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Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness

  • Global Health Services Research
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH.

Methods

This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP’s “Homeless” variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs.

Results

Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0–98.2%). Adjusted costs were 32.7% higher (95% CI 14.5–53.9%) among PEH.

Conclusions

PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.

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Acknowledgement

The authors do not have any relevant conflicts of interest or disclosures. This study received no direct funding support. CMS and LMJ receive support from the National Cancer Institute (T32CA247801). AMS was funded by the American Association for the Surgery of Trauma, the American College of Surgeons and the National Institutes of Health/National Heart Lung and Blood Institute (K23HL157832-01). RPM receives support from the Society of Surgery of the Alimentary Tract. RR receives editorial compensation from JAMA Network Open.

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Authors and Affiliations

  1. Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Casey M. Silver MD, MS, Lauren M. Janczewski MD, MS, David J. Bentrem MD, MS & Anne M. Stey MD, MS

  2. Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Regina Royan MD, MPH

  3. Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA

    Regina Royan MD, MPH

  4. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Jeannette W. Chung PhD & Karl Y. Bilimoria MD, MS

  5. Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA

    Hemal K. Kanzaria MD, MS

  6. Department of Surgery, University of Chicago, Chicago, IL, USA

    Ryan P. Merkow MD, MS

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  1. Casey M. Silver MD, MS
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Correspondence to Ryan P. Merkow MD, MS.

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Disclosures

The authors report no relevant conflicts of interest. CMS and LMJ receive support from the National Cancer Institute (T32CA247801). AMS was funded by the American Association for the Surgery of Trauma, the American College of Surgeons and the National Institutes of Health/National Heart Lung and Blood Institute (K23HL157832-01). RPM receives support from the Society of Surgery of the Alimentary Tract. RR receives editorial compensation from JAMA Network Open. HKK’s salary is supported by a grant from the Benioff Homelessness and Housing Initiative, University of California, San Francisco, CA. HKK reported to be an advisory board member with equity for Amae Health, Inc., outside the submitted work.

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Silver, C.M., Janczewski, L.M., Royan, R. et al. Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness. Ann Surg Oncol 31, 1468–1476 (2024). https://doi.org/10.1245/s10434-023-14713-8

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