title: Multimorbidity and access to major cancer surgery at high-volume hospitals in a regionalized era.
abstract: BACKGROUND
  The Institute of Medicine has recently prioritized access of quality cancer care to vulnerable persons including multimorbid patients. Despite promotional efforts to regionalize major surgical procedures to high-volume hospitals (HVHs), little is known about change in access to HVH over time among multimorbid patients in need of major cancer surgery. We performed a time-trend appraisal of access of multimorbid persons to HVH for major cancer surgery within a large nationally representative cohort.
  
  
  METHODS
  We identified 168,934 patients who underwent 6 major cancer surgeries from the Nationwide Inpatient Sample (1998 to 2010). Comorbidities were identified using Elixhauser's method. HVHs were defined as hospitals of highest procedure volumes that treated 1/3 of all the patients. Logistic regression models and predictive margins were used to assess the adjusted effects of comorbidity on receiving major cancer surgeries at HVH.
  
  
  RESULTS
  Of all, 45.7% of the patients had 2 comorbidities or more. Multimorbidity predicted decreased access to HVH for esophagectomy, total gastrectomy, pancreatectomy, hepatectomy, and proctectomy, but not for distal gastrectomy, after controlling for covariates. A comorbidity level by year interaction analysis also showed that little disparity existed for receiving distal gastrectomy at an HVH, whereas the predicted difference in probability of receiving any of the other 5 major cancer procedures remained prominent between the years 1998 and 2010.
  
  
  CONCLUSIONS
  In this large 12-year time-trend study, multimorbid cancer patients have sustained low access to HVH for major cancer surgery across many oncologic resections. These results continue to reinforce and highlight the need for policy targeted research and intervention aimed at improving these access gaps.
authors.affiliation: Department of General Surgery, MedStar Washington Hospital Center, 106 Irving St, NW, POB Suite 3900, Washington, DC, 20010, USA. Electronic address: Chukwuemeka.u.Ihemelandu@medstar.net.
authors.forename: Chukwuemeka
authors.initials: C
authors.lastname: Ihemelandu
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.
authors.forename: Chaoyi
authors.initials: C
authors.lastname: Zheng
authors.affiliation: Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Hall
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.
authors.forename: Russell C
authors.initials: RC
authors.lastname: Langan
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA; MedStar Health Research Institute, Hyattsville, Maryland, USA.
authors.forename: Nawar
authors.initials: N
authors.lastname: Shara
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC, USA; Lombardi Comprehensive Cancer Center, Washington, DC, USA.
authors.forename: Lynt
authors.initials: L
authors.lastname: Johnson
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA; MedStar Health Research Institute, Hyattsville, Maryland, USA; Lombardi Comprehensive Cancer Center, Washington, DC, USA.
authors.forename: Waddah
authors.initials: W
authors.lastname: Al-Refaie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006297:Health Services Accessibility; D061847:Hospitals, High-Volume; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000601:surgery*; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D014481:United States
keywords: Cancer surgery; High-volume hospitals; Multimorbidity; Regionalized era