title: Who receives their complex cancer surgery at low-volume hospitals?
abstract: BACKGROUND
  Previous literature has consistently shown worse operative outcomes at low-volume hospitals (LVH) after complex cancer surgery. Whether patient-related factors impact this association remains unknown. We hypothesize that patient-related factors contribute to receipt of complex cancer surgery at LVH.
  
  
  METHODS
  Using the 2003-2008 National Inpatient Sample, we identified 59,841 patients who underwent cancer operations for lung, esophagus, and pancreas tumors. Logistic regression models were used to examine the impact of sociodemographic factors on receipt of complex cancer surgery at LVH.
  
  
  RESULTS
  Overall, 38.4% received their cancer surgery at LVH. A higher proportion of esophagectomies were performed at LVH (70.3%), followed by pancreatectomy (38.2%) and lung resection (33.8%). Patients who were non-white, with non-private insurance, and had more comorbidities were all more likely to receive their cancer surgery at LVH (for all, p < 0.05). Multivariate analyses continued to demonstrate that non-white race, insurance status, increased comorbidities, region, and nonelective admission predicted receipt of cancer surgery at LVH across all 3 procedures.
  
  
  CONCLUSIONS
  In this large national study, non-white race and increased comorbidities contributed to receipt of cancer surgery at LVH. Patient selection and access to high-volume hospitals are likely reasons worthy of additional investigation. This study provides additional insight into the volume-outcomes relationship. Given the demonstrated outcomes disparity between high-volume hospitals and LVH, future policy and research should encourage mechanisms for referral of patients with cancer to high-volume hospitals for their surgical care.
authors: Minnesota Surgical Outcomes Research Center, Department of Surgery, University of Minnesota and Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55455, USA. alref003@umn.edu
authors: Waddah B
authors: WB
authors: Al-Refaie
authors: Binyam
authors: B
authors: Muluneh
authors: Wei
authors: W
authors: Zhong
authors: Helen M
authors: HM
authors: Parsons
authors: Todd M
authors: TM
authors: Tuttle
authors: Selwyn M
authors: SM
authors: Vickers
authors: Elizabeth B
authors: EB
authors: Habermann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000706:statistics & numerical data*; D005260:Female; D006276:Health Facility Size / Q000706:statistics & numerical data*; D006801:Humans; D008175:Lung Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010180:Pancreatectomy / Q000706:statistics & numerical data*; D010190:Pancreatic Neoplasms / Q000601:surgery*; D011013:Pneumonectomy / Q000706:statistics & numerical data*