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Weeks KS, Gao X, Kahl AR, Engelbart J, Greteman BB, Hassan I, Kapadia MR, Nash SH, Charlton ME. Perspectives on Referring for Rectal Cancer Surgery: a Survey Study of Gastroenterologist and General Surgeons in Iowa. J Gastrointest Cancer 2024; 55:681-690. [PMID: 38151606 DOI: 10.1007/s12029-023-00998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.
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Affiliation(s)
- Kristin S Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, 43210, Columbus, OH, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
| | - Jacklyn Engelbart
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Breanna B Greteman
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Imran Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, 27599, Chapel Hill, NC, USA
| | - Sarah H Nash
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Mary E Charlton
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA.
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA.
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Nash S, Weeks K, Kahl AR, Del Vecchio NJ, Gao X, Guyton K, Charlton M. Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients. J Gastrointest Cancer 2024; 55:355-364. [PMID: 37646879 DOI: 10.1007/s12029-023-00963-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.
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Affiliation(s)
- Sarah Nash
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Kristin Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, Columbus, OH, 43210, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Natalie J Del Vecchio
- Division of Public Health Science, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Kristina Guyton
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Mary Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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McDermott J, Wang H, DeLia D, Sweeney M, Bayasi M, Unger K, Stein DE, Al-Refaie WB. Impact of Clinician Linkage on Unequal Access to High-Volume Hospitals for Colorectal Cancer Surgery. J Am Coll Surg 2022; 235:99-110. [PMID: 35703967 DOI: 10.1097/xcs.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Understanding drivers of persistent surgical disparities remains an important area of cancer care delivery and policy. The degree to which clinician linkages contribute to disparities in access to quality colorectal cancer surgery is unknown. Using hospital surgical volume as a proxy for quality, the study team evaluated how clinician linkages impact access to colorectal cancer surgery at high-volume hospitals (HVHs). STUDY DESIGN Maryland's Health Services Cost Review Commission was used to evaluate 6,909 patients who underwent colon or rectal cancer operations from 2013 to 2018. Two linkages based on patient sharing were examined separately for colon and rectal cancer surgery: (1) from primary care clinicians to specialists (gastroenterologist or medical oncologist) and (2) from specialists to surgeons (general or colorectal). A referral link was defined as 9 or more shared patients between 2 clinicians. Adjusted regression models examined associations between referral links and odds of receiving colon or rectal cancer operations at HVHs. RESULTS The cohort included 5,645 colon and 1,264 rectal cancer patients across 52 hospitals. Every additional referral link between a primary care clinician and a specialist connected to a HVH was associated with a 12% and 14% increased likelihood of receiving colon (odds ratio [OR] 1.12, CI 1.07 to 1.17) and rectal (OR 1.14, CI 1.08 to 1.20]) cancer operations at a HVH, respectively. Every additional referral link between a specialist and a surgeon at a HVH was associated with at least a 25% increased likelihood of receiving colon (OR 1.28, CI 1.20 to 1.36) and rectal (OR 1.25, CI 1.15 to 1.36) cancer operation at a HVH. CONCLUSIONS Patients of clinicians with linkages to HVHs are more likely to have their colorectal cancer operations at these hospitals. These findings suggest that policy interventions targeting clinician relationships are an important step in providing equitable surgical care.
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Affiliation(s)
- James McDermott
- From the David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA (McDermott)
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
| | - Haijun Wang
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
| | - Derek DeLia
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Matthew Sweeney
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
| | - Mohammed Bayasi
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Keith Unger
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - David E Stein
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Waddah B Al-Refaie
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
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Impact of Age on Multimodality Treatment and Survival in Locally Advanced Rectal Cancer Patients. Cancers (Basel) 2022; 14:cancers14112741. [PMID: 35681721 PMCID: PMC9179565 DOI: 10.3390/cancers14112741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Optimal treatment for locally advanced rectal cancer is neoadjuvant (chemo)radiation followed by radical surgery. This is challenging in the aging population because of frequently concomitant comorbidity. We analyzed whether age below and above 70 years is associated with differences in treatment strategy and outcome in this population-based study. Methods: Data between 2008 and 2016 were extracted from the Netherlands Cancer Registry with follow-up until 2021. Differences in therapy, referral and outcome were analyzed using χ2 tests, multivariable logistic regression and relative survival analysis. Results: In total, 6524 locally advanced rectal cancer patients were included. A greater proportion of patients <70 years underwent resection compared to older patients (89% vs. 71%). Patients ≥70 years were more likely treated with neoadjuvant radiotherapy (OR 3.4, 95% CI 2.61−4.52), than with chemoradiation (OR 0.3, 95% CI 0.23−0.37) and less often referred to higher volume hospitals for resection (OR 0.7, 95% CI 0.51−0.87). Five-year relative survival after resection following neoadjuvant therapy was comparable and higher for both patients <70 years and ≥70 years (82% and 77%) than after resection only. Resection only was associated with worse survival in the elderly compared to younger patients (56% vs. 75%). Conclusion: Elderly patients with locally advanced rectal cancer received less intensive treatment and were less often referred to higher volume hospitals for surgery. Relative survival was good and comparable after optimal treatment in both age groups. Effort is necessary to improve guideline adherence, and multimodal strategies should be tailored to age, comorbidity and performance status.
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