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Survival post-surgery linked to hospital differences

By Andrew M. Seaman

NEW YORK (Reuters Health) - Disparities between rich and poor in who survives major cancer surgeries may have more to do with the hospitals where they're treated than with individuals' wealth or lack of it, a new study suggests.

Researchers found that even the wealthiest patients at hospitals treating primarily poor communities tended to fare worse after major cancer surgeries than the poorest patients at hospitals treating primarily wealthy communities.

"We know people in the lower socioeconomic status have worse outcomes, but it's always harder to get at the underlying mechanism for those worse outcomes," Dr. Amir Ghaferi told Reuters Health.

Ghaferi is the study's senior author from the Center for Healthcare Outcomes and Policy at the University of Michigan in Ann Arbor.

Several studies have found that a person's risk of death after major cancer surgery is linked to economic status, Ghaferi and his colleagues write in JAMA Surgery.

Poor people who have part of their stomach removed because of cancer, for example, are 55 percent more likely to die than their richer counterparts, the researchers note.

Economic status is often an indicator of other factors, however. Those include a person's general health or the quality of the healthcare available in their community.

While a hospital's quality is often measured by how many of its patients experience complications during their stays or after operations, the authors of the new study used a measure known as failure to rescue or FTR.

FTR identifies patients who die after major complications following surgery, because the hospitals were unable to "rescue" them.

"If you do develop a complication, it's very important how that complication is recognized and ultimately treated," Ghaferi said.

For the study, he and his colleagues used data spanning the years 2003 to 2007 from Medicare, the U.S. health insurance program for the elderly and disabled.

They identified 596,222 people who were 65 years old or older and had a major surgery for cancer during that time. Those people were then matched with U.S. Census data to estimate their socioeconomic status.

As in other studies, the researchers found that the poorest patients were more likely to die and experience complications after their surgeries, compared to the richest patients.

They also found that about 27 percent of the poorest patients were recorded as FTR, compared to about 23 percent of the richest patients.

Overall, the poorest patients were about 20 percent more likely to be FTR, compared to the richest patients.

The disparity held after researchers took into account patient characteristics like employment, education and other health conditions.

But after taking into account the hospitals where the procedures were performed, researchers found that most of the increased FTR risk among the poorest patients disappeared.

The likelihood of FTR among patients of any economic status was higher at hospitals that serve mostly poor communities, compared to hospitals that serve mostly wealthy communities.

The new study can't say which aspect of care at the hospitals may be most closely linked to FTR rates, but Ghaferi said a number of factors could be involved.

"When it comes down to it, your surgical care doesn't happen within a silo," he said. "It happens within the greater system of a large or small hospital."

He added that he believes much of the increased risk of FTR may come from the attitude a hospital and its staff have toward patient safety.

"I have for a long time been worrying that part of the disparity is that poor folks tend to get their healthcare in poor health systems," Dr. Otis Brawley told Reuters Health.

Brawley, who was not involved in the new study, is chief medical officer of the American Cancer Society in Atlanta.

"If you have the opportunity to pick the hospital you can go to, you should go to a hospital that has a high volume of doing the operation you need," he said.

He added, however, that poor people living in urban areas may have few options.

SOURCE: http://bit.ly/1cXioxH JAMA Surgery, online March 12, 2014.

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