The effect of hospital safety-net burden status on short-term outcomes and cost of care after head and neck cancer surgery

Objective: To determine the association between safety-net hospital care and short-term outcomes after head and neck cancer surgery. Design: Cross-sectional analysis. Safety-net burden was calculated as the percentage of patients with head and neck cancer with Medicaid or no insurance. Setting: Nationwide Inpatient Sample database. Patients: Adults who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 through 2008. Main Outcome Measures: Associations between hospital safety-net burden and short-term morality, medical and surgical complications, length of hospitalization, and costs. Results: Overall, 123 662 patients underwent surgery in 2001 through 2008. Patients treated at high-safetynet burden hospitals were significantly more likely to be admitted urgently or emergently (odds ratio [OR], 1.54; 95% CI, 1.06-1.15 [P=.03]), undergo major surgical procedures (OR, 1.24; 95% CI, 1.09-1.39 [P=.001]), have advanced comorbidity (OR, 1.35; 95% CI, 1.06-1.72 [P=.02]), and be black (OR, 1.70; 95% CI, 1.29-2.23 [P<.001]), but less likely to be elderly (OR, 0.66; 95% CI, 0.53-0.82 [P<.001]). High safety-net burden hospitals were significantly more likely to be teaching hospitals (OR, 2.04; 95% CI, 1.26-3.29 [P=.004]) and less likely to be located in the West (OR, 0.18; 95% CI, 0.07-0.44 [P<.001]). Safety-net burden was not associated with in-hospital mortality, acute medical complications, surgical complications, or hospital-related costs after controlling for all other variables including hospital volume status, but was associated with a mean increase in length of hospitalization of 24 hours (P<.001). Conclusions: These data suggest that safety-net hospitals provide valuable specialty care to a vulnerable population without an increase in complications or costs. Health care reform must address the economic challenges that threaten the viability of these institutions at the same time that demand for their services increases.