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Peterson KJ, Drezdzon MK, Sparapani R, Calata JF, Ridolfi TJ, Ludwig KA, Peterson CY. Traveling Long Distances for Rectal Cancer Care: Institutional Outcomes and Patient Experiences. J Surg Res 2024; 302:916-924. [PMID: 39265279 DOI: 10.1016/j.jss.2024.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 07/18/2024] [Accepted: 07/24/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Mounting evidence supports traveling to high-volume centers for complex surgical procedures, such as a proctectomy, yet the burden of travel and outcomes of patients traveling long distances is not yet clear. Thus, we aimed to evaluate oncologic outcomes, quality of life, and travel burdens for patients treated for rectal cancer at a single tertiary-care institution. METHODS A retrospective study of patients treated with proctectomy for locally advanced rectal cancer was performed comparing long and short travel distance (STD) cohorts. Primary outcome measures included overall mortality, disease recurrence, and quality of life. Secondary outcomes included out-of-pocket expenses. The cohorts were compared using Wilcoxon rank-sum and Chi-square tests for continuous and categorical variables, respectively. Kaplan-Meier plots were created to evaluate overall and disease-free survival. RESULTS Among 102 patients, 51 (50%) were classified as long travel distance (LTD, mean 57.8 miles) and 51 (50%) were classified as STD (mean 12.8 miles). There was no statistical difference in 5-y mortality (4% LTD versus 4% STD, P = 1.000), disease recurrence (26% LTD versus 18% STD, P = 0.336), or quality of life (0.85 LTD versus 0.87 STD, P = 0.690). The LTD cohort did have significantly lower postresection compliance with surveillance (84% LTD versus 96% STD, P = 0.046). LTD cohort also had significantly more lodging ($77.1 LTD versus $0 STD, P = 0.025) and transportation expenses ($133.6 LTD versus $92.6 STD, P = 0.010). CONCLUSIONS As the surgical management of rectal cancer becomes increasingly centralized, this study found patients who traveled long-distances received comparable care with outcomes similar to those who lived locally. Higher travel costs and lower compliance with surveillance were identified as barriers to care in the long-distance population, but a number of solutions can be implemented to address these issues.
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Affiliation(s)
- Kent J Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Melissa K Drezdzon
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jed F Calata
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Timothy J Ridolfi
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Carrie Y Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin.
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Hasan K, Kayum S. Patient Experience and Satisfaction with Orthopedic Services at a Community (Rural) Setting Hospital-How Is It Different from Urban Setting. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2024; 12:209-215. [PMID: 39193539 PMCID: PMC11348020 DOI: 10.3390/jmahp12030017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/30/2024] [Accepted: 07/26/2024] [Indexed: 08/29/2024]
Abstract
Patient experience and satisfaction are the keystones in evaluating the effectiveness of clinical care in musculoskeletal medicine. Although all orthopedic settings work on the same principles of providing safe and quality health care, community hospitals represent a unique environment. There may be key differences with regard to patient experience between these settings. Accessibility to care, choices of provider, personalized care, availability of and access to resources, cultural and social variances, and waiting times are a few of the many elements that may impact patient experience and satisfaction. This narrative review aims to explore the core differences in these settings and how they can reflect on patient experience and satisfaction.
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Affiliation(s)
- Khalid Hasan
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Shahin Kayum
- Department of Orthopedics, University of Toronto, Toronto, ON M5T 1P5, Canada
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Beiriger J, Puyana J, Deeb AP, Silver D, Lu L, Boland S, Brown JB. Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria. J Trauma Acute Care Surg 2024:01586154-990000000-00779. [PMID: 39093636 DOI: 10.1097/ta.0000000000004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. METHODS We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage. RESULTS A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients (p < 0.05). CONCLUSION Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. LEVEL OF EVIDENCE Diagnostic; Level IV.
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Affiliation(s)
- Jamison Beiriger
- From the Division of Trauma and General Surgery, Department of Surgery (J.B., J.P., D.S., L.L., S.B., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Department of Surgery (A.-P.D.), Advent Health, Orlando, Florida
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English NC, Ivankova NV, Smith BP, Jones BA, Herbey II, Rosamond B, Kim DH, Oslock WM, Schoenberger-Godwin YMM, Pisu M, Chu DI. Providers' and survivors' perspectives on the availability and accessibility of surgery in gastrointestinal cancer care. J Gastrointest Surg 2024; 28:1330-1338. [PMID: 38824070 PMCID: PMC11298309 DOI: 10.1016/j.gassur.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Surgery is essential for gastrointestinal (GI) cancer treatment. Many patients lack access to surgical care that optimizes outcomes. Scarce availability and/or low accessibility of appropriate resources may be the reason for this, especially in economically disadvantaged areas. This study aimed to investigate providers' and survivors' perspectives on barriers and facilitators to the availability and accessibility of surgical care. METHODS Semistructured interviews informed by surgical disparities and access-to-care conceptual frameworks with purposively selected GI cancer providers and survivors in Alabama and Mississippi were conducted. Survivors were within 3 years of diagnosis of stage I to III esophageal, pancreatic, or colorectal cancer. Transcripts were analyzed using inductive thematic and content analysis techniques. Intercoder agreement was reached at 90 %. RESULTS The 27 providers included surgeons (n = 11), medical oncologists (n = 2), radiation oncologists (n = 2), a primary care physician (n = 1), nurses (n = 8), and patient navigators (n = 3). This study included 36 survivors with ages ranging from 44 to 87 years. Of the 36 survivors, 21 (58.3 %) were male, and 11 (30.6 %) identified as Black. Responses were grouped into 3 broad categories: (i) transportation/geographic location, (ii) specialized care/testing, and (iii) patient-/provider-related factors. The barriers included lack and cost of transportation, reluctance to travel because of uneasiness with urban centers, low availability of specialized care, overburdened referral centers, provider-related referral biases, and low health literacy. Facilitators included availability of charitable aid, centralizing multidisciplinary care, and efficient appointment scheduling. CONCLUSION In the Deep South, barriers and facilitators to the availability and accessibility of GI surgical cancer care were identified at the health system, provider, and patient levels, especially for rural residents. Our data suggest targets for improving the use of surgery in GI cancer care.
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Affiliation(s)
- Nathan C English
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General Surgery, University of Cape Town, Cape Town, South Africa
| | - Nataliya V Ivankova
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Burkely P Smith
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bayley A Jones
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ivan I Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brendan Rosamond
- Department of General Surgery, Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, TX, United States
| | - Dae Hyun Kim
- Department of Health Management and Policy, Georgetown University, DC, United States
| | - Wendelyn M Oslock
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of Quality, Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States
| | - Yu-Mei M Schoenberger-Godwin
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maria Pisu
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Mallick S, Chervu NL, Balian J, Charland N, Valenzuela AR, Sakowitz S, Benharash P. Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States. PLoS One 2024; 19:e0303586. [PMID: 38875301 PMCID: PMC11178205 DOI: 10.1371/journal.pone.0303586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/16/2024] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.
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Affiliation(s)
- Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
| | - Jeffrey Balian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nicole Charland
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Alberto R Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
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Brauer DG, Gonen M, Drebin JA, Groeger JS, Jewell EL. Establishing Regionalized Acute Care Across a Health Care System to Decentralize Postoperative Care After Oncologic Surgery. JCO Oncol Pract 2024; 20:666-672. [PMID: 38295332 DOI: 10.1200/op.23.00392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024] Open
Abstract
PURPOSE Patients undergoing oncologic surgery at major referral centers frequently experience postdischarge care fragmentation, which has been associated with poor outcomes. This report describes and evaluates the outcomes of an intervention at Memorial Sloan Kettering Cancer Center (MSKCC) to decentralize postdischarge postoperative acute care within our health care system. METHODS In 2018, MSKCC completed the addition of six regional acute care clinics called symptom care clinics (SCCs) to existing regional outpatient clinics. Acute care was previously only available within our system at a single centralized urgent care center (UCC). All patients undergoing surgery in our system between January 1, 2019, and June 30, 2021, were followed for 90 days. The exposure was the site of initial acute care presentation-UCC or SCC-and outcomes included utilization, access, financial toxicity, and mortality. Mortality was adjusted using hierarchical modeling at the level of the region. RESULTS A total of 6,992 postsurgical patients experienced 10,525 acute care visits in our system within 90 days of surgery. Twenty-nine percent of these patients presented to the SCC first. These patients were older but had fewer comorbidities and shorter index length of stay compared with UCC patients. Utilization of SCCs increased substantially while UCC utilization decreased during a period of stable case volume. SCCs were closer to patients' homes, and wait times were shorter. Rates of financial toxicity were similar between groups. Of this high-risk cohort accessing acute care postoperatively, 90-day mortality was similar for UCC and SCC patients (P = .731). CONCLUSION This model of decentralized acute care after oncologic surgery was increasingly used over time with comparable patient safety. Health systems should emphasize patient-centered care by supporting safe strategies for regionalized care even when treatments are delivered at centralized referral centers.
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Affiliation(s)
- David G Brauer
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Mithat Gonen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey S Groeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elizabeth L Jewell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Munir MM, Woldesenbet S, Endo Y, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants? Ann Surg Oncol 2024; 31:2856-2866. [PMID: 38194046 PMCID: PMC10997543 DOI: 10.1245/s10434-023-14852-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/17/2023] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
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Meier J, Murimwa G, Nehrubabu M, DiMartino L, Singal AG, Karagkounis G, Yopp A, Zeh HJ, Polanco PM. Effect of Hospital Cancer Designation on use of Multimodal Therapy and Survival of Metastatic Colorectal Cancer: A State-Wide Analysis. Ann Surg Oncol 2024; 31:2591-2597. [PMID: 38245645 DOI: 10.1245/s10434-023-14859-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/17/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Stage IV colorectal cancer (CRC) often requires multidisciplinary approach. However, multimodal treatment options (receipt of > 1 type of treatment) may not be uniformly delivered across health systems. We characterized the association between center-level cancer center designation and receipt of multimodal treatment and survival. METHODS The Texas Cancer Registry was used to identify patients diagnosed with stage IV CRC from 2004-2017. We identified those who received care at either: a National Cancer Institute-designated (NCI-D), an American College of Surgeons-Commission on Cancer-designated (ACS-D), or an undesignated facility. We used multivariable logistic regression and Cox regression for analysis to assess receipt of one or more treatment modality and 5-year overall survival. RESULTS Of 19,355 patients with stage IV CRC, 2955 (15%) received care at an NCI-D facility and 5871 (30%) received multimodal therapy. Both NCI-D (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.49-1.81) and ACS-D (OR 1.37; 95% CI 1.27-1.48) were associated with increased likelihood of multimodal therapy compared with undesignated centers. NCI-D also was associated with significantly improved survival (hazard ratio [HR] 0.74; 95% CI 0.70-0.78), although ACS-D was associated with a modest improvement in survival (HR 0.95; 95% CI 0.92-0.99). Receipt of multimodal therapy was strongly associated with improved survival (HR 0.61; 95% CI 0.59-0.63). CONCLUSIONS In patients with stage IV CRC, treatment at ACS-D and NCI-D facilities was associated with increased use of multimodality therapy and improved survival. However, only a small proportion of patients have access to these specialized centers, highlighting a need for expanded access to multimodal therapies at other centers.
