Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States

Abstract

Background

Pancreaticoduodenectomy (PD) is associated with better outcomes in high-volume hospitals. However, it is unknown whether and to what extent the improved performance of high-volume hospitals may be associated with racial and socioeconomic factors, which have been shown to impact operative and postoperative outcomes in major surgeries. This review aims to identify the differences in racial and socioeconomic characteristics of patients who underwent PD surgery in high- and low-volume hospitals.

Methods

PubMed, Cochrane, and Web of Science were systematically searched between May 1, 2023 and May 7, 2023 without any time restriction on publication date. Studies that were conducted in the United States and had a direct comparison between high- and low-volume hospitals were included.

Results

A total of 30 observational studies were included. When racial proportions were compared by hospital volume, thirteen studies reported that compared to high-volume hospitals, a higher percentage of racial minorities underwent PD in low-volume hospitals. Disparities in traveling distance, education levels, and median income at baseline between high- and low-volume hospitals were reported by four, three, and two studies, respectively.

Conclusion

A racial difference at baseline between high- and low-volume hospitals was observed. Socioeconomic factors were less frequently included in existing literature. Future studies are needed to understand the socioeconomic differences between patients receiving PD surgery in high- and low-volume hospitals.

Keywords

pancreaticoduodenectomy whipple procedure systematic review hospital volume

Introduction

The Whipple procedure, or pancreaticoduodenectomy (PD), is a major surgical operation to treat benign and malignant neoplasms originating from the pancreas, peri-ampullary carcinomas, and cholangiocarcinoma. Because of the complexity of the procedure and associated potential complications, PD is often recommended to be performed in high-volume hospitals.¹ Research has found that high-volume hospitals have shorter average hospital stays, lower readmission rates, and reduced mortality rates.^2–5 Factors contributing to this higher success rate may include hospital experience and surgeon expertise.⁶ However, it is not fully understood how much of the better performance can be attributed to patient characteristics or if there are fundamental differences between patients treated at high-volume and low-volume hospitals.

The results of major surgical outcomes can be heavily influenced by patients’ socioeconomic characteristics.⁷ Studies that investigated hospital volume-based disparities in various types of surgeries indicated that racial and socioeconomic characteristics are significant factors in such disparities.^8,9 For instance, in a study with more than 1 million inpatient sample,¹⁰ Bennett et al (2010) reported that operative mortality is strongly associated with patients' socioeconomic status. The study also reported a higher mortality rate among patients with the lowest socio-economic status. Another study by Liu et al⁸ (2006) on multiple surgical operations including pancreatic cancer resections suggested that Blacks, Hispanics, and Asians are less likely to be treated at high-volume hospitals.

Socioeconomic factors such as income can have substantial influence on postoperative PD outcomes.^7,11 A study by Jerath et al (2020) reported that among 13 types of major surgery patients including PD, the risk of postoperative complications and 30-day mortality was significantly higher among patients in the lowest income quartile.¹¹ Education is another major socioeconomic factor that can significantly affect outcomes in pancreatic surgery.¹² In a study that included pancreatic resection patients, the length of hospital stay was greater among patients with lower health literacy level.¹² Similarly, current research suggests the existence of a geographical disparity in the form of distance or rurality which may affect surgical outcomes.¹³

Racial disparity is another key factor that can affect surgical access and outcomes. Khubchandani et al¹⁴ (2018) reported a lack of emergency general surgery hospitals in counties with a larger proportion of African Americans. Whites also have been shown to have higher rates of surgery per 100,000 people compared to Black or Hispanic population suggesting disparity in access.¹⁵

As discussed above, existing evidence suggests that there is a substantive impact of racial and socioeconomic factors on operative and postoperative surgical outcomes. Therefore, it is plausible that better surgical outcomes in high-volume hospitals for PD are also potentially driven by patients’ characteristics such as race and socioeconomic profile. To date, many studies have compared operative and postoperative PD-related outcomes in high- and low-volume hospitals; however, few have explored the extent to which the disparities in surgical outcomes between high- and low-volume hospitals can be attributed to differences in patient populations in terms of race and socioeconomic status. Therefore, by using the existing evidence, this study aims to systematically review racial and socioeconomic characteristics among patients who underwent PD in high- and low-volume patients to ascertain any differences.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the systematic search.¹⁶ Using the PRISMA guideline, we searched three electronic databases: PubMed, Cochrane, and Web of Science. We used various combinations of the three basic search terms (pancreaticoduodenectomy, high-volume hospitals, and low-volume hospitals), details of which are provided in the supplementary file. The systematic search was conducted between May 1, 2023 and May 7, 2023, and no time restriction was place on publication date of the articles.

