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Yee EK, Hallet J, Look Hong NJ, Nguyen L, Coburn N, Wright FC, Gandhi S, Jerzak KJ, Eisen A, Roberts A. Impact of Location of Residence and Distance to Cancer Centre on Medical Oncology Consultation and Neoadjuvant Chemotherapy for Triple-Negative and HER2-Positive Breast Cancer. Curr Oncol 2024; 31:4728-4745. [PMID: 39195336 DOI: 10.3390/curroncol31080353] [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: 07/03/2024] [Revised: 07/25/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024] Open
Abstract
Despite consensus guidelines, most patients with early-stage triple-negative (TN) and HER2-positive (HER2+) breast cancer do not see a medical oncologist prior to surgery and do not receive neoadjuvant chemotherapy (NAC). To understand barriers to care, we aimed to characterize the relationship between geography (region of residence and cancer centre proximity) and receipt of a pre-treatment medical oncology consultation and NAC for patients with TN and HER2+ breast cancer. Using linked administrative datasets in Ontario, Canada, we performed a retrospective population-based analysis of women diagnosed with stage I-III TN or HER2+ breast cancer from 2012 to 2020. The outcomes were a pre-treatment medical oncology consultation and the initiation of NAC. We created choropleth maps to assess the distribution of the outcomes and cancer centres across census divisions. To assess the relationship between distance to the nearest cancer centre and outcomes, we performed multivariable regression analyses adjusted for relevant factors, including tumour extent and nodal status. Of 14,647 patients, 29.9% received a pre-treatment medical oncology consultation and 77.7% received NAC. Mapping demonstrated high interregional variability, ranging across census divisions from 12.5% to 64.3% for medical oncology consultation and from 8.8% to 64.3% for NAC. In the full cohort, compared to a distance of ≤5 km from the nearest cancer centre, only 10-25 km was significantly associated with lower odds of NAC (OR 0.83, 95% CI 0.70-0.99). Greater distances were not associated with pre-treatment medical oncology consultation. The interregional variability in medical oncology consultation and NAC for patients with TN and HER2+ breast cancer suggests that regional and/or provider practice patterns underlie discrepancies in the referral for and receipt of NAC. These findings can inform interventions to improve equitable access to NAC for eligible patients.
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Affiliation(s)
- Elliott K Yee
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Nicole J Look Hong
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- ICES, Toronto, ON M4N 3M5, Canada
| | | | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- ICES, Toronto, ON M4N 3M5, Canada
| | - Frances C Wright
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Sonal Gandhi
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Katarzyna J Jerzak
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Andrea Eisen
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Amanda Roberts
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
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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] [Grants] [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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Khalil M, Munir MM, Woldesenbet S, Katayama E, Diaz A, Chen JC, Obeng-Gyasi S, Pawlik TM. Association Between Historical Redlining and Access to High-Volume Hospitals Among Patients Undergoing Complex Cancer Surgery in California. Ann Surg Oncol 2024; 31:1477-1487. [PMID: 38082168 DOI: 10.1245/s10434-023-14679-7] [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: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations. METHODS The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners' Loan Corporation grades (A: 'Best'; B: 'Still Desirable'; C: 'Definitely Declining'; and D: 'Hazardous/Redlined'). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance. RESULTS Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the 'Best', whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1-14.4) and travel time was 16.1 min (IQR 10.7-25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44-2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH. CONCLUSION Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J C Chen
