Regionalization and Its Alternatives

How to direct patients to high-volume hospitals: exploring the influencing drivers

BACKGROUND

During the last decade, planning concentration policies have been applied in healthcare systems. Among them, attention has been given to guiding patients towards high-volume hospitals that perform better, acccording to the volume-outcome association. This paper analyses which factors drive patients to choose big or small hospitals (with respect to the international standards of volumes of activity).

METHODS

We examined colon cancer surgeries performed in Piedmont (Italy) between 2004 and 2018. We categorised the patient choice of the hospital as big/small, and we used this outcome as main dependent variable of descriptive statistics, tests and logistic regression models. As independent variables, we included (i) patient characteristics, (ii) characteristics of the closest big hospital (which should be perceived as the most immediate to be chosen), and (iii) territorial characteristics (i.e., characteristics of the set of hospitals among which the patient can choose). We also considered interactions among variables to examine which factors influence all or a subset of patients.

RESULTS

Our results confirm that patient personal characteristics (such as age) and hospital characteristics (such as distance) play a primary role in the patient decision process. The findings seem to support the importance of closing small hospitals when they are close to big hospitals, although differences emerge between rural and urban areas. Other interesting insights are provided by examining the interactions between factors, e.g., patients affected by comorbidities are more responsive to hospital quality even though they are distant.

CONCLUSIONS

Reorganising healthcare services to concentrate them in high-volume hospitals emerged as a crucial issue more than forty years ago. Evidence suggests that concentration strategies guarantee better clinical performance. However, in healthcare systems in which patients are free to choose where to be treated, understanding patients' behaviour and what drives them towards the most effective choice is of paramount importance. Our study builds on previous research that has already analysed factors influencing patients' choices, and takes a step further to enlighten which factors drive patients to choose between a small or a big hospital (in terms of volume). The results could be used by decision makers to design the best concentration strategy.

Factors associated with the closure of obstetric units in German hospitals and its effects on accessibility

BACKGROUND

An increase in regionalization of obstetric services is being observed worldwide. This study investigated factors associated with the closure of obstetric units in hospitals in Germany and aimed to examine the effect of obstetric unit closure on accessibility of obstetric care.

METHODS

Secondary data of all German hospital sites with an obstetrics department were analyzed for 2014 and 2019. Backward stepwise regression was performed to identify factors associated with obstetrics department closure. Subsequently, the driving times to a hospital site with an obstetrics department were mapped, and different scenarios resulting from further regionalization were modelled.

RESULTS

Of 747 hospital sites with an obstetrics department in 2014, 85 obstetrics departments closed down by 2019. The annual number of live births in a hospital site (OR = 0.995; 95% CI = 0.993-0.996), the minimal travel time between two hospital sites with an obstetrics department (OR = 0.95; 95% CI = 0.915-0.985), the availability of a pediatrics department (OR = 0.357; 95% CI = 0.126-0.863), and population density (low vs. medium OR = 0.24; 95% CI = 0.09-0.648, low vs. high OR = 0.251; 95% CI = 0.077-0.822) were observed to be factors significantly associated with the closure of obstetrics departments. Areas in which driving times to the next hospital site with an obstetrics department exceeded the 30 and 40 min threshold slightly increased from 2014 to 2019. Scenarios in which only hospital sites with a pediatrics department or hospital sites with an annual birth volume of ≥ 600 were considered resulted in large areas in which the driving times would exceed the 30 and 40 min threshold.

CONCLUSION

Close distances between hospital sites and the absence of a pediatrics department at the hospital site associate with the closure of obstetrics departments. Despite the closures, good accessibility is maintained for most areas in Germany. Although regionalization may ensure high-quality care and efficiency, further regionalization in obstetrics will have an impact on accessibility.

Access to urologic cancer care for Medicaid-insured patients

BACKGROUND

The expansion of state Medicaid programs associated with the Affordable Care Act has led to significant increases in insurance coverage for economically vulnerable patients, however barriers to accessing cancer care still exist. To develop strategies to improve healthcare access, we characterized access to new urologic cancer care for patients with Medicaid insurance in the United States.

METHODS

Using a secret shopper approach, we contacted a representative sample of facilities designated for cancer care in United States. Trained volunteers posed as a family member seeking urologic cancer care using a simulated scenario of a parent with a new diagnosis of a localized kidney tumor. The primary study outcome was acceptance of Medicaid. In addition, we assessed facility characteristics associated with Medicaid acceptance relating to state Medicaid expansion status, Medicare reimbursement rates, and teaching hospital status using data from the Medicare & Medicaid Services Hospital General Information data file, the American Hospital Directory, and the American Medical Association of Colleges Organizational Characteristics Database.

