Persistent racial disparities in the use of high-volume esophagectomy centers in the United States.

Abstract

Although the volume-outcome relationship in esophagectomy has been established, disparities in the use of high-volume esophagectomy centers persist. The present study examined the representation of various racial groups undergoing esophagectomy at high-volume hospitals and explored the associated clinical and financial outcomes. All elective adult (≥18 years) hospitalizations entailing esophagectomy were identified in the 2012-2021 National Inpatient Sample. Hospitals performing ≥20 esophagectomy procedures annually were classified as high-volume hospitals on the basis of the Leapfrog volume standard, whereas those performing fewer were classified as low-volume hospitals. Multivariable regression models evaluated the relationship between high-volume hospitals status and in-hospital mortality, perioperative complications, and resource use. Of an estimated 45,455 hospitalizations, 50.5% of esophagectomy patients received their operation at an high-volume hospital. Although the proportion of patients treated at high-volume hospitals remained stable across multiple racial groups during the study period, Asian patients had an increase in high-volume hospital use over the study period (nptrend < 0.001). After risk adjustment, management at high-volume hospitals was associated with reduced odds of mortality (adjusted odds ratio, 0.70; 95% confidence interval, 0.54-0.90) as well as infectious (adjusted odds ratio, 0.76; 95% confidence interval, 0.66-0.87) and respiratory complications (adjusted odds ratio, 0.75; 95% confidence interval, 0.67-0.84), relative to low-volume hospital. In addition, high-volume hospital status was associated with reduced hospital duration of stay by 0.8 days (95% confidence interval, 0.3-1.3 days) and greater hospitalization costs by $3,500 (95% confidence interval, $900-6,100) compared with low-volume hospitals. Although esophagectomy centralization has been associated with improved perioperative outcomes, Black and Hispanic patients continue to be less likely to undergo esophagectomy at high-volume hospitals. Future efforts to increase the delivery of guideline-concordant care at low-volume hospitals may facilitate equitable access to high-volume hospital-like quality care among underserved populations.