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Kim JY, Love M, Woo Y, Campos B, Yu A, Chang J, Erhunmwunsee L, Krouse RS, Melstrom L, Sun V. Pilot study of a telehealth intervention for personalized self-management for eating symptoms after gastroesophageal cancer surgery. J Surg Oncol 2024; 129:728-733. [PMID: 38164022 DOI: 10.1002/jso.27568] [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: 09/27/2023] [Revised: 11/14/2023] [Accepted: 12/10/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVES Following gastric and esophageal cancer surgery, patients often experience significant, prolonged eating-related symptoms. One promising approach to help patients improve their eating-related quality of life (QOL) is through self-management coaching to aid in diet modification. We performed a randomized pilot study of a nutritionist-led telehealth intervention for the self-management of eating after gastroesophageal cancer surgery. METHODS Patients who were within 30 days of resuming oral intake after undergoing surgery for gastric and/or esophageal cancer were consented and then randomized to the intervention or usual care. The intervention was performed by a nutritionist trained in self-management coaching and delivered in four telehealth sessions over 4 months. The following outcomes were measured at baseline and at 6 months after baseline: QOL (EORTC QLQC30), weight, body mass index, and sarcopenia. RESULTS Fifty-three patients were enrolled. 22/27 usual care and 21/26 intervention patients completed the study for a retention rate of 81%. Differences between the intervention and control groups were not statistically significant, but the intervention group had indications of greater improvements in overall QOL as measured by EORTC QLQC30 Summary Score (8.7 vs. 2.3, p = 0.17) as well as greater improvements in 4/5 functional domains (p > 0.3). The intervention group also had slightly more weight gain (6 kg vs. 3 kg, p = 0.3) and less sarcopenia (3/16 vs. 9/18, p = 0.07). CONCLUSIONS This pilot study demonstrated the feasibility and acceptability of a telehealth intervention for self-management of eating symptoms after gastroesophageal cancer surgery. There were trends toward improved overall QOL in the intervention group. A larger study is needed to validate the results.
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Affiliation(s)
- Jae Y Kim
- Department of Surgery, City of Hope Cancer Center, Duarte, California, USA
| | - Madeleine Love
- Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope Cancer Center, Duarte, California, USA
| | - Beatriz Campos
- Department of Clinical Nutrition, City of Hope, Duarte, California, USA
| | - Adern Yu
- Department of Clinical Nutrition, City of Hope, Duarte, California, USA
| | - Justin Chang
- Touro University College of Osteopathic Medicine, Vallejo, California, USA
| | | | - Robert S Krouse
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laleh Melstrom
- Department of Surgery, City of Hope Cancer Center, Duarte, California, USA
| | - Virginia Sun
- Department of Surgery, City of Hope Cancer Center, Duarte, California, USA
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, California, USA
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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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Solsky I, Patel A, Leonard G, Russell G, Perry K, Votanopoulos KI, Shen P, Levine EA. Distance Traveled and Disparities in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2024; 31:1035-1048. [PMID: 37980711 DOI: 10.1245/s10434-023-14469-1] [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: 04/12/2023] [Accepted: 10/05/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The impact of distance traveled on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) outcomes needs further investigation. METHODS This retrospective study reviewed a prospectively managed single-center CRS/HIPEC 1992-2022 database. Zip codes were used to calculate distance traveled and to obtain data on income and education via census data. Patients were separated into three groups based on distance traveled in miles (local: ≤50 miles, regional: 51-99 miles, distant: ≥100 miles). Descriptive statistics, Kaplan-Meier method, and Cox regression were performed. RESULTS The 1614 patients in the study traveled a median distance of 109.5 miles (interquartile range [IQR], 53.36-202.29 miles), with 23% traveling locally, 23.9% traveling regionally, and 53% traveling distantly. Those traveling distantly or regionally tended to be more white (distant: 87.8%, regional: 87.2%, local: 83.2%), affluent (distant: $61,944, regional: $65,014, local: $54,390), educated (% without high school diploma: distant: 10.6%, regional: 11.5%, local: 13.0%), less often uninsured (distant: 2.3%, regional: 4.6%, local: 5.2%) or with Medicaid (distant: 3.3%, regional: 1.3%, local: 9.7%). They more often had higher Peritoneal Carcinomatosis Index (PCI) scores (distant: 15.4, regional: 15.8, local: 12.7) and R2 resections (distant: 50.3%, regional: 52.2%, local: 40.5%). Median survival did not differ between the groups, and distance traveled was not a predictor of survival. CONCLUSION More than 50% of the patients traveled farther than 100 miles for treatment. Although regionalization of CRS/HIPEC may be appropriate given the lack of survival difference based on distance traveled, those who traveled further had fewer health care disparities but higher PCI scores and more R2 resections, which raises concerns about access to care for the underserved, time to treatment, and surgical quality.
