Accessing surgical care for pancreaticoduodenectomy: Patient variation in travel distance and choice to bypass hospitals to reach higher volume centers

Abstract

Background While better outcomes at high‐volume surgical centers have driven regionalization of complex surgical care, access to high‐volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. Methods The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher‐volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher‐volume center. Results Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high‐volume destination hospital. Specifically, average annual PD volume at the nearest “bypassed” vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure‐to‐rescue: 14.5% vs 9.1%). PD at a high‐volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22‐0.95). High‐volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3‐4.4). Among patients who had surgery at a low‐volume center, nearly 20% bypassed a high‐volume hospital in route. Furthermore, among patients who did not bypass a high‐volume hospital, one‐third would have needed to travel only an additional 30 miles or less to reach the nearest high‐volume hospital. Conclusion Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher‐volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low‐volume center.

Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery

“…Pancreatic resection was used as the index procedure given its relatively high morbidity and mortality, as well as data suggesting variation in outcomes relative to access to care. 36 – 38 In addition, we used the diversity index, which was a validated tool utilized by the Census Bureau to measure residential segregation. 28 Of note, patients from the lowest racially integrated counties had 16% lower odds to experience a TO following pancreatic resection compared with patients from high-diversity communities.…”

Geographic Disparities in Oncologic Treatment and Outcomes: The Urban–Rural Divide

“…2 Specifically, centralization of care can result in an increased travel burden for many patients undergoing complex cancer operations at highvolume centers. 5,6 While most studies have focused on the centralization of surgery, there remains a question as to whether centralization of the continuum of cancer care, including surgery, radiation, and chemotherapy, has led to disparities in access and outcomes. By using a large, longitudinal cancer state registry, Sutton et al retrospectively analyzed outcomes among 740 patients who received either all or some of their cancer care at one of two cancer referral centers versus non-referral centers.…”

“…To this point, our group and others have demonstrated that many patients undergoing a complex cancer operation bypass a high-volume hospital on the way to a lower-volume site of care. 6,[8][9][10] Identifying and developing strategies to improve the care of these patients may improve oncologic outcomes without increasing patient travel burden. Sutton et al also demonstrated that patients receiving some or all oncologic treatment (i.e., surgery, radiation, chemotherapy) at one of two referral centers, both of which were high-volume academic medical centers, had better oncologic outcomes, including overall survival.…”

Insurance status and high‐volume surgical cancer: Access to high‐quality cancer care

“…In particular, providers and policy makers must be certain that policies are designed to achieve the intended outcome. For example, centralization of high‐risk procedures can increase travel burden on patients, particularly on those individuals who are already vulnerable and marginalized 17,18 . Similarly, some accreditation programs may not be associated with improved outcomes and even may contribute to increased disparities 19 .…”

“…For example, centralization of high-risk procedures can increase travel burden on patients, particularly on those individuals who are already vulnerable and marginalized. 17,18 Similarly, some accreditation programs may not be associated with improved outcomes and even may contribute to increased disparities. 19 In turn, in thinking about improving access to high-quality cancer surgery, surrogate markers must be chosen wisely.…”