Barriers to Transanal Endoscopic Surgery Referral in Canada

Abstract

Abstract Backgroud: Transanal endoscopic surgery (TES) is a minimally invasive procedure that allows for full thickness local excision of adenomas and select early rectal adenocarcinomas. Despite its advantages, TES is not uniformly utilized across Canada. Methods Potential barriers to TES referral were explored via a survey distributed to endoscopists across Canada, using a stratified sampling method. Results In total, 199/501 endoscopists completed our survey, including 62 (31%) gastroenterologists and 136 (69%) surgeons, consistent with a 39% response rate. For patients with clear and unclear indications for TES, 30/146 (27%) and 64/146 (44%) of referring endoscopists have a low referral rate, respectively. On univariable analysis, factors associated with low referral rate include lack of confidence with indications for TES [OR 9.9 (CI 3.15–31.4) p < 0.001], poor understanding regarding the advantages of TES [OR 11.3 (CI 3.83–33.1) p < 0.001], low comfort with referring [OR 183.7 (CI 21.9-1537.5) p < 0.001], distance greater than one hour from a TES surgeon [OR 5.786 (CI 2.63–12.8) p < 0.001] and lack of access to TES [OR 7.8 (CI 3.34-18.0) p < 0.001]. Gastroenterologists are more likely to have a low referral rate than surgeons [OR 2.76 (CI 1.30–5.8) p < 0.01]. On multivariable analysis, low comfort with referring [OR 67.4 (CI 5.8-779.8) p < 0.001] and greater distance to a TES surgeon [OR 4.5 (CI 1.17–16.9 p < 0.001)] remained independently associated with low referral rate. Provinces with a population of > 1 million [OR 3.66 (CI 1.49-9.0) p < 0.01], academic practice settings [OR 3.05 (CI 1.29–7.3) p < 0.05], and surgeon endoscopists [OR 4.5 (CI 1.68, 12.1) p < 0.01] were all independently associated with greater TES accessibility. Conclusions Many patients who are potentially eligible for TES are not being referred for consideration. An educational gap regarding indications, lack of comfort among referring physicians and geographic inaccessibility are among the greatest barriers to referral.