Relationship Between Case Volume and Outcomes for Pulmonary Resection for Lung Cancer at Safety-Net Hospitals

Background: Safety-net hospital (SNH) status is associated with high perioperative morbidity in pulmonary resection. Multiple etiologies have been proposed, including delays in diagnosis and inefficient care pathways. In integrated health systems, surgical volume has been shown to improve outcomes in pulmonary resection. However, whether surgical volume can overcome the inherent challenges of SNHs is unclear. We hypothesize that surgical volume is associated with improved outcomes at SNHs. Methods: The 2016 to 2021 Nationwide Readmissions Database was queried for all adult (≥18 years) patients undergoing elective lobectomy for lung cancer. Centers in the top quartile of Medicaid or self-pay/uninsured admissions were defined as SNHs. SNHs were further stratified by lobectomy caseload as a low-volume hospital (<10 cases/y), medium-volume hospital (10-33 cases/y), or high-volume hospital (>33 cases/y). Multivariable regressions were built to consider the independent association of hospital volume on acute clinical and financial outcomes among patients treated at SNHs. Results: Care at high-volume centers remained associated with significantly reduced likelihood of overall major morbidity (adjusted odds ratio [AOR], 0.81; 95% CI, 0.68-0.97), respiratory complications (AOR, 0.79; 95% CI, 0.65-0.96), need for blood transfusion (AOR, 0.67; 95% CI, 0.48-0.93), and nonhome discharge (AOR, 0.66; 95% CI, 0.48-0.88). Care at high-volume centers was also associated with a decrease in duration of hospitalization (β = -1.02 days; 95% CI, -1.48 to -0.54 days) and overall expenditures (β = -$4360; 95% CI, -$7020 to -$1700). Conclusions: Surgical volume is associated with improved outcomes in pulmonary resection at SNHs. Patients who are eligible for care only at SNHs can still benefit from undergoing pulmonary resection at a high-volume center.