Digestive Diseases and Sciences

, Volume 61, Issue 6, pp 1669–1676 | Cite as

Socioeconomic Inequalities in the Utilization of Colorectal Stents for the Treatment of Malignant Bowel Obstruction

  • Philip N. Okafor
  • Derrick J. Stobaugh
  • Louis M. Wong Kee Song
  • Paul J. Limburg
  • Jayant A. Talwalkar
Original Article



Colorectal stents are increasingly employed as a bridge to surgery or for palliative relief of malignant large bowel obstruction.


To explore determinants of inpatient colorectal stent utilization (CRSU).


An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, 9th revision, codes were used to identify discharges associated with CRSU and patient/hospital factors for inclusion in a logistic regression model.


We identified 217,055 inpatient colonoscopies, approximating 1.1 million inpatient colonoscopies nationwide. Colorectal stents were placed in 1.4 % of all procedures. Across all racial groups, Medicare was the most common payer. Patients with commercial insurance had lower CRSU compared with Medicare patients [adjusted odds ratio (OR) 0.83, 95 % confidence interval (CI) 0.75–0.92]. No gender disparities were identified (OR 0.96, 95 % CI 0.89–1.03). In addition, no racial differences in CRSU existed between Caucasians versus African-Americans (OR 0.94, 95 % CI 0.83–1.06) and Caucasians versus Hispanics (OR 0.96, 95 % CI 0.83–1.1). Compared with patients living in less affluent neighborhoods, those residing in more affluent areas had higher CRSU (OR 1.65, 95 % CI 1.46–1.86). This displayed a linear relationship with the odds of CRSU increasing as household income increased. Less affluent patients also had the highest total charges and longest wait time to CRSU. CRSU was highest among patients treated in larger medical centers (OR 1.7, 95 % CI 1.51–1.93) and teaching hospitals (OR 3.9, 95 % CI 3.2–4.8).


Individuals from less affluent neighborhoods have lower colorectal stent utilization. This disparity is independent of race and likely related to poorer access to healthcare resources.


Disparities Healthcare resource utilization Self-expanding metal stents Palliative endoscopy 



Colorectal stent utilization


Nationwide Inpatient Sample


Author Contributions

Philip N. Okafor involved in study concept and design, literature review, data acquisition, interpretation, and preparation of the manuscript. Derrick J. Stobaugh involved in study design, data acquisition, analysis, interpretation, and manuscript preparation. Louis M. Wong Kee Song involved in data interpretation and critical revision of manuscript for important intellectual content. Paul J. Limburg involved in data interpretation and critical revision of manuscript for important intellectual content. Jayant A. Talwalkar involved in study concept, design, critical revision of manuscript for important intellectual content and study supervision.

Compliance with ethical standards

Conflict of interest

All authors have no financial, professional, or personal conflicts to disclose.


