Impact of Race, Insurance and Socioeconomic Status in Failure to Rescue after Complex Hepato-Pancreato-Biliary Surgeries in the United States

Introduction: Successful rescue of surgical patients from post-operative complications (POC) represents an important quality of care indicator. Our study aims to describe how racial, socioeconomic, and insurance-status factors affect failure to rescue (FTR) after complex hepato-pancreatico-biliary (HPB) surgeries nationwide. Methods: We conducted a retrospective analysis (2004-2017) of the US Nationwide Inpatient Sample for elective HPB surgeries (n=98,788). Major (MaC) and minor (MiC) were identified using validated ICD9/10 codes. Mortality and FTR (in-patient mortality after major complications) were calculated. Logistic regression was used to assess the impact of racial/socioeconomic/demographic factors on FTR occurrence adjusting for all covariates. Results: Of 90,788 patients, 35,526 (36%) underwent liver surgery, while 21,006 (21%) had biliary and 45,256 (43%) had pancreatic operations. 59% were cancer-related operations. The rates of MiC and MaC were 26% and 21% respectively. FTR occurred in 8% (n=1,655) and overall mortality rate was 2% (n=2,129). Factors independently associated with increased risk for FTR were: Charlson-comorbidity-index ≥ 4, lower-income quartile (<$38,999), Medicare insurance, older age, male sex, and Southern region hospitals (all p<0.001). Conversely, Black race, female gender, private insurance, high-income quartile (≥$63.000), and surgery in later study periods were associated with decreased odds of FTR (all p<0.05). Conclusions: Medicare insurance, male gender, lowest-income quartile, and surgery in the early years of the study period were associated with increased risk for FTR. Targeted efforts should be enacted to increase an equitable delivery of care in all racial, socioeconomic, and insurance status groups after complex HPB surgeries.