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Comparative Study
. 2014 May;149(5):475-81.
doi: 10.1001/jamasurg.2013.5076.

Socioeconomic disparities in mortality after cancer surgery: failure to rescue

Bradley N Reames  1 , Nancy J O Birkmeyer  1 , Justin B Dimick  1 , Amir A Ghaferi  1
Affiliations
Comparative Study

Socioeconomic disparities in mortality after cancer surgery: failure to rescue

Bradley N Reames et al. JAMA Surg. 2014 May.

Abstract

Importance: Disparities in operative mortality due to socioeconomic status (SES) have been consistently demonstrated, but the mechanisms underlying this disparity are not well understood.

Objective: To determine whether variations in failure to rescue (FTR) contribute to socioeconomic disparities in mortality after major cancer surgery.

Design, setting, and participants: We performed a retrospective cohort study using the Medicare Provider Analysis and Review File and the Medicare Denominator File. A summary measure of SES was created for each zip code using 2000 US Census data linked to residence. Multivariable logistic regression was used to examine the influence of SES on rates of FTR, and fixed-effects hierarchical regression was used to evaluate the extent to which disparities could be attributed to differences among hospitals. A total of 596,222 patients undergoing esophagectomy, pancreatectomy, partial or total gastrectomy, colectomy, lung resection, and cystectomy for cancer from 2003 through 2007 were studied.

Main outcomes and measures: Operative mortality, postoperative complications, and FTR (case fatality after ≥1 major complication).

Results: Patients in the lowest quintile of SES had mildly increased rates of complications (25.6% in the lowest quintile vs 23.8% in the highest quintile, P = .003), a larger increase in mortality (10.2% vs 7.7%, P = .0009), and the greatest increase in rates of FTR (26.7% vs 23.2%, P = .007). Analysis of hospitals revealed a higher FTR rate for all patients (regardless of SES) at centers treating the largest proportion of patients with low SES. The adjusted odds ratios (95% CIs) of FTR according to SES ranged from 1.04 (0.95-1.14) for gastrectomy to 1.45 (1.21-1.73) for pancreatectomy. Additional adjustment for hospital effect nearly eliminated the disparity observed in FTR across levels of SES.

Conclusions and relevance: Patients in the lowest quintile of SES have significantly increased rates of FTR. This finding appears to be in part a function of the hospital where patients with low SES are treated. Future efforts to improve socioeconomic disparities should concentrate on hospital processes and characteristics that contribute to successful rescue.

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Conflict of interest statement

Financial Disclosure: BNR, AAG have no conflicts of interest or disclosures related to the content of this manuscript. JBD is a consultant and has an equity interest in ArborMetrix, Inc, which provides software and analytics for measuring hospital quality and efficiency. NJOB has no conflicts of interest outside those of her husband, who is chief scientific officer of ArborMetrix, Inc, mentioned above. The company had no role in conduction of this research or creation of this manuscript.

Figures

Figure 1
Figure 1
Rates of mortality, failure to rescue, and major complications for all operations across quintiles of SES (SES: socioeconomic status)
Figure 2
Figure 2
Adjusted failure to rescue among the lowest and highest patient quintiles of SES within the lowest and highest hospital quintiles of SES (SES: socioeconomic status; FTR: failure to rescue)
See this image and copyright information in PMC

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