The Population Uptake of Laparoscopic Colon Cancer Surgery in Canada:2004-2014
BACKGROUND Although the safety and efficacy of laparoscopic surgery in colon cancer (LAC) have been established, the proportion of colectomies for cancer being performed laparoscopically (use) and uptake (change in use) of the procedure in Canada is not known. OBJECTIVES The primary objective of this study was to describe the use and uptake of LAC in Canada on national and provincial levels. The secondary objective was to examine the impact of demographic (province, rural/urban residence, year of surgery), patient (age, sex, comorbidities, segment of colon resected), and system (average annual surgeon and hospital volume) factors on the use of LAC. METHODS This study was a time series analysis. The Discharge Abstract Database (DAD), held by the Canadian Institute for Health Information (CIHI), was used to identify all colectomies for colon cancer performed in all Canadian provinces, except Quebec, from April 1, 2004 to March 31, 2015. The overall and annual numbers of colectomies as well as proportions performed open and laparoscopically were described at national and provincial level. The impact of predictor variables on LAC by year of surgery was described. Multiple logistic regression was used to estimate the associations between demographic, patient and system covariates and the outcome of undergoing LAC. RESULTS Among 63,504 patients undergoing colon cancer resection, LAC was used in 19,691 (31%) while an open approach was used in 43,813 (69%). Across the nine provinces, the overall proportion of patients undergoing LAC increased from 9% in 2004 to 52% in 2014 in a relatively constant fashion. There were marked differences in rates of LAC by province; at the end of the study period it ranged from 11% in Newfoundland (NL) to 60% in British Columbia (p<0.001). On multivariate analysis, year of surgery (OR 9.31; 95% CI=8.60-10.09 for 2014 compared to 2004), urban residence (OR 1.24; 95% CI=1.18-1.30), high hospital volume (OR 2.04; 95% CI=1.96-2.13) and high surgeon volume (OR 1.29; 95% CI=1.24-1.35) were associated with increased use of LAC, whereas male sex (OR 0.94; 95% CI=0.90-0.98), low provincial uptake [OR 0.14; 95% CI=0.12-0.16 for NL compared to Ontario (ON)], higher level of comorbidities (OR 0.79; 95% CI=0.63-0.98 compared to no comorbidities) and left sided resections (OR 0.91; 95% CI=0.87-0.95 for left hemicolectomy, OR 0.58; 95% CI=0.55-0.62 for anterior resection compared to right hemicolectomy) were associated with decreased use. CONCLUSION Although there has been considerable uptake of LAC in Canada over the past decade, wide interprovincial variation remains. The use of laparoscopy at the individual patient level is related to patient factors, urban versus rural residence, and the local practice pattern as measured by average colectomy volumes at the surgeon level and hospital level.