Patients with Low Socioeconomic Status are More Likely to Present for Non-Elective Ovarian Cancer Surgery
Summary
Objective: Our objective was to characterize the association between demographic features and perioperative outcomes in patients undergoing non-elective ovarian cancer surgery.
Methods: Women undergoing ovarian cancer surgery between 2010 and 2015 were identified in the Nationwide Readmissions Database. Patients were divided by whether they had elective or non-elective surgery. Demographic and clinical characteristics, post-operative outcomes including length of stay, adjusted costs at index hospitalization, readmission rates, and mortality were compared between groups. Multivariable analyses were employed to assess the association between baseline characteristics and non-elective surgery, and relevant clinical outcomes.
Results: Of 101,993 patients undergoing ovarian cancer surgery, 19,349 (19.0%) were classified as non-elective. Non-elective patients were more likely to have Medicaid coverage (13.3 vs. 6.4%, p<0.001) and had a higher average Elixhauser Comorbidity Index (3.7 vs. 3.2, p<0.001). Significant predictors of non-elective admission included lowest income quartile relative to highest (odds ratio (OR)=1.27 [1.12-1.43]) and age <50 relative to age > 70 (OR=1.62 [1.45-1.82]). Multivariable analysis revealed that patients presenting for non-elective surgery had significantly higher in-hospital mortality (OR=2.82 [95% Confidence Interval (CI)=2.22-3.58]) and 30-day readmission rates (OR=1.25 [1.15-1.36]). Patients presenting non-electively spent 3.3 more days in the hospital [95%CI: 3.0-3.5]) with $6,188 more in adjusted costs [95%CI: $5,497-6,879].
Discussion: The rate of non-elective ovarian cancer surgery remains high, with increased patient mortality and resource utilization. An independent association between lower income, public insurance, and increased rate of non-elective surgery was observed, highlighting the need to address low socioeconomic populations at risk for ovarian cancer to prevent emergent hospitalization.
Keywords: Ovarian cancer; Non-elective admission; Socioeconomic status
Introduction
Ovarian cancer is associated with significant morbidity and mortality among women in the United States. It is predicted to be the fifth-leading cause of cancer death among U.S. women in 2020 and is associated with a 5-year survival rate of 48% [1]. Optimal treatment strategies vary by histologic subtype, patient comorbidities, and suspected stage at presentation but typically include a combination of cytoreductive surgery and chemotherapy [2]. Management strategies for suspected ovarian cancer are usually developed in a non-urgent setting through patient consultation with a multidisciplinary team, including a gynecologic oncologist.
However, a major challenge of ovarian cancer management is the acuity with which these patients may initially present. Despite much effort, there remains no universal practice for screening, with several studies failing to demonstrate any survival benefit from screening with serum tumor markers or transvaginal ultrasound [3- 5]. As a result, 75% of patients present with late-stage disease, often with metastases to the peritoneal cavity as well as extra-abdominal structures [6]. Given the extent of their disease, these patients may present acutely in an emergency room setting and necessitate urgent surgical intervention; a situation in which they are unlikely to receive extensive counseling or optimal debulking at the time of surgery. They may not have a gynecologic oncologist involved in their treatment planning in this urgent setting. Review of ovarian cancer patient outcomes shows improved overall survival when a gynecologic oncologist is involved in the surgical management of these patients [7,8]. Previous research has demonstrated that these non-elective surgeries are also associated with higher rates of postoperative complications and mortality [9,10]. However, patients who undergo non-elective ovarian cancer surgery remain a poorly characterized population and few studies have examined the risk factors associated with emergent or urgent surgery.
Given the potential to reduce the morbidity and mortality associated with non-elective surgery, this study used the Nationwide Readmissions Database (NRD), a large national database, to characterize demographic and clinical features, identify risk factors, and evaluate outcomes in women undergoing urgent and emergent ovarian cancer surgery. An understanding of this population is the first step in identifying opportunities to reduce the morbidity and mortality associated with non-elective presentation.
