Accessing surgical care for esophageal cancer: patient travel patterns to reach higher volume center

Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

INTRODUCTION

We sought to define the individual contributions of patient characteristics (PCs), hospital characteristics (HCs), case volume (CV), and social determinants of health (SDoH) on in-hospital mortality (IHM) after complex cancer surgery.

METHODS

The California Department of Health Care Access and Information database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PD), or proctectomy (PR) for a malignant diagnosis between 2010 and 2020. Multi-level multivariable regression was performed to assess the proportion of variance explained by PCs, HCs, CV and SDoH on IHM.

RESULTS

A total of 52,838 patients underwent cancer surgery (ES: n = 2,700, 5.1%; PN: n = 30,822, 58.3%; PD: n = 7530, 14.3%; PR: n = 11,786, 22.3%) across 294 hospitals. The IHM for the overall cohort was 1.7% and varied from 4.4% for ES to 0.8% for PR. On multivariable regression, PCs contributed the most to the variance in IHM (overall: 32.0%; ES: 21.6%; PN: 28.0%; PD: 20.3%; PR: 39.9%). Among the overall cohort, CV contributed 2.4%, HCs contributed 1.3%, and SDoH contributed 1.2% to the variation in IHM. CV was the second highest contributor to IHM among ES (5.3%), PN (5.3%), and PD (5.9%); however, HCs were a more important contributor among patients who underwent PR (8.0%). The unexplained variance in IHM was highest among ES (72.4%), followed by the PD (67.5%) and PN (64.6%) patient groups.

CONCLUSIONS

PCs are the greatest underlying contributor to variations in IHM following cancer surgery. These data highlight the need to focus on optimizing patients and exploring unexplained sources of IHM to improve quality of surgical care.

Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients

BACKGROUND

Behavioral health disorders (BHDs) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes.

STUDY DESIGN

Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018 and 2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Postoperative textbook outcomes (ie no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed.

RESULTS

Among 694,836 cancer patients, 46,719 (6.7%) patients had at least 1 BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs BHD: 20.3%; p < 0.001). Among surgical patients, individuals with BHD had higher odds of a complication (odds ratio [OR] 1.32 [1.26 to 1.39]), prolonged length of stay (OR 1.36 [1.29 to 1.43]), and 90-day readmission (OR 1.57 [1.50 to 1.65]) independent of social vulnerability or hospital-volume status resulting in lower odds to achieve a TO (OR 0.66 [0.63 to 0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs BHD: $17,432; p < 0.001). Of note, patients with BHD had worse long-term postoperative survival (median, no BHD: 46.6 [45.9 to 46.7] vs BHD: 37.1 [35.6 to 38.7] months) even after controlling for other clinical factors (hazard ratio 1.26 [1.22 to 1.31], p < 0.001).

CONCLUSIONS

BHD was associated with lower likelihood to achieve a postoperative textbook outcome, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Variations in Travel Patterns Affect Regionalization of Complex Cancer Surgery in California

INTRODUCTION

Regionalization of complex surgical procedures may improve healthcare quality. We sought to define the impact of regionalization on access to high-volume hospitals for complex oncologic procedures in the state of California.

METHODS

The California Department of Health Care Access and Information Database (2012-2016) identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR). Geospatial analysis was conducted to determine travel patterns. Clustered multivariable regression was performed to assess the probability of receiving care at a high-volume center.

RESULTS

Among 25,070 patients (ES: n = 1216, 4.9%; PN: n = 13,247, 52.8%; PD: n = 3559, 14.2%; PR: n = 7048, 28.1%), 6575 (26.2%) individuals resided within 30 min, 11,046 (44.1%) resided within 30-60 min, 7125 (28.4%) resided within 60-90 min, and 324 (1.3%) resided beyond a 90-min travel window from a high-volume center. Median travel distance was 13.4 miles (interquartile range [IQR] 6.0-28.7). On multivariable regression, patients residing further away were more likely to bypass a low-volume center to undergo care at a high-volume hospital (odds ratio 1.32, 95% confidence interval 1.12-1.55) versus individuals residing closer to high-volume centers. Approximately one-third (29.7%) of patients lived beyond a 1-h travel window to the nearest high-volume hospital, of whom 5% traveled over 90 min. While hospital mortality rates across different travel time windows did not differ, surgery at a high-volume center was associated with an overall 1.2% decrease in in-hospital mortality.

CONCLUSIONS

Regionalization of complex cancer surgery may be associated with a significant travel burden for a large subset of patients with complex cancer.

