKGROUND: We investigated the influence preexisting type 2 diabetes mellitus (T2DM) and antidiabetic drugs have on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer. METHODS: 9221 women aged <64 years diagnosed with breast cancer and reported to the New York State (NYS) Cancer Registry from 2004 to 2016 were linked with Medicaid claims. Preexisting T2DM was determined by three diagnosis claims for T2DM with at least one claim prior to breast cancer diagnosis and a prescription claim for an antidiabetic drug within three months following breast cancer diagnosis. Estimated menopausal status was determined by age (premenopausal age <50; postmenopausal age ≥50). Hazard ratios (HR) and 95 % confidence intervals (95 %CI) were calculated with Cox proportional hazards regression, adjusting for confounders. RESULTS: Women with preexisting T2DM had greater all-cause (HR = 1.40; 95 %CI 1.21, 1.63), cancer-specific (HR = 1.24; 95 %CI 1.04, 1.47), and cardiovascular-specific (HR = 2.46; 95 %CI 1.54, 3.90) mortality hazard compared to nondiabetic women. In subgroup analyses, the association between T2DM and all-cause mortality was found among non-Hispanic White (HR 1.78 95 %CI 1.38, 2.30) and postmenopausal (HR = 1.47; 95 %CI 1.23, 1.77) women, but not among other race/ethnicity groups or premenopausal women. Additionally, compared to women prescribed metformin, all-cause mortality hazard was elevated among women prescribed sulfonylurea (HR = 1.44; 95 %CI 1.06, 1.94) or insulin (HR = 1.54; 95 %CI 1.12, 2.11). CONCLUSION: Among Medicaid-insured women with breast cancer, those with preexisting T2DM have an increased mortality hazard, especially when prescribed sulfonylurea or insulin. Further research is warranted to determine the role antidiabetic drugs have on survival among women with breast cancer.

Centralizing Rectal Cancer Surgery: What Is the Impact of Travel on Patients?

BACKGROUND: It is unclear what impact centralizing rectal cancer surgery may have on travel burden for patients. OBJECTIVE: This study aimed to determine the impact of centralizing rectal cancer surgery to high-volume centers on patient travel distance. DESIGN: This is a population-based study. SETTINGS: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for patients with rectal cancer undergoing proctectomy. PATIENTS: Patients with stage I to III rectal cancer who underwent surgical resection between 2004 and 2014 were included. MAIN OUTCOME MEASURES: The outcome of interest was travel distance calculated as the straight-line distance between the centroid of the patient residence zip code and the hospital zip code. Mean distance was compared by using the Student t test. RESULTS: A total of 5860 patients met inclusion criteria. The total number of hospitals performing proctectomies for rectal cancer decreased between 2004 and 2014. The average number of proctectomies performed at high-volume centers (20+ resections/year) increased from 16.6 to 24.4 during this time. The average number of miles traveled by patients was 12.1 miles in 2004, and this increased to 15.4 in 2014. If proctectomies were centralized to high-volume centers, there would be 11 facilities. The mean distance traveled would be 24.5 miles. LIMITATIONS: This study is subject to the limitations of an administrative data set. There are no patient preference or referral data. CONCLUSIONS: The number of hospitals performing rectal cancer resections in New York State is decreasing and volume by center is increasing. There was a statistically significant difference in the mean distance traveled by patients over time. If rectal cancer resections were centralized to high-volume centers, the mean travel distance would increase by 9.5 miles. There would be a 321% increase in the number of patients having to travel 50+ miles for surgery. Any plan for centralization in New York State will require careful planning to avoid placing undue travel burden on patients. See Video Abstract at http://links.lww.com/DCR/B138. CENTRALIZACIÓN DE LA CIRUGÍA DE CÁNCER RECTAL: ¿CUÁL ES EL IMPACTO DEL VIAJE PARA LOS PACIENTES?: No está claro qué impacto puede tener la centralización de la cirugía de cáncer rectal en la carga de viaje para los pacientes.Determinar el impacto de centralizar la cirugía de cáncer rectal en centros de alto volumen sobre la distancia de viaje del paciente.Este es un estudio basado en cohorte poblacional.El Registro de Cáncer del Estado de Nueva York y el Sistema Cooperativo de Planificación e Investigación Estatal fueron consultados para pacientes con cáncer rectal sometidos a proctectomía.Pacientes con cáncer rectal en estadio I-III que se sometieron a resección quirúrgica entre 2004-2014.El resultado de interés fue la distancia de viaje calculada como la distancia en línea recta entre el centroide de la residencia del paciente y el código postal del hospital. La distancia media se comparó mediante la prueba t de Student.Un total de 5,860 pacientes cumplieron los criterios de inclusión. El número total de hospitales que realizaron proctectomías para cáncer rectal disminuyó entre 2004-2014. El número promedio de proctectomías realizadas en centros de alto volumen (más de 20 resecciones/año) aumentó de 16.6 a 24.4 durante este tiempo. El número promedio de millas recorridas por los pacientes fue de 12.1 millas en 2004 y esto aumentó a 15.4 en 2014. Si las proctectomías se centralizaran en centros de alto volumen, habría 11 instalaciones. La distancia media recorrida sería de 24.5 millas.Limitaciones inherentes a un conjunto de datos administrativos. No existen datos sobre preferencia del paciente o sobre referencia de los mismos.El número de hospitales que realizan resecciones de cáncer rectal en Nueva York está disminuyendo y el volumen por centro está aumentando. Hubo una diferencia estadísticamente significativa en la distancia media recorrida por los pacientes a lo largo del tiempo. Si las resecciones por cáncer rectal se centralizaran en centros de gran volumen, la distancia media de viaje aumentaría 9.5 millas. Habría un aumento del 321% en el número de pacientes que tienen que viajar más de 50 millas para la cirugía. Cualquier plan de centralización en Nueva York requerirá una planificación cuidadosa para evitar imponer una carga de viaje excesiva a los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B138.

