MedicalResearch.com Interview with:
Emanuela Taioli MD PhD
Professor, Population Health Science and Policy, and Thoracic Surgery
Director, Institute for Translational Epidemiology
Director, Center for the Study of Thoracic Diseases Outcome
Director, Division of Social Epidemiology
Icahn Medical Institute,
New York, NY 10029
MedicalResearch.com: What is the background for this study?
Response: Extensive literature documenting the relationship between hospital volume and clinical outcomes has resulted in the centralization of cancer care advocating patients to seek cancer surgical procedures at high-volume (HV) hospitals. Lung resection and cystectomy have been specifically recommended for centralization, but improvements in outcomes are not shared equally among racial groups. It has also been reported that black patients more commonly undergo surgery at low-volume and lower-quality hospitals, despite living in close proximity to higher quality hospitals.
We investigated the effects of centralization on HV hospital utilization and surgical outcomes for lung (n = 28,047 White; n = 2,638 Black) and bladder (n = 7,593 White; n = 567 Black) cancer patients over a 15 year time span (1997-2011) in New York State. We hypothesized that centralization has improved utilization of HV hospitals and outcomes for both black and white patients, but significant disparities remain between black and white patients.
MedicalResearch.com: What are the main findings?
Response: Black patients have lower HV hospital utilization and worse in-hospital outcomes than white patients. In-hospital mortality did not significantly improve (β = 0.0056, p = 0.9128) in black bladder patients over the study period, and black race was significantly positively associated with in-hospital mortality (lung: ORadj: 1.36; 95%CI [1.08-1.70]; bladder: ORadj: 1.89; 95%CI [1.17-3.05]) and long length of stay (lung: ORadj: 1.26; 95%CI [1.16-1.38]; bladder: ORadj: 1.74; 95%CI [1.46-2.09]) compared to whites for both cancers in multivariable logistic regressions.
MedicalResearch.com: What should readers take away from your report?
Response: Although centralization has improved HV hospital utilization and surgical outcomes, racial differences persisted in both lung and bladder cancer surgery. Centralization may do little to address access and outcome disparities and improve the quality of care provided in underserved populations.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: While proximity and insurance are important determinants of quality care, other personal and community variables are influential in accessing quality lung and bladder surgical treatment. Barriers to improving the quality of care in underserved populations while facilitating access to such care must be tackled in order to fully address disparities. In addition, in person interviews should be conducted with minority patients to better understand what drove their choice of a LV hospital for their surgery
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Effect of Centralization on Health Disparities in Lung and Bladder Cancer Surgery
Authors: Wil Lieberman-Cribbin, Martin Casey, Matthew Galsky, Apichat Tantraworasin, Bian Liu, William Oh, Raja Flores, Emanuela Taioli. Icahn School of Medicine at Mount Sinai, New York, NY
Background: Centralization has been advocated for both cystectomy and pneumonectomy, since it has been associated with reductions in mortality. Racial disparities exist for both lung and bladder cancer surgical outcomes despite trends in hospital centralization. We hypothesized that disparities exist in the centralization process for both lung and bladder cancer surgery, and that this has differentially affected surgical outcomes in black and white patients.
Methods: The study population was extracted from the New York Statewide Planning and Research Cooperative System (SPARCS) database spanning 1997 to 2011, and included 26,750 lung cancer surgeries and 8,168 cystectomies. Hospitals were classified according to procedure volume; patient-hospital distance (PHD) and distance to the nearest high volume / very-high volume (HV/VHV) were calculated. Logistic models were performed to determine factors associated with the utilization of HV/VHV or low volume / very-low volume (LV/VLV) hospitals. Additional models were then performed to assess the association between race and in-hospital mortality, stratified according to whether patients used HV/VHV or LV/VLV hospitals.
For cystectomy, PHD increased over the study period while distance to the nearest HV/VHV decreased; for lung cancer surgery, PHD increased but distance to the nearest HV/VHV hospital was constant. For both surgical procedures, black patients experienced increased odds of LV/VLV utilization over time (for lung cancer surgery, ORadj: 1.20; 95%CI [1.01-1.43]; for cystectomy, ORadj: 1.59; 95%CI [1.26-2.02]). When HV/VHV hospitals were located farther from patients, the odds of HV/VHV utilization decreased while the odds of LV/VLV increased for both lung cancer and bladder cancer patients. Lung cancer and bladder cancer in-hospital mortality was higher in blacks (ORadj: 1.50; 95%CI [1.21-1.86]; ORadj: 1.80; 95%CI [1.12-2.90], respectively) compared to whites.
Racial differences persisted in hospital utilization and in surgical outcome for both lung and bladder cancers. While proximity and insurance are important determinants of quality care, other personal and community variables not captured by SPARCS are influential in lung and bladder surgical treatment and ultimately outcome. Specific interventions are needed to address accessing and utilizing quality care in underserved populations, including black and low SES patients, and patients with large distances from high-volume hospitals.
The original abstract is included for reference on the left. Since the submission however we explored trends over time in HV utilization and outcome (Black vs White) according to cancer type. The initial idea had results that discussed accessing HV hospitals (as a function of proximity), but in the poster and here we moved away from that to focus on outcomes.
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