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Affiliation(s)
- Ian Solsky
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ana Patel
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Grey Leonard
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Gregory Russell
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kathleen Perry
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Perry Shen
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Edward A Levine
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
- Division of Surgical Oncology, Department of General Surgery, Medical Center Boulevard, Winston-Salem, NC, USA.
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Munir MM, Endo Y, Woldesenbet S, Beane J, Dillhoff M, Ejaz A, Cloyd J, Pawlik TM. Variations in Travel Patterns Affect Regionalization of Complex Cancer Surgery in California. Ann Surg Oncol 2023; 30:8044-8053. [PMID: 37659977 DOI: 10.1245/s10434-023-14242-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/26/2023] [Indexed: 09/04/2023]
Abstract
INTRODUCTION Regionalization of complex surgical procedures may improve healthcare quality. We sought to define the impact of regionalization on access to high-volume hospitals for complex oncologic procedures in the state of California. METHODS The California Department of Health Care Access and Information Database (2012-2016) identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR). Geospatial analysis was conducted to determine travel patterns. Clustered multivariable regression was performed to assess the probability of receiving care at a high-volume center. RESULTS Among 25,070 patients (ES: n = 1216, 4.9%; PN: n = 13,247, 52.8%; PD: n = 3559, 14.2%; PR: n = 7048, 28.1%), 6575 (26.2%) individuals resided within 30 min, 11,046 (44.1%) resided within 30-60 min, 7125 (28.4%) resided within 60-90 min, and 324 (1.3%) resided beyond a 90-min travel window from a high-volume center. Median travel distance was 13.4 miles (interquartile range [IQR] 6.0-28.7). On multivariable regression, patients residing further away were more likely to bypass a low-volume center to undergo care at a high-volume hospital (odds ratio 1.32, 95% confidence interval 1.12-1.55) versus individuals residing closer to high-volume centers. Approximately one-third (29.7%) of patients lived beyond a 1-h travel window to the nearest high-volume hospital, of whom 5% traveled over 90 min. While hospital mortality rates across different travel time windows did not differ, surgery at a high-volume center was associated with an overall 1.2% decrease in in-hospital mortality. CONCLUSIONS Regionalization of complex cancer surgery may be associated with a significant travel burden for a large subset of patients with complex cancer.
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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
| | - Yutaka Endo
- 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
| | - Joal Beane
- 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
| | - Aslam Ejaz
- 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
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Munir MM, Endo Y, Alaimo L, Moazzam Z, Lima HA, Woldesenbet S, Azap L, Beane J, Kim A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Impact of Community Privilege on Access to Care Among Patients Following Complex Cancer Surgery. Ann Surg 2023; 278:e1250-e1258. [PMID: 37436887 DOI: 10.1097/sla.0000000000005979] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE We sought to define the impact of community privilege on variations in travel patterns and access to care at high-volume hospitals for complex surgical procedures. BACKGROUND With increased emphasis on centralization of high-risk surgery, social determinants of health play a critical role in preventing equitable access to care. Privilege is a right, benefit, advantage, or opportunity that positively impacts all social determinants of health. METHODS The California Office of State-wide Health Planning Database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for a malignant diagnosis between 2012 and 2016 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated metric of both spatial polarization and privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the probability of undergoing care at a high-volume center, bypassing the nearest and high-volume center, and total real driving time and travel distance. RESULTS Among 25,070 patients who underwent a complex oncologic operation (ES: n=1216, 4.9%; PN: n=13,247, 52.8%; PD: n=3559, 14.2%; PR: