Socioeconomic Disparities in Outcomes and Access to High-Volume Centers for Anatomic Pulmonary Resections

J. Hadaya¹, S. Mallick², A. Vadlakonda³, Y. Sanaiha⁴, S. Kim², N. Cho⁵, P. Benharash^6
1David Geffen School of Medicine at UCLA, Los Angeles, California ²UCLA, Los Angeles, California ³David Geffen School of Medicine at UCLA, Saratoga, California ⁴University of California, Los Angeles, Los Angeles, California ⁵David Geffen School of Medicine, Los Angeles, California ⁶UCLA Division of Cardiac Surgery, Los Angeles, California

Purpose: There is significant evidence for improved surgical outcomes at high-volume centers performing major thoracic and abdominal operations. With limited data regarding disparities in access, we evaluated the association of race, sex, income, and insurance type on access to high-volume hospitals, as well as acute outcomes following pulmonary resection.

Methods: The 2016 to 2020 National Inpatient Sample was used to identify all elective adult hospitalizations for anatomic lung resections for lung cancer. The NIS approximates 97% of hospitalizations in the United States and is a component of the Healthcare Cost and Utilization Project, a national effort to evaluate healthcare outcomes and costs. Based on published guidelines by the Leapfrog group, centers performing 40 cases or greater were considered high-volume centers (HVC). The primary outcome of the study was in-hospital mortality while secondary endpoints included major complications, length of stay, and hospitalization costs. Complications were grouped into neurologic (stroke), cardiac (ventricular arrhythmias, heart failure, tamponade), pulmonary (pneumonia, empyema, mechanical ventilation > 24 hours, tracheostomy), postoperative infection, and renal (acute kidney injury). Mixed effects regression models were fit to evaluate the impact of demographic factors on receipt of care at a high-volume center, as well as outcomes following lung resection.

Results: Among 144,015 patients meeting study criteria, 54.6% were performed at high-volume centers. Compared to others, patients treated at HVC were of similar age (67.4 vs 67.0 years, p=0.03), sex distribution (53.3% vs 54.1% female, p< 0.001), but more commonly had private insurance (28.5% vs 24.7%). In addition, patients managed at HVC were more commonly White (81.5% vs 80.7%, p< 0.001) and more commonly in the highest income quartile (25.5% vs 21.7%, p< 0.001). After risk-adjustment, age and female sex were not associated with receipt of care at HVC. Relative to Private, Medicare (odds ratio, OR, 0.89, 95% CI 0.82-0.96) and Medicaid (OR 0.73, 95% CI 0.65-0.83) insurance were associated with reduced odds of care at HVC. Relative to White race, only Hispanic race had lower odds of treatment at HVC (OR 0.70, 95% CI 0.56-0.88), while other studied races were comparable. Regardless of insurance status, those in the lowest income quartiles had reduced probability of treatment at HVC (Figure). Prior to and following risk adjustment, care at HVC was associated with reduced mortality and complications (Table). In addition, care at HVC was associated with reduced inpatient resource use, including shorter length of stay, as well as a reduction in non-home discharge (Table).

Conclusion: Among patients undergoing lung resection, HVC appears to be associated with superior clinical outcomes and reduced resource use. However, HVC treat a lower proportion of individuals that have low-income, are non-White, or have Medicaid or Medicare. These findings have important implications towards improving access to high-quality centers for lung resection.

Identify the source of the funding for this research project: None.