How Safe Is the Safety Net? Comparison of Ivor-Lewis Esophagectomy at a Safety-Net Hospital Using the NSQIP Database

Abstract

Recent data suggest that surgical outcomes at hospitals caring for low-income, vulnerable populations are suboptimal compared with outcomes from nonsafety-net hospitals. Therefore, the purpose of our study was to compare outcomes for patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital with the National Surgical Quality Improvement Program (NSQIP) database. We retrospectively reviewed the medical records of consecutive patients who underwent an Ivor-Lewis esophagectomy, between September 2013 and January 2017, at a single safety-net hospital. Patient characteristics and outcomes were compared with the 2013 to 2015 NSQIP database. Continuous variables were compared using Student's t-test, and categorical variables were analyzed using chi-square tests. Values of p < 0.05 were considered significant. We identified 78 patients from the safety-net hospital and 1,825 patients in the NSQIP database who underwent an Ivor-Lewis esophagectomy. Baseline characteristics were similar, except the safety-net hospital patients were more likely to have COPD (19.2% vs 8.1%; p=0.001) and be current smokers (42.3% vs 26.0%; p= 0.001); patients in the NSQIP group had a higher BMI (28 kg/m2 vs 26 kg/m2; p= 0.001). There were no differences between groups for mortality, readmission, discharge destination, or mean operative time. Safety-net hospital patients had significantly fewer complications (16.7% vs 33.3%; p=0.003), fewer reoperations (6.4% vs 14.5%; p= 0.046), and shorter hospital length of stay (10.3 vs 13.1 days; p= 0.001). Patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital had fewer complications and reoperations, and a shorter hospital length of stay compared with a national cohort. These findings illustrate the value of clinical pathways in optimizing the patient outcomes at safety-net hospitals and providing excellent care to their vulnerable patient population.