n=7048, 28.1%), 5019 (20.0%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 4994 (19.9%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). Median travel distance was 33.1 miles (interquartile range 14.4-72.2). Roughly, three-quarters of patients (overall: 74.8%, ES: 35.0%; PN: 74.3%; PD: 75.2%; PR: 82.2%) sought surgical care at a high-volume center. On multivariable regression, patients residing in the least advantaged communities were less likely to undergo surgery at a high-volume hospital (overall: odds ratio 0.65, 95% CI 0.52-0.81). Of note, individuals in the least privileged areas had longer travel distances (28.5 miles, 95% CI 21.2-35.8) to reach the destination facility, as well as over 70% greater odds of bypassing a high-volume hospital to undergo surgical care at a low-volume center (odds ratio 1.74, 95% CI 1.29-2.34) versus individuals living in the highest privileged areas. CONCLUSIONS AND RELEVANCE Privilege had a marked effect on access to complex oncologic surgical care at high-volume centers. These data highlight the need to focus on privilege as a key social determinant of health that influences patient access to and utilization of health care resources.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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10
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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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11
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Khalil M, Tsilimigras DI, Endo Y, Khan MMM, Munir MM, Katayama E, Rashid Z, Resende V, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Association of Textbook Outcome and Hospital Volume with Long-Term Survival Following Resection for Hepatocellular Carcinoma: What Matters More? J Gastrointest Surg 2023; 27:2763-2770. [PMID: 37940807 DOI: 10.1007/s11605-023-05880-w] [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: 09/16/2023] [Accepted: 10/28/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Both textbook outcome (TO) and hospital volume have been identified as quality metrics following cancer surgery. We sought to examine whether TO or hospital volume is more important relative to long-term survival following surgical resection of hepatocellular carcinoma (HCC). METHODS Patients who underwent surgery for HCC between 2004 and 2018 were identified using the National Cancer Database. TO was defined as R0 margin resection, no extended length of stay, no 30-day readmissions, and no 90-day mortality. The impact of TO and hospital case volume on long-term survival was determined using multivariable Cox regression. RESULTS Among 24,895 patients who underwent HCC resection, 9.0% (n = 2,252), 79.5% (n = 19,787), and 11.5% (n = 2,856) of patients were operated on at low-, medium-, and high-volume hospitals, respectively. Treatment at high-volume hospitals and achievement of a post-operative TO were independently associated with improved 5-year overall survival (OS). Pairwise comparison demonstrated that patients treated at high-volume hospitals who did not achieve a TO still had a better 5-year OS versus individuals treated at low-volume hospitals who did achieve a TO (5-year OS, no TO vs. TO: low-volume hospitals, 26.5% vs. 48.6%; high volume hospitals: 62.6% vs. 74.9%, respectively; p < 0.001). Overall, resection of HCC at a high-volume hospital was independently associated with a 54% reduction in mortality. CONCLUSION Long-term survival following HCC resection was largely associated with hospital case volume rather than TO. The effect of TO on long-term outcomes was largely mediated by hospital case volume highlighting the importance of centralization of care for patients with HCC.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Vivian Resende
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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12
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Contrera KJ, Tam S, Pytynia K, Diaz EM, Hessel AC, Goepfert RP, Lango M, Su SY, Myers JN, Weber RS, Eguia A, Pisters PWT, Adair DK, Nair AS, Rosenthal DI, Mayo L, Chronowski GM, Zafereo ME, Shah SJ. Impact of Cancer Care Regionalization on Patient Volume. Ann Surg Oncol 2023; 30:2331-2338. [PMID: 36581726 DOI: 10.1245/s10434-022-13029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs). METHODS This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution. RESULTS The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299). CONCLUSIONS The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.