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Affiliation(s)
- Jennie Meier
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Gilbert Murimwa
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Mithin Nehrubabu
- Department of Mathematics, University of Texas at Dallas, Dallas, TX, USA
| | - Lisa DiMartino
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern, Dallas, TX, USA
| | - Amit G Singal
- Division of Digestive & Liver Diseases, University of Texas Southwestern, Dallas, TX, USA
| | | | - Adam Yopp
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Patricio M Polanco
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA.
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Kahn RM, Ma X, Gordhandas S, Yeoshoua E, Ellis RJ, Zhang X, Aviki EM, Abu-Rustum NR, Gardner GJ, Sonoda Y, Zivanovic O, Long Roche K, Jewell E, Boerner T, Chi DS. Regionalizing ovarian cancer cytoreduction to high-volume centers and the impact on patient travel in New York State. Gynecol Oncol 2024; 182:141-147. [PMID: 38262237 PMCID: PMC10960664 DOI: 10.1016/j.ygyno.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE To evaluate the theoretical impact of regionalizing cytoreductive surgery for ovarian cancer (OC) to high-volume facilities on patient travel. METHODS We retrospectively identified patients with OC who underwent cytoreduction between 1/1/2004-12/31/2018 from the New York State Cancer Registry and Statewide Planning and Research Cooperative System. Hospitals were stratified by low-volume (<21 cytoreductive surgical procedures for OC annually) and high-volume centers (≥21 procedures annually). A simulation was performed; outcomes of interest were driving distance and time between the centroid of the patient's residence zip code and the treating facility zip code. RESULTS Overall, 60,493 patients met inclusion criteria. Between 2004 and 2018, 210 facilities were performing cytoreductive surgery for OC in New York; 159 facilities (75.7%) met low-volume and 51 (24.3%) met high-volume criteria. Overall, 10,514 patients (17.4%) were treated at low-volume and 49,979 (82.6%) at high-volume facilities. In 2004, 78.2% of patients were treated at high-volume facilities, which increased to 84.6% in 2018 (P < .0001). Median travel distance and time for patients treated at high-volume centers was 12.2 miles (IQR, 5.6-25.5) and 23.0 min (IQR, 15.2-37.0), and 8.2 miles (IQR, 3.7-15.9) and 16.8 min (IQR, 12.4-26.0) for patients treated at low-volume centers. If cytoreductive surgery was centralized to high-volume centers, median distance and time traveled for patients originally treated at low-volume centers would be 11.2 miles (IQR, 3.8-32.3; P < .001) and 20.2 min (IQR, 13.6-43.0; P < .001). CONCLUSIONS Centralizing cytoreductive surgery for OC to high-volume centers in New York would increase patient travel burden by negligible amounts of distance and time for most patients.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiaoyue Ma
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Ellis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiuling Zhang
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Emeline M Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elizabeth Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Verm RA, Baker MM, Cohn T, Park S, Swanson J, Freeman R, Abdelsattar ZM. Fragmented care, Commission on Cancer accreditation, and overall survival in patients receiving surgery and chemotherapy for esophageal cancer. Surgery 2024; 175:618-628. [PMID: 37743107 DOI: 10.1016/j.surg.2023.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/21/2023] [Accepted: 07/08/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Increasing regionalization for esophagectomy for cancer may lead patients to travel for surgery at one institution and receive chemotherapy at another closer to home. We explore the effects on survival for care fragmentation, the Commission on Cancer status of secondary institutions providing chemotherapy, and the type of institution performing surgery. METHODS We queried the National Cancer Database to identify all patients who underwent esophagectomy for esophageal cancer and received perioperative chemotherapy between 2006 and 2019. Patients were divided into single-center care, fragmented-to-Commission on Cancer care, or fragmented-to-non-Commission on Cancer care. We identified associations using multivariable logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards models. RESULTS A total of 18,502 patients met the criteria for inclusion: 8,290 (44.8%) received single-center care; 3,414 (18.5%) fragmented-to-Commission on Cancer care; and 6,798 (36.4%) fragmented-to-non-Commission on Cancer care. Fragmented care was more likely in White patients (adjusted odds ratio = 1.25; P < .001) and in patients nonadjacent to a metropolitan area (adjusted odds ratio = 1.36; P < .001). Overall survival was equivalent between single-center and fragmented care, but undergoing an esophagectomy at an academic center was associated with improved survival (adjusted hazard ratio = 0.82; P = .016). In patients with an esophagectomy at a nonacademic center, overall survival was best if perioperative chemotherapy was administered at Commission on Cancer-accredited facilities compared with chemotherapy at fragmented-to-non-Commission on Cancer centers (P = .022). CONCLUSION Most of the esophageal cancer care in the US is fragmented at multiple institutions. When care is fragmented, it is most commonly at non-Commission on Cancer centers for perioperative chemotherapy. Overall survival is best when esophagectomy is performed at an academic center, and perioperative therapy is administered at Commission on Cancer-accredited facilities.
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Affiliation(s)
- Raymond A Verm
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL. https://twitter.com/RaymondVerm
| | - Marshall M Baker
- Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Tyler Cohn
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Simon Park
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - James Swanson
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Richard Freeman
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Zaid M Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL.
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11
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Wang CC, Bharadwa S, Domenech I, Barber EL. In the patient's shoes: The impact of hospital proximity and volume on stage I endometrial cancer care patterns and outcomes. Gynecol Oncol 2024; 182:91-98. [PMID: 38262244 DOI: 10.1016/j.ygyno.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/13/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE To compare the impact of travel burden and hospital volume on care patterns and outcomes in stage I endometrial cancer. METHODS This retrospective cohort study identified patients from the National Cancer Database with stage I epithelial endometrial carcinoma who underwent hysterectomy between 2012 and 2020. Patients were categorized into: lowest quartiles of travel distance and hospital surgical volume for endometrial cancer (Local) and highest quartiles of distance and volume (Travel). Primary outcome was overall survival. Secondary outcomes were surgery route, lymph node (LN) assessment method, length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. Results were stratified by tumor recurrence risk. Outcomes were compared using propensity-score matching. Propensity-adjusted survival was evaluated using Kaplan-Meier curves and compared using log-rank tests. Cox models estimated hazard ratios for death. Sensitivity analysis using modified Poisson regressions was performed. RESULTS Among 36,514 patients, 51.4% were Local and 48.6% Travel. The two cohorts differed significantly in demographics and clinicopathologic characteristics. Upon propensity-score matching (p < 0.05 for all), more Travel patients underwent minimally invasive surgery (88.1%vs79.1%) with fewer conversions to laparotomy (2.0%vs2.6%), more sentinel (20.5%vs11.3%) and fewer traditional LN assessments (58.1vs61.7%) versus Local. Travel patients had longer intervals to surgery (≥30 days:56.7%vs50.1%) but shorter LOS (<2 days:76.9%vs59.8%), fewer readmissions (1.9%vs2.7%%), and comparable 30- and 90-day mortality. OS and HR for death remained comparable between the matched groups. CONCLUSIONS Compared to surgery in nearby low-volume hospitals, patients with stage I epithelial endometrial cancer who travelled longer distances to high-volume centers experienced more favorable short-term outcomes and care patterns with comparable long-term survival.
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Affiliation(s)
- Connor C Wang
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA.
| | - Sonya Bharadwa
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Issac Domenech
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Emma L Barber
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
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12
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Vierra M, Bansal VV, Morgan RB, Witmer HDD, Reddy B, Dhiman A, Godley FA, Ong CT, Belmont E, Polite B, Shergill A, Turaga KK, Eng OS. Fragmentation of Care in Patients with Peritoneal Metastases Undergoing Cytoreductive Surgery. Ann Surg Oncol 2024; 31:645-654. [PMID: 37737968 DOI: 10.1245/s10434-023-14318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The delivery of multimodal treatment at a high-volume center is known to optimize the outcomes of gastrointestinal malignancies. However, patients undergoing cytoreductive surgery (CRS) for peritoneal metastases often must 'fragment' their surgical and systemic therapeutic care between different institutions. We hypothesized that this adversely affects outcomes. PATIENTS AND METHODS Adults undergoing CRS for colorectal or appendiceal adenocarcinoma at our institution between 2016 and 2022 were identified retrospectively and grouped by care network: 'coordinated care' patients received exclusively in-network systemic therapy, while 'fragmented care' patients received some systemic therapy from outside-network providers. Factors associated with fragmented care were also ascertained. Overall survival (OS) from CRS and systemic therapy-related serious adverse events (SAEs) were compared across the groups. RESULTS Among 85 (80%) patients, 47 (55%) had colorectal primaries and 51 (60%) received fragmented care. Greater travel distance [OR 1.01 (CI 1.00-1.02), p = 0.02] and educational status [OR 1.04 (CI 1.01-1.07), p = 0.01] were associated with receiving fragmented care. OS was comparable between patients who received fragmented and coordinated care in the colorectal [32.5 months versus 40.8 months, HR 0.95 (CI 0.43-2.10), p = 0.89] and appendiceal [31.0 months versus 27.4 months, HR 1.17 (CI 0.37-3.74), p = 0.55] subgroups. The frequency of SAEs (7.8% versus 17.6%, p = 0.19) was also similar. CONCLUSIONS There were no significant differences in survival or SAEs based on the networks of systemic therapy delivery. This suggests that patients undergoing CRS at a high-volume center may safely receive systemic therapy at outside-network facilities with comparable outcomes.
