title: Socioeconomic disparities in mortality after cancer surgery: failure to rescue.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
authors.forename: Bradley N
authors.initials: BN
authors.lastname: Reames
authors.affiliation: Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
authors.forename: Nancy J O
authors.initials: NJ
authors.lastname: Birkmeyer
authors.affiliation: Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
authors.forename: Justin B
authors.initials: JB
authors.lastname: Dimick
authors.affiliation: Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
authors.forename: Amir A
authors.initials: AA
authors.lastname: Ghaferi
mesh_terms: D002423:Cause of Death; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D009369:Neoplasms / Q000401:mortality* / Q000601:surgery*; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality*; D018635:Rescue Work / Q000706:statistics & numerical data*; D012151:Resuscitation / Q000401:mortality; D012189:Retrospective Studies; D020379:Risk Adjustment / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative / Q000401:mortality*; D015996:Survival Rate; D014481:United States