Potential impact of a volume pledge on spatial access: A population-level analysis of patients undergoing pancreatectomy

Abstract

Background A minimum-volume policy restricting hospitals not meeting the threshold from performing complex surgery may increase travel burden and decrease spatial access to surgery. We aim to identify vulnerable populations that would be sensitive to an added travel burden. Methods We performed a retrospective analysis of the California Office of Statewide Health Planning and Development database for patients undergoing pancreatectomy from 2005 to 2014. Number of hospitals bypassed was used as a metric for travel. Patients bypassing fewer hospitals were deemed to be more sensitive to an added travel burden. Results There were 13,374 patients who underwent a pancreatectomy, of which 2,368 (17.7%) were non-bypassers. On unadjusted analysis, patients >80 year old travelled less than their younger counterparts, bypassing a mean of 10.9 ± 9.5 hospitals compared to 14.2 ± 21.3 hospitals bypassed by the 35–49 year old age group (p<0.001). Racial minorities travelled less when compared to Non-Hispanic Whites (p<0.001). Patients identifying their payer status as self-pay (8.9 ± 15.6 hospitals bypassed) and Medicaid (10.1 ± 17.2 hospitals bypassed) also travelled less when compared to patients with private insurance (13.8 ± 20.4 hospitals bypassed, p<0.001). On multivariate analysis, advanced age, racial minority and patients with self-pay or Medicaid payer status were independently associated with increased sensitivity to an added travel burden. Conclusion In patients undergoing pancreatectomy, the elderly, racial minorities and patients with self-pay or Medicaid payer status were associated with an increased sensitivity to an added travel burden. This vulnerable cohort may be disproportionately affected by a minimum-volume policy.

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

“…The volume‐outcome relationship related to complex surgical procedures has been well‐documented . In the current centers, it was interesting to note that destination PD hospitals were likely to be academic medical centers, had more mean annual admissions, more hospital beds, more operating rooms, as well as more full time nurses (Table ).…”

“…The volume-outcome relationship related to complex surgical procedures has been well-documented. [13][14][15] In the current centers, it was interesting to note that destination PD hospitals were likely to be academic medical centers, had more mean annual admissions, more hospital beds, more operating rooms, as well as more full time nurses ( Table 2). In aggregate, patients who bypassed a closer hospital to be treated at a destination had lower peri-operative morbidity and failure-to-rescue, as well as an incidence of perioperative mortality that was almost one-half lower.…”

“…Of note, the travel distance burden may affect vulnerable populations disproportionately. For example, among patients undergoing pancreatectomy, the elderly, racial minorities, and patients with self‐pay or Medicaid payer status were most sensitive to travel burden . Access to comprehensive oncologic care at major cancer programs is important because delays in treatment may lead to worse oncologic outcomes …”

“…High-volume surgical centers have lower morbidity and mortality compared with low-volume centers, especially among patients undergoing more complex and high-risk cancerrelated surgical procedures. [13][14][15] These high-volume centers are often located, however, in urban areas, which compounded by the closure of existing rural hospital-based surgical services, may hinder rural community access to high-quality surgical care. 13,[15][16][17] For example, although the number of hospitals that provided surgical services with an approved American College of Surgeons (ACS) cancer program slightly increased since 2005, the number of people living greater than 60 minutes has increased from 6% to 11%.…”

“…Surgical services are a large part of curative‐intent therapy for patients with cancer. High‐volume surgical centers have lower morbidity and mortality compared with low‐volume centers, especially among patients undergoing more complex and high‐risk cancer‐related surgical procedures . These high‐volume centers are often located, however, in urban areas, which compounded by the closure of existing rural hospital‐based surgical services, may hinder rural community access to high‐quality surgical care .…”