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Affiliation(s)
- Mason Vierra
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Varun V Bansal
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ryan B Morgan
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Hunter D D Witmer
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Biren Reddy
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Frederick A Godley
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Cecilia T Ong
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Erika Belmont
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Blasé Polite
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Kiran K Turaga
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, University of California, Irvine, Orange, CA, USA.
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13
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Ramian H, Sun Z, Yabes J, Jacobs B, Sabik LM. Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds. JCO Oncol Pract 2024; 20:123-130. [PMID: 37590899 PMCID: PMC10827295 DOI: 10.1200/op.22.00851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.
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Affiliation(s)
- Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Jacobs
- Department of Urology, Division of Health Services Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
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14
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Lizalek JM, Reames BN. Time, Space, and Place: Can Geospatial Information Systems Clarify the Tension Between Regionalization and Access for Complex Cancer Surgery? Ann Surg Oncol 2023; 30:7915-7917. [PMID: 37684367 DOI: 10.1245/s10434-023-14292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Jason M Lizalek
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
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15
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Martins RS, Chang YH, Etzioni D, Stucky CC, Cronin P, Wasif N. Understanding Variation in In-hospital Mortality After Major Surgery in the United States. Ann Surg 2023; 278:865-872. [PMID: 36994756 DOI: 10.1097/sla.0000000000005862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US). BACKGROUND The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown. STUDY DESIGN Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each. RESULTS Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups. CONCLUSIONS Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM.
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Affiliation(s)
- Russell Seth Martins
- Centre for Clinical Best Practices (CCBP), Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ
| | - David Etzioni
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Chee-Chee Stucky
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Patricia Cronin
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Nabil Wasif
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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16
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Ofoma UR, Lanter TJ, Deych E, Kollef M, Wan F, Joynt Maddox KE. Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis. Crit Care Explor 2023; 5:e1009. [PMID: 38046937 PMCID: PMC10688774 DOI: 10.1097/cce.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. OBJECTIVES We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. MAIN OUTCOMES AND MEASURES We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. RESULTS Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). CONCLUSIONS AND RELEVANCE Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Tierney J Lanter
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Elena Deych
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
- Center for Advancing Health Services, Policy and Economics Research, Washington University Institute of Public Health, St. Louis, MO
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Venchiarutti RL, Sharman AR, Dawson T, Elliott MS, Clark JR, Palme CE. Patient-reported experiences and satisfaction with head and neck surgery outreach clinics in regional New South Wales, Australia: A cross-sectional survey. J Eval Clin Pract 2023; 29:1302-1313. [PMID: 37608573 DOI: 10.1111/jep.13918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023]
Abstract
RATIONALE Head and neck surgery services are increasingly being centralised in Australia. Outreach models can overcome burdens of travel that patients in regional and rural areas experience when attending routine appointments, by providing services closer to home. AIM To explore patient-reported experiences and satisfaction with regional outreach services for head and neck surgery in Australia. METHODS Patients who attended two regional outreach clinics in New South Wales (NSW), Australia, were surveyed over a 6-month period. Patients completed the Outpatient Cancer Clinics Survey (2020 version) that explored perceptions and experiences of the clinic. Patients with cancer were asked to complete the Edmonton Symptom Assessment System and the Communication and Attitudinal Self-Efficacy scale. Descriptive statistics and analysis of data was performed, and results were compared to the NSW statewide Outpatient Cancer Clinics Survey (2020). Content analysis of free text responses was performed. RESULTS Some 128 patients responded (56% response rate; mean age 67.2 years, 46.1% female). Compared to the 2020 NSW survey, a higher proportion of patients in our cohort responded positively to 14 of the 26 questions, with the greatest differences observed for questions regarding waiting area comfort (+12.1%, p = 0.008), being informed about different treatment options (+9.5%, p = 0.04), and issues relating to parking (+9.5%, p = 0.03). A lower proportion of our sample responded positively to the question about whether health professionals knew enough about their medical history (-19.3%, p < 0.001). Respondents appreciated having a local clinic that helped them avoid travel to major cities and associated expenses and highlighted benefits of expert consultation and timeliness of investigations. However, cost of appointments and level of reimbursements remain barriers for some patients. CONCLUSIONS Patients had a high level of satisfaction with regional outreach clinics for head and neck surgery across most domains, indicating patients highly value this service.
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Affiliation(s)
- Rebecca L Venchiarutti
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Ashleigh R Sharman
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Tania Dawson
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Michael S Elliott
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan R Clark
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Carsten E Palme
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
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18
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Boerkoel A, Tischler L, Kaul K, Krause H, Stentzel U, Schumann S, van den Berg N, de Laffolie J. Healthcare service use in paediatric inflammatory bowel disease: a questionnaire on patient and parent care experiences in Germany. BMC Gastroenterol 2023; 23:378. [PMID: 37932708 PMCID: PMC10626645 DOI: 10.1186/s12876-023-03021-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Paediatric inflammatory bowel disease (PIBD) patients require chronic care over the lifespan. Care for these patients is complex, as it is adapted for childrens' life stages and changing disease activity. Guideline based care for this patient group recommends a multidisciplinary approach, which includes in addition to paediatric gastroenterologists, nutritional and psychological care services. For PIBD patients, a discrepancy between available guideline-based multidisciplinary care and actual care has been found from the provider side, but to what extent patients experience this is unclear. OBJECTIVES To identify which healthcare services were used and whether socio-demographic, geographic or disease related factors have an influence on health service utilisation. METHODS A standardised questionnaire (CEDNA) was distributed amongst parents of children aged 0-17 diagnosed with PIBD and adolescents (aged 12-17) with a PIBD. Items related to health service use were analysed, these included specialist care, additional care services, reachability of services and satisfaction with care. Logistic regression models on additional service use were calculated. Service availability and reachability maps were made. RESULTS Data was analysed for 583 parent and 359 adolescent questionnaires. Over half of the respondents had Crohn's Disease (CD, patients n = 186 parents n = 297). Most patients and parents reported their paediatric gastroenterologist as their main care contact (patients 90.5%; parents 93%). Frequently reported additional services were nutritional counselling (patients 48.6%; parents 42.2%) and psychological support (patients 28.1%; parents 25.1%). Nutritional counselling was more frequently reported by CD patients in both the patient (OR 2.86; 95%CI 1.73-4.70) and parent (OR 3.1; 95%CI 1.42-6.71) sample. Of the patients, 32% reported not using any additional services, which was more likely for patients with an illness duration of less than one year (OR 3.42; 95%CI 1.26-9.24). This was also observed for the parent population (OR 2.23; 95%CI 1.13-4.4). The population-based density of specialised paediatric gastroenterologists was not proportionate to the spatial distribution of patients in Germany, which may have an influence on access. CONCLUSIONS Parents and children reported highly specialised medical care. Multidisciplinary care offers do not reach the entire patient population. Access to multidisciplinary services needs to be ensured for all affected children.
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Affiliation(s)
- Aletta Boerkoel
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany.
| | - Luisa Tischler
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Kalina Kaul
- General Pediatrics & Pediatric Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Heiko Krause
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Ulrike Stentzel
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Schumann
- General Pediatrics & Pediatric Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Neeltje van den Berg
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jan de Laffolie
- General Pediatrics & Pediatric Gastroenterology, Justus-Liebig-University, Giessen, Germany
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19
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Brooks GA, Tomaino MR, Ramkumar N, Wang Q, Kapadia NS, O’Malley AJ, Wong SL, Loehrer AP, Tosteson ANA. Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival. J Natl Cancer Inst 2023; 115:1171-1178. [PMID: 37233399 PMCID: PMC10560598 DOI: 10.1093/jnci/djad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/07/2023] [Accepted: 05/24/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer. METHODS We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression. RESULTS We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26). CONCLUSIONS Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.
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Affiliation(s)
- Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Marisa R Tomaino
- Center for Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | | | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - A James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, NH, USA
| | - Sandra L Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Huston-Paterson H, Mao Y, Tseng CH, Kim J, Yeh MW, Wu JX. Disparities in Initial Thyroid Cancer Care by Hospital Treatment Volume: Analysis of 52,599 Cases in California. Thyroid 2023; 33:1215-1223. [PMID: 37498775 DOI: 10.1089/thy.2023.0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background: Racially minoritized patients with thyroid cancer are less likely to receive high-quality and guideline-concordant care. Inaccessibility of high-volume centers may contribute to inequalities in thyroid cancer outcomes. This study sought to understand the extent to which access to higher volume thyroid cancer centers is associated with patient outcomes. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for thyroid cancer patients who received thyroid surgery between 1999 and 2017. Hospitals were stratified by their median annual volume of thyroid cancer operations: ultra-low volume (0-5 cases/year), low-volume (6-25 cases/year), mid-volume (26-50 cases/year), and high-volume (>50 cases/year). We analyzed the rates of complications, rates of reoperation for cancer recurrence, use of radioactive iodine (131I), and mortality by median hospital volume of thyroid surgery. A multivariable regression controlled for high-risk tumor features. Differences in access by center volume were assessed based on patient demographics. Results: We studied 52,599 thyroid cancer patients who underwent thyroidectomy. Patients who underwent thyroidectomy at ultra-low volume centers were more likely to undergo reoperations for recurrent/persistent disease compared with patients at low- (odds ratio [OR] 1.17 [CI 1.02-1.35]), mid- (OR 1.25 [CI 1.06-1.46]), and high-volume centers (OR 1.26 [CI 1.03-1.56]). Patients who received thyroid operations at ultra-low volume centers were also less likely to receive guideline-concordant 131I ablation compared with patients at higher volume centers (OR 0.77 [CI 0.72-0.82]). A pair-wise comparison between all volume categories for all outcomes revealed no statistically significant differences in outcomes between low-, mid-, or high-volume centers. Only ultra-low volume centers had significantly higher rates of adverse outcomes. Ultra-low volume centers were disproportionately accessed by women (p < 0.05), Hispanic, Asian/Pacific Islander, and American Indian people (p < 0.01), those from the lowest three quintiles of socio-economic status (p < 0.01), and the uninsured and those on Medicaid or Medicare (p < 0.01) when compared with higher volume centers. Conclusions: Patients receiving thyroid cancer surgery at centers performing ≤5 such operations per year were more likely to require reoperation for recurrent/persistent disease and less likely to receive appropriate 131I ablation. Ultra-low volume centers served higher proportions of socially and economically marginalized communities.
