Endometrial cancer surgery in Arizona: A statewide analysis of access to care

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Abstract

Objectives

To investigate access to surgical care for endometrial cancer in Arizona.

Methods

The Arizona HealthQuery (AZHQ) data warehouse with claims information on over 7 million patients in Arizona was searched using the International Classification of Disease (ICD-9) codes and Current Procedural Terminology (CPT) codes for endometrial cancer surgery from 2005 to 2008. Coordinates were gathered for patients and hospital to determine the distance traveled, race, insurance and annual caseload per hospital/surgeon were collected. Distance traveled was local (< 50 miles) or distant (≥ 50 miles) and served as the primary independent variable. Secondary variables included age, race, insurance, surgeon annual volume, and hospital annual volume. Logistic regression for distance traveled was performed for insurance coverage, race, hospital volume, and surgeon volume and expressed as an odds ratio.

Results

There were 1532 endometrial cancer surgeries performed at 67 hospitals by 242 surgeons in 15 counties. Most (61%) were performed by high-volume surgeons. Approximately 1 in 5 (19%) of patients traveled greater than 50 miles. Medicare insured patients were twice (OR = 2.07, 95% CI = 1.38–3.13) and Medicaid patients were three times (OR = 3.41, 95% CI = 1.89–6.15) as likely to travel over 50 miles. No significant difference was found between uninsured and privately insured patients (OR = 0.87, 95% CI = 0.45–1.68). Patients were more likely to travel to a high volume facility (OR 2.39, 95% CI = 1.26–4.51). Hispanics (OR = 2.72, 95% CI = 1.72–4.32) and Native Americans (OR = 8.60, 95% CI = 3.43–21.52) were more likely to travel compared to Caucasians.

Conclusion

In Arizona significantly different patterns of care are seen for endometrial cancer surgery based upon insurance coverage, race, surgeon and hospital. Patients travel farther to a high-volume hospital and high-volume surgeon. Hispanics or Native Americans travel farther for care when compared with Caucasians. Patients on government funded insurance plans travel farther for care than patients covered by private insurance or those lacking insurance.

Research Highlights

► We queried a statewide database of over 7 million patients. ► Different patters of care were observed by insurance, race, surgeon and hospital. ► Hispanics and Native Americans as well as those with public insurance travel farther.

Introduction

Endometrial cancer is the most commonly diagnosed gynecological malignancy in the United States. The American Cancer Society estimates that in 2009, there were 42,160 new endometrial cancers diagnosed and 7780 deaths [1]. The 5-year relative survival rate for endometrial cancer diagnosed at all stages is 83%. For early stage disease the 5-year survival approaches 96% [2].

In recent years, considerable interest in patterns of care has emerged in the oncology literature as data have illustrated better outcomes when surgeries are performed by specialists and high volume centers. Decreased mortality has been observed in surgeries done for pancreatic, esophageal, and bladder cancer resections when performed by high volume surgeons [3]. Harmon has reported similar patterns for colorectal cancer [4].

Bristow has extensively studied volume-based care in ovarian cancer in Maryland. Initial investigation found the majority (56%) of ovarian cancer cases were performed by low volume surgeons [5]. In a follow up study, the number of surgeries being performed by high volume surgeons increased from 35% to 65%. The number of cases done at high volume hospitals also increased from 22% to 61%. Analysis of this data revealed that high volume surgeons were significantly more likely to perform surgery that included a hysterectomy and staging, as well as cytoreductive surgical procedures [6]. Additional research has shown that annual hospital ovarian case volume of less than 10 cases is associated with a 2 times greater likelihood of suboptimal cytoreductive surgery [7].

Focusing on endometrial cancer, research by Diaz-Montes found that high volume surgeons and high volume hospitals have improved clinical outcomes, including a 48% reduction in the risk of in-hospital death [8]. Roland has compared clinical outcomes of cases initially managed by a general gynecologist to a gynecologic oncologist. When a gynecologic oncologist is involved with initial surgical staging of endometrial cancer, patients are more likely to receive complete staging. Further, patients are less likely to receive unnecessary radiation therapy for early stage disease [9]. These studies highlight the importance of specialty expertise when performing complex oncologic procedures.

At the time of this writing, The Society of Gynecologic Oncologists member directory lists 12 full and candidate members in Arizona. By comparison, the next less populous state (Massachusetts) has 28 full/candidate members. Calculations using data from the U.S. Census Bureau show there is 1 gynecologic oncologist per 540,000 residents in Arizona, while Massachusetts has 1 per 230,000 residents. Maryland, the focus of previous gynecologic oncology studies, has 1 per 240,000 residents [10].

According to the US Census Bureau, Arizona has had a 28.6% increase in its population from 2000 to 2009. With 1.6 million residents, its largest city, Phoenix, is the fifth largest city in the United States. The U.S. Census Bureau ranks Arizona as fourth in rate of population growth. Twenty-four percent of Arizona's population resides in remote and rural areas [10]. All 12 practicing gynecologic oncologists in Arizona are located in the Phoenix or Tucson metro areas. These data underscore the shortage of gynecologic oncologists in Arizona. With Arizona's diverse population, paucity of gynecologic oncologists, and geographic challenges, we chose to investigate surgical patterns of care for endometrial cancer in our state.

Section snippets

Materials and methods

The study design is a cross-sectional analysis of patient information investigating surgical care for endometrial cancer in Arizona. Arizona HealthQuery (AZHQ) is a data warehouse with healthcare claims information on over 7 million patients statewide in Arizona. The AZHQ was searched using the International Classification of Disease (ICD-9) codes and Current Procedural Terminology (CPT) codes for all surgeries performed in Arizona for endometrial cancer from 2005 to 2008. ICD-9 diagnosis codes

Demographics

From 2005 to 2008, 1532 endometrial cancer surgeries were performed at 67 hospitals by 242 surgeons in 15 counties in Arizona. Demographic characteristics are shown in Table 1. Most patients were Caucasians (80%) and privately insured (46%). The majority of patients were between ages 55 and 74 (50%). Most patients were characterized as local with surgery done at high volume hospitals by high volume surgeons. The majority of cases (49%) were performed in Maricopa County, in which Phoenix is

Conclusions

In Arizona significantly different patterns of care are seen for endometrial cancer staging based upon insurance coverage, race, surgeon and hospital. Patients travel farther to have surgery at a high-volume hospital by a high-volume surgeon compared with low-volume hospitals and/or surgeons. Hispanics or Native Americans travel farther for care when compared with Caucasians. Patients relying on government funded public insurance plans travel farther for care than patients covered by private

Conflict of interest statement

The authors declare that there are no conflicts of interest.

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Presented at the Society of Gynecologic Oncologists 41st Annual Meeting on Women's Cancer, San Francisco, Ca, March 14–17, 2010.

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