Quality and outcomes of hysterectomy performed at low-income hospitals for patients with apparent early-stage endometrial cancer

Abstract

<h3>Objectives:</h3> Evaluate the outcomes of hysterectomy for apparent early stage endometrial carcinoma performed at low-income hospitals. <h3>Methods:</h3> Patients diagnosed between 2004 and 2016 with an uterine, cervical or ovarian tumor with known insurance status were drawn from the National Cancer Database. Low-income hospitals (LIH) were determined as those with the highest percentage (>75th percentile) of uninsured or Medicaid patients. Hospitals with lowest percentage (<25th percentile) served as comparison (non-LIH). Patients diagnosed between 2010-2015 with apparent stage I endometrial carcinoma who underwent hysterectomy at the reporting facility with known route of surgery were selected for further analysis. Peri-operative outcomes and overall survival (OS) was compared between patients managed at a LIH or non-LIH. <h3>Results:</h3> A total of 1237 facilities who reported patients with gynecologic malignancies were identified. The average percentage of uninsured or Medicaid patients at LIH was 25.3% compared to 4.54% for non-LIH. A total of 53500 patients with apparent early stage endometrial carcinoma who met the inclusion criteria were identified; 40.3% were managed at a LIH. Compared to patients having surgery at a non-LIH, those undergoing hysterectomy at a LIH were younger (median 61 vs 62 years, p<0.001) more likely to be Black (14.1% vs 6.1%, p<0.001), with comorbidities (29% vs 25.1%, p<0.001) and non-endometriod tumors (10% vs 8.6%, p<0.001). They were less likely to undergo MIS (63.1% vs 77.4%, p<0.001) and lymphadenectomy (62.1% vs 65.9%, p<0.001) while they had higher unplanned 30-day re-admission rate (2.8% vs 2.3%, p<0.001), and 90-day mortality (0.6% vs 0.4%, p=0.007). After controlling for patient age, race, and presence of comorbidities patients who had hysterectomy at a LIH were less likely to undergo MIS (OR: 0.52, 95% CI: 0.50, 0.54) and had higher odds of unplanned re-admission (OR: 1.17, 95% CI: 1.04, 1.31) and 90-day mortality (OR: 1.34, 95% CI: 1.04, 1.73). After controlling for substage, tumor histology and size, patients undergoing hysterectomy at a LIH were less likely to undergo LND (OR: 0.82, 95% CI: 0.79, 0.85). When examining patients who had MIS, those who had surgery at a LIH were less likely to be discharged within 1 day from procedure (70% vs 76.7%, p<0.001) and more likely to have conversion to laparotomy (3.6% vs 2.9%, p=0.001). After controlling for confounders overall was worse for patients managed in LIH (HR 1.07, 95% CI 1.01, 1.14) compared to those managed at a non-LIH. <h3>Conclusions:</h3> Patients with apparent early stage endometrial cancer undergoing surgery at a LIH have lower access to MIS techniques and increased peri-operative morbidity compared to those managed at non-LIH. A small increase in overall mortality was also noted.