  1. 1.
    Mulcahy HE, Skelly MM, Husain A, et al. Long-term outcome following curative surgery for malignant large bowel obstruction. Br J Surg. 1996;83:46–50.CrossRefPubMedGoogle Scholar
  2. 2.
    Watt AM, Faragher IG, Griffin TT, et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg. 2007;246:24–30.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Dohmoto M, Rupp KD, Hohlbach G. Endoscopically-implanted prosthesis in rectal carcinoma. Dtsch Med Wochenschr. 1990;115:915.PubMedGoogle Scholar
  4. 4.
    van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2014;46:990–1053.CrossRefPubMedGoogle Scholar
  5. 5.
    Moroi R, Endo K, Ichikawa R, et al. The effectiveness of self-expandable metallic stent insertion in treating right-sided colonic obstruction: a comparison between SEMS and decompression tube placement and an investigation of the safety and difficulties of SEMS insertion in right colons. Gastroenterol Res Pract. 2014;2014:372918.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hong SP, Kim TI. Colorectal stenting: an advanced approach to malignant colorectal obstruction. World J Gastroenterol. 2014;20:16020–16028.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Repici A, de Paula Pessoa Ferreira D. Expandable metal stents for malignant colorectal strictures. Gastrointest Endosc Clin N Am. 2011;21:511–533. (ix).CrossRefPubMedGoogle Scholar
  8. 8.
    Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev. 2011;11:CD007378.PubMedGoogle Scholar
  9. 9.
    Cennamo V, Luigiano C, Coccolini F, et al. Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction. Int J Colorectal Dis. 2013;28:855–863.CrossRefPubMedGoogle Scholar
  10. 10.
    Kim BK, Hong SP, Heo HM, et al. Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery. Gastrointest Endosc. 2012;75:294–301.CrossRefPubMedGoogle Scholar
  11. 11.
    Alese OB, Kim S, Chen Z, et al. Management patterns and predictors of mortality among US patients with cancer hospitalized for malignant bowel obstruction. Cancer. 2015;121:1772–1778.CrossRefPubMedGoogle Scholar
  12. 12.
    Fitzgerald TL, Bradley CJ, Dahman B, et al. Gastrointestinal malignancies: when does race matter? J Am Coll Surg. 2009;209:645–652.CrossRefPubMedGoogle Scholar
  13. 13.
    Robbins AS, Siegel RL, Jemal A. Racial disparities in stage-specific colorectal cancer mortality rates from 1985 to 2008. J Clin Oncol. 2012;30:401–405.CrossRefPubMedGoogle Scholar
  14. 14.
    Pruitt SL, Davidson NO, Gupta S, et al. Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer. 2014;14:927.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Chen AY, Fedewa S, Pavluck A, et al. Improved survival is associated with treatment at high-volume teaching facilities for patients with advanced stage laryngeal cancer. Cancer. 2010;116:4744–4752.CrossRefPubMedGoogle Scholar
  16. 16.
    Alter DA, Naylor CD. Catheterization after myocardial infarction and the mismeasure of un-American inactivity. J Am Coll Cardiol. 1999;34:23–24.CrossRefPubMedGoogle Scholar
  17. 17.
    Eden SV, Heisler M, Green C, et al. Racial and ethnic disparities in the treatment of cerebrovascular diseases: importance to the practicing neurosurgeon. Neurocrit Care. 2008;9:55–73.CrossRefPubMedGoogle Scholar
  18. 18.
    Groeneveld PW, Epstein AJ, Yang F, et al. Medicare’s policy on carotid stents limited use to hospitals meeting quality guidelines yet did not hurt disadvantaged. Health Aff (Millwood). 2011;30:312–321.CrossRefGoogle Scholar
  19. 19.
    Chambers JD, May KE, Neumann PJ. Medicare covers the majority of FDA-approved devices and Part B drugs, but restrictions and discrepancies remain. Health Aff (Millwood). 2013;32:1109–1115.CrossRefGoogle Scholar
  20. 20.
    Zaide GB, Pekmezaris R, Nouryan CN, et al. Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care. 2013;11:5–11.CrossRefPubMedGoogle Scholar
  21. 21.
    Spencer BA, Insel BJ, Hershman DL, et al. Racial disparities in the use of palliative therapy for ureteral obstruction among elderly patients with advanced prostate cancer. Support Care Cancer. 2013;21:1303–1311.CrossRefPubMedGoogle Scholar
  22. 22.
    Katz MH. Hope for decreasing socioeconomic disparities. JAMA Intern Med. 2015;175:607.CrossRefPubMedGoogle Scholar
  23. 23.
    Chidi AP, Bryce CL, Myaskovsky L, et al. Differences in physician referral drive disparities in surgical intervention for hepatocellular carcinoma: a retrospective cohort study. Ann Surg. 2015;4:7–9.CrossRefGoogle Scholar
  24. 24.
    Dayyeh BK, Baron TH. Editorial: endoscopic stent placement as a bridge to surgery in malignant colorectal obstruction: a balance between study validity and real-world applicability. Am J Gastroenterol. 2011;106:2181–2182.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Philip N. Okafor
    • 1
  • Derrick J. Stobaugh
    • 2
  • Louis M. Wong Kee Song
    • 1
  • Paul J. Limburg
    • 1
  • Jayant A. Talwalkar
    • 1
    • 3
  1. 1.Division of Gastroenterology and HepatologyMayo ClinicRochesterUSA
  2. 2.North Shore University Health SystemSkokieUSA
  3. 3.Division of Health Care Policy and Research, Department of Health Sciences ResearchMayo ClinicRochesterUSA

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