Disparity in Access to High-Volume Facilities for Pancreatic Surgery: Intersection of Race, Socioeconomics, and Geography

Background: Pancreaticoduodenectomy or total pancreatectomy for cancers involving the pancreatic head is a complex, high-risk operation. While studies show improved survival at high-volume centers, many cases are still performed at low-volume centers (<10 cases per year). We aimed to examine if patient factors, including racial, geographic, and socioeconomic disparities, influence the choice of center. Study Design: We analyzed 63,385 patients in the National Cancer Database who underwent pancreaticoduodenectomy or total pancreatectomy between 2011-2021. High-volume centers were defined as performing ≥10 cases annually. We performed univariate analysis and a Cox proportional hazards model adjusting for histology, stage, neoadjuvant treatment, Charlson-Deyo score, race, ethnicity, insurance, income, and community status, with overall survival as the primary outcome. Results: 24.83% of cases were performed at low-volume centers. The hazard ratio for survival at high-volume centers was 0.805 compared to low-volume centers (SE 0.011, p <0.001). Median survival was significantly longer at high-volume centers (33.0 months, 95% CI: 32.53-33.61) compared to low-volume centers (24.7 months, 95% CI: 24.05-25.43). Black and Hispanic patients were more often treated at low-volume centers. Socioeconomically disadvantaged patients were also more likely to be treated at low-volume centers. Mortality rates were higher at low-volume centers (30-day: 5.12% vs 2.38%, p<0.001; 90-day: 9.33% vs 5.16%, p<0.001). Patients at low-volume centers lived closer (26.57 miles vs 69.93 miles, p<0.001). Conclusions: Disadvantaged patients are more likely to receive care at low-volume centers, where they experience poorer outcomes. Significant investment is needed to improve access to high-volume centers and address these disparities.