title: Disparities in selective referral for cancer surgeries: implications for the current healthcare delivery system.
abstract: OBJECTIVE
  Among considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance and/or socioeconomic disparities exist in the use of high-volume hospitals for complex surgical oncological procedures within the USA.
  
  
  METHODS
  Patients undergoing colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy or prostatectomy were identified retrospectively, using the Nationwide Inpatient Sample, between years 1999 and 2009. This resulted in a weighted estimate of 2 508 916 patients.
  
  
  METHODS
  Distribution of patients according to race, insurance and income characteristics was examined according to low-volume and high-volume hospitals (highest 20% of patients according to the procedure-specific mean annual volume). Generalised linear regression models for prediction of access to high-volume hospitals were performed.
  
  
  RESULTS
  Insurance providers and county income levels varied differently according to patients' race. Most Caucasians resided in wealthier counties, regardless of insurance types (private/Medicare), while most African Americans resided in less wealthy counties (≤$24 999), despite being privately insured. In general, Caucasians, privately insured, and those residing in wealthier counties (≥$45 000) were more likely to receive surgery at high-volume hospitals, even after adjustment for all other patient-specific characteristics. Depending on the procedure, some disparities were more prominent, but the overall trend suggests a collinear effect for race, insurance type and county income levels.
  
  
  CONCLUSIONS
  Prevailing disparities exist according to several patient and sociodemographic characteristics for utilisation of high-volume hospitals. Efforts should be made to directly reduce such disparities and ensure equal healthcare delivery.
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada.
authors.forename: Maxine
authors.initials: M
authors.lastname: Sun
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Sammon
authors.forename: Shyam
authors.initials: S
authors.lastname: Sukumar
authors.forename: Mai-Kim
authors.initials: MK
authors.lastname: Gervais
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
authors.forename: Toni K
authors.initials: TK
authors.lastname: Choueiri
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
mesh_terms: D001741:Black or African American; D000368:Aged; D005260:Female; D000069576:Health Equity; D054625:Healthcare Disparities; D006761:Hospitals; D006801:Humans; D007182:Income; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000601:surgery*; D044469:Racial Groups; D012017:Referral and Consultation; D012923:Social Class; D014481:United States; D044465:White People
keywords: Health Services Administration & Management