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Affiliation(s)
- Kevin J Contrera
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Tam
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kristen Pytynia
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo M Diaz
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miriam Lango
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arturo Eguia
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | | | - Deborah K Adair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ajith S Nair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren Mayo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory M Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shalin J Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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Raoof M, Ituarte PHG, Haye S, Jacobson G, Sullivan KM, Eng O, Kim J, Fong Y. Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients. J Clin Oncol 2023; 41:1239-1249. [PMID: 36356283 DOI: 10.1200/jco.21.01359] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Nearly half of all Medicare beneficiaries are enrolled in privatized Medicare insurance plans (Medicare Advantage [MA]). Little comparative information is available about access, outcomes, and cost of inpatient cancer surgery between MA and Traditional Medicare (TM) beneficiaries. We set out to assess and compare access, postoperative outcomes, and estimated cost of inpatient cancer surgery among MA and TM beneficiaries. METHODS Retrospective cohort analysis of MA or TM beneficiaries undergoing elective inpatient cancer surgery (for cancers located in lung, esophagus, stomach, pancreas, liver, colon, or rectum) was performed using the Office of Statewide Health Planning Inpatient Database linked to California Cancer Registry from 2000 to 2020. For each cancer site, risk-standardized access to high-volume hospitals, postoperative 30-day mortality, complications, failure to rescue, and surgery-specific estimated costs were compared between MA and TM beneficiaries. RESULTS This analysis of 76,655 Medicare beneficiaries (median age 74 years, 51% female, 39% MA) included 31,913 colectomies, 10,358 proctectomies, 4,604 hepatectomies, 2,895 pancreatectomies, 3,639 gastrectomies, 1,555 esophagectomies, and 21,691 lung resections. Except for colon surgery, MA beneficiaries were less likely to receive care at a high-volume hospital. Mortality was significantly higher among MA beneficiaries (v TM) for gastrectomy (adjusted risk difference [ARD], 1.5%; 95% CI, 0.01 to 2.9; P = .036), pancreatectomy (ARD, 2.0%; CI, 0.80 to 3.3; P = .002), and hepatectomy (ARD, 1.4%; 95% CI, 0.1 to 2.9; P = .04). By contrast, compared with TM, MA beneficiaries incurred lower estimated hospital costs. CONCLUSION Enrollment in MA plan is associated with lower estimated hospital costs. However, compared with TM, MA beneficiaries had lower access to high-volume hospitals and increased 30-day mortality for stomach, pancreas, or liver surgery.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | | | - Sidra Haye
- Department of Economics, University of California Irvine, Irvine, CA
| | | | - Kevin M Sullivan
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Oliver Eng
- Department of Surgery, University of California Irvine, Irvine, CA
| | - Jae Kim
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
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Frosch ZAK, Namoglu EC, Mitra N, Landsburg DJ, Nasta SD, Bekelman JE, Iyengar R, Guerra CE, Schapira MM. Willingness to Travel for Cellular Therapy: The Influence of Follow-Up Care Location, Oncologist Continuity, and Race. JCO Oncol Pract 2022; 18:e193-e203. [PMID: 34524837 PMCID: PMC8757965 DOI: 10.1200/op.21.00312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Patients weigh competing priorities when deciding whether to travel to a cellular therapy center for treatment. We conducted a choice-based conjoint analysis to determine the relative value they place on clinical factors, oncologist continuity, and travel time under different post-treatment follow-up arrangements. We also evaluated for differences in preferences by sociodemographic factors. METHODS We administered a survey in which patients with diffuse large B-cell lymphoma selected treatment plans between pairs of hypothetical options that varied in travel time, follow-up arrangement, oncologist continuity, 2-year overall survival, and intensive care unit admission rate. We determined importance weights (which represent attributes' value to participants) using generalized estimating equations. RESULTS Three hundred and two patients (62%) responded. When all follow-up care was at the center providing treatment, plans requiring longer travel times were less attractive (v 30 minutes, importance weights [95% CI] of -0.54 [-0.80 to -0.27], -0.57 [-0.84 to -0.29], and -0.17 [-0.49 to 0.14] for 60, 90, and 120 minutes). However, the negative impact of travel on treatment plan choice was mitigated by offering shared follow-up (importance weights [95% CI] of 0.63 [0.33 to 0.93], 0.32 [0.08 to 0.57], and 0.26 [0.04 to 0.47] at 60, 90, and 120 minutes). Black participants were less likely to choose plans requiring longer travel, regardless of follow-up arrangement, as indicated by lower value importance weights for longer travel times. CONCLUSION Reducing travel burden through shared follow-up may increase patients' willingness to travel to receive cellular therapies, but additional measures are required to facilitate equitable access.
