C. Lee1, S. Sakowitz2, P. Benharash3, H. Keshava1 1University Of California – Irvine, Thoracic Surgery, Orange, CA, USA 2University Of California – Los Angeles, Cardiovascular Outcomes Research Laboratories, Los Angeles, CA, USA 3University Of California – Los Angeles, Cardiac Surgery, Los Angeles, CA, USA
Introduction:
Safety net hospital status is associated with high perioperative morbidity in pulmonary resection. Multiple etiologies have been proposed including delays in diagnosis, nonadherence to clinical protocols, and inefficiencies in care pathways. In integrated health systems, surgical volume has been shown to improve outcomes in pulmonary resection. However, it is unclear whether surgical volume can overcome the inherent challenges of safety net hospitals. We hypothesize that surgical volume is associated with improved perioperative morbidity at safety net hospitals.
Methods:
The 2016-2021 Nationwide Readmissions Database was queried for all adult (≥18 years) hospitalization records entailing elective lobectomy for lung cancer. The proportion of Medicaid or self-pay/uninsured admissions was computed for each institution, with centers in the top quartile defined as SNH. Based on annual lobectomy caseload, SNH were further stratified as Low (LVH, <10 cases/year), Medium (MVH, 10-33 cases/year), and High-Volume Centers (HVH, >33 cases/year). Multivariable regressions were built to consider the independent association of hospital volume on acute clinical and financial outcomes among patients treated at SNH.
Results:
Of a total 381 SNH, 87 (23%) were considered LVH and 12% HVH. HVH patients more frequently received video assisted thoracoscopic (41.5 vs 29.3%) or robotic lobectomy (27.8 vs 6.9%, P<0.001).
Following comprehensive risk adjustment, care at HVH remained associated with significantly reduced likelihood of major morbidity, with LVH as reference (AOR 0.81, 95%CI 0.68-0.97). Specifically, HVH was linked with lower likelihood of respiratory complications (AOR 0.79, CI 0.65-0.96) and need for blood transfusion (AOR 0.67, CI 0.48-0.93), as well as a near statistically-significant reduction in odds of perioperative infection (AOR 0.77, CI 0.57-1.02). HVH was associated with reduced likelihood of non-home discharge (AOR 0.66, CI 0.48-0.88), and a decrement in duration of hospitalization (β-1.02 days, CI -1.48, -0.54) and overall expenditures (β$-4,360, CI -7,020, -1,700).
Conclusion:
Surgical volume is associated with improved perioperative outcomes in pulmonary resection at safety net hospitals. Patients who are eligible for care only at safety net hospitals can still benefit from undergoing pulmonary resection at a high-volume centers.