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Affiliation(s)
- Hattie Huston-Paterson
- Section of Endocrine Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California, USA
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, California, USA
| | - Yifan Mao
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jiyoon Kim
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - James X Wu
- Section of Endocrine Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Nguyen CA, Beaulieu ND, Wright AA, Cutler DM, Keating NL, Landrum MB. Organization of Cancer Specialists in US Physician Practices and Health Systems. J Clin Oncol 2023; 41:4226-4235. [PMID: 37379501 PMCID: PMC10852402 DOI: 10.1200/jco.23.00626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/01/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers. METHODS Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center. RESULTS More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas. CONCLUSION Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.
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Affiliation(s)
- Christina A. Nguyen
- Massachusetts Institute of Technology, Cambridge, MA
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Nancy D. Beaulieu
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - David M. Cutler
- Department of Economics, Harvard University, Cambridge, MA
- National Bureau of Economic Research, Cambridge, MA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of General Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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22
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Morrow AA, McCombie A, Jeffery F, Frampton C, Hore T. Centralisation of specialist cancer surgery: an assessment of patient preferences for location of care in the upper South Island of New Zealand. ANZ J Surg 2023; 93:2180-2185. [PMID: 37525374 DOI: 10.1111/ans.18643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND A positive association between volume and outcome for certain operations has led to increasing centralization. The latter is associated with a greater travel burden for patients. This study investigated patient preferences for location of care for cancer surgery. METHODS Two hundred and one participants were recruited from those who have had recent cancer surgery and from general practice or outpatient clinics in both urban and rural locations in the upper South Island of New Zealand. A questionnaire presented participants with a hypothetical scenario of needing cancer surgery and they were asked to indicate their preference of either a hospital 1 or 5 h away. Scenarios evolved in risk of mortality, complications and need for hospital transfer due to a complication. RESULTS The majority of participants preferred surgery at the closer hospital when there was a negligible difference in risk. Preference shifted to the distant hospital in a linear relationship as the risk of mortality or complications at the closer hospital increased. Respondents were more likely to prefer the distant hospital from the outset if there was a risk of requiring transfer. CONCLUSION The majority of participants preferred surgery at the closer hospital if risks were comparable but chose to travel as the risk increased and to avoid hospital transfer due to a complication. New Zealand's unique geography and population make it impossible to replicate centralization models from other countries. The drive for improved outcomes must take equity and patient values into consideration.
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Affiliation(s)
- Ahrin Anna Morrow
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew McCombie
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Fraser Jeffery
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Ellis O, Kirby D, Williamson B, Bader J, Nelson D, Porta C. Patient Attitudes Regarding High-Risk Low-Volume Surgery. Mil Med 2023; 188:e1821-e1827. [PMID: 36564941 DOI: 10.1093/milmed/usac398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/04/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Significant controversy surrounds the "Take the Volume Pledge" campaign and the use of volume as a surrogate for quality. However, data on patient-reported attitudes toward this initiative are limited. We sought to examine patient preferences and perceptions regarding the location of their health care and the factors that may influence that decision. MATERIALS AND METHODS After IRB approval, we conducted a prospective study at a 109-bed tertiary referral military hospital, which performs 8 of the 10 defined high-risk low-volume surgeries. From 2018 to 2019, patients from all specialties completed anonymous questionnaires during preoperative registration. Univariate and multivariable analyses were performed to identify factors associated with patients desiring referral. Additional investigations into patient risk tolerance and thresholds regarding hospital/surgeon volume, postoperative complication risk, and cancer survival were analyzed. RESULTS Six hundred and three surveys were completed and available for analysis. Only 1.5% expressed a desire to seek care from a high-volume subspecialist. On multivariable analysis, the only independent predictors for patients desiring referral were perceived displeasure with their care (P = .02) and not being asked their opinion on where to have surgery (P = .04). Most patients (57.6%) expressed willingness to stay at their home institution even if only half of the recommended volume of surgeries are performed. Of patients, 49.8% would accept a 10% increased risk of postoperative complications, and 55.3% would accept decreased long-term cancer survival to stay at their home institution. CONCLUSIONS Only 1.5% of our population desired referral to a high-volume center. Our study showed that an open discussion and shared decision-making are the most important factors for patients when deciding where to have surgery. Moreover, most were willing to accept greater risk and lower volume to stay at their local hospital. Although performed at a single military facility, this study showed that patient preferences are extremely important and should not be understudied.
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Affiliation(s)
- Oriana Ellis
- General Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Derek Kirby
- General Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Bethany Williamson
- General Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Julia Bader
- General Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
| | - Daniel Nelson
- General Surgery, William Beaumont Army Medical Center, El Paso, TX 79918, USA
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Dollars and Sense: The Business of Pediatric Surgery. J Surg Res 2023; 285:220-228. [PMID: 36706657 DOI: 10.1016/j.jss.2022.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION This study evaluated North American pediatric surgeons' opinions and knowledge of business and economics in medicine and their perceptions of trends in their healthcare delivery environment. METHODS We conducted an elective online survey of 1119 American Pediatric Surgical Association members. Over 8 mo, we iteratively developed the survey focused on four areas: opinion, knowledge, current practice environment, and trends in practice environment over the past 5 y. RESULTS We received 227 (20.3%) complete surveys from pediatric surgeons. One hundred ninety four (85.5%) perceive healthcare as a business and most (85.9%) believe healthcare decisions may affect patients' out-of-pocket expenses. More than half (51.1%) of surgeons believe it has become more challenging to perform emergent cases and most believe staff quality has decreased for elective (56.4%) and emergent (63.0%) cases over the past 5 y. CONCLUSIONS Pediatric surgeons recognize that medicine is a business and have concerns regarding the decreasing quality of operating room staff and the increasing difficulty providing surgical care over the last 5 y.
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Patil SA, Vail DG, Cox JT, Chen E, Mruthyunjaya P, Tsai JC, Parikh R. Private equity in ophthalmology and optometry: a time series analysis from 2012 to 2021. Digit J Ophthalmol 2023; 29:1-8. [PMID: 37101563 PMCID: PMC10125728 DOI: 10.5693/djo.01.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Purpose To identify temporal and geographic trends in private equity (PE)-backed acquisitions of ophthalmology and optometry practices in the United States from 2012 to 2021. Methods In this cross-sectional time series, acquisition data from 10/21/2019 to 9/1/2021 and previously published data from 1/1/2012 to 10/20/2019 were analyzed. Acquisition data were compiled from 6 financial databases, 5 industry news outlets, and publicly available press releases. Linear regression models were used to compare rates of acquisition. Outcomes included number of total acquisitions, practice type, locations, provider details, and geographic footprint. Results A total of 245 practices associated with 614 clinical locations and 948 ophthalmologists or optometrists were acquired by 30 PE-backed platform companies between 10/21/2019 and 9/1/2021. Of 30 platform companies, 18 were new vis-à-vis our prior study. Of these acquisitions, 127 were comprehensive practices, 29 were retina practices, and 89 were optometry practices. From 2012 to 2021, monthly acquisitions increased by 0.947 acquisitions per year (P < 0.001*). Texas, Florida, Michigan, and New Jersey were the states with the greatest number of PE acquisitions, with 55, 48, 29, and 28 clinic acquisitions, respectively. Average monthly PE acquisitions were 5.71 per month from 1/1/2019 to 2/29/2020 (pre-COVID), 5.30 per month from 3/1/2020 to 12/31/2020 (COVID pre-vaccine [P = 0.81]), and 8.78 per month from 1/1/2021 to 9/1/2021 (COVID post-vaccine [P = 0.20]). Conclusions PE acquisitions increased during the period 2012-2021 as companies continue to utilize regionally focused strategies for acquisitions.
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Affiliation(s)
- Sachi A. Patil
- Department of Ophthalmology, New York University, Grossman School of Medicine, New York, New York
| | - Daniel G. Vail
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Jacob T. Cox
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Evan Chen
- Department of Ophthalmology, University of California, San Francisco, California
| | - Prithvi Mruthyunjaya
- Byers Eye Institute, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
| | - James C. Tsai
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Ravi Parikh
- Department of Ophthalmology, New York University, Grossman School of Medicine, New York, New York
- Manhattan Retina and Eye Consultants, New York, New York
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Ostrovsky AM, Prebay ZJ, Chung PH. Trends in Male and Female Urethral Endoscopic Management and Urethroplasty Using the TriNetX Database. J Clin Med 2023; 12:jcm12062137. [PMID: 36983140 PMCID: PMC10057331 DOI: 10.3390/jcm12062137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND How quickly providers adapt to new practice guidelines is not well known. The objective of this study was to evaluate temporal trends in the performance of urethral endoscopic management and urethroplasty surrounding the release of the American Urological Association (AUA) Male Urethral Stricture Guidelines in 2017. We also evaluate in parallel trends in female urethral stricture disease, where AUA guidelines are not present. We hypothesized that the ratio of urethroplasty versus urethral endoscopic management in both males and females is increasing and that guidelines do not result in immediate changes in management trends. METHODS Endoscopic management and urethroplasty data were collected from the TriNetX database on adult males and females five years before (starting 1 January 2012) and after (ending 31 December 2022) the 2017 AUA guidelines. Cohorts were built using Current Procedural Terminology (CPT) codes and grouped into urethral endoscopic management (Males: CPT 52275, 52281, 52282, 53600, 53601, 53620, 53621; Females: CPT 52270, 53660, 53661, 53665) or urethroplasty (Males: CPT 53000, 53010, 53400, 53410, 53415, 53420, 53450, 53460; Females: CPT 53430). Data on patient age, race, and geographic distribution were also collected. RESULTS In total, 27,623 (Males: 25,039; Females: 2584) endoscopic managements and 11,771 (Males: 11,105; Females: 666) urethroplasties were reviewed across 51 Health Care Organizations. The mean age of endoscopic management and urethroplasty patients was 67.1 and 55.7, respectively (p < 0.01). The urethroplasty-to-endoscopic management ratio decreased for males between 2012 and 2013 and then steadily increased until 2017. The ratio steadily increased for females from 2012 to 2017. The urethroplasty-to-endoscopic management ratio showed a slight decline from 2017 to 2020 across both males and females before rising again through 2022 to a study high (Males: 0.62; Females: 0.63). Regional differences were identified, with the West having the highest urethroplasty-to-endoscopic management ratios for both males and females, the Northeast having the lowest urethroplasty-to-endoscopic management ratio for males, and the Midwest having the lowest ratio for females. CONCLUSIONS The utilization of urethroplasty for males and females is increasing. An immediate benefit on post-guideline urethroplasty rates was not observed, and the utilization of female urethroplasty increased despite the absence of AUA guidelines. These illustrate that the impact of guideline dissemination takes time and supports the need for continued provider outreach and education on urethral stricture disease and management.