Study eligibility

We included studies that examined patient outcomes from PD. Studies that included both high- and low-volume hospitals were included. We excluded studies that were not conducted in English, and only studies that were conducted in the United States were included. We also excluded studies that included other surgical procedures such as distal pancreatectomy and total pancreatectomy, etc. along with PD. The exclusion criteria also extended to the studies that did not have a direct comparison between high- and low-volume hospitals. Further, studies that mainly examined the impact of surgeon volume were excluded. The inclusion criteria were not limited to the type of studies (observational or randomized control trials).

Study selection

Two authors independently screened the titles and abstracts to match the eligibility criteria. Full text of the studies that matched eligibility criteria was then evaluated. The detailed study selection process is provided in the flow chart (Figure 1). Overall, the search in three databases produced 1301 studies. After applying the inclusion and exclusion criteria, we finally included 30 studies.

Figure 1.

Study selection flow chart.

Results

A total of 30 studies were included in this study. The study sample size in these studies ranged from 100 to 42 402. Various outcomes were evaluated in these studies such as in-hospital mortality, readmission, length of stay, minor and major complications, cost, resource utilization, etc. All studies had an observational design. A comparison between high- and low-volume hospitals was presented in Table 1.

Table 1.

A Comparison Between High- and Low-Volume Hospitals.

