A. A. Mokdad1, A. G. Singal2, J. A. Marrero2, A. C. Yopp1 1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Internal Medicine,Dallas, TX, USA
Introduction: Safety net hospitals play an integral role in the care of “vulnerable” patients with cancer. Following the institution of the Affordable Care Act (ACA), the fate of safety net hospitals is unclear. Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths and the fastest growing cancer in the United States. The role of safety net hospitals in the management of this health taxing cancer has not been investigated. This study explores the presentation, treatment, and outcomes of patients with HCC at safety net hospitals in effort to guide resource allocation during an evolving healthcare platform.
Methods: A total of 17,551 patients with HCC were identified in the Texas Cancer Registry between 2001 and 2012. Hospitals in the highest quartile of disproportionate share hospital index were classified safety net. Patient demographics, tumor presentation, treatment, and overall survival were compared among patients managed at safety net hospital(s), non-safety net hospital(s), or both. Risk-adjusted treatment utilization and overall survival were examined using multivariable analysis. The proportion of patients presenting at safety net hospitals over time was explored using time trend analysis. Transfer patterns between safety net and non-safety net hospitals were examined.
Results: A total of 328 acute short term hospitals were identified, 74 (23%) were designated safety net. Safety net hospitals were more likely teaching compared to non-safety net hospitals; oncology and radiology resources were comparable. Forty-three percent of HCC patients sought care at a safety net hospital (33% exclusively at safety net hospital(s) and 10% at both safety net and non-safety net hospitals). The proportion of HCC patients presenting at safety net hospitals did not significantly change over the study period time. Patients at safety net hospitals were mostly Hispanic (58%) and poor (61%). Tumor stage was comparable between hospitals categories. Overall treatment utilization was lower at safety net hospitals (adjusted odds ratio [OR]=0.85, 95% confidence interval [CI]=0.78-0.92) which was largely related to lower chemotherapy use (26% vs. 34%, P < 0.01). Overall survival was comparable (adjusted hazard ratio [HR]=1.03, 95% CI=0.99-1.08). In patients managed at both hospital groups, diagnosis and management of disease recurrence/persistence were more common at non-safety net hospitals, while first course treatment of HCC was more common at safety net hospitals.
Conclusion: Almost one in two patients with HCC seek care at safety net hospitals. While the fate of safety net hospitals remains uncertain under the ACA, monitoring the redistribution of HCC patients and anticipating resource allocation will be key in an evolving healthcare platform.