Intersection of Race, Rurality, and Income in Defining Access to Minimally Invasive Lung Surgery

J W Awori Hayanga; Xun Luo; Islam Hasasna; Paul Rothenberg; Shalini Reddy; J Hunter Mehaffey; Jason Lamb; Vinay Badhwar; Alper Toker

doi:10.1016/j.athoracsur.2024.03.040

Intersection of Race, Rurality, and Income in Defining Access to Minimally Invasive Lung Surgery

Ann Thorac Surg. 2024 Apr 17:S0003-4975(24)00289-3. doi: 10.1016/j.athoracsur.2024.03.040. Online ahead of print.

Authors

J W Awori Hayanga¹, Xun Luo², Islam Hasasna², Paul Rothenberg², Shalini Reddy², J Hunter Mehaffey², Jason Lamb², Vinay Badhwar², Alper Toker²

Affiliations

¹ Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, United States. Electronic address: jeremiah.hayanga@wvumedicine.org.
² Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, United States.

PMID: 38641193
DOI: 10.1016/j.athoracsur.2024.03.040

Abstract

Background: Race is a potent influencer of healthcare access. Geography and income may exert equal or greater influence on patient outcomes. We sought to define the intersection of race, rurality, and income and their influence on access to minimally invasive lung surgery in Medicare beneficiaries.

Methods: Medicare and Medicaid Services data were used to evaluate patients with lung cancer who underwent right upper lobectomy, via open, robotic-assisted (RATS), or video-assisted thoracic surgery (VATS) between 2018 and 2020. International Classification of Diseases 10^th edition was used to define diagnoses and procedures. We excluded sub-lobar, segmental, wedge, bronchoplastic, or reoperative patients with non-malignant or metastatic disease or a history of neoadjuvant chemotherapy. Risk adjustment was performed using inverse probability of treatment weighting (IPTW) propensity scores with generalized linear models and Cox Proportional Hazards models.

Results: The cohort comprised 13,404 patients, 4,291 (32.1%) open, 4,317 (32.2%) RATS, and 4,796 (35.8%) VATS. Black/Urban patients had significantly higher RATS and VATS rates (p<0.001), higher long-term survival (p=0.007), fewer open resections (p<0.001), and lower overall mortality (p=0.007). Low-income Black/Urban patients had higher RATS (p=0.002), VATS (p<0.001), higher long-term survival (p=0.005), fewer open resections (p<0.001), and lower overall mortality compared to rural white patients. (p=0.005).

Conclusions: Rural white populations living close to the federal poverty line may suffer a burden of disparity traditionally observed among poor Black people. This suggests a need for health policies that extend services to impoverished, rural areas to mitigate social determinants of health.