Impact of Community Privilege on Access to Care Among Patients Following Complex Cancer Surgery

OBJECTIVE

We sought to define the impact of community privilege on variations in travel patterns and access to care at high-volume hospitals for complex surgical procedures.

BACKGROUND

With increased emphasis on centralization of high-risk surgery, social determinants of health play a critical role in preventing equitable access to care. Privilege is a right, benefit, advantage, or opportunity that positively impacts all social determinants of health.

METHODS

The California Office of State-wide Health Planning Database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for a malignant diagnosis between 2012 and 2016 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated metric of both spatial polarization and privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the probability of undergoing care at a high-volume center, bypassing the nearest and high-volume center, and total real driving time and travel distance.

RESULTS

Among 25,070 patients who underwent a complex oncologic operation (ES: n=1216, 4.9%; PN: n=13,247, 52.8%; PD: n=3559, 14.2%; PR: n=7048, 28.1%), 5019 (20.0%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 4994 (19.9%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). Median travel distance was 33.1 miles (interquartile range 14.4-72.2). Roughly, three-quarters of patients (overall: 74.8%, ES: 35.0%; PN: 74.3%; PD: 75.2%; PR: 82.2%) sought surgical care at a high-volume center. On multivariable regression, patients residing in the least advantaged communities were less likely to undergo surgery at a high-volume hospital (overall: odds ratio 0.65, 95% CI 0.52-0.81). Of note, individuals in the least privileged areas had longer travel distances (28.5 miles, 95% CI 21.2-35.8) to reach the destination facility, as well as over 70% greater odds of bypassing a high-volume hospital to undergo surgical care at a low-volume center (odds ratio 1.74, 95% CI 1.29-2.34) versus individuals living in the highest privileged areas.

CONCLUSIONS AND RELEVANCE

Privilege had a marked effect on access to complex oncologic surgical care at high-volume centers. These data highlight the need to focus on privilege as a key social determinant of health that influences patient access to and utilization of health care resources.

Social Vulnerability And Outcomes For Access-Sensitive Surgical Conditions Among Medicare Beneficiaries

Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery

BACKGROUND

Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery.

METHODS

Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined.

RESULTS

Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]_FPC vs 72 years [interquartile range: 68-77]_non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]_FPC vs 3 [interquartile range: 2-8]_non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]_FPC vs 51.3 [interquartile range: 27.9-69.4]_non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84).

CONCLUSION

Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

Utilization of High-Volume Hospitals for High-Risk Cancer Surgery in California Following Medicaid Expansion

INTRODUCTION

A primary goal of the recent state and federal health reform is to increase access to care through expanded insurance coverage. We sought to evaluate the effect of Medicaid expansion (ME) on four high-risk cancer operations in California.

METHODS

The California Office of Statewide Health Planning database was used to identify patients who underwent either lung, esophageal, pancreas, or rectal resection for cancer between 2012 and 2016. To include only patients eligible for Medicaid and not Medicare, patients > 65 years were excluded. Trends in insurance coverage rates and utilization of high-volume hospitals were evaluated relative to the pre-policy (2012-2013) versus the post-policy (2014-2016) period.

RESULTS

Overall 10,569 individuals (esophageal: 5.6%; lung: 38%; pancreas: 14.1%; rectal: 42.3%) underwent a cancer operation. Following ME, Medicaid coverage increased from 12.4 to 20.2% (p < 0.001). There were no differences in age, sex, and race of Medicare beneficiaries pre- versus post-policy implementation (all p > 0.05). Of note, following ME, there was an increase in probability of utilization of high-volume hospitals for lung (47.6% vs. 56.3%), rectal (74.0% vs. 77.7%), and pancreas (60.2% vs. 68.5%) (p < 0.05 for all) cancer operations. Overall probability of surgery at a high-volume center after expansion increased by 5.8% among Medicaid beneficiaries versus other patients in the same time period. ME was not associated, however, with improvement in clinical outcomes such as complications, in-hospital mortality, or readmission (all p > 0.05).

CONCLUSION

ME was associated with an increase in Medicaid coverage, which resulted in more beneficiaries undergoing cancer operations at high-volume hospitals. While ME was associated with increased access to care, peri-operative outcomes were comparable pre- versus post-ME implementation.

Association of social vulnerability with the use of high-volume and Magnet recognition hospitals for hepatopancreatic cancer surgery

BACKGROUND

In an effort to improve perioperative and oncologic outcomes, there have been multiple quality improvement initiatives, including regionalization of high-risk procedures and hospital accreditation designations from independent organizations. These initiatives may, however, hinder access to high-quality surgical care for certain patients living in areas with high social vulnerability who may be disproportionally affected, leading to disparities in access and worse postoperative outcomes.

