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Trends in hospital volume and disparities in surgical care: should New England take The Pledge?
Susanna W.L. de Geus1, Teviah E. Sachs1, Megan G. Janeway1, Alaina D. Geary1, Sing Chau Ng1, Michael R. Cassidy1, Jennifer F. Tseng1, David McAneny1
1Boston Medical Center, Boston University School of Medicine, Boston, MA, USA

Background: The purpose of this study was to evaluate trends in hospital volume and to identify patients at risk for losing access to care with enforcement of volume standards.

Methods: Patients who underwent stomach, colon, or pancreas operations in New England, from 2006-2014, were identified in the NCDB. Hospital volume was stratified into tertiles based upon the number of annual resections.

Results: In total, 1,411 gastrectomies, 17,041 colectomies, and 1,554 pancreatectomies were identified. The proportion of patients who underwent operations at a high-volume center increased significantly for stomach (20.2% in 2006-2008 vs 29.5% in 2012-2014), colon (47.5% in 2006-2008 vs 52.2% in 2012-2014), and pancreas (24.3% in 2006-2008 vs 31.9% in 2012-2014) cancers. The mortality of colectomy (3.8% in 2006-2008 vs 2.6% in 2012-2014), and pancreatectomy (2.8% in 2006-2008 vs 1.1% in 2012-2014) decreased. On multivariate analysis, significant predictors for surgery at a low/intermediate volume hospital were Black or Hispanic race (gastrectomy: OR, 1.59), income ≤ $47,999 (pancreatectomy: OR, 2.12), and no private insurance (colectomy: OR, 1.53; pancreatectomy: OR, 2.38).

Conclusion: During the past decade, operations for stomach, colon, and pancreas cancers have become more centralized throughout New England. This phenomenon has been accompanied by a decrease in surgical mortality. However, this study suggests that patients who are less affluent or belong to minority groups may be less likely to receive care at high-volume centers. Therefore, those who develop future health care policies must consider the potential impact of these changes upon access to care and disparities for minority groups.

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