Defining the surgical workforce for colorectal cancer liver metastases: Impact on access to curative care.

Abstract

Access to liver surgeons for assessing colorectal cancer liver metastases reflects a critical resource influencing disparities in oncologic care. We analyzed the geographic distribution of liver surgeons treating Medicare patients with colorectal cancer liver metastases and its impact on survival. Liver surgeons were identified from hepatectomy billing claims for a cohort of patients aged 66-85 years with colorectal cancer liver metastases and no extrahepatic disease in the paired Surveillance, Epidemiology, and End Results-Medicare database (2008-2019) linked to the Medicare Data on Provider Practice and Specialty file. Surgeon distribution, clinic evaluation, and treatment rates were analyzed at the level of the health service area and the contributing state registry. Survival outcomes were assessed using multivariable Cox regression. A total of 421 surgeons performed 1,774 hepatic resections for 16,686 patients (resection rate 10.6%). Surgeon distribution varied, with 1 liver surgeon for every 143,000-534,000 people per contributing state. Many patients (42.4%) lived in a health service area where no liver surgery (for the study population) was performed. Living in a health service area with a liver surgeon significantly increased the odds of a clinic evaluation (odds ratio 1.22, 95% confidence interval 1.11-1.34). States with the fewest population-adjusted liver surgeons demonstrated lower odds of clinic evaluation (odds ratio 0.83, 95% confidence interval 0.74-0.93). Evaluation by a liver surgeon was associated with a decreased risk of death (hazards ratio 0.72, 95% confidence interval 0.67-0.78). Geographic disparities in liver surgeon distribution impacted rates of clinic evaluation and survival of patients with colorectal cancer liver metastases identified in Surveillance, Epidemiology, and End Results-Medicare. Future research should focus on strategies for improving access to liver surgeons.