Impact of Patient, Hospital, and Operative Characteristics relative to Social Determinants of Health: Compliance with National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer.

INTRODUCTION: Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN) guidelines remains sub-optimal. We sought to assess the impact of patient (PCs), operative (OCs), and hospital characteristics (HCs), and social determinants of health (SDoH) on non-compliance with NCCN guidelines for colon cancer. METHODS: Patients treated for Stage I-III colon cancer from 2004-2017 were identified from National Cancer Database. Multi-level multivariable regression analysis was performed to identify factors associated with receipt of NCCN-compliant care, as well as quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH. RESULTS: Among 468,097 patients with colon cancer treated across 1,319 hospitals, one in four patients did not receive NCCN-compliant care (n=122,170, 26.1%). On regression analysis, older age (0.96, 95% CI 0.96-0.96), female sex (0.97, 95% CI 0.96-0.99), Black race (0.96, 95% CI 0.94-0.98), higher Charlson-Deyo score (0.84, 95% CI 0.82-0.86), tumor stage ≥II (0.42, 95% CI 0.40-0.44), and tumor grade ≥3 (0.33, 95% CI 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all p-values<0.05). Higher hospital volume (1.02, 95% CI 1.02-1.03), minimally invasive or robotic surgical approach (1.26, 95% CI 1.23-1.29), adequate (≥12) lymph node assessment (3.46, 95% CI 3.38-3.53), private insurance status (1.33, 95% CI 1.26-1.40), Medicare insurance status (1.42, 95% CI 1.35-1.49), and higher educational status (1.06, 95% CI 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all p-values<0.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, OCs contributed 12.9% to variation in guideline compliant care; SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care. CONCLUSION: Variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, while SDoH were associated with a smaller proportion of the variation.