RESULTS

We sampled a total of 389 facilities, of which 14.4% did not accept new Medicaid patients. Medicaid acceptance was higher in facilities located in states that elected to expand Medicaid through the ACA vs. non-expansion states (90.1% vs. 77.4% respectively, P < 0.001). Facilities accepting patients with Medicaid were located in states with higher mean Medicaid-to-Medicare fee indexes (0.70 for Medicaid-accepting vs. 0.65 for non-accepting facilities, P < 0.001). In addition, Medicaid acceptance was higher in teaching hospitals vs. non-teaching facilities (93.8% vs. 83.4% P = 0.02), and medical school affiliated facilities (89.2% vs. 79.7% P = 0.01).

CONCLUSION

We identified access disparities for patients with Medicaid insurance seeking urologic cancer care at centers. These findings highlight opportunities to improve the quality and timeliness of cancer care.

Hospital Surgical Volume Is Poorly Correlated With Delivery of Multimodal Treatment for Localized Pancreatic Cancer

Using Donabedian’s quality of care model, this study assessed process (hospital multimodal treatment) and structure (hospital surgical case volume) measures to evaluate localized pancreatic cancer outcomes.

Making sense of the French public hospital system: a network-based approach to hospital clustering using unsupervised learning methods

BACKGROUND

Hospitals in the public and private sectors tend to join larger organizations to form hospital groups. This increasingly frequent mode of functioning raises the question of how countries should organize their health system, according to the interactions already present between their hospitals. The objective of this study was to identify distinctive profiles of French hospitals according to their characteristics and their role in the French hospital network.

METHODS

Data were extracted from the national hospital database for year 2016. The database was restricted to public hospitals that practiced medicine, surgery or obstetrics. Hospitals profiles were determined using the k-means method. The variables entered in the clustering algorithm were: the number of stays, the effective diversity of hospital activity, and a network-based mobility indicator (proportion of stays followed by another stay in a different hospital of the same Regional Hospital Group within 90 days).

RESULTS

Three hospital groups were identified by the clustering algorithm. The first group was constituted of 34 large hospitals (median 82,100 annual stays, interquartile range 69,004 - 117,774) with a very diverse activity. The second group contained medium-sized hospitals (with a median of 258 beds, interquartile range 164 - 377). The third group featured less diversity regarding the type of stay (with a mean of 8 effective activity domains, standard deviation 2.73), a smaller size and a higher proportion of patients that subsequently visited other hospitals (11%). The most frequent type of patient mobility occurred from the hospitals in group 2 to the hospitals in group 1 (29%). The reverse direction was less frequent (19%).

CONCLUSIONS

The French hospital network is organized around three categories of public hospitals, with an unbalanced and disassortative patient flow. This type of organization has implications for hospital planning and infectious diseases control.

Pancreaticoduodenectomy is safe in appropriately resourced rural hospitals

BACKGROUND

Research shows improved safety and treatment outcomes for patients undergoing pancreaticoduodenectomy at high-volume centers. Regionalization of pancreaticoduodenectomy to high-volume urban centers can result in unintended negative consequences for rural patients and communities. This report examines outcomes after pancreaticoduodenectomy performed at a rural hospital and compares them with national standards.

METHODS

A prospectively maintained database of pancreatic operations performed at a rural tertiary hospital was queried. Demographic and clinical information for patients undergoing pancreaticoduodenectomy (2007-2019) was analyzed. Primary outcomes were the rates of patient mortality and morbidity. Secondary outcomes were readmission rates, indications, and associations with clinical variables.

RESULTS

We included 118 patients in our study. There were 41 postoperative complications (34.7%), including 1 death (0.9%). The 90-day readmission rate was 24.6%. The most common indication for readmission was deep space infection (n = 7, 24.1%). Patients requiring an intraoperative transfusion were more likely to need hospital readmission (41.4% vs 9.0% of patients without transfusion, P = .016). Patients with postoperative complications required readmission more frequently (51.7% vs 29.2%, P = .093). These findings are similar to data from urban hospitals.

CONCLUSION

Patient safety and surgical outcomes after pancreaticoduodenectomy performed in appropriately resourced rural hospitals can be comparable with national standards. Safely treating rural patients near their home benefits patients and their communities.

Travel distance and overall survival in hepatocellular cancer care

BACKGROUND

Our objective was to assess the relationship between overall survival (OS) and distance travelled to the treating facility for patients undergoing liver resection for hepatocellular carcinoma and to determine whether this relationship was dependent upon the structural factors of the treating facility.

METHODS

Using National Cancer Database, we focused on extremes of travel: Local (<12.5 miles to treating facility) and Travel (≥50 miles). We analyzed OS with Cox models; we estimated stratified models to assess interaction between distance and facility characteristics (volume, academic status).

RESULTS

We included 6860 patients. After correction for confounding, distance travelled was not associated with OS (p = 0.444). However, Travel patients treated at high-volume, academic centers had worse OS compared to Local patients (HR 1.54, 95%CI 1.07-2.21); this association was not seen for patients treated at low volume, academic centers (p = 0.708) high volume non-academic centers (p = 0.174) or low volume non-academic centers (p = 515).

CONCLUSION

For those patients treated at high-volume, academic centers, living far from the facility was associated with worse OS. The reasons for this association should be investigated further.

Regionalization for health improvement: A systematic review

Regionalization is the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region. This method was adopted by several countries to improve the quality of provided care and to properly utilize available resources. Thus, a systematic review was conducted to verify effective interventions to improve health and management indicators within the health services regionalization. The protocol was registered in PROSPERO (CRD42016042314). We performed a systematic search in databases during February and March 2017 which was updated in October 2020. There was no language or date restriction. We included experimental and observational studies with interventions focused on regionalization-related actions, measures or policies aimed at decentralizing and organizing health offerings, rationalizing scarce capital and human resources, coordinating health services. A methodological assessment of the studies was performed using instruments from the Joanna Briggs Institute and GRADE was also used to assess outcomes. Thirty-nine articles fulfilled the eligibility criteria and sixteen interventions were identified that indicated different degrees of recommendations for improving the management of health system regionalization. The results showed that regionalization was effective under administrative decentralization and for rationalization of resources. The most investigated intervention was the strategy of concentrating procedures in high-volume hospitals, which showed positive outcomes, especially with the reduction of hospitalization days and in-hospital mortality rates. When implementing regionalization, it must be noted that it involves changes in current standards of health practice and in the distribution of health resources, especially for specialized services.

Optimization of transmural care by implementation of an online expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases: A prospective analysis

INTRODUCTION

Centralization of oncological care results in a growing demand for specialized consultations and referrals. Improved telemedicine solutions are needed to facilitate access to specialist care and select patients eligible for referral. The purpose of this quality improvement initiative was to optimize transmural care for patients suffering from colorectal cancer liver metastases through implementation of an online expert panel.

METHODS

A digital communication platform was developed to share medical data, including high-quality diagnostic imaging of patients suffering from colorectal cancer liver metastases. Feasibility of local treatment strategies was assessed by a panel of liver specialists to select patients for referral. After implementation, an observational cohort study was conducted to evaluate quality improvement in transmural care using revised Standards for Quality Improvement Reporting Excellence guidelines.

RESULTS

From September 2016-September 2018, eight hospitals were connected to the platform, covering a population of 3 m. In total, 123 cases were assessed, of which 54 (43.9%) were prevented from needless physical referral. Assessment of treatment strategy by an online expert panel significantly reduced the average lead time during multidisciplinary team meetings from 3.73 min to 2.12 min per patient (p < 0.01).

CONCLUSIONS

Implementation of an online expert panel is an innovative, accessible and user-friendly way to provide cancer-specific expertise to regional hospitals. E-consultation of such panels may result in more efficient multidisciplinary team meetings and prevent fragile patients from needless referral. Sustainability of these panels however is subject to structural financial compensation, so a cost-effectiveness analysis is warranted.

Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn't.

Does Distance to Treatment Affect Mortality Rate for Surgical Oncology Patients?

INTRODUCTION

Using the National Cancer Database (NCDB), we seek to analyze the relationship of patient distance to hospital of treatment on mortality trends after surgery, since patients often travel large distances to referral centers.

METHODS

A retrospective cohort study of the NCDB from 2004 to 2013 was performed, and patients with gastrointestinal, melanoma, and head and neck primary site tumors who underwent surgery were included. We excluded cases with no recorded mortality status or distance from the hospital. A multivariable logistic regression was conducted with adjustments for population density, treating facility location, age, race, gender, education, income, insurance, comorbidities (Charlson-Deyo score), days from diagnosis to treatment, positive margin, tumor stage and grade, and lymph or vascular invasion.

RESULTS

A total of 1 424 482 patients were included. Overall median distance to hospital was 9.7 miles (range 4.2-23.7 miles); 696 647 (48.91%) of the sample traveled a distance greater than 10 miles to the institution where the procedure was performed. The multivariable regression analysis demonstrated overall lower mortality for those patients travelling a longer distance to care for multiple tumor types, including: liver (OR .87, .77-.99, P = .032), pancreas (OR .82, .76-.89, P < .001), colon (OR .92, .89-.95, P < .001), rectum (OR .90, .83-.96, P = .003), melanoma (OR .83, .79-.88, P < .001), and tumors of the larynx (OR .80, .69-.94, P = .005).

DISCUSSION

Increased distance traveled for surgical treatment has a significant correlation with decreased odds of mortality for multiple cancers, highlighting the importance of centralized referral patterns for oncology care.

Travel distance and its interaction with patient and hospital factors in pancreas cancer care

BACKGROUND

Although volume-outcome literature supports regionalization for complex procedures, travel may be burdensome. We assessed the relationship between overall survival and travel distance for patients undergoing pancreatic resection for adenocarcinoma.

METHODS

We analyzed the Fall 2018 National Cancer Database Public Use File. We defined distance traveled as a categorical variable (<12.5 miles, 12.5-50mi, and >50mi). We analyzed overall survival (OS) as a function of distance traveled using the log rank test and Cox proportional hazards models; we estimated stratified models to assess for interaction between distance and other relevant covariates.

RESULTS

In adjusted analysis of 39,089 patients, greater distance was associated with decreased OS (p = 0.0029). We found interactions between distance and center type, comorbidities, and age. Distance traveled was a negative factor for patients treated at low-volume academic centers (but not high-volume academic or non-academic centers). Additionally, distance traveled was a negative factor for OS in young, healthy patients but not geriatric, ill patients.

CONCLUSION

Traveling more than 12.5 miles for pancreatic resection was associated with worse OS. Prior to regionalization, evaluation of local resources may be necessary.

Analyzing National Incidences and Predictors of Open Conversion During Minimally Invasive Partial Nephrectomy for cT1 Renal Masses

Objectives: To analyze predictors of open conversion during minimally invasive partial nephrectomy (MIPN) for cT1 renal masses. Methods: The National Cancer Database (NCDB) was investigated for kidney cancer patients who underwent partial nephrectomy (PN) between 2010 and 2015. Patients who underwent MIPN were stratified into converted and nonconverted groups. Sociodemographics, facility characteristics, and surgical outcomes were compared between the two groups, and multivariate logistic regression model was fitted to identify independent predictors of open conversion. Results: In total, 54,246 patients underwent PN for kidney cancer during the 6-year period. Of those, 18,994 (35%) were open partial nephrectomies (OPNs) and 35,252 (64%) were MIPN. Overall, 1010 (2.87%) of MIPNs were converted to OPN. There was an increasing utilization of MIPN from 50.35% in 2010 to 74.73% in 2015. Patients who had open conversion had more 30-day readmissions (5.95% vs 3.31%, p < 0.01). On multivariate analysis; high-volume facility (>30 MIPNs/year), year of surgery (2015 vs 2010), and robotic approach predicted a lower likelihood of conversion (odds ratio [OR] 0.52, confidence interval [CI] 0.44-0.62; OR 0.59, CI 0.47-0.73; and OR 0.31, CI 0.27-0.35; respectively, p < 0.001 for all). Conversely, Medicaid (vs private insurance; OR 1.75, CI 1.39-2.19, p < 0.001) and male sex (OR 1.26, CI 1.11-1.44, p < 0.001) were independent predictors of conversion. Conclusions: Open conversion in MIPN occurred in 2.87% of cases. There was an increasing utilization of MIPN associated with decreased conversion rates. Higher volume hospitals and progressing year of surgery were associated with less likelihood of conversion.

Use of an Online Crowdfunding Platform for Unmet Financial Obligations in Cancer Care

This cross-sectional study identified characteristics of patients using an online crowdfunding platform for unmet financial obligations associated with cancer care.

Association of hospital and surgeon volume with mortality following major surgical procedures: Meta-analysis of meta-analyses of observational studies

Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.