Author	No of Patients	Definition of Hospital Volume	High vs Low-Volume Key Outcomes	Race Distribution by Hospital Volume	Income
Adam et al¹⁷ (2017)	865	Low-volume hospitals <11 cases/year	Higher hospital volume was associated with reduced complications. Complication likelihood declined at 22 cases per year	High-volume center had higher percentages of White patients compared to low-volume center	No
Birkmeyer et al¹⁸ (1999_a)	7229	Very low = 0-.99/y, low = 1-1.99/y, medium = 2-4.99/y, and high = 5+/y	Compared to high-volume hospitals a 3 to 4-times higher mortality rate was observed in low and very low-volume hospitals in-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals	Race distribution was not provided	No
Birkmeyer et al¹⁹ (1999_b)	7229	Very low = 0-.99/y, low = 1-1.99/y, medium = 2-4.99/y, and high = 5+/y	A higher survival rate was observed in high-volume center compared to others. Late mortality was also lower in the high-volume center	Race distribution was not provided	No
Conroy et al² (2022)	3079	Low-volume, medium = 2-4.99/y, and high = 5+/y	90-day mortality rate was higher in low-volume center (OR 2.7; P = .002). Length of stay, positive surgical margins, 30-day readmission, and overall survival were similar	High-volume center had higher percentages of Whites and lower percentage of Black patients compared to low-volume center	No
Geus et al³ (2022)	24 572	Low- and high-volume hospitals were dichotomized at 11 operations/year	The odds of 30-day mortality was higher in low-volume hospital (OR = 2.068) compared to high-volume hospitals. The 30-day mortality rate at high- and low-volume hospitals were 2.5 and 5.6% respectively	High-volume center had higher percentages of Whites and lower percentage of Black patients compared to low-volume center
Diaz et al⁴ (2019)	23 014	High-volume >20 cases	Mortality (OR = .46 95% CI, .22‐.95) was lower at high-volume center. Greater than 20 PD cases was predictive of hospital bypass (OR = 3.8 95% CI, 3.3‐4.4)	Race distribution was not provided by hospital volume	No
Eguia et al²⁰ (2021)	4742	Low-volume = 1-18 PDs/year, moderate = 19-44 PDs/year, and high >44 PDs/high >44 PDs/year	At high-volume hospitals Blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR .44, 95% CI [.33, .57], OR .56, 95% CI [.43, .73])	For Black, 51% PDs were performed in low-volume hospitals and 21.7% in high-volume hospitals. For Hispanics, the figures were 51.6% and 16.4% respectively. While for the Whites, 33.7% were performed in high-volume hospitals	Compared to Whites, Hispanics and Blacks were more likely to be in lower income quartile
Ertel et al²¹ (2016)	9737	Definition was not provided	Resource utilization score was higher for the high-volume center compared to low-volume centers	Race distribution was not provided by hospital volume
Gordon et al²² (1998)	795	Average volume of 20 cases over 12 years period was defined as high-volume hospital	Relative risk of in-Hospital death and death was higher in low-volume hospital	High-volume center had higher percentages of Whites (84% vs 72.3%) and lower percentage of Black (13.1 vs 26.0%) patients compared to low-volume center	No
Ho et al²³ (2003)	6652	Very low = 1, low (2 or 3), medium (4-9), and high = ?	Lower rate of inpatient mortality was observed in high- and medium-volume hospitals	no	no
Kasumova et al²⁴ (2016)	2548	Very low-volume hospitals = 7 PD/year,low = 7-49 PD/year,medium = 50-79 PD/year, andhigh-volume hospitals >= 80 PD/year	Very low-volume hospital was a predictor of risk of hemorrhage. (OR 1.62, P = .016)	Not presented by hospital volume	Not presented by hospital volume
Kulshrestha et al²⁵ (2022)	3566	High >20,moderate = 10-19,low = 5-9, andvery low <5	High-volume hospitals had higher adjusted rates of textbook outcomes (odds ratio: 2.39, [2.02, 2.85], P < .001)	Race distribution was not provided by hospital volume	No
Kutlu et al²⁶ (2018)	4739	Calculated as quartiles. With cut-offs 1-5, 6-13, 14-25, and 25+	30- and 90-day mortality were the highest in low-volume hospitals	No	No
Lidsky et al⁵ (2017)	7086	Based on quartile. Quartile was calculated based on traveling time and hospital-volume	Long distance/high-volume hospitals (LT/HV) had shorter hospitalizations, lower mortality compared to short distance/low-volume hospitals (ST/LV). 30-day readmission rate was similar between the two types of hospitals	In LT/HV, White and Black were 82.5 and 11.7%, respectively. In ST/LV, the percentages were 94.0 vs 3.5%, respectively	In ST/LV, 70% had income above median while in LT/HV it was 57.6%
Panni et al²⁷ (2021)	42 402	Recommended 9, 9 to 35, and more than 35 cases as hospital volume breakdown	When the hospital volume was greater than 9, highest 90-day mortality improvement was observed. Among the hospitals that performed more than 9-cases, the best result was observed at 36-cases annually	no	no
Papageorge et al²⁸ (2022)_a	2717	PD volume was divided into tertiles (1st: <5, 2nd: 5 – 14, 3rd: >=15)	Compared to high-volume hospitals, patient treated at low-, mixed low-, and mixed high-volume hospital had higher risk of complications and 90-day mortality	High-volume center had higher percentages of Whites (86.2% vs 89.4.3%) and lower percentage of Black (6.4 vs 5.8%) patients compared to low-volume center	No+
Papageorge et al²⁹ (2022)_b	2450	Low <9 and high >= 9	Length of stay and major complications were higher in low-volume hospitals	High-volume center had higher percentages of Whites and lower percentage of Black patients compared to low-volume center	no
Schneider et al³⁰ (2013)	5190	Low = 1-9, medium = 10-31, and high >32	The risk of prolonged risk of stay was lower in high-volume hospitals	High-volume center had higher percentages of Whites and lower percentage of Black patients compared to low-volume center
Suraci et al³¹ (2021)	4085	No	Lower-volume hospitals had a higher than expected rates of positive margins	Comparison not provided based on hospital volume	Income breakdown was not based on hospital volume
Sutton et al³² (2014)	9883	Lowest = 1-22, low = 23-36,middle = 37-56, high volume = 57-90, and highest = 97	Perioperative mortality rate was higher in the lowest volume centers. Moreover, total indirect cost was also higher when in low-volume hospitals when index and readmission costs were taken into account	No	No
Sutton et al³³ (2015)	9805	Divided into four quintiles, varied year by year	Unadjusted readmission rate was lower in the highest two quantiles compared to the lowest quantile hospitals	Higher quintiles hospitals had higher percentage of Caucasians and lower percentage of African Americans compared to lower quintile	No
Swan et al³⁴ (2014)		Low (one to nine/year), medium (10 to 19/year), and high (20/year or more)	At different time periods mortality rate and mortality odds ratio was significantly lower in high-volume hospitals	No	No
Torphy et al³⁵ (2019)	3754	Low <10, moderate >10 to 23, and high >23	90-day mortality was lower in high-volume hospitals	Not by hospital volume	Not by hospital volume
Torphy et al³⁶ (2021)	3814	Cumulative MIPD Volume	Minimally invasive PD-related mortality was higher in low-volume hospitals during implementation		Not by hospital volume
Tran et al³⁷ (2016)_a	15 599	Low-volume <19.High-volume >= 19	Mortality rate and hospital stay was lower in high-volume hospitals	no	no
Tran et al³⁸ (2016)_b	15 574	High-volume >= 19. Low-volume <19	High-volume hospital had shorter hospital stay and lower median hospital charges	No	No
Eguia et al³⁹ (2019)	488 + 4544	Low: < 17,moderate to high: >17 or < 127 PD/year, and very high volume>127 PD/year	Open PD cost were higher in low and moderate high-volume hospitals compared to OPD in very high-volume hospitals	No distribution by hospital volume. Blacks and Hispanics race had higher 90-day aggregated cost than Whites	No
Ertel et al²¹ (2016)		Divided into tertiles (low, medium, and high)	Resource utilization was not associated with hospital volume	Higher percentages of Whites in high-volume center	no
O'Mahoney et al⁴⁰ (2016)	6185	Low = 0-10, medium = 11-25, and high = 25-60.Very high = 61+	Mortality and morbidity rates were lower in high-volume hospitals. 30-days readmission rates were similar	Compared to low-volume hospitals, high-volume hospitals had higher percentage of Whites	no
Toomey et al⁴¹ (2016)	50 + 50	Leapfrog definition	30-day mortality and readmission were low in high-volume hospitals. Moreover, operation duration and blood loss was less in high-volume hospitals	no	no

