Temporal trends in centralization and racial disparities in utilization of high-volume hospitals for lung cancer surgery

Abstract

Racial disparities have been suggested in hospital utilization and outcome for lung cancer surgery, but the effect of hospital centralization on closing this gap is unknown. We hypothesized that centralization has increased the utilization of high- or very-high-volume (HV/VHV) hospitals, a proxy for access to high-quality care, over the study period independently from race.Inpatient records were extracted from the New York Statewide Planning and Research Cooperative System database (1995–2012) according to Clinical Modification of the International Classification of Diseases, 9th Revision diagnosis codes 162.∗ and 165.∗ and surgical procedure codes 32.2–32.6 (n = 31,931). Patients treated exclusively with surgery of black or white race with a valid zip code were included. Logistic models were performed to determine factors associated with utilization of HV/VHV or low- or very-low-volume (LV/VLV) hospitals; these models were subsequently stratified by race.The percentage of both black and white patients utilizing HV/VHV hospitals increased over the study period (+22.7% and 13.9%, respectively). The distance to the nearest HV/VHV hospital and patient–hospital distance were significantly lower in black compared to white patients, however, blacks were consistently less likely to use HV/VHV than whites (odds ratioadj: 0.26; 95% confidence interval: 0.23–0.29), and were significantly more likely to utilize urban, teaching, and lower volume hospitals than whites. Likelihood of HV/VHV utilization decreased with an increasing distance from a HV/VHV hospital, overall and separately for black and white patients.Although centralization has increased the utilization of HV/VHV for both black and white patients, racial differences in access and utilization of HV hospitals persisted.

Lung Cancer Surgical Regionalization Disproportionately Worsens Travel Distance for Rural Patients

“…As these procedures are regionalizing, travel distance is also increasing; the effect on travel distance varies by age, race, and the specific procedure performed. 16,19,36,42 Our findings are in agreement with this literature. However, we find the overall increases in travel distance are driven by increases in travel distance for rural patients only, as urban patients actually saw a non-significant slight decrease in travel distance.…”

“…Although no specific policies have mandated regionalization in the United States, the spontaneous regionalization demonstrated in this study is occurring across the country for many types of major oncologic resections. 10,13,16,[30][31][32][33][34][35][36] The literature surrounding the extent of regionalization in cancer surgery primarily focuses on major gas-trointestinal and hepatobiliary resections. Pancreatic, esophageal, and hepatic resections are regionalizing over time and being performed at higher-volume hospitals with associated improvements in mortality.…”

“…The proportion of lung resections performed at HVC (defined as the highest tercile, >33 per year) increased from 33.8% to 45.7%. Lieberman-Cribbin and associates 36 showed over a 17-year period (1995-2012) in New York State that the total number of hospitals performing lung resection decreased from 134 to 96. The proportion of patients utilizing very high-volume hospitals (>55 surgeries per year) increased from 16.4% to 33.3%.…”

“…18 Multiple studies have examined the extent of regionalization for major gastrointestinal and hepatobiliary resections, 10,13,16,[30][31][32][33][34][35] but few studies have examined this specifically in lung cancer. 10,13,36 In addition, data examining the associated effect of regionalization on travel distance for rural patients are lacking.…”

Outcomes for Thoracoscopy Versus Thoracotomy Not Just Technique Dependent: A Study of 9,787 Patients

“…It is logical that VATS lobectomy would be performed at a higher rate in more recent years as surgeons have adopted the technique more commonly. Other differences may relate to practice patterns, such as wealthier patients with private insurance seeking care at nonteaching (private) hospitals or those with larger annual lung surgery volume [12]. Differences in the baseline characteristics for VATS and open sublobar resection cohorts may have similar influences, explaining why VATS patients were older, healthier and had surgery in a more recent year or at a hospital with higher annual lung surgery volume.…”