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Affiliation(s)
- Adam M Ostrovsky
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Zachary J Prebay
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Paul H Chung
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Kemp Bohan PM, Chang SC, Grunkemeier GL, Spitzer HV, Carpenter EL, Adams AM, Vreeland TJ, Nelson DW. Impact of Mediating and Confounding Variables on the Volume-Outcome Association in the Treatment of Pancreatic Cancer. Ann Surg Oncol 2023; 30:1436-1448. [PMID: 36460898 DOI: 10.1245/s10434-022-12908-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND High-volume centers (HVC), academic centers (AC), and longer travel distances (TD) have been associated with improved outcomes for patients undergoing surgery for pancreatic adenocarcinoma (PAC). Effects of mediating variables on these associations remain undefined. The purpose of this study is to examine the direct effects of hospital volume, facility type, and travel distance on overall survival (OS) in patients undergoing surgery for PAC and characterize the indirect effects of patient-, disease-, and treatment-related mediating variables. PATIENTS AND METHODS Using the National Cancer Database, patients with non-metastatic PAC who underwent resection were stratified by annual hospital volume (< 11, 11-19, and ≥ 20 cases/year), facility type (AC versus non-AC), and TD (≥ 40 versus < 40 miles). Associations with survival were evaluated using multiple regression models. Effects of mediating variables were assessed using mediation analysis. RESULTS In total, 19,636 patients were included. Treatment at HVC or AC was associated with lower risk of death [hazard ratio (HR) 0.90, confidence interval (CI) 0.88-0.92; HR 0.89, CI 0.86-0.91, respectively]. TD did not impact OS. Patient-, disease-, and treatment-related variables explained 25.5% and 41.8% of the survival benefit attained from treatment at HVC and AC, reducing the survival benefit directly attributable to each variable to 4.9% and 6.4%, respectively. CONCLUSIONS Treatment of PAC at HVC and AC was associated with improved OS, but the magnitude of this benefit was less when mediating variables were considered. From a healthcare utilization and cost-resource perspective, further research is needed to identify patients who would benefit most from selective referral to HVC or AC.
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Affiliation(s)
| | - Shu-Ching Chang
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Gary L Grunkemeier
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Holly V Spitzer
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | | | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA.
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Henry LR, Li J, Arciero C, von Holzen UW, Schwarz R, Jatoi I. National Economic Conditions May Impact the Financial Barriers to Travel for Cancer Operations. ANNALS OF SURGERY OPEN 2023; 4:e236. [PMID: 37600883 PMCID: PMC10431358 DOI: 10.1097/as9.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/30/2022] [Indexed: 01/31/2023] Open
Abstract
Background Better cancer-related outcomes are associated with physicians and hospitals with higher case volume. This serves as an incentive to refer patients requiring complex cancer operations to large referral centers, which may require increased travel for patients. However, barriers exist for patients to travel for cancer care, some of which may be aggravated or alleviated by factors relating to the health of the national economy. This impact may be reflected in variability of travel distances for cancer operations over time particularly for complex operation such as pancreatectomy and esophagectomy compared with less complex resections such as those for breast cancer or melanoma. Methods We obtained the estimated travel distance for patients undergoing operations for cancer of the pancreas, esophagus, skin (melanoma), and breast from the National Cancer Database from 2004 to 2017 and correlated them with economic factors obtained from public sources. We then examined the impact of unemployment rates, gas prices, and inflation on travel distances regarding disadvantaged groups. Correlations were measured by the (rank-based, nonparametric) Spearman's correlation coefficient, and the corresponding P value is obtained by the asymptotic distribution of the coefficient. A P value of 0.05 equates to an absolute correlation value of 0.532. To adjust for multiple tests, a more restrictive P value of 0.01 was also assessed, which equates to correlation coefficients of absolute value greater than 0.661. Results There were 4,222,380 cases in the dataset, of which 1,781,056 remained after exclusion. The economic factors that were associated most strongly with the distance patients traveled for all cancer operation types were the labor force participation rate, personal savings, consumer price index, and changes in gasoline prices. Inflation and rising gasoline prices were often inversely related with travel distance in lower-income and less well-educated regions and African American patients. Conclusions Several macroeconomic factors correlate with the travel distance for operations, suggesting that the economic health of the nation may aggravate or alleviate the financial barriers to travel for cancer operations. Financially disadvantaged groups may be particularly vulnerable to changes in gasoline prices and inflation. Organizations serving these populations may need to increase patient support services during times of economic hardship to avoid the exacerbation of health care disparities.
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Affiliation(s)
- Leonard R. Henry
- From the The Nancy N and JC Lewis Cancer and Research Pavilion at St Josephs Candler Healthsystem, Savannah, GA 31405
| | - Jun Li
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN
| | - Cletus Arciero
- Division of Surgical Oncology, Emory University, Atlanta, GA
| | | | - Roderich Schwarz
- Division of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY
| | - Ismail Jatoi
- Division of Surgical Oncology, UT San Antonio, San Antonio, TX
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How Far Is Too Far? Cost-Effectiveness Analysis of Regionalized Rectal Cancer Surgery. Dis Colon Rectum 2023; 66:467-476. [PMID: 36538713 DOI: 10.1097/dcr.0000000000002636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Regionalized rectal cancer surgery may decrease postoperative and long-term cancer-related mortality. However, the regionalization of care may be an undue burden on patients. OBJECTIVE This study aimed to assess the cost-effectiveness of regionalized rectal cancer surgery. DESIGN Tree-based decision analysis. PATIENTS Patients with stage II/III rectal cancer anatomically suitable for low anterior resection were included. SETTING Rectal cancer surgery performed at a high-volume regional center rather than the closest hospital available. MAIN OUTCOME MEASURES Incremental costs ($) and effectiveness (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and effectiveness. RESULTS Regionalized surgery economically dominated local surgery. Regionalized rectal cancer surgery was both less expensive on average ($50,406 versus $65,430 in present-day costs) and produced better long-term outcomes (10.36 versus 9.51 quality-adjusted life years). The total costs and inconvenience of traveling to a regional high-volume center would need to exceed $15,024 per patient to achieve economic breakeven alone or $112,476 per patient to satisfy conventional cost-effectiveness standards. These results were robust on sensitivity analysis and maintained in 94.6% of scenario testing. LIMITATIONS Decision analysis models are limited to policy level rather than individualized decision-making. CONCLUSIONS Regionalized rectal cancer surgery improves clinical outcomes and reduces total societal costs compared to local surgical care. Prescriptive measures and patient inducements may be needed to expand the role of regionalized surgery for rectal cancer. See Video Abstract at http://links.lww.com/DCR/C83 . QU TAN LEJOS ES DEMASIADO LEJOS ANLISIS DE COSTOEFECTIVIDAD DE LA CIRUGA DE CNCER DE RECTO REGIONALIZADO ANTECEDENTES:La cirugía de cáncer de recto regionalizado puede disminuir la mortalidad posoperatoria y a largo plazo relacionada con el cáncer. Sin embargo, la regionalización de la atención puede ser una carga indebida para los pacientes.OBJETIVO:Evaluar la rentabilidad de la cirugía oncológica de recto regionalizada.DISEÑO:Análisis de decisiones basado en árboles.PACIENTES:Pacientes con cáncer de recto en estadio II/III anatómicamente aptos para resección anterior baja.AJUSTE:Cirugía de cáncer rectal realizada en un centro regional de alto volumen en lugar del hospital más cercano disponible.PRINCIPALES MEDIDAS DE RESULTADO:Los costos incrementales ($) y la efectividad (años de vida ajustados por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilístico multivariable modeló la incertidumbre en las probabilidades, los costos y la efectividad.RESULTADOS:La cirugía regionalizada predominó económicamente la cirugía local. La cirugía de cáncer de recto regionalizado fue menos costosa en promedio ($50 406 versus $65 430 en costos actuales) y produjo mejores resultados a largo plazo (10,36 versus 9,51 años de vida ajustados por calidad). Los costos totales y la inconveniencia de viajar a un centro regional de alto volumen necesitarían superar los $15,024 por paciente para alcanzar el punto de equilibrio económico o $112,476 por paciente para satisfacer los estándares convencionales de rentabilidad. Estos resultados fueron sólidos en el análisis de sensibilidad y se mantuvieron en el 94,6% de las pruebas de escenarios.LIMITACIONES:Los modelos de análisis de decisiones se limitan al nivel de políticas en lugar de la toma de decisiones individualizada.CONCLUSIONES:La cirugía de cáncer de recto regionalizada mejora los resultados clínicos y reduce los costos sociales totales en comparación con la atención quirúrgica local. Es posible que se necesiten medidas prescriptivas e incentivos para los pacientes a fin de ampliar el papel de la cirugía regionalizada para el cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C83 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Lim J, Akbar Ali S, Prawira A, Sim HW. Impact of travel distance on outcomes for clinical trial patients: the Kinghorn Cancer Centre experience. Intern Med J 2023; 53:242-249. [PMID: 34613656 DOI: 10.1111/imj.15561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/18/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Geographic isolation and travel distance to specialist care is a known social determinant of health and contributes to poorer oncology survival outcomes. AIMS To compare survival and toxicity outcomes for patients travelling long distances (>50 km) for treatment on clinical trials with local patients (<10 km and 10-50 km). METHODS We performed a retrospective cohort study based at the Kinghorn Cancer Centre, a comprehensive cancer care centre in metropolitan Sydney. We included adult patients with advanced solid-organ malignancies who were enrolled on therapeutic clinical trials between July 2015 and December 2017. Outcome measures included overall survival, progression-free survival, rates of grade 3-4 toxicity and unplanned hospital admissions for the duration of the clinical trial. RESULTS We included 173 patients, of whom 27% lived within 10 km, 29% lived between 10 and 50 km and 44% lived further than 50 km. We did not identify significant differences between survival or toxicity outcomes between patients travelling long distances and local patients. CONCLUSIONS All patients should be considered for clinical trial referral based on clinical parameters and preference, regardless of geographic proximity. In the meantime, improving access to clinical trials for rural and regional patients continues to be a priority.