Methods
The National Readmissions Database (NRD) was accessed and all adult patients (>18 years) admitted for surgical management of ovarian cancer between January 2010 and September 2015 were identified. The NRD is a database that utilizes state inpatient databases of the Healthcare Cost and Utilization Project (HCUP) to estimate national readmission rates for all patients regardless of insurance status. Importantly, the NRD contains verified patient linkage numbers that can be used to track patients across hospitals within a state, and accounts for 58.2% of all US hospitalizations. When weighted, this database estimates data for approximately 36 million hospital discharges each year.
Using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, the study included patients with a diagnosis of ovarian cancer undergoing cytoreductive surgery, which was defined as any surgery involving oophorectomy. The patient cohort was stratified by the nature of surgical intervention – elective versus non-elective, as coded in the NRD, with the latter defined as emergent or urgent surgery not scheduled in advance (i.e. in the setting of acute onset abdominal pain, nausea and vomiting, or peritoneal signs) [11].
Medical information for patients was extracted from the deidentified dataset for each surgical intervention group, including demographic information such as zip-code derived income quartiles and insurance coverage status, baseline comorbidities (HCUP comorbidities encoded in the NRD, as well as a calculated Elixhauser Comorbidity Index for standardized comparison), hospital care setting, operative details and post-operative outcomes. The Elixhauser index is a widely utilized marker of the relative morbidity of surgical patients [12]. In addition to the route of surgery (open, laparoscopic or robotic assisted), operative details captured included intraoperative need for small and large bowel resection, rectosigmoid resection, ileostomy or colostomy, hysterectomy, lymph node dissection, and splenic, gastric, hepatic and diaphragmatic resection. Post-operative outcomes included length of stay (LOS), adjusted costs at index hospitalization, discharge location, 30-day and 90-day readmission rates as well as in-hospital mortality.
The distributions of continuous and categorical variables were compared between ovarian cancer patients who had non-elective surgery and those who had elective surgery. Continuous variables were analyzed using the Kruskal-Wallis test, while categorical variables were evaluated using chi-square tests. Multivariable logistic regression analysis was used to identify clinical factors independently associated with non-elective surgery. Multivariable logistic regressions were also utilized to identify the independent, predictive value of non-elective surgery on intra-operative procedures and post-operative outcomes. Statistical significance was considered a P value <0.05. All statistical analyses were performed using STATA 15.1 (StataCorp LP, College Station, Texas). This study was deemed exempt by the Institutional Review Board at the University of California, Los Angeles.
Results
Within the NRD, 101,993 patients undergoing ovarian cancer surgery were identified, of whom 19,349 (19.0%) had non-elective surgery (Table 1). Patients presenting non-electively were on average younger (59.4 vs 61.2 years, p<0.001) and were more likely to fall into the 1st (lowest) income quartile (25.8 vs. 20.9%, p<0.001) and less likely to fall into the 4th (highest) income quartile (23.1 vs. 28.5%, p<0.001) than elective surgery patients. Patients undergoing non-elective surgery had a greater proportion of Medicaid coverage (13.3 vs. 6.4%, p<0.001), and reduced private insurance coverage (37.2 vs. 47.3%, p<0.001) relative to elective patients. Relative to patients undergoing elective surgery, non-elective patients had a higher average Elixhauser comorbidity index (3.7 vs. 3.2, p<0.001), with higher rates of diabetes mellitus (13.6 vs. 11.6%, p<0.001), anemia (26.5 vs. 15.9%, p<0.001), and congestive heart failure (2.9 vs. 1.9%, p<0.001). Non-elective surgery patients were less likely to undergo robotic-assisted surgery (3.0 vs 4.1%, p=0.002) relative to elective patients, although there was no difference in the rate of open surgery (92.0 vs 92.4%, p=0.167).
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