V23: Effect of Hospital Safety Net Designation on Treatment Utilization and Associated Survival in Colorectal Cancer

Racial/ethnic minorities and socioeconomically disadvantaged patients with colorectal cancer (CRC) have worse survival than non-Hispanic whites and patients from higher socioeconomic status (SES). Comparing patient outcome measures across health care delivery systems can identify mutable system level factors contributing to this disparity. The goal of this study was to compare the presentation, treatment, and survival measures of patients with CRC treated at safety net hospitals (SNHs) and non-SNHs.


Methods: Patients diagnosed with CRC between 2004 and 2017 were identified in a combined dataset of the Texas and California Cancer Registries. Safety net designation was assigned according to each hospital’s disproportionate share hospital (DSH) index value, extracted from CMS impact files. DSH indexes in the upper 25^th percentile were designated as SNHs. Hospital and patient-level factors were compared across SNHs and non-SNHs.  Covariate-adjusted treatment use and disease specific survival (DSS) were compared.


Results: SNHs cared for 23% of the 181,248 CRC patients and disproportionately delivered care to racial/ethnic minorities, those in the lowest SES, and those who presented with metastatic disease. SNH (OR 0.73, 95%CI 0.70-0.76), Black race (OR 0.8, 95%CI 0.76-0.85), lowest SES (OR 0.77, 95%CI 0.73-0.82), and age >65 (OR 0.46, 95%CI 0.43-0.49) were associated with decreased odds of treatment receipt.  Compared to non-SNH, SNH was associated with worse five year-DSS for localized, regional, and metastatic disease. (Figure 1) When adjusting for co-variates (not including treatment receipt), care at a SNH was associated with worse DSS for localized (HR 1.2, 95%CI 1.1-1.2) and regional disease (HR 1.1, 95%CI 1.1-1.2) (Model 1). However, adding treatment receipt to Model 1, care at a SNH was not independently associated with worse DSS for any stage of disease.


Conclusions: Patients at SNHs undergo less treatment of any kind compared to non-SNHs. When corrected for appropriate factors the lack of treatment receipt at SNH is associated with worse DSS. Further studies are needed to determine the multi-level factors associated with failure to treat in SNHs.