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Affiliation(s)
- Jennifer Lim
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Syafiq Akbar Ali
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Amy Prawira
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Hao-Wen Sim
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
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Abiri A, Pang JC, Roman K, Goshtasbi K, Birkenbeuel JL, Kuan EC, Tjoa T, Haidar YM. Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer. Laryngoscope 2023; 133:443-450. [PMID: 35822421 PMCID: PMC9837308 DOI: 10.1002/lary.30280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/26/2022] [Accepted: 06/13/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population. STUDY DESIGN Retrospective database study. METHODS The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS). RESULTS Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p = 0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001). CONCLUSIONS Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities. LEVEL OF EVIDENCE 4 Laryngoscope, 133:443-450, 2023.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Kelsey Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
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Shalowitz DI, Magalhaes M, Miller FG. Ethical Outreach for Rural Cancer Care in the United States: Balancing Access With Optimal Clinical Outcomes. JCO Oncol Pract 2023; 19:225-229. [PMID: 36689691 DOI: 10.1200/op.22.00629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- David I Shalowitz
- Section on Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Monica Magalhaes
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ
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Foote RL, Tsujii H, Imai R, Tsuji H, Hug EB, Kanai T, Lu JJ, Debus J, Engenhart-Cabillic R, Mahajan A. The Majority of United States Citizens With Cancer do not Have Access to Carbon Ion Radiotherapy. Front Oncol 2022; 12:954747. [PMID: 35875126 PMCID: PMC9304691 DOI: 10.3389/fonc.2022.954747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
As of December 31, 2020, there were 12 facilities located in Asia and Europe which were treating cancer patients with carbon ion radiotherapy (CIRT). Between June 1994 and December 2020, 37,548 patients were treated with CIRT worldwide. Fifteen of these patients were United States (U.S.) citizens. Using the Surveillance, Epidemiology, and End Results cancer statistics database, the Mayo Clinic in Rochester, MN has conservatively estimated that there are approximately 44,340 people diagnosed each year in the U.S. with malignancies that would benefit from treatment with CIRT. The absence of CIRT facilities in the U.S. not only limits access to CIRT for cancer care but also prevents inclusion of U.S. citizens in phase III clinical trials that will determine the comparative effectiveness and cost effectiveness of CIRT for a variety of malignancies for FDA approval and insurance coverage. Past and present phase III clinical trials have not been able to enroll U.S. citizens due to their unwillingness or inability to travel abroad for CIRT for an extended period. These barriers could be overcome with a limited number of CIRT facilities in the U.S.
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Affiliation(s)
- Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
- *Correspondence: Robert L. Foote,
| | | | - Reiko Imai
- Department of Bone and Soft Tissue Tumors, QST Hospital, Chiba, Japan
| | - Hiroshi Tsuji
- International Particle Therapy Research Center Director, QST Hospital, Chiba, Japan
| | - Eugen B. Hug
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Tatsuaki Kanai
- Department of Radiation Oncology and Radiation Therapy, Osaka Heavy Ion Therapy Center, Osaka, Japan
| | - Jiade J. Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Juergen Debus
- Department of Radiation Oncology and Radiation Therapy, Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
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Goyal A, Zreik J, Brown DA, Kerezoudis P, Habermann EB, Chaichana KL, Chen CC, Bydon M, Parney IF. Disparities in access to surgery for glioblastoma multiforme at high-volume Commission on Cancer-accredited hospitals in the United States. J Neurosurg 2022; 137:32-41. [PMID: 34767534 DOI: 10.3171/2021.7.jns211307] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although it has been shown that surgery for glioblastoma (GBM) at high-volume facilities (HVFs) may be associated with better postoperative outcomes, the use of such hospitals may not be equally distributed. The authors aimed to evaluate racial and socioeconomic differences in access to surgery for GBM at high-volume Commission on Cancer (CoC)-accredited hospitals. METHODS The National Cancer Database was queried for patients with GBM that was newly diagnosed between 2004 and 2015. Patients who received no surgical intervention or those who received surgical intervention at a site other than the reporting facility were excluded. Annual surgical case volume was calculated for each hospital, with volume ≥ 90th percentile defined as an HVF. Multivariable logistic regression was performed to identify patient-level predictors for undergoing surgery at an HVF. Furthermore, multiple subgroup analyses were performed to determine the adjusted odds ratio of the likelihood of undergoing surgery at an HVF in 2016 as compared to 2004 for each patient subpopulation (by age, race, sex, educational group, etc.). RESULTS A total of 51,859 patients were included, with 10.7% (n = 5562) undergoing surgery at an HVF. On multivariable analysis, Hispanic White patients (OR 0.58, 95% CI 0.49-0.69, p < 0.001) were found to have significantly lower odds of undergoing surgery at an HVF (reference = non-Hispanic White). In addition, patients from a rural residential location (OR 0.55, 95% CI 0.41-0.72, p < 0.001; reference = metropolitan); patients with nonprivate insurance status (Medicare [OR 0.78, 95% CI 0.71-0.86, p < 0.001], Medicaid [OR 0.68, 95% CI 0.60-0.78, p < 0001], other government insurance [OR 0.68, 95% CI 0.52-0.86, p = 0.002], or who were uninsured [OR 0.61, 95% CI 0.51-0.72, p < 0.001]); and lower-income patients ($50,354-$63,332 [OR 0.68, 95% CI 0.63-0.74, p < 0.001], $40,227-$50,353 [OR 0.84, 95% CI 0.76-0.92, p < 0.001]; reference = ≥ $63,333) were also found to be significantly associated with a lower likelihood of surgery at an HVF. Subgroup analyses revealed that elderly patients (age ≥ 65 years), both male and female patients and non-Hispanic White patients, and those with private insurance, Medicare, metropolitan residential location, median zip code-level household income in the first and second quartiles, and educational attainment in the first and third quartiles had increased odds of undergoing surgery at an HVF in 2016 compared to 2004 (all p ≤ 0.05). On the other hand, patients with other governmental insurance, patients with a rural residence, and those from a non-White racial category did not show a significant difference in odds of surgery at an HVF over time (all p > 0.05). CONCLUSIONS The present analysis from the National Cancer Database revealed significant disparities in access to surgery at an HVF for GBM within the United States. Furthermore, there was evidence that these racial and socioeconomic disparities may have widened between 2004 and 2016. The findings should assist health policy makers in the development of strategies for improving access to HVFs for racially and socioeconomically disadvantaged populations.
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Affiliation(s)
- Anshit Goyal
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
| | - Jad Zreik
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
- 5Central Michigan University College of Medicine, Mount Pleasant, Michigan
| | | | | | - Elizabeth B Habermann
- 2Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
| | | | - Clark C Chen
- 4Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota; and
| | - Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
| | - Ian F Parney
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
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Michaels JA. Value assessment frameworks: who is valuing the care in healthcare? JOURNAL OF MEDICAL ETHICS 2022; 48:419-426. [PMID: 33687915 DOI: 10.1136/medethics-2020-106503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/27/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
Many healthcare agencies are producing evidence-based guidance and policy that may determine the availability of particular healthcare products and procedures, effectively rationing aspects of healthcare. They claim legitimacy for their decisions through reference to evidence-based scientific method and the implementation of just decision-making procedures, often citing the criteria of 'accountability for reasonableness'; publicity, relevance, challenge and revision, and regulation. Central to most decision methods are estimates of gains in quality-adjusted life-years (QALY), a measure that combines the length and quality of survival. However, all agree that the QALY alone is not a sufficient measure of all relevant aspects of potential healthcare benefits, and a number of value assessment frameworks have been suggested. I argue that the practical implementation of these procedures has the potential to lead to a distorted assessment of value. Undue weight may be ascribed to certain attributes, particularly those that favour commercial or political interests, while other attributes that are highly valued by society, particularly those related to care processes, may be omitted or undervalued. This may be compounded by a lack of transparency to relevant stakeholders, resulting in an inability for them to participate in, or challenge, the decisions. The makes it likely that costly new technologies, for which inflated prices can be justified by the current value frameworks, are displacing aspects of healthcare that are highly valued by society.
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Affiliation(s)
- Jonathan Anthony Michaels
- Health Economics and Decision Science, University of Sheffield School of Health and Related Research, Sheffield, UK
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Dinger TL, Kroon HM, Traeger L, Bedrikovetski S, Hunter A, Sammour T. Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit. ANZ J Surg 2022; 92:1772-1780. [PMID: 35502647 PMCID: PMC9541368 DOI: 10.1111/ans.17699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/05/2022] [Accepted: 03/30/2022] [Indexed: 12/09/2022]
Abstract
Backgrounds Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ). Methods Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+). Results A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001). Conclusion Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.
