Enthusiasm, Opinion Leaders, Comparative Advantage, and the Uptake Of Laparoscopic Resection For Colorectal Cancer Liver
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ORIGINAL ARTICLE – HEPATOBILIARY TUMORS
Enthusiasm, Opinion Leaders, Comparative Advantage, and the Uptake Of Laparoscopic Resection For Colorectal Cancer Liver Metastases in Ontario, Canada: A Population-Based Cohort Study Julian Wang, MD1, Pablo E. Serrano, MD2, Christopher Griffiths, MD2, Sameer Parpia, PhD3, and Marko Simunovic, MD2,3 1
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; 2Department of Surgery, McMaster University, Hamilton, ON, Canada; 3Department of Oncology, McMaster University, Hamilton, ON, Canada
ABSTRACT Background. Numerous factors likely influence adoption of surgical innovations in large regions. We considered the role of comparative advantage, surgeon enthusiasm, and opinion leaders on uptake of minimally invasive liver resection (MILR) for colorectal cancer (CRC) metastases in Ontario. Methods. We used administrative data for patients undergoing liver resection for CRC metastases from years 2006–2015. Fourteen regions were divided into three groups based on overall rate of MILR for CRC metastases. Outcomes included postoperative complications, length of hospital stay (LOS), operative mortality, and 1-year survival. We evaluated uptake of MILR among groups and within groups between opinion leader and nonopinion leader surgeons. Results. There were 2675 patients in the low-rate (n = 937), medium-rate (n = 919), and high-rate (n = 819) groups. In these same groups, the number of opinion leader surgeons was six, five, and six. Patient outcomes were similar among groups, except in the low-rate group LOS was 1 day greater (7 vs. 6 and 6; p = 0.017). The rate of MILR for CRC metastases did not change significantly among opinion leaders in any group. This rate among nonopinion leader surgeons was steady and low in the low-
Society of Surgical Oncology 2020 First Received: 6 July 2020 Accepted: 12 September 2020 M. Simunovic, MD e-mail: [email protected]
rate group (1.7–8.0%, p = 0.80) and increased in the midrate group (2.4–31.8%, p = 0.0026) and in the high-rate group (7.7–40.9%, p \ 0.001). Conclusions. Greater use of MILR was associated with a 1-day shorter LOS. Relative enthusiasm for MILR for CRC metastases among a small number of opinion leader surgeons likely facilitated or dampened uptake of this complex innovation.
Rogers suggested that in a healthcare system, the uptake of new therapies or procedures is largely driven by characteristics of individual adopters, and, innovation factors such as comparative advantage of an innovation over current standards.1 In surgery, numerous studies have demonstrated marked differences in rates of specific procedures among geographic regions (i.e., small area rate variations (SARVs)) and that these differences are not associated—or explained—by factors, such as burden of disease, resource levels, or even rates of inappropriate or uncertain care.2,3 Chassin hypothesized that SARVs for a given procedure are due to a small number of clinicians in high-rate regions having high ‘‘enthusiasm’’ and facilitating high
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