Definition of hospital volume

There was no universal cut-off used to define high- and low-volume hospitals. The thresholds were defined using various cut-offs, including categories such as very low, low, medium, medium-high, high, and very high. For example, Birkmeyer et al (1999 a,b) and Kasumova et al (2016) defined very low-volume as less than 1 PD case and 7 cases/year, respectively.^18,19,24 Similarly, the definition of low-volume varied. Birkmeyer et al (1999_a) used 1-1.99 cases, Conroy et al (2022) used 2-4.99 cases, Geus et al (2022) used 11 cases, and so on.^2,3,18 Similarly, various cut-off values were used to define medium, high, and very high volume. Conroy et al defined high-volume hospitals as those with greater than 5 PD cases per year while Kasumova et al (2016) defined high-volume hospitals as those with 80 or more PD cases per year.^2,24 Some studies used quantiles and tertiles for defining high- and low-volume hospitals.^21,28,33 One study used cumulative volume over the years for defining hospital volume,³⁶ while another study combined traveling distance along with hospital volume for the definition.⁵

Race and ethnicity

Only one study was found that primarily focused on race as the key variable.²⁰ Eguia et al (2021) reported that at high-volume hospitals, Blacks and Hispanics had a lower adjusted risk of any serious morbidity (OR .44, 95% CI [.33, .57], OR .56, 95% CI [.43, .73])²⁰ than non-Hispanic Whites at high-volume hospitals. Thirteen studies reported that a higher percentage of Whites underwent PD surgery in high-volume hospitals while a lower percentage of Blacks and Hispanics had their PD performed in high-volume hospitals.^{2,3,5,17,20–22,28,29,33,39,40} Other studies did not include race in the analysis.

Socioeconomic characteristics

Income

Baseline differences in income level of patients at high- vs low-volume hospitals were only provided in two studies.^5,20 The findings on baseline income levels diverged in those two studies. Eguia et al (2021) reported that Hispanics and Blacks were more likely to be in the lower income quartile compared to Whites.²⁰ In contrast, Lidsky et al (2017) reported that patients in long travel/high-volume hospitals had a lower median income compared to the patients in short travel/low-volume hospitals.⁵

Education

Education level was rarely included as one of the key characteristics in the studies. Only three studies reported education levels.^5,25,35 Kulshrestha et al (2022) reported that lower educational attainment was associated with worse standard surgical outcomes such as 30-day readmission, 90-day mortality, prolonged hospitalizations, etc. However, they did not provide a breakdown of educational levels between high- and low-volume hospitals. Lidsky et al (2017) reported that the proportion of patients with education above median was similar between short travel/low-volume (58.8%) hospitals and long-distance/high-volume hospitals (58.0%).⁵ Torphy et al³⁵ (2019) adjusted for education in the propensity scoring but did not provide a breakdown by hospital volume.

