County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States

Abstract

Although counties are the smallest geographic level for comprehensive health-care delivery analysis, little is known about county-level variations in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States. A total of 179,189 patients aged≥ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the Districtof Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with≥ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression. Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8%to 48.6%in the lowest decile of counties, to 74.3%to 91.7%in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25%absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status. Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors.