Increased Variation in Esophageal Cancer Treatment and Geographic Healthcare Disparity in Michigan

Abstract

Background: Regional variation in complex healthcare is shown to negatively impact health outcomes. We sought to characterize geographical variance in esophageal cancer surgery in Michigan. Study Design: Data for patients with loco-regional esophageal cancer from the Michigan Cancer Surveillance Program from 2000-2013 was analyzed. We reviewed the incidence of esophageal cancer by county and region, and those with loco-regional disease receiving an esophagectomy. Counties were aggregated into existing state-level “urban vs rural” designations, regions were aggregated using the Michigan Economic Recovery Council designations, and data was analyzed with Anova, F-test, and chi-squared test. Results: 8,664 patients had loco-regional disease, with 2,370 (27.4%) treated with surgery. Men were significantly more likely to receive esophagectomy than women (p<0.001), White more than non-White patients (p<0.001), insured more than non-insured patients (p=0.004), and rural more than urban patients (p<0.001). There were 8 regions and 83 counties, with 61 considered rural, and 22 urban. Region 1 (Detroit metro area, Southeast) contains the largest urban and suburban population and 4 major hospital systems, and was considered the baseline standard for access to care. Regions 2 (West) (p=0.011), 3 (Southwest) (p=0.024), 4 (East Central) (p=0.012), 6 (Northern Lower Peninsula) (p=0.008), and 8 (Upper Peninsula) (p<0.001) all had a statistically significant greater variance in annual rates of surgery compared to Region 1. Region 8 had the largest variance and was the most rural and furthest from Region 1. The variance in surgery rate between urban and rural differed significantly (P = 0.005). Conclusions: A significant increase in variation of care was found in rural vs urban counties, as well as in regions distant to larger hospital systems. Those of male sex, White race, rural residence, and also having insurance were significantly more likely to receive surgery.