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Affiliation(s)
- Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Sarap MD. Quality and Value in Rural Cancer Care. Am Surg 2022; 88:1749-1753. [PMID: 35430908 DOI: 10.1177/00031348221086801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 60 million people reside in rural America with only 10% of US general surgeons providing for their surgical care. Rural cancer care has been maligned in the literature due to a lack of understanding of local resource limitations and to the difficulties involved in documenting the quality of local cancer care in small and rural communities. A majority of US cancer patients are diagnosed and treated in community cancer programs, many of which are Commission on Cancer Accredited and deliver care that is of high quality and value. The article discusses the components of high quality health care and offers suggestions for solo or small group rural surgeons to assist in collection of their own quality data and comparison to national benchmarks. One small rural program in Appalachian Ohio is used for a best-case example.
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Affiliation(s)
- Michael D Sarap
- 21457Southeastern Ohio Regional Medical Center, Cambridge, OH, USA
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Hopper W, Zeller R, Burke R, Lindsey T. The association between operating margin and surgical diversity at Critical Access Hospitals. J Osteopath Med 2022; 122:339-345. [DOI: 10.1515/jom-2022-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Context
Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services.
Objectives
This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability.
Methods
The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region.
Results
The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001).
Conclusions
A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.
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Affiliation(s)
- Wade Hopper
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Robert Zeller
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Rachel Burke
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Tom Lindsey
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
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Stoyanov DS, Conev NV, Donev IS, Tonev ID, Panayotova TV, Dimitrova-Gospodinova EG. Impact of travel burden on clinical outcomes in lung cancer. Support Care Cancer 2022; 30:5381-5387. [PMID: 35288785 DOI: 10.1007/s00520-022-06978-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/10/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Our study explores the influence of travel burden (measured as travel distance and travel time) on clinical outcomes in lung cancer patients. METHODS A retrospective analysis of a single Bulgarian center was performed. A total of 9240 lung cancer patients were included in the study. Travel distance and travel time between patients' city of residence and the treating facility were calculated with an online tool to determine the shortest route for travel using the existing road network. The probability of survival was estimated using the Kaplan-Meier method, and differences in survival in each subgroup were evaluated with a log-rank test. RESULTS About one third of all included patients were living in the same city as the treating facility (n = 2746, 29.7%). Overall survival in our patient population was significantly lower with increasing travel distance (p < 0.001, Mantel-Cox log rank) and travel time (p < 0.001, Mantel-Cox log rank). The 1-year OS rate according to travel distance was 27.1% in the same city group, 22.4% in < 50-km group, and 20.5% in ≥ 50-km group (p < 0.001). The corresponding values for the 5-year OS rate were 2.9%, 2.6%, and 1.4% (p < 0.001). CONCLUSION In this retrospective study, we discovered significant differences in the overall survival of patients with lung cancer depending on travel distance and travel time to the treating oncological facility. Despite having similar clinical and pathological characteristics (age, sex, stage at initial diagnosis, histologic subtype), the median overall survival was significantly lower in those subgroups of patients with a higher travel burden.
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Affiliation(s)
- Dragomir Svetozarov Stoyanov
- Department of Oncology, Medical University Varna, Varna, Bulgaria.
- Clinic of Medical Oncology, UMHAT Sveta Marina, 1, Hristo Smirnenski Blvd, Varna, 9010, Bulgaria.
| | - Nikolay Vladimirov Conev
- Department of Oncology, Medical University Varna, Varna, Bulgaria
- Clinic of Medical Oncology, UMHAT Sveta Marina, 1, Hristo Smirnenski Blvd, Varna, 9010, Bulgaria
| | | | | | - Teodorika Vitalinova Panayotova
- Department of Oncology, Medical University Varna, Varna, Bulgaria
- Clinic of Medical Oncology, UMHAT Sveta Marina, 1, Hristo Smirnenski Blvd, Varna, 9010, Bulgaria
| | - Eleonora Georgieva Dimitrova-Gospodinova
- Department of Oncology, Medical University Varna, Varna, Bulgaria
- Clinic of Medical Oncology, UMHAT Sveta Marina, 1, Hristo Smirnenski Blvd, Varna, 9010, Bulgaria
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Kulshrestha S, Sweigert PJ, Tonelli C, Bunn C, Luchette FA, Abdelsattar ZM, Pawlik TM, Baker MS. Textbook oncologic outcome in pancreaticoduodenectomy: Do regionalization efforts make sense? J Surg Oncol 2022; 125:414-424. [PMID: 34617590 PMCID: PMC8799483 DOI: 10.1002/jso.26712] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/13/2021] [Accepted: 09/30/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Few empiric studies evaluate the effects of regionalization on pancreatic cancer care. METHODS We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy for clinical stage I/II pancreatic adenocarcinoma between 2006 and 2015. Facilities were categorized by annual pancreatectomy volume. Textbook oncologic outcome was defined as a margin negative resection, appropriate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of adjuvant chemotherapy. Multivariable regression adjusted for comorbid disease, pathologic stage, and facility characteristics was used to evaluate the relationship between facility volume and textbook outcome. RESULTS Sixteen thousand six hundred and two patients underwent pancreaticoduodenectomy; 3566 (21.5%) had a textbook outcome. Operations performed at high volume centers increased each year (45.8% in 2006 to 64.2% in 2015, p < 0.001) as did textbook outcome rates (14.3%-26.2%, p < 0.001). Surgical volume was associated with textbook outcome. High volume centers demonstrated higher unadjusted rates of textbook outcome (25.4% vs. 11.8% p < 0.01) and increased adjusted odds of textbook outcome relative to low volume centers (odds ratio: 2.39, [2.02, 2.85], p < 0.001). Textbook outcome was associated with improved overall survival independent of volume. CONCLUSIONS Regionalization of care for pancreaticoduodenectomy to high volume centers is ongoing and is associated with improved quality of care.
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Affiliation(s)
- Sujay Kulshrestha
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL,Department of Surgery, Loyola University Medical Center, Maywood, IL
| | | | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL,Edward Hines Jr. Veterans Affair Hospital, Hines, IL
| | - Corinne Bunn
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL,Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A. Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL,Edward Hines Jr. Veterans Affair Hospital, Hines, IL
| | - Zaid M. Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Marshall S. Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL,Edward Hines Jr. Veterans Affair Hospital, Hines, IL
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Aitken RJ. Pancreaticoduodenectomy in Australia: a national quality improvement clinical registry is long overdue. ANZ J Surg 2022; 92:6-8. [PMID: 35212115 DOI: 10.1111/ans.17395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 12/15/2022]
Affiliation(s)
- R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Alvarez E, Spunt SL, Malogolowkin M, Li Q, Wun T, Brunson A, Thorpe S, Kreimer S, Keegan T. Treatment at Specialized Cancer Centers Is Associated with Improved Survival in Adolescent and Young Adults with Soft Tissue Sarcoma. J Adolesc Young Adult Oncol 2021; 11:370-378. [PMID: 34910881 PMCID: PMC9536344 DOI: 10.1089/jayao.2021.0110] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Soft tissue sarcomas (STS) are a heterogeneous group of tumors whose management benefits from a multidisciplinary therapeutic approach. Published data suggest that cancer treatment at a specialized cancer center (SCC) can improve survival in other cancers. Therefore, we examined the impact of the location of treatment on survival in children and adolescents and young adults (AYAs) with STS. Methods: We performed a population-based analysis of children and AYAs hospitalized within 1 year of diagnosis with first primary STS (2000-2014) using the California Cancer Registry linked with hospitalization data. Patients were categorized based on receiving all inpatient treatments at a SCC versus part/none. Multivariable Cox proportional hazards regression identified factors associated with overall and STS-specific survival by age group. Results are presented as adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Of the 1,674 patients with STS, 142 were children (0-14) and 1,532 were AYAs (15-39) and 89.4% and 40.4% received all inpatient treatments at a SCC, respectively. Overall, the 5-year survival was improved for patients who received all inpatient care at a SCC (59.8% vs. those who received part/none, 50.7%). Multivariable regression analysis found that having all treatments at a SCC was associated with better overall survival (HR, 0.79, CI: 0.65-0.95) in AYAs, but not in children. Conclusions: Our findings demonstrate that treatment for STS at a SCC is associated with better survival in AYAs. Eliminating barriers to treatment of AYAs with STS at SCCs could improve survival in this population.
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Affiliation(s)
- Elysia Alvarez
- Division of Pediatric Hematology/Oncology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Sheri L Spunt
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Marcio Malogolowkin
- Division of Pediatric Hematology/Oncology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Qian Li
- Division of Hematology/Oncology, Center for Oncology, Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, California, USA
| | - Ted Wun
- Division of Hematology/Oncology, Center for Oncology, Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, California, USA
| | - Ann Brunson
- Division of Hematology/Oncology, Center for Oncology, Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, California, USA
| | | | - Sara Kreimer
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Theresa Keegan
- Division of Hematology/Oncology, Center for Oncology, Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, California, USA
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Maroongroge S, Wallington DG, Taylor PA, Zhu D, Guadagnolo BA, Smith BD, Yu JB, Ballas LK. Geographic Access to Radiation Therapy Facilities in the United States. Int J Radiat Oncol Biol Phys 2021; 112:600-610. [PMID: 34762972 DOI: 10.1016/j.ijrobp.2021.10.144] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The current distribution of radiation therapy (RT) facilities in the US is not well established. A comprehensive inventory of US RT facilities was last assessed in 2005, based on data from state regulatory agencies and dosimetric quality assurance bodies. We updated this database to characterize population-level measures of geographic access to RT and analyze changes over the past 15 years. METHODS We compiled data from regulatory and accrediting organizations to identify US facilities with linear accelerators used to treat humans in 2018-2020. Addresses were geocoded and analyzed with Geographic Information Services (GIS) software. Geographic access was characterized by assessing the Euclidian distance between zip code tabulation areas (ZCTA)/county centroids and RT facilities. Populations were assigned to each county to estimate the impact of facility changes at the population level. Logistic regressions were performed to identify features associated with increased distance to RT and associated with regions that gained an RT facility between the two time points studied. RESULTS In 2020, a total of 2,313 US RT facilities were reported compared to 1,987 in 2005, representing a 16.4% growth in facilities over nearly 15 years. Based on population attribution to ZCTA centroids, 77.9% of the US population lives within 12.5 miles of an RT facility, and 1.8% of the US population lives more than 50 miles from an RT facility. We found that increased distance to RT was associated with non-metro status, less insurance, older median age, and less populated regions. Between 2005 and 2020, the population living within 12.5 miles from an RT facility increased by 2.1 percentage points, while the population living furthest from RT facilities decreased 0.6 percentage points. Regions with improved geographic RT access are more likely to be higher income and better insured. CONCLUSION 1.8% of the US population has limited geographic access to radiation therapy. We found that people benefiting from improved access to RT facilities are more economically advantaged, suggesting disparities in geographic access may not improve without intervention.
