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HISPANIC ETHNICITY IS ASSOCIATED WITH PROPORTIONATELY DECREASED USE OF WHIPPLE PROCEDURE: RESULTS OF A NATIONWIDE ANALYSIS
Paul T. Kroner*, Mohammad Afsh, John Stauffer, Frank Lukens
Mayo Clinic Florida, Jacksonville, FL
Introduction
Pancreatic cancer is the 4th leading cause of cancer-related death. Resection remains the therapeutic method of choice to attempt achieving cure with surgical approaches such as the Whipple procedure (WP). Studies have suggested the existence of racial disparities when comparing Caucasians to African Americans (AA) in areas such as access to surgical evaluation or outcomes. However, despite the Hispanic population continues to grow and now represents 17% of the US population, no study to date has examined disparities in this group. Therefore, the aim of this study was to assess the use of WP and other healthcare outcomes in Hispanic patients in the US using a national database.
Methods
Case-control study using the National Inpatient Sample 2014, the largest publically available inpatient database in the US. All patients with ICD-9 CM codes for WP were included. None were excluded. Hispanic patients were identified within the database. Population estimates were obtained from the US National Census Bureau. The primary outcome was the use of WP. Secondary outcomes were inpatient mortality, morbidity, resource utilization; length of hospital stay (LOS), total hospitalization charges and costs. Propensity score matching was used to create a 1:1 matching population, and was regressed against gender, age and Charlson Comorbidity Index. Multivariate analysis was used to adjust for income in patients' zip code, hospital region, location, size and teaching status.
Results
10,190 patients underwent WP, of which 1,780 were propensity-matched to controls (885 Hispanic). Mean age was 60 years, 46% were female. The use of WP in Hispanics was 1.6/100,000 persons (21.9/100,000 admissions) compared to 3.6/100,000 persons (29.9/100,000 admissions) of all other ethnicities. Hispanics had significantly lower incomes compared to all other ethnicities. All outcomes are in Table 1. Hispanics had associated increased odds of ICU stay (aOR:2.37,p=0.03), although no other associated difference in morbidity. Although mortality, postoperative complications, LOS and hospital costs did not otherwise differ, total charges were significantly higher in Hispanics compared to non-Hispanics.
Conclusion
Less Hispanics proportionately underwent WP compared to other ethnicities, suggesting the presence of ethnic disparities such as access to screening, healthcare and surgery. These may in themselves be explained by cultural or socioeconomic factors, which were evident in our study. No inpatient differences were noted in terms of morbidity, mortality or postoperative complications. Interestingly, although LOS and total costs did not differ from other ethnicities, total hospitalization charges were increased, suggesting potential differences in insurance models and coverage.
Table 1
| Variable | Hispanics | All Other Ethnicities | p-value | Whipple Procedure (per 100,000 persons)
| 1.6 | 3.6 | <0.01 | Whipple Procedure (per 100,000 admissions)
| 21.9 | 29.9 | <0.01 | Mean Income in Zipcode
$1 - $37,999
$38K - $47,999
$48K - $63,999
>$64,000 | 31%
31%
21%
17% | 21%
24%
21%
35% | <0.01 | | Variable | Adjusted Means | 95% CI | p-value | | Additional Hospital Costs | $5,971
| -$3,523 - $15,466
| 0.22 | | Additional Hospital Charges | $42,626
| $197 - $85,055
| 0.05 | | Additional Length of Stay (days) | 1.3 | -1.5 - 4.1
| 0.038 | | Variable | Adjusted Odds Ratio | 95% CI | p-value | | Mortality | 1.35 | 0.39-4.76
| 0.63 | | Shock | 0.63 | 0.22-1.81
| 0.40 | | ICU | 2.37 | 1.09-5.16
| 0.03 | | TPN | 1.06 | 0.48-2.37
| 0.89 | | Abdominal Ultrasound | 3.09 | 0.48-2.37
| 0.03 | | Multi-Organ Failure | 1.05 | 0.53-2.10
| 0.88 | Post-Operative Complications
Thromboembolism
Infection
Pulmonary Complications
Shock
Bleeding
Fistula Formation | 0.76
1.31
1.57
5.65
2.30
2.69 | 0.27 - 2.13
0.59 - 2.94
0.56 - 4.36
0.71 - 45.32
0.74 - 7.15
0.12 - 58.96 | 0.60
0.50
0.39
0.10
0.15
0.53 |
Table 1 - Prevalence, resource utilization, odds of bariatric surgery, inpatient mortality and morbidity of admitted Hispanic patients compared to all other ethnicities.
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