C. M. Branche1, S. Sakowitz1,3, N. Cho1,3, N. Chervu1,2, S. Mallick1, J. Curry1,3, P. Benharash1,2 1David Geffen School Of Medicine, University Of California At Los Angeles, Cardiovascular Outcomes Research Laboratories, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Surgery, Los Angeles, CA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA
Introduction: While safety-net hospitals (SNH) play an essential role in caring for underserved patients, literature has reported inferior surgical outcomes and reduced access to minimally invasive (MIS) procedures at SNH. Nevertheless, the impact of hospital SNH status on surgical approach for colon resection remain ill defined. The present study aimed to define the association between SNH and likelihood of MIS resection for elective colectomy. We also evaluated for the interaction of race on clinical and financial outcomes at SNH.
Methods: All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Hospital-level safety-net burden was defined using the proportion of Medicaid or self-pay/uninsured admissions following Agency for Healthcare Research and Quality guidelines, with centers in the top quartile considered SNH. Surgical indication was identified using International Classification of Diseases, Tenth Edition codes. The primary outcome was receipt of MIS resection, with MIS comprising both laparoscopic and robotic operations. Secondary outcomes of interest included duration of hospitalization (LOS) and costs. Multivariable regression models were developed to assess the impact of SNH status on outcomes of interest. An interaction term was introduced to examine the incremental effect of race on SNH.
Results: Of an estimated 794,060 patients, 171,250 (21.6%) were treated at SNH. The SNH cohort was younger (60.0 ± 14.4 vs 62.4 ± 13.9 years, p<0.001), more commonly of lowest income quartile (30.9 vs 21.8%, p<0.05), and more commonly Black (12.1 vs 8.1%, p<0.05). Following adjustment, treatment at SNH was independently associated with decreased odds of MIS resection (Adjusted Odds Ratio AOR] 0.89, 95% Confidence Interval [CI] 0.84-0.94), (See Figure 1). Additionally, patients at SNH faced reduced likelihood of undergoing robotic resection (AOR 0.87, 95% CI 0.79-0.95). Management at SNH was also associated with increased costs (β +$2,100, 95% CI $1,500-2,700) and longer LOS (β +0.26 days, 95% CI 0.16-0.36 days). Considering Black patients, treatment at SNH was linked with decreased odds of both overall MIS (AOR 0.90, 95% CI 0.82-0.99) as well as robotic resection (AOR 0.85, 95% CI 0.74-0.97).
Conclusion: Management at SNH was linked with significantly lower likelihood of MIS resection. In addition, SNH status was associated with increased LOS and costs. Notably, at SNH Black patients demonstrated a striking reduction in odds MIS, suggesting an even greater racial disparity. Further investigations are warranted to identify hospital-level factors contributing to disparities in resource utilization at SNHs.