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Affiliation(s)
- Sean Maroongroge
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | - Paige A Taylor
- Imaging and Radiation Oncology Core Houston QA Center, MD Anderson Cancer Center, Houston, TX
| | - Diana Zhu
- Department of Economics, Yale University, New Haven, CT
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James B Yu
- Department of Therapeutic Radiology, Yale University, New Haven, CT; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
| | - Leslie K Ballas
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA
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Association of age with treatment at high-volume hospitals and distance traveled for care, in patients with rectal cancer who seek curative resection. Am J Surg 2021; 223:848-854. [PMID: 34598778 DOI: 10.1016/j.amjsurg.2021.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/12/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. METHODS We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004-2015). Tertiles were used to categorize facility volume and distance traveled. RESULTS Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50-59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. CONCLUSIONS Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.
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Acher AW, Weber SM, Pawlik TM. Does the Volume-Outcome Association in Pancreas Cancer Surgery Justify Regionalization of Care? A Review of Current Controversies. Ann Surg Oncol 2021; 29:1257-1268. [PMID: 34522998 DOI: 10.1245/s10434-021-10765-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/15/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Increasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy. METHODS A PubMed literature search was conducted for the years 1995-2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps. RESULTS Based on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges. CONCLUSION The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.
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Affiliation(s)
- Alexandra W Acher
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University College of Medicine, The James Comprehensive Cancer Center, Columbus, OH, USA.
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Burkamp JR, Bühn S, Schnitzbauer A, Pieper D. Preference between medical outcomes and travel times: an analysis of liver transplantation. Langenbecks Arch Surg 2021; 407:707-716. [PMID: 34324059 PMCID: PMC8933375 DOI: 10.1007/s00423-021-02258-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022]
Abstract
Background There is evidence of a volume outcome relationship for liver transplantation. In Germany, there is a minimum volume threshold of 20 transplantations per year for each center. Thresholds potentially lead to centralization of the healthcare supply, generating longer travel times. Objective This study assessed whether patients are willing to travel longer times to transplantation centers for better outcomes (lower hospital mortality and higher 3-year survival) and identified patient characteristics influencing their choices. Methods Participants were recruited in hospitals and via random samples at registration offices. Discrete choice experiments were used to identify trade-offs in their choices between local and regional centers. Descriptive statistics and logistic regression models were used to measure patients’ preferences and quantify potentially influencing characteristics. Results Overall, 82.22% (in-hospital mortality) and 84.44% (3-year survival) of the participants opted to accept a longer travel time in order to receive a liver transplantation with better outcomes. Conclusion Most participants were willing to trade shorter travel times for lower mortality risks and higher 3-year survival in cases of liver transplantation. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02258-x.
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Affiliation(s)
- Jasper Richard Burkamp
- Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany.
| | - Stefanie Bühn
- Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Andreas Schnitzbauer
- Universitätsklinikum Frankfurt, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Frankfurt am Main, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
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Freedland AR, Muller RL, Hoyo C, Turner EL, Moorman PG, Faria EF, Carvalhal GF, Reis RB, Mauad EC, Carvalho AL, Freedland SJ. Implications of Regionalizing Care in the Developing World: Impact of Distance to Referral Center on Compliance to Biopsy Recommendations in a Brazilian Prostate Cancer Screening Cohort. Prostate Cancer 2021; 2021:6614838. [PMID: 34239732 PMCID: PMC8241493 DOI: 10.1155/2021/6614838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/09/2021] [Indexed: 11/18/2022] Open
Abstract
Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004-2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135-718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.
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Affiliation(s)
- Alexis R. Freedland
- Department of Epidemiology, UCI School of Medicine, University of California, Irvine, CA, USA
| | - Roberto L. Muller
- Division of Urology, Center of Oncologic Research, Florianopolis, Santa Catarina, Brazil
| | - Cathrine Hoyo
- Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
| | - Elizabeth L. Turner
- Global Health Institute, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University Graduate School, Durham, NC, USA
| | - Patricia G. Moorman
- Department of Community and Family Medicine, Cancer Control and Population Sciences, Duke Cancer Institute, Durham, NC, USA
| | - Eliney F. Faria
- Division of Urologic Oncology and Laparoscopy, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | | | - Rodolfo B. Reis
- Division of Urology, Ribeirao Preto Medical School of Sao Paulo University (USP), Ribeirao Preto, São Paulo, Brazil
| | - Edmundo C. Mauad
- Department of Preventative Medicine, Barretos Cancer Hospital and Pio XII Foundation, Barretos, São Paulo, Brazil
| | - Andre L. Carvalho
- Research Support Center, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Stephen J. Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. The centralization of bladder cancer care and its implications for patient travel distance. Urol Oncol 2021; 39:834.e9-834.e20. [PMID: 34162498 DOI: 10.1016/j.urolonc.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.
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Affiliation(s)
| | - Jonathan G Yabes
- Center for Research on Health Care; Division of General Internal Medicine, Department of Medicine
| | | | | | | | - Lindsay M Sabik
- Center for Research on Health Care; Department of Health Policy and Management, Graduate School of Public Health
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology; Center for Research on Health Care
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Schwartz AJ, Yost KJ, Bozic KJ, Etzioni DA, Raghu TS, Kanat IE. What Is The Value Of A Star When Choosing A Provider For Total Joint Replacement? A Discrete Choice Experiment. Health Aff (Millwood) 2021; 40:138-145. [PMID: 33400583 DOI: 10.1377/hlthaff.2020.00085] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The past decade witnessed a rapid rise in the public reporting of surgeon- and hospital-specific quality-of-care measures. However, patients' interpretations of star ratings and their importance relative to other considerations (for example, cost, distance traveled) are poorly understood. We conducted a discrete choice experiment in an outpatient setting (an academic joint arthroplasty practice) to study trade-offs that patients are willing to make in choosing a provider for a hypothetical total joint arthroplasty. Two hundred consecutive new patients presenting for hip or knee pain in 2018 were included. The average patient was willing to pay $2,607 and $3,152 extra for an additional hospital or physician star, respectively, and an extra $11.45 to not travel an extra mile for arthroplasty care. History of prior surgery and prior experience with rating systems reduced the relative value of an incremental star by $539.25 and $934.50, respectively. Patients appear willing to accept significantly higher copayments for higher quality of care, and surgeon quality seems relatively more important than hospital quality. Further study is needed to understand the value and trust patients place in publicly reported hospital and surgeon quality ratings.
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Affiliation(s)
- Adam J Schwartz
- Adam J. Schwartz is an associate professor of orthopedic surgery at the Mayo Clinic College of Medicine and Science and a consultant in the Department of Orthopedic Surgery, Mayo Clinic, in Phoenix, Arizona
| | - Kathleen J Yost
- Kathleen J. Yost is a professor of health services research in the Department of Health Sciences Research at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota
| | - Kevin J Bozic
- Kevin J. Bozic is a professor and chair of the Department of Surgery and Perioperative Care in the Dell Medical School at the University of Texas at Austin, in Austin, Texas
| | - David A Etzioni
- David A. Etzioni is a professor at the Mayo Clinic College of Medicine and Science and chair of the Department of Surgery, Mayo Clinic Arizona
| | - T S Raghu
- T. S. Raghu is a professor in and chair of the Department of Information Systems in the W. P. Carey School of Business at Arizona State University, in Tempe, Arizona
| | - Irfan Emrah Kanat
- Irfan Emrah Kanat is an assistant professor in the Department of Digitalization at Copenhagen Business School, in Frederiksberg, Copenhagen, Denmark
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Diaz A, Cloyd JM, Manilchuk A, Dillhoff M, Beane J, Tsung A, Ejaz A, Pawlik TM. Travel Patterns among Patients Undergoing Hepatic Resection in California: Does Driving Further for Care Improve Outcomes? J Gastrointest Surg 2021; 25:1471-1478. [PMID: 32514651 DOI: 10.1007/s11605-019-04501-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Better outcomes at high-volume surgical centers have driven regionalization of complex surgical care. In turn, access to high-volume centers often requires travel over longer distances. We sought to characterize travel patterns among patients who underwent a hepatectomy. METHODS The California Office of Statewide Health Planning database was used to identify patients who underwent hepatectomy between 2005 and 2016. Total distance traveled and whether a patient bypassed the nearest hospital that performed hepatectomy to get to a higher-volume center were assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. RESULTS Overall, 13,379 adults underwent a hepatectomy in 229 hospitals; only 26 hospitals were high volume (> 15 cases/year). Median travel time to a hospital that performed hepatectomy was 25.2 min (IQR: 13.1-52.0). The overwhelming majority of patients (91.6%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, 75.5% went to a high-volume hospital. Outcomes at destination hospitals were improved compared with nearest hospitals (incidence of complications: 20.4% vs. 22.9% %; failure-to-rescue: 7.1% vs 10.9%; mortality 1.5% vs. 2.6%). Medicaid beneficiaries (OR 0.69, 95%CI 0.56-0.85) were less likely to bypass the nearest hospital to go to a high-volume hospital; additionally, Medicaid patients were less likely to undergo hepatectomy at a high-volume hospital independent of bypassing the nearest hospital (OR 0.60, 95%CI 0.48-0.76). Among the 3703 patients who underwent hepatectomy at a low-volume center, 2126 patients had actually bypassed a high-volume hospital. Among the remaining 1577 patients, 95% of individuals would have needed to travel less than 1 additional hour to reach a high-volume center. CONCLUSION Roughly, one-quarter of patients undergoing hepatectomy received care at a low-volume center; nearly all of these patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center. Travel distance needs to be considered in policies and healthcare delivery design to improve care of patients undergoing hepatic resection.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Jordan M Cloyd
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Andrei Manilchuk
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joel Beane
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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