Transportation

Birkmeyer et al¹⁹ (1999_b) reported that low-volume hospitals had substantially lower percentages of patients from their hospital referral regions compared to high-volume hospitals (11% vs 60%). The authors also reported that the in-hospital mortality rate of local patients in low-volume hospitals was higher compared to those from a distant location, whereas in the high-volume hospitals, the mortality rate of local patients was slightly better. Geus et al³ (2022) reported that the median travel distance of the patients in high-volume hospitals was much higher (27.9% vs 9.8%) compared to low-volume hospitals. Diaz et al (2019) reported that patients are more likely to bypass the nearest hospital (68.8%) and travel to a high-volume hospital.⁴ The authors also reported that PDs at high-volume centers were associated with lower mortality. Lidsky et al (2017) incorporated traveling distance in their categorization of high- and low-volume hospitals.⁵ The median distance for short travel/low-volume was 3.2 miles while for long travel/high-volume hospitals the average distance was 97.3 miles. The authors reported that traveling to a high-volume hospital was associated with better 30-day and 90-day mortality.

Two additional studies included travel distance in their analysis. Torphy et al³⁵ (2019) adjusted the propensity score for distance from the hospitals but did not provide the distribution by hospital volume. The distance was also considered as one of the confounders by Kutlu et al²⁶ (2018), but how the distance was distributed between high- and low-volume hospitals was unavailable.

None of the 30 included studies examined other socioeconomic characteristics such as marital status, neighborhood quality, and food security.

Key outcome

Based on hospital volume status, we examined key outcomes such as mortality rate, readmission, and economic outcomes. Most studies reported better outcomes for high-volume hospitals. Specifically, these outcomes include better mortality rate, readmission rate, survival rate, length of stay, and economic outcomes (Table 2).

Table 2.

Classification of Studies Based on Key Outcomes.

Mortality Rate	(Birkmeyer et al (1999), Conroy et al (2022), Geus et al (2022), Diaz et al (2019), Gordon et al (1998)), Ho et al (2003), Kutlu et al (2018), Lidsky et al (2017), Panni et al (2021), Papageorge et al (2022), Sutton et al (2014), Swan et al (2014), Torphy et al (2019), Tran et al (2016), Enomoto et al (2014), O'Mahoney et al (2016), and Toomey et al (2016))
Readmission rate	(Conroy et al (2022), Lidsky et al (2017), Sutton et al (2014), Sutton et al (2015), O'Mahoney et al (2016), and Toomey et al (2016))
Survival rate	(Birkmeyer et al (1999) and Conroy et al (2022))
Length of stay	(Conroy et al (2022), Papageorge et al (2022), Enomoto et al (2014), Papageorge et al (2022), and Toomey et al (2016))
Economic outcomes	(Sutton et al (2014), Eguia et al (2019), and Enomoto et al (2014))

Discussion

In this study, we systematically reviewed the existing literature on PDs performed in high- and low-volume hospitals. We particularly focused on disparities in patient characteristics in these two types of hospitals.

In this review, we found 13 studies that reported a racial difference at baseline between high-volume and low-volume hospitals.^{2,3,5,17,20–22,28,29,33,39,40} It was observed that most high-volume centers had higher percentages of non-Hispanic White PD patients than low-volume centers. The high-volume hospitals had lower percentages of African American and Hispanic PD patients compared to low-volume hospitals. For example, Eguia et al (2021) reported that Black and Hispanics were less likely than Whites to undergo PD in high-volume centers.²⁰ The hospital volume-related racial disparity in PD is consistent with prior literature on surgical procedures in general.^14,15 Previous studies indicated that Hispanics and non-Hispanic Blacks are less likely to be treated at high-volume centers.^8,42 Dimick et al (2013) reported that despite a comparatively higher percentage of Black patients living near high-quality hospitals (determined by composite measures that include hospital volume along with other measures), they are more likely than White patients to undergo surgery in low-quality hospitals.⁴² In a systematic review, Haider et al⁴³ (2013) suggested that hospital volume may play a role in minority-based outcome disparity. A potential solution to such disparity could be changes in policy which would increase the access of ethnic minorities to high-volume hospitals. Eguia et al reported that minorities treated in high-volume hospitals had better outcomes than minorities treated in low-volume hospitals,²⁰ suggesting that such policies would improve outcomes for minorities. However, none of the studies examined how racial differences in high- and low-volume hospitals affect operative and postoperative outcomes in high- and low-volume hospitals.

