Regional Variation in Surgery for Gastroesophageal Reflux Disease in Ontario

Regional variation in the use of surgery in Ontario

BACKGROUND

Regional variation in the use of surgery implies that there is uncertainty regarding appropriate use. The objectives of this study were to identify which surgical procedures are most commonly performed in the province of Ontario and measure the extent of variation in the use of surgical procedures across Ontario counties.

METHODS

We used the Canadian Institute for Health Information Discharge Abstract Database, Same Day Surgery Database and National Ambulatory Care Reporting System to retrieve information on all inpatient and day surgery visits in Ontario between Apr. 1, 2002, and Mar. 31, 2011. We identified the 84 most common procedures according to Canadian Classification of Interventions codes. We calculated rates of use for each procedure throughout the 49 Ontario counties and then calculated measures of variation (quartile ratio and systematic component of variation) in use between the counties.

RESULTS

Colonoscopy was the most commonly performed procedure during the study period, with an average adjusted rate of 2012 per 100 000 population. The procedure with the highest measure of variation was iridectomy, with a quartile ratio of 6.7, followed by colposcopy (5.2), cervical biopsy (4.2) and femoral arteriography (4.1). These procedures were less commonly performed. Common procedures such as colonoscopy, cataract extraction and vaginal delivery had lower quartile ratios. Analysis using the systematic component of variation as the measure of variation gave similar results.

INTERPRETATION

Colonoscopy was the most commonly performed procedure in Ontario, and cataract extraction was the most common surgical procedure. Procedures with the highest measures of variation between counties tended to be those that occurred less commonly in Ontario, and common procedures were associated with less regional variation.

Who’s in the driver's seat? The influence of patient and physician enthusiasm on regional variation in degenerative lumbar spinal surgery: a population-based study

STUDY DESIGN

Cross-sectional population-based study using administrative databases, census data, and surveys of orthopedic/neurosurgeons, family physicians (FPs) and patients in Ontario, Canada.

OBJECTIVE

To determine the influence of the enthusiasm of patients, FPs, and surgeons for surgery on the regional variation in surgical rates for degenerative diseases of the lumbar spine (DDLS), such as spinal stenosis and degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Rates of surgery and healthcare costs for treating DDLS have been increasing. Regional variation in spinal surgical rates has been observed and it is thought that the enthusiasm of patients and physicians for surgery contributes to this variation.

METHODS

Using population-based administrative databases, we included all patients aged 50 years and older who underwent DDLS surgery (i.e., decompression/laminectomy, fusion) from 2002 to 2006 and calculated standardized utilization rates across counties. We measured regional "enthusiasm for surgery" for surgeons, FPs, and patients, using responses from a province-wide survey. Small-area variation analysis and multivariate Poisson regression models were performed calculating incidence rate ratios (IRRs) controlling for county demographics, socioeconomic measures, prevalence of disease, and community resources.

RESULTS

We identified 10,318 DDLS surgeries (mean age 65 years, 50.6% female). Significant regional variation was observed (extremal quotient 5.0, coefficient of variation 28.0). Counties with higher rates of surgery had higher surgeon enthusiasm for surgery (IRR: 1.26, P < 0.013), older (IRR: 2.17, P < 0.0001) male patients (IRR: 1.19, P < 0.0001), lower income (IRR: 0.89, P < 0.0015), more knowledge of official languages (IRR: 1.12, P < 0.0003), and the presence of magnetic resonance imaging scanners (IRR: 1.30, P < 0.004). FP and patient enthusiasm for surgery, physician supply, and prevalence of disease were not statistically associated with higher surgical rates.

CONCLUSION

Prior studies have not addressed the role of patient enthusiasm for surgery. Although patients and FPs had variable enthusiasm for surgery, surgeon enthusiasm was the dominant potentially modifiable factor influencing surgical rates. Prevalence of disease and community resources were not related to surgical rates. Strategies targeting surgeon practices may reduce regional variation in care and improve access disparities.