Disparity in Access to High-Volume Facilities for Pancreatic Surgery: Intersection of Race, Socioeconomics, and Geography.

Abstract

Pancreaticoduodenectomy or total pancreatectomy for cancers involving the pancreatic head is a complex, high-risk operation. Although studies show improved survival at high-volume centers, many cases are still performed at low-volume centers (fewer than 10 cases per year). We aimed to examine whether patient factors, including racial, geographic, and socioeconomic disparities, influence the choice of center. We analyzed 63,385 patients in the National Cancer Database who underwent pancreaticoduodenectomy or total pancreatectomy between 2011 and 2021. High-volume centers were defined as performing 10 cases or more annually. We performed univariate analysis and a Cox proportional hazards model adjusting for histology, stage, neoadjuvant treatment, Charlson-Deyo Score, race, ethnicity, insurance, income, and community status, with overall survival as the primary outcome. At low-volume centers, 24.83% of cases were performed. The hazard ratio for survival at high-volume centers was 0.805 compared with low-volume centers (SE 0.011, p < 0.001). Median survival was significantly longer at high-volume centers (33.0 months, 95% CI 32.53 to 33.61) compared with low-volume centers (24.7 months, 95% CI 24.05 to 25.43). Black and Hispanic patients were more often treated at low-volume centers. Socioeconomically disadvantaged patients were also more likely to be treated at low-volume centers. Mortality rates were higher at low-volume centers (30-day mortality: 5.12% vs 2.38%, p < 0.001; 90-day mortality: 9.33% vs 5.16%, p < 0.001). Patients at low-volume centers lived closer to their centers (26.57 vs 69.93 miles, p < 0.001). Disadvantaged patients are more likely to receive care at low-volume centers, where they experience poorer outcomes. Significant investment is needed to improve access to high-volume centers and address these disparities.