We observed that social determinants of health such as income and education were less frequently incorporated in PD research. In this review, we did not find any study that evaluated the impact of income levels on hospital volume-based outcomes. We found only two studies that reported income in the baseline characteristics.^5,20 Income levels can have a substantial impact on PD outcomes as income can affect access to health care, cancer screening, and overall health status.^44,45 Lower income is often associated with delayed diagnosis and treatment.⁴⁶ Although not specific to PD, previous studies have reported that lower income levels are associated with higher length of stay and higher mortality rates.¹¹ Therefore, it would be interesting to see how income levels impact access to PD surgery in high- and low-volume hospitals as well as how it impacts postoperative complications. The only study reporting income and hospital volume found that short travel/lower-volume hospitals had a higher percentage of PD patients with income levels above the median.⁵ The reason for higher percentages of above median income patients in low-volume hospitals could be due to the fact that cost of pancreatic surgery in low-volume hospitals is generally higher than the high-volume hospitals.^47,48

Education level is another key social determinant that was very rarely included in PD research. Education level can significantly impact health literacy and understanding, medical information processing, and informed decision-making.^49,50 A study by Kugelman et al⁵¹ (2017) reported that patients with lower educational attainments are more likely to experience postoperative complications following a surgical procedure. We did not find any study that evaluated the impact of education level and hospital volume-based outcomes among PD patients. Examining the impact of education on mortality rate, readmission, and postoperative complications among PD patients in high- and low-volume hospitals is an important future research direction.

Traveling distance from the hospital is another factor that impacts patients’ decisions. Onega et al (2008) reported that certain population groups have difficulty accessing specialized cancer care, and travel time was higher for specialized cancer treatment facilities.⁵² Although there were only two studies in this area, both indicated that high-volume hospitals had more patients from outside of the residential area while low-volume hospitals have more patients from the local area.^4,19 Many patients may bypass low-volume hospitals for PDs in high-volume hospitals.⁴ However, other than distance we did not find any studies that evaluated transportation barriers (eg reliable transportation) in PD surgery. It would be interesting to investigate whether and how the transportation barrier plays a role in patients' preference in choosing high- vs low-volume hospitals.

We also found that the impact of other social determinants such as marital status, neighborhood and built environment, and social and community context were vastly understudied when examining the impact of hospital volume on PD patient outcomes.

Most studies included in this review reported better clinical outcomes for PD patients operated in high-volume hospitals. In general, better outcomes in high-volume hospitals are attributed to several factors such as the experience and expertise of the surgical team, availability of multidisciplinary teams, necessary infrastructure and resources, comprehensive and specialized postoperative care, and development of standardized protocols for patient care. However, biological and social differences in patient characteristics can significantly influence PD-related outcomes in high- and low-volume hospitals. This review showed that some patient characteristics such as race and distance from the referral hospital are unequal in these two types of hospitals. It is plausible that other important social determinants such as income, educational level, food security, transportation barrier, and access to care could also be different between high- and low-volume hospitals. It was also observed that most of these parameters were largely absent in PD research in the United States. Therefore, future studies should emphasize including these parameters in the analysis.

This systematic review has some limitations. We did not review studies that included other surgical procedures along with PD. As the primary aim of this review was to evaluate racial and socioeconomic factors and there is a lack of quantifiable data in these categories, we did not perform a meta-analysis.

Nevertheless, this review provides comprehensive details of patient characteristic differences between high- and low-volume hospitals based on existing literature. This review highlights that racial distribution, income levels, and distance from referral hospitals are different at baseline between high- and low-volume hospitals. Moreover, in this review, we found that many socioeconomic factors are understudied and their role in the outcomes related to high- and low-volume hospitals is unknown. Future studies should focus more on the role of socioeconomic factors in PD-related operative and postoperative outcomes at high- and low-volume hospitals.

Supplemental Material

Supplemental Material - Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States

Supplemental Material for Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States by Mohammad Ikram, Chan Shen, and Colette R. Pameijer in The American Surgeon™.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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