Exploring rural-urban differences in the receipt of nonelective cancer-specific gastrointestinal surgery using a multilevel mixed-effects approach

Crisanto M Torres; Sara Myers; Megan G Janeway; Sabrina E Sanchez; Dane R Scantling; Elizabeth S Davis; Sing Chau Ng; Tracey Dechert; Teviah E Sachs; Kelly M Kenzik

doi:10.1016/j.gassur.2024.10.013

Exploring rural-urban differences in the receipt of nonelective cancer-specific gastrointestinal surgery using a multilevel mixed-effects approach

J Gastrointest Surg. 2024 Oct 16:101858. doi: 10.1016/j.gassur.2024.10.013. Online ahead of print.

Affiliations

¹ Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States; Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States. Electronic address: crtorres@bu.edu.
² Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States.
³ Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States; Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States.
⁴ Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States; Department of Surgical Oncology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States.

PMID: 39419275
DOI: 10.1016/j.gassur.2024.10.013

Abstract

Background: Rural communities constitute a populace marked by various social challenges influencing health outcomes. As such, nonelective surgeries for cancer may have a disproportionate impact on rural populations. We explored patient and county-level factors contributing to differences in the receipt of nonelective cancer-specific surgery between rural and urban residents.

Methods: This retrospective study included adult patients captured in the Surveillance, Epidemiology, and End Results-Medicare data between January 2008 and December 2015 with an incident stage I to IV cancer of the stomach, liver/intrahepatic bile duct, pancreas, gallbladder/other biliary origin, or small intestine who underwent a cancer-specific surgery. The primary outcome was a nonelective cancer-directed surgery among rural vs urban residents. We conducted a multivariable mixed-effects logistic regression model to adjust for confounders while accounting for county-level clustering.

Results: The sample included 10,136 patients who underwent a surgical intervention; 2941 (29%) were nonelective. The incidence of nonelective surgery was lower among rural than urban patients (351 [27%] and 2590 [29%]; P = .05). There was no statistically significant difference in the unadjusted and adjusted odds of nonelective surgery between rural and urban residents (odds ratio, 0.88; 95% CI, 0.76-1.03; P = .11; adjusted odds ratio [aOR], 0.86; 95% CI, 0.72-1.02; P = .080). In addition, high social vulnerability index (SVI) counties or Black race was significantly associated with increase odds of nonelective surgery (aOR, 1.33; 95% CI, 1.07-1.65; P = .009; aOR, 1.49; 95% CI, 1.26-1.77; P < .0001, respectively).

Conclusion: This study found no difference in the odds of receiving nonelective surgery for gastrointestinal foregut cancers between rural and urban populations. However, Black race and high SVI were associated with higher odds of the receipt of nonelective surgery. Further research is warranted to explore whether disparities in clinical outcomes exist despite the comparable likelihood of receiving nonelective surgery between rural and urban communities.

Keywords: Emergency surgery; Inequities; Nonelective surgery; Rural outcomes; Rural-urban disparity.