Impact of race and payor status on patterns of utilization of partial and radical nephrectomy in patients with renal cell carcinoma in California

Background

Prospective trials have shown similar outcomes with partial nephrectomy (PN) in patients with localized renal cell carcinoma (RCC), and multiple studies suggest increasing the use of the technique. We hypothesize that patients who stem from minority groups, as well as Medicare and Medical, have less access to this specialized procedure and, therefore, have a higher rate of radical nephrectomy (RN).

Methods

We interrogated the California Office of Statewide Health Planning and Development (OSHPD) database, which collects information from all inpatient admissions, emergency room visits and inpatient/outpatient procedures in the state. All patients undergoing nephrectomy for RCC were identified from 2012 to 2018 using CPT and ICD-9/10 codes to identify patients with RCC undergoing RN and PN. Variables of interest included patient demographics, comorbidities, payor status and type of institution where the surgery was performed. We performed univariate and multivariable analysis to explore associations between patient factors and type of nephrectomy performed.

Results

In total, 31,093 patients who had undergone a nephrectomy in the study period were identified. Overall, most were 57% male, with a mean age of 58 years. PN and RN were performed in 15,840 (50.9%) and 15,253 (49.1%) patients, respectively. PN rates differed according to race/ ethnicity, as it was performed in 8576 (53.1%) White, 1124 (55.3%) Black, 1286 (46.0%) Asian, 4107 (47.5%) Hispanic and 747 (50.5%) other race patients (P < 0.001). Use of PN also differed among patients based on payor status, with 6800 (56.4%) private, 5,036 (43.9%) Medicare, 1,817 (38.3%) Medical, and 2,187 (77.7%) other insurance patients (P < 0.001). On multivariate analysis controlling for age, gender, comorbidities, and frailty, race was independently associated with the type of nephrectomy, but payor was not.

Conclusions

Our study confirms that race and payor status may have an influence on the utilization of partial versus status radical nephrectomy, with the highest rate of partial nephrectomies among Black patients and those with private insurance. Although there are multiple potential confounders (e.g., latency of diagnosis and resulting tumor size/complexity), it is possible access to care is a driver of this phenomenon.