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Socioeconomic Status and Access to Care: Do They Influence Outcomes in Pancreaticoduodenectomy?
Gregory C. Wilson*, Jeffrey M. Sutton, Koffi Wima, Ian M. Paquette, Jeffrey Sussman, Syed Ahmad, Michael J. Edwards, Shimul a. Shah, Daniel E. Abbott
Surgery, University of Cincinnati, Cincinnati, OH
PURPOSE: For pancreatic surgery, high volume (HV) centers have demonstrated superior outcomes. However, the effects of socioeconomic status (SES) and access to care on outcomes in pancreaticoduodenectomy (PD) are unknown.
METHODS: The University Healthsystems Consortium (UHC) database was queried to identify 9,883 adult patients undergoing (PD) from 2009-2011. Patients were stratified into quintiles based on a validated SES score. Patient distance to center was calculated using Maptitude Geographic Information System. Logistic regression determined how patient characteristics, including distance to center, influenced center access.
RESULTS: Lower SES patients undergoing PD were more likely to be younger (64 years vs. 67 years, p<0.001), black (20.9% vs. 3.4%, p<0.001), and have a higher severity of illness index (p<.001). Lower SES patients also had longer hospital stays (10 d vs. 9 d, p<0.001), increased hospital costs ($20,876 vs. $18,708, p<0.001) and were less likely to receive care at a HV center (37.7% vs. 43.8%, p<.001). Compared to the lowest SES patients, the highest SES patients resided closer to HV centers (36.2 miles [IQR 16.4-136.3] vs. 129.8 [IQR 46.0-217.9], p<0.001) and traveled less to undergo PD (18.7 miles [IQR 9.2-35.5] vs. 54.8 miles [IQR 13.6-109.1], p<0.001). Patients in the lowest SES quintile undergoing care at a HV center traveled a median distance of 71.1 miles (IQR 29.0-137.2), significantly further than the closest available center (43.0 [IQR 9.9-78.4], p<0.001) Lowest SES patients, when undergoing surgery at LV vs. HV centers, had longer hospital stays (12d vs. 9d, p<.001), increased hospital cost ($21,914 vs. $19,111, p<.001) and higher readmission rates (21.5% vs. 16.1%, p=0.01).
CONCLUSIONS: Low SES patients are less likely to access high volume centers, travel significantly further to do so, and have worse outcomes with disproportionate utilization of care at low volume centers. These data suggest that increased access to HV centers could improve outcomes in low SES patients.
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