Disparities in Access to Neuro-oncologic Care in the United States

HYPOTHESIS: Race/ethnicity and social status influence admission to high-volume hospitals among patients who undergo craniotomy for tumor biopsy or resection. DESIGN: Retrospective analysis of the Nationwide Inpatient Sample (1988-2005), with additional factors from the Area Resource File. SETTING: A 20% representative sample of all hospitals in 37 US states. PATIENTS: A total of 76 436 patients 18 years or older who were admitted and underwent craniotomy for tumor biopsy or resection. MAIN OUTCOME MEASURES: Odds ratios (ORs) for the association of age, sex, race/ethnicity, insurance status, Charlson Comorbidity Index, and county-level characteristics with admission to high-volume hospitals (>50 craniotomies per year) or low-volume hospitals. RESULTS: A total of 25 481 patients (33.3%) were admitted to high-volume hospitals. Overall access to high-volume hospitals improved over time. However, racial/ethnic disparities in access to high-volume hospitals dramatically worsened for Hispanics (OR, 0.49) and African Americans (OR, 0.62) in recent years. Factors associated with better access to high-volume hospitals included years since 1988 (OR, 1.11), greater countywide neurosurgeon density (OR, 1.66), and higher countywide median household income (OR, 1.71). Factors associated with worse access to high-volume hospitals included older age (OR, 0.34 per year increase), increased countywide poverty rate (OR, 0.57), Hispanic race/ethnicity (OR, 0.68), and higher Charlson Comorbidity Index (OR, 0.96 per point increase). CONCLUSIONS: African Americans and Hispanics have disproportionately worse access to high-quality neuro-oncologic care over time compared with whites. Higher countywide median household income and decreased countywide poverty rate were associated with better access to high-volume hospitals, implicating socioeconomic factors in predicting admission to high-quality centers.