METHODS

Medicare beneficiaries who underwent liver or pancreas resection for cancer were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals were designated as high-volume based on Leapfrog criteria. The Centers for Disease Control and Prevention's social vulnerability index database was used to abstract social vulnerability index information based on each beneficiary's county of residence at the time of operation. The probability that a patient received care at a high-volume hospital stratified by the social vulnerability of the patient's county of residence was examined. Risk-adjusted postoperative outcomes were compared across low, average, and high levels of vulnerability at both low- and high-volume hospitals.

RESULTS

Among 16,978 Medicare beneficiaries who underwent a pancreatectomy (n = 13,393, 78%) or a liver resection (n = 3,594, 21.2%) for cancer, the mean age was 73.3 years (standard deviation: 5.8), nearly half the cohort was female (n = 7,819, 46%), and the overwhelming majority were White (n = 15,034, 88.5%). Mean social vulnerability index was 49.8 (standard deviation 24.8) and mean Charlson comorbidity index was 4.8 (standard deviation: 3). Overall, 8,251 (48.6%) of patients had their operations at a high-volume hospital, and 3,802 patients had their operations at a hospital with Magnet recognition. Age and sex were similar within the low-, average-, and high-social vulnerability index cohorts (P > .05); however, race differed across social vulnerability index groups. White patients made up 93% (n = 3,241) of the low social vulnerability index compared with 83.9% (n = 2,706) of the high-social vulnerability index group, whereas non-Whites made up 7% (n = 244) of the low-social vulnerability index group compared with 16.1% (n = 556) of the high-social vulnerability index group (P < .001). The risk-adjusted overall probability of having surgery at a high-volume hospital decreased as social vulnerability increased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Risk-adjusted probability of postoperative complications increased with social vulnerability index; however, among patients with high social vulnerability, risk of postoperative complications was lower at high-volume hospitals compared with low-volume hospitals. In contrast, there was no difference in postoperative complications between hospitals with and without Magnet recognition across social vulnerability index.

CONCLUSION

Patients residing in communities characterized by a high social vulnerability index were less likely to undergo high-risk cancer surgery at a high-volume hospital. Although postoperative complications and mortality increased as social vulnerability index increased, some of the risk appeared to be mitigated by having surgery at a high-volume hospital. These data highlight the importance of access to high-quality surgical care, especially among patients who may already be more vulnerable.

Association of Neighborhood Characteristics with Utilization of High-Volume Hospitals Among Patients Undergoing High-Risk Cancer Surgery

INTRODUCTION

As high-risk cancer surgery continues to become more centralized, it is important to understand the association of neighborhood characteristics relative to access to surgical care. We sought to determine the neighborhood level characteristics that may be associated with travel patterns and utilization of high-volume hospitals.

METHODS

The California Office of Statewide Health Planning database was used to identify patients who underwent pancreatectomy (PD), esophagectomy (ES), proctectomy (PR), or pneumonectomy (PN) for cancer between 2014 and 2016. Total minutes (m) traveled as well as whether a patient bypassed the nearest hospital that performed the operation to get to a higher-volume center was assessed. Data were merged with the Centers for Disease control social vulnerability index (SVI).

RESULTS

Overall, 26,937 individuals (ES: 4.7%; PN: 53.5% PD: 13.9% PR: 27.9%) underwent a complex oncologic operation. Median travel time was 16 m (interquartile range [IQR] 8.3-30.24) [ES: 21.8 m (IQR 10.6-46.9); PN: 14 m (IQR 7.8-27.0); PD: 21.2 m (IQR 10.6-42.6); PR: 15 m (IQR 8.1-28.4)]. Nearly three-quarter of patients (ES: 34%; PN: 73%; PD: 72%; LR: 81%) underwent an operation at a high-volume hospital. For all four operations, patients who resided in a county with a high overall SVI were less likely to have surgery at a high-volume hospital (ES: odds ratio [OR] 0.39, 95% confidence interval [CI] 0.24-0.65; PN: OR: 0.67, 95% CI 0.51-0.88; PD: OR 0.61, 95% CI 0.44-0.84; PR: OR 0.76, 95% CI 0.58-0.98).

CONCLUSIONS

Patients residing in communities of high social vulnerability were less likely to undergo high-risk cancer surgery at a high-volume hospital. The identification of society-based contextual disparities in access to complex surgical care should serve to inform targeted strategies to direct additional resources toward these vulnerable communities.