BackgroundWhile safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy.MethodsAll adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010–2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days.ResultsOf an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03–1.50), intraoperative complications (AOR 1.45, 95% CI 1.20–1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35–1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64–2.10), costs (+10,400, 95% CI 6,900–14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00–1.23).ConclusionsCare at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.