Race, Insurance, and Sex-Based Disparities in Access to High-Volume Centers for Pancreatectomy

Abstract

Abstract Background With a large body of literature demonstrating positive volume-outcome relationships for most major operations, minimum volume requirements have been suggested for concentration of cases to high-volume centers (HVCs). However, data are limited regarding disparities in access to these hospitals for pancreatectomy patients. Methods The 2005–2018 National Inpatient Sample (NIS) was queried for all elective adult hospitalizations for pancreatectomy. Hospitals performing more than 20 annual cases were classified as HVCs. Mixed-multivariable regression models were developed to characterize the impact of demographic factors and case volume on outcomes of interest. Results Of an estimated 127,527 hospitalizations, 79.8% occurred at HVCs. Patients at these centers were more frequently white (79.0 vs 70.8%; p < 0.001), privately insured (39.4 vs 34.2%; p < 0.001), and within the highest income quartile (30.5 vs 25.0%; p < 0.001). Adjusted analysis showed that operations performed at HVCs were associated with reduced odds of in-hospital mortality (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.34–0.55), increased odds of discharge to home (AOR, 1.17; 95% CI, 1.04–1.30), shorter hospital stay (β, −0.81 days; 95% CI, −1.2 to −0.40 days), but similar costs. Patients who were female (AOR, 0.88; 95% CI, 0.79–0.98), non-white (black: AOR, 0.66; 95% CI, 0.59–0.75; Hispanic: AOR, 0.56; 95% CI, 0.47–0.66; reference, white), insured by Medicaid (AOR, 0.63; 95% CI, 0.56–0.72; reference, private), and within the lowest income quartile (AOR, 0.73; 95% CI, 0.59–0.90; reference, highest) had decreased odds of treatment at an HVC. Conclusions For those undergoing pancreatectomies, HVCs realize superior clinical outcomes but treat lower proportions of female, non-white, and Medicaid populations. These findings may have implications for improving access to high-quality centers.