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Affiliation(s)
- Zachary A. K. Frosch
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Zachary A. K. Frosch, MD, MSHP, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111; e-mail:
| | - Esin C. Namoglu
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel J. Landsburg
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Sunita D. Nasta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Justin E. Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raghuram Iyengar
- Marketing Department, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Carmen E. Guerra
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA
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15
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Lorenzon L, Biondi A, Agnes A, Scrima O, Persiani R, D’Ugo D. Quality Over Volume: Modeling Centralization of Gastric Cancer Resections in Italy. J Gastric Cancer 2022; 22:35-46. [PMID: 35425653 PMCID: PMC8980598 DOI: 10.5230/jgc.2022.22.e4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background The correlation between hospital volume and postoperative outcomes has led to the centralization of complex procedures in several countries. However, the results reported in relation to gastric cancer (GC) are contradictory. This study aimed to analyze GC surgical volumes and 30-day postoperative mortality in Italy and to provide a simulation for modeling centralization of GC resections based on district case volumes. Methods A national registry was used to identify all GC resections, record mortality rates, and track the national in-border GC resection health travel. Hospitals were grouped according to caseload. Centralization of all GC procedures performed within the same district was modeled. The outcome measures were a minimal volume of 25 GC resections/year and the 30-day postoperative mortality. Results In 2018, 5,873 GC resections were performed in 498 Italian hospitals (mean resections per hospital per year: 11.8); the postoperative mortality rate (5.51%) was tracked from 2016–2018. GC resection health travel ranged from 2% to 50.5%, with a significant (P<0.001) difference between northern and central/southern Italy. The mean mortality rate was 7.7% in hospitals performing one to 3 GC resections per year, compared with 4.7% in those with >17 GC resections/year (P≤0.01). Most Italian districts achieved 25 procedures/year after centralization; however, 66.3% of GC cases in southern Italy vs. 42.2% in central and 52.7% in the northern regions (P<0.001) required reallocation. Conclusion Postoperative mortality after GC resection correlated with hospital volume. Despite health travel, most Italian districts can reach a high-volume threshold, but discrepancies in mortality rates are alarming. Trial Registration
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Affiliation(s)
- Laura Lorenzon
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alberto Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Annamaria Agnes
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ottavio Scrima
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Persiani
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D’Ugo
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Raoof M, Jacobson G, Fong Y. Medicare Advantage Networks and Access to High-volume Cancer Surgery Hospitals. Ann Surg 2021; 274:e315-e319. [PMID: 34506325 DOI: 10.1097/sla.0000000000005098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine how Medicare Advantage (MA) health plan networks impact access to high-volume hospitals for cancer surgery. BACKGROUND Cancer surgery at high-volume hospitals is associated with better short- and long-term outcomes. In the United States, health insurance is a major detriment to seeking care at high-volume hospitals. A third of older (>65 years) Americans are enrolled in privatized MA health plans. The impact of MA plan networks on access to high-volume surgery hospitals is unknown. METHODS We analyzed in-network hospitals for MA plans offered in Los Angeles county during open enrollment of 2015. For the purposes of this analysis, MA network data from provider directories were linked to hospital volume data from California Office of Statewide Health Planning and Development. Volume thresholds were based on published literature. RESULTS A total of 34 MA plans enrolled 554,754 beneficiaries in Los Angeles county during 2014 open enrollment for coverage starting in 2015 (MA penetration ∼43%). The proportion of MA plans that included high-volume cancer surgery hospital varied by the type of cancer surgery. While most plans (>71%) included at least one high-volume hospital for colon, rectum, lung, and stomach; 59% to 82% of MA plans did not include any high-volume hospitals for liver, esophagus, or pancreatic surgery. A significant proportion of beneficiaries in MA plans did not have access to high-volume hospitals for esophagus (93%), stomach (44%), liver (39%), or pancreas (70%) surgery. In contrast, nearly all MA beneficiaries had access to at least one high-volume hospital for lung (93%), colon (100%), or rectal (100%) surgery. Overall, Centers for Medicare & Medicaid Services plan rating or plan popularity were not correlated with access to high-volume hospital (P > 0.05). CONCLUSIONS The study identifies lack of high-volume hospital coverage in MA health plans as a major detriment in regionalization of cancer surgery impacting at least a third of older Americans.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
| | - Gretchen Jacobson
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
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17