Impact of geo-imputation on epidemiologic associations in a study of outdoor air pollution and respiratory hospitalization.

Imputation of missing spatial attributes in health records may facilitate linkages to geo-referenced environmental exposures, but few studies have assessed geo-imputation impacts on epidemiologic inference. We imputed patient Census tracts in a case-crossover analysis of fine particulate matter (PM2.5) and respiratory hospitalizations in New York State (2000-2005). We observed non-significantly higher PM2.5 exposures, high accuracy of binary exposure assignment (89 to 99%), and marginally different hazard ratios (HRs) (-0.2 to 0.7%). HR differences were greater in urban versus rural areas. Given its efficiency and nominal influence on accuracy of exposure classification and measures of association, geo-imputation is a candidate method to address missing spatial attributes for health studies.

Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer.

BACKGROUND: We examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. METHODS: Patients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. RESULTS: Among 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). CONCLUSIONS: Although extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.

A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer.

BACKGROUND: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Association Between Power Morcellation and Mortality in Women With Unexpected Uterine Cancer Undergoing Hysterectomy or Myomectomy.

PURPOSE: Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, we aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy is associated with increased mortality risk in women with occult uterine cancer. METHODS: By linking statewide hospital discharge records with cancer registry data in New York, we identified 843 women with occult endometrial carcinoma and 334 women with occult uterine sarcoma who underwent a hysterectomy or myomectomy for presumed benign indications during the period October 1, 2003, through December 31, 2013. Within this cohort, we compared disease-specific and all-cause mortality of women who underwent laparoscopic supracervical hysterectomy/laparoscopic myomectomy (LSH/LM), a surrogate indicator for uncontained power morcellation, with women who underwent supracervical abdominal hysterectomy and total abdominal hysterectomy (TAH), which did not involve power morcellation. Multivariable Cox regressions and propensity score method were used to adjust for patient characteristics. RESULTS: Among women with occult uterine sarcoma, LSH/LM was associated with a higher risk for disease-specific mortality than TAH (adjusted hazard ratio [aHR], 2.66, 95% CI, 1.11 to 6.37; adjusted difference in 5-year disease-specific survival, -19.4%, 95% CI, -35.8% to -3.1%). In the subset of women with leiomyosarcoma, LSH/LM was associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR, 3.64, 95% CI, 1.50 to 8.86; adjusted difference in 5-year disease-specific survival, -31.2%, 95% CI, -50.0% to -12.3%) and TAH (aHR, 4.66, 95% CI, 1.97 to 11.00; adjusted difference in 5-year disease-specific survival, -37.3%, 95% CI, -54.2% to -20.3%). Among women with occult endometrial carcinoma, there was no significant association between surgical approach and disease-specific mortality. CONCLUSION: Uncontained power morcellation was associated with higher mortality risk in women with occult uterine sarcoma, especially in those with occult leiomyosarcoma.

Surgeon, Hospital, and Geographic Variation in Minimally Invasive Colectomy.

OBJECTIVE: To identify sources of variation in the use of minimally invasive surgery (MIS) for colectomy. BACKGROUND: MIS is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study identified factors explaining variation in MIS use for colectomy. METHODS: The Statewide Planning and Research Cooperative System was queried for scheduled admissions in which a colectomy was performed for neoplastic, diverticular, or inflammatory bowel disease between 2008 and 2015. Mixed-effects analyses were performed assessing surgeon, hospital, and geographic variation and factors associated with an MIS approach. RESULTS: Among 45,714 colectomies, 68.1% were performed using an MIS approach. Wide variation in the rate of MIS was present across 1253 surgeons (median 50%, interquartile range 10.9%-84.2%, range 0.3%-99.7%). Calculating intraclass correlation coefficients after controlling for case-mix, 62.8% of the total variation in MIS usage was attributable to surgeon variation compared with 28.5% attributable to patient variation, 7% attributable to hospital variation, and 1.6% attributable to geographic variation. Surgeon-years in practice since residency/fellowship completion explained 19.2% of the surgeon variation, surgeon volume explained 5.2%, hospital factors explained 0.1%, and patient factors explained 0%. CONCLUSIONS: Wide surgeon variation exists regarding an MIS approach for colectomy, and most of the total variation is attributable to individual surgeon practices-much of which is related to year of graduation. As increasing surgeon age is inversely proportional to the rate of MIS, patient referral and/or providing tailored training to older surgeons may be constructive targets in increasing the use of MIS and reducing healthcare utilization.

Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients.

BACKGROUND: The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival. METHODS: Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1. RESULTS: Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival. DISCUSSION: Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.