Disparities in Surgical Oncologic Care
.jpg "Zachary A. Whitham, MD (he/him/his) photo")
Zachary A. Whitham, MD (he/him/his)
Resident
University of Texas Southwestern
Dallas, Texas, United States
Zachary A. Whitham, MD (he/him/his)
Resident
University of Texas Southwestern
Dallas, Texas, United States
Zachary A. Whitham, MD (he/him/his)
Resident
University of Texas Southwestern
Dallas, Texas, United States
Matthew R. Porembka, MD (he/him/his)
Associate Professor
University of Texas Southwestern Medical Center
Dallas, Texas, United States
Patricio M. Polanco, MD
Associate Professor
Department of Surgery, University of Texas Southwestern Medical Center
Dallas, Texas, United States
Sam C. Wang, MD
Associate Professor
University of Texas Southwestern Medical Center
Dallas, Texas, United States
John Mansour, MD
Professor of Surgery and Vice Chair of Quality
University of Texas Southwestern
Dallas, TX, United States
Herbert J. Zeh, III, MD
Professor and Chair
Department of Surgery, University of Texas Southwestern Medical Center
Dallas, TX, United States
Amit Singal, MD
Professor of Internal Medicine and Chair of Liver Disease
University of Texas Southwestern, United States
Adam Yopp, MD
Professor and Division Chief
UT Southwestern Medical School
Dallas, Texas, United States
Safety net hospitals (SNHs) deliver a disproportionate amount of care to under- and uninsured cancer patients providing the majority of care to racial/ethnic minority and low SES patients Hepatocellular carcinoma (HCC) disproportionately impacts racial/ethnic minorities, who consistently experience higher incidence and worse survival than non-Hispanic whites. Comparing patient outcomes across health care delivery systems can identify care delivery mechanisms contributing to this disparity and lead to the implementation of strategies to provide equity. The aim of this study was to characterize the intersectionality of hospital volume and SNH status in the treatment and survival of HCC patients.
Methods:
Patients diagnosed with HCC from 2004-2019 were identified in the Texas and California Cancer Registries. Hospital volume was stratified into low (LV) and high volume (HV) using Contal’s outcome-based method (HV:24 cases/year). Hospitals with CMS disproportionate share hospital index value in the upper 25th percentile were designated as SNH. We compared hospital and patient characteristics across four intersectional categories: HV/SNH, LV/SNH, HV/non-SNH, and LV/non-SNH. Covariate-adjusted treatment use and overall survival with shared frailty were compared among the 4 categories.
Results:
A total of 50,168 patients from 659 hospitals were identified and stratified into four intersectional categories: HV/SNH 13%; LV/SNH 12%; HV/non-SNH 37%; LV/non-SNH 38%. Black and Hispanic patients were disproportionately seen at SNHs, both high and low volume. Although tumor stage at presentation was similar, receipt of any treatment across all tumor stages was significantly lower at LV/SNHs (p< 0.001 for each SEER stage). After adjusting for patient demographics, race/ethnicity, tumor stage, diagnosis year, SES, and insurance status, LV/SNH was associated with less treatment (adjusted OR 0.84; 95%CI 0.79-0.89). Overall survival differed by intersectional category and after adjustment for covariates, LV/SNH, Black race/ethnicity, absence of treatment, and advanced tumor stage was associated with worse overall survival. HV/SNH, HV/non-SNH, Hispanic or Asian race/ethnicity was associated with improved overall survival. (Figure 1)
Conclusions:
Patients at LV/SNH are less likely to undergo any HCC treatment even when diagnosed at early stage, which likely contributes to worse overall survival. Hospital volume appears to mitigate racial/ethnic and SES disparities in HCC prognosis within lower resource care delivery systems.