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Gandjian M, Williamson C, Sanaiha Y, Hadaya J, Tran Z, Kim ST, Revels S, Benharash P. Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective. Ann Thorac Surg 2021; 114:426-433. [PMID: 34437854 DOI: 10.1016/j.athoracsur.2021.07.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications and resource use following esophageal resection. METHODS The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as high-volume (HVH) if performing at least 20 esophagectomies annually, and low-volume (LVH) if fewer. Multivariable models were developed to study the impact of volume on outcomes of interest which included in-hospital mortality, complications, duration of hospitalization (LOS), inflation adjusted costs, readmissions, and non-home discharge. RESULTS Of an estimated 23,176 hospitalizations, 45.6% occurred at HVH. Incidence of esophagectomy increased significantly along with median institutional case load over the study period, while the proportion on hospitals considered HVH remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH was associated with decreased mortality (AOR=0.65), LOS (β=-1.83 days), pneumonia (AOR=0.69), prolonged ventilation (AOR=0.50), sepsis (AOR=0.80), and tracheostomy (AOR=0.66), but increased odds of non-home discharge (AOR=1.56, all P<0.01), with LVH as reference. CONCLUSIONS Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Samuel T Kim
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sha'shonda Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
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Morse E, Lohia S, Dooley LM, Gupta P, Roman BR. Travel distance is associated with stage at presentation and laryngectomy rates among patients with laryngeal cancer. J Surg Oncol 2021; 124:1272-1283. [PMID: 34390494 DOI: 10.1002/jso.26643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The impact of travel distance on stage at presentation and management strategies of laryngeal squamous cell carcinoma (SCC) is unknown. We investigated this relationship. METHODS Retrospective review of patients with laryngeal SCC in the National Cancer Data Base from 2004 to 2016. Multivariate analysis determined relationships between travel distance, sociodemographic, geographic, and hospital factors. Logistic regression determined the influence of travel distance on T-stage and overall stage at presentation, and receipt of total laryngectomy. RESULTS Sixty thousand four hundred and thirty-nine patients were divided into groups based on distance to treatment: short (<12.5 miles); intermediate (12.5-49.9 miles); and long (>50 miles). Increased travel was associated with T4-stage (intermediate vs. short OR 1.11, CI 1.04-1.18, p = 0.001; long vs. short OR 1.5, CI 1.36-1.65, p < 0.001), and total laryngectomy (intermediate vs. short OR 1.40, CI 1.3-1.5, p ≤ 0.001; long vs. short OR 2.52, CI 2.28-2.79, p ≤ 0.001). In T4 disease, total laryngectomy was associated with improved survival compared to nonsurgical treatment (HR 0.75, CI 0.70-0.80, p < 0.001) regardless of travel distance. CONCLUSION Longer travel distance to care is associated with increased stage at presentation, rate of laryngectomy, and improved survival in advanced laryngeal SCC. Health policy efforts should be directed towards improving early access to diagnosis and care.
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Affiliation(s)
- Elliot Morse
- Department of Otolaryngology, Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Shivangi Lohia
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, USA
| | - Laura M Dooley
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, USA
| | - Piyush Gupta
- Department of Otolaryngology, University of Missouri, Columbia, Missouri, USA
| | - Benjamin R Roman
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Yee EK, Coburn NG, Zuk V, Davis LE, Mahar AL, Liu Y, Gupta V, Darling G, Hallet J. Geographic impact on access to care and survival for non-curative esophagogastric cancer: a population-based study. Gastric Cancer 2021; 24:790-799. [PMID: 33550518 DOI: 10.1007/s10120-021-01157-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among patients not undergoing curative-intent therapy for esophagogastric cancer, access to care may vary. We examined the geographic distribution of care delivery and survival and their relationship with distance to cancer centres for non-curative esophagogastric cancer, hypothesising that patients living further from cancer centres have worse outcomes. METHODS We conducted a population-based analysis of adults with non-curative esophagogastric cancer from 2005 to 2017 using linked administrative healthcare datasets in Ontario, Canada. Outcomes were medical oncology consultation, receipt of chemotherapy, and overall survival. Using geographic information system analysis, we mapped locations of cancer centres and outcomes across census divisions. Bivariate choropleth maps identified regional outcome discordances. Multivariable regression models assessed the relationship between distance from patient residence to the nearest cancer centre and outcomes, adjusting for demographic, clinical, and socioeconomic factors. RESULTS Of 10,228 patients surviving a median 5.1 months (IQR: 2.0-12.0), 68.5% had medical oncology consultation and 32.2% received chemotherapy. Certain distances (reference ≤ 10 km) were associated with lower consultation [relative risk 0.79 (95% CI 0.63-0.97) for ≥ 101 km], chemotherapy receipt [relative risk 0.67 (95% CI 0.53-0.85) for ≥ 101 km], and overall survival [hazard ratio 1.07 (95% CI 1.02-1.13) for 11-50 km, hazard ratio 1.13 (95% CI 1.04-1.23) for 51-100 km]. CONCLUSION A third of patients did not see medical oncology and most did not receive chemotherapy. Outcomes exhibited high geographic variability. Location of residence influenced outcomes, with inferior outcomes at certain distances > 10 km from cancer centres. These findings are important for designing interventions to reduce access disparities for non-curative esophagogastric cancer care.
