The Role of Hospital Safety-Net Burden in the Treatment of Oral Cavity Cancers: Evaluating its Impact on Survival Outcomes

Abstract

To investigate the relationships between hospital safety-net burden, clinicopathologic characteristics, and overall survival in oral cavity cancer (OCC) patients From the National Cancer Database, we identified 48,176 OCC patients diagnosed with oral cavity cancer between the years 2004 to 2015. Facilities treating 0-30th, >30-75th, and >75-100th percentiles of uninsured/Medicaid patients were defined as no safety-net burden hospitals (NBH), low safety-net burden hospitals (LBH), and high safety-net burden hospitals (HBH), respectively. Social demographic and clinicopathologic variables assessed were age, distance to treatment facility, time to first treatment, gender, race, Hispanic origin, insurance status, median household income, year of diagnosis, Charlson-Deyo score, location of primary site, AJCC stage, facility type and volume, and treatment modality. Safety-net burden of treatment facilities was used as the primary independent predictor in this analysis, and the primary outcome of interest was overall survival. Crude and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) were computed using Cox regression modelling, where clustering of patients within facilities was accounted for using robust sandwich covariance matrix estimates. There were 380 NBH (29.9%), 573 LBH (45.2%), and 316 HBH (24.9%) identified among the 1,269 treatment facilities evaluated for their respective safety-net burden and survival outcomes in oral cavity cancer patients. The median percentage of uninsured/Medicaid patients treated was 23.5% (range 18.6-100%) at HBH, 11.6% (range 1.2-18.5%) at LBH, and 0% (range 0-0%) at NBH. Median follow-up in all surviving patients was 49.0 months. A total of 22,466 deaths were reported, and the overall 5-year survival rate was 53.5% (median survival = 69.7 months). Median survival for NBH, LBH and HBH was 68.6, 74.8 and 55.0 months, respectively (p<0.0001). Compared to NBH and LBH, HBH facilities treated more patients of advanced cancers, lower socioeconomic status, and racial and ethnic minorities. After adjusting for the aforementioned social demographic and clinicopathologic variables, no significant survival difference was noted in LBH (aHR 0.97 95% CI 0.91-1.04, p = 0.405) or HBH (aHR 1.05 95% CI 0.98-1.13, p = 0.175) when compared to patients treated at NBH facilities. High safety-net burden hospitals treated disproportionately more patients of late-staged cancers, lower socioeconomic status, and racial and ethnic minorities. Thus, while lower actuarial survival rates were observed in HBH compared to LBH and NBH, these findings may be driven by socioeconomic and clinicopathologic characteristics, rather than hospital safety-net burden. Therefore, high burden safety-net hospitals may play a more critical role in caring for vulnerable populations with oral cavity cancer than it is attributed for at first glance.