Socioeconomic Disparities in Mortality After Cancer Surgery Reflect Higher Failure-to-Rescue Rates in Hospitals Treating More Low-Income Patients
Although it has been found that lower socioeconomic status is associated with higher operative mortality, the factors explaining this disparity have not been clearly defined. In a study of major cancer surgery reported in JAMA Surgery, Reames et al found that hospitals with the highest proportion of low socioeconomic status patients have higher failure-to-rescue rates among all socioeconomic status strata.
Study Details
This retrospective cohort study used the Medicare Provider Analysis and Review File and the Medicare Denominator File to identify 596,222 patients undergoing esophagectomy, pancreatectomy, partial or total gastrectomy, colectomy, lung resection, or cystectomy for cancer from 2003 through 2007. A summary measure of socioeconomic status was calculated for each zip code using 2000 U.S. Census data linked to residence.
The effect of socioeconomic status on rates of failure to rescue was analyzed by multivariable logistic regression, and the association of disparities with differences among hospitals was analyzed by fixed-effects hierarchical regression. The primary outcome measures were operative mortality, postoperative complications, and failure to rescue (defined as fatality after at least one complication).
Higher Failure-to-Rescue Rates
Patients in the lowest vs highest quintile of socioeconomic status had significantly increased rates of complications (25.6% vs 23.8%, P = .003), mortality (10.2% vs 7.7%, P = .0009), and failure to rescue (26.7% vs 23.2%, P = .007).
Crude odds ratios (ORs) for failure to rescue for lowest vs highest socioeconomic status quintiles were 1.20 (95% confidence interval [CI] = 1.16–1.25) for all operations and 1.10 for colectomy, 1.15 for cystectomy, 1.17 for gastrectomy, 1.23 for lung resection, 1.28 for esophagectomy, and 1.43 for pancreatectomy, with odds ratios being statistically significant for all operations and for each operation type except cystectomy.
After adjustment for patient factors, odds ratios were 1.16 (95% CI = 1.12–1.19) for all operations and 1.17 for colectomy, 1.18 for cystectomy, 1.04 for gastrectomy, 1.27 for lung resection, 1.12 for esophagectomy, and 1.45 for pancreatectomy and remained significant for all operations, colectomy, lung resection, and pancreatectomy.
Hospital Effect
For each operation, there was a higher rate of failure to rescue at hospitals treating more patients with low socioeconomic status, with all patients treated at these hospitals having higher failure-to-rescue rates regardless of patient socioeconomic status. Also for each operation, patients in the highest socioeconomic status quintile treated at hospitals with the most low socioeconomic status patients (lowest hospital quintile) had a higher failure-to-rescue rate than patients in the lowest socioeconomic status quintile treated at hospitals with the fewest low socioeconomic status patients (highest hospital quintile). The disparity was particularly marked for cystectomy and pancreatectomy.
Adjustment of failure-to-rescue analysis for hospital effect markedly reduced socioeconomic status–associated disparities. Thus, after correction for both patient characteristics and hospital effect, odds ratios for failure to rescue for lowest vs highest socioeconomic status were reduced to 1.05 (95% CI = 1.01–1.09) for all operations and 1.07 for colectomy, 0.96 for cystectomy, 0.95 for gastrectomy, 1.02 for lung resection, 0.95 for esophagectomy, and 1.22 for pancreatectomy, and were significant only for all operations and colectomy.
The investigators concluded, “Patients in the lowest quintile of [socioeconomic status] have significantly increased rates of [failure to rescue]. This finding appears to be in part a function of the hospital where patients with low [socioeconomic status] are treated. Future efforts to improve socioeconomic disparities should concentrate on hospital processes and characteristics that contribute to successful rescue.”
Amir A. Ghaferi, MD, MS, of University of Michigan, Ann Arbor, is the corresponding author or the JAMA Surgery article.
The study was supported by a grant from the National Institutes of Health. For full disclosures of the study authors, visit archsurg.jamanetwork.com.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
