Comparative Effects of Hospital Volume and Safety-Net Status on Treatment Use and Outcome Measures in Hepatocellular...

Comparing patient outcomes across health systems can identify mechanisms contributing to disparities. We aimed to characterize the intersectionality of hospital volume and safety-net hospital (SNH) status in the treatment and survival of patients with hepatocellular carcinoma (HCC).

Patients diagnosed with HCC from 2004 to 2019 were identified in the Texas and California Cancer Registries. Hospital volume was stratified into low volume (LV) and high volume (HV) using Contal's outcome-based method (HV ≥21 cases/year). Hospitals with CMS disproportionate share hospital index in the upper 25th percentile were designated as SNHs. Covariate-adjusted treatment use and overall survival with shared frailty were compared across the categories: LV/SNH, LV/non-SNH, HV/SNH, and HV/non-SNH.

A total of 535 hospitals, including 50,167 patients, were categorized as follows: 12% LV/SNH, 36% LV/non-SNH, 13% HV/SNH, and 38% HV/non-SNH. HCC detection at a localized stage and treatment receipt were lower in LV hospitals, regardless of SNH status. Compared with HV/SNHs, lower treatment receipt was observed in LV/SNHs (odds ratio [OR], 0.43; 95% CI, 0.40-0.47) and LV/non-SNHs (OR, 0.46; 95% CI, 0.43-0.50), and higher treatment receipt was observed in HV/non-SNHs (OR, 1.23; 95% CI, 1.14-1.33). In adjusted models, compared with HV/SNH, higher mortality was observed in LV/SNHs (hazard ratio [HR], 1.33; 95% CI, 1.28-1.39) and LV/non-SNHs (HR, 1.32; 95% CI, 1.27-1.36) and lower mortality was observed in HV/non-SNHs (HR, 0.91; 95% CI, 0.88-0.95).

Patients at LV centers are less likely to undergo HCC treatment, despite similar early-stage presentation, likely contributing to worse overall survival. High hospital volume appears to mitigate disparities in HCC outcome measures in lower-resource safety-net health systems.