title: Opportunities to Improve Care of Hepatocellular Carcinoma in Vulnerable Patient Populations.
abstract: BACKGROUND
  Hepatocellular carcinoma (HCC) patients with Medicaid or no health insurance have inferior survival compared with privately insured patients. Safety-net hospitals that care for these patients are often criticized for their inferior outcomes. We hypothesized that HCC survival was related to appropriate surgical management.
  
  
  METHODS
  The American College of Surgeons National Cancer Database was queried for patients diagnosed with HCC (n = 111,481) from 1998 to 2010. Hospitals were stratified according to safety-net burden, defined as the percentage of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared with lower-burden hospitals with regard to patient demographics, cancer presentation, surgical management, and survival.
  
  
  RESULTS
  Patients at safety-net hospitals were less often white, had less income and education, but presented with similar stage HCC. Safety-net hospital patients were less likely to receive surgery (odds ratio 0.77; p < 0.01), and among curable patients (stages 1 and 2) who underwent surgical intervention, liver transplantation and resection were performed less often at safety-net hospitals than at other hospitals (50.7% vs 66.7%). Procedure-specific mortality rates were also higher at safety net hospitals (p < 0.01). However, multivariate analysis adjusting for cancer stage and type of surgery revealed similar survival for safety-net hospital patients who had surgery and survived for longer than 30 days (p = 0.73).
  
  
  CONCLUSIONS
  Vulnerable patients with HCC are commonly treated at safety-net hospitals, are less likely to receive curative surgery, and have worse short-term outcomes. However, safety-net patients who can endure liver surgery have a similar prognosis as patients at nonsafety-net hospitals. Providing equal access to surgery may improve survival for vulnerable populations of HCC patients.
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Hoehn
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Hanseman
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
authors.forename: Vikrom K
authors.initials: VK
authors.lastname: Dhar
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
authors.forename: Derek E
authors.initials: DE
authors.lastname: Go
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Edwards
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH. Electronic address: Shimul.shah@uc.edu.
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000191:economics / Q000401:mortality / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000191:economics / Q000208:ethnology / Q000706:statistics & numerical data*; D006498:Hepatectomy / Q000401:mortality / Q000706:statistics & numerical data; D006801:Humans; D008113:Liver Neoplasms / Q000191:economics / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D064876:Safety-net Providers; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D035862:Vulnerable Populations