The Effect of Hospital Volume and Insurance Status on Overall Survival in Sinonasal Carcinoma: A National Cancer Database (NCDB) Analysis

Abstract

Although sinonasal malignant neoplasms are rare, accounting for 3% of malignancies in the upper aerodigestive tract, they continue to have a poor prognosis. The 5-year disease-free survival rate is approximately 40% and has remained largely unchanged over the past 3 years. As yet, there is limited data regarding the factors that affect survival outcomes in patients with sinonasal carcinomas. Recent publications examined the role of clinical factors that affect overall survival (OS) in patients with sinonasal cancers however, the effect of hospital volume and medical insurance on OS is yet unknown. Using NCDB data, we examined the effect of hospital volume and medical insurance on patients’ OS. The number of cases treated at each facility was calculated, and the threshold for distinguishing high volume vs. low volume was determined using the 80th percentile of the number of cases treated per facility. Insurance status was categorized as not insured, private insurance, and Medicaid/Medicare/Other government. OS was estimated using the Kaplan-Meier method, and OS was compared using log-rank tests. Multivariable Cox proportional hazards models were fit for OS as a function of center volume, insurance, histology, pathologic T-stage, facility type, age at diagnosis, and treatment. A total of 5000 patients were included in the multivariable analysis (MVA). We found that private insurance was significantly associated with overall survival compared to those who receive government insurance (p<0.001) but not compared to those without insurance (P=.63). Facility type (P=.82) and facility volume (P=.06) did not have a statistically significant effect on OS. This retrospective analysis represents the largest study in sinonasal carcinoma to date. One significant limitation of this study is that we were unable to assess for disease free survival using NCDB data, only overall survival. However, these data confirm findings from smaller studies that demonstrate the effect of patient age, tumor stage and histology on survival outcomes. Additionally, it provides information on how hospital volume and medical insurance can affect the survival of patients with sinonasal carcinomas.