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Affiliation(s)
- Elliott K Yee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Victoria Zuk
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Laura E Davis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ying Liu
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Vaibhav Gupta
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gail Darling
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, ON, Canada
| | - Julie Hallet
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada.
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20
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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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21
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Wu Y, Zhu L, Yu T, Zhang S. A Comprehensive Evaluation of Township Hospitals in the Severely Cold Areas of China. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2021; 14:93-113. [PMID: 34000857 DOI: 10.1177/19375867211010268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aims of this study are to establish an evaluation system and find the existing problems in the architectural design of township hospitals in the severely cold regions of China. BACKGROUND Due to the geographical location and economic factors, development still has some key problems, such as inadequate construction, old facilities, and backward technology, which are more prominent in the severely cold regions. METHODS First, evaluation factors have been selected and determined by literature review and on-site investigation. Evaluation rules have been determined using fuzzy membership function. Then, the analytic hierarchy process is used to determine the weights of the evaluation factors at all levels. Finally, take a township hospital as an example to calculate the comprehensive evaluation results. RESULTS A comprehensive evaluation index system with 28 elements and 76 factors for the township hospitals in severely cold regions including the basic health service capacity, the emergency capacity, and the climate fitness. CONCLUSIONS The establishment of the comprehensive evaluation system of township hospitals in severely cold areas in this study aims to find out the problems through the evaluation of the existing township hospitals in the severely cold areas and provide guidance for the transformation of existing township hospitals in the severely cold areas. By comparing the scheme evaluation for building hospitals, we shall look for the optimal solution to provide reference for future development in the construction of township hospitals.
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Affiliation(s)
- Yue Wu
- Key Laboratory of Cold Region Urban and Rural Human Settlement Environment Science and Technology, School of Architecture, 47822Harbin Institute of Technology, China
| | - Lei Zhu
- Key Laboratory of Cold Region Urban and Rural Human Settlement Environment Science and Technology, School of Architecture, 47822Harbin Institute of Technology, China
| | - Tingting Yu
- Key Laboratory of Cold Region Urban and Rural Human Settlement Environment Science and Technology, School of Architecture, 47822Harbin Institute of Technology, China
| | - Shanshan Zhang
- Key Laboratory of Cold Region Urban and Rural Human Settlement Environment Science and Technology, School of Architecture, 47822Harbin Institute of Technology, China
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22
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Brauer DG, Wu N, Keller MR, Humble SA, Fields RC, Hammill CW, Hawkins WG, Colditz GA, Sanford DE. Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database. J Am Coll Surg 2021; 232:921-932.e12. [PMID: 33865977 DOI: 10.1016/j.jamcollsurg.2021.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference. STUDY DESIGN Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level. RESULTS There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226). CONCLUSIONS For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.
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Affiliation(s)
- David G Brauer
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO.
| | - Ningying Wu
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew R Keller
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Sarah A Humble
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Graham A Colditz
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Dominic E Sanford
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
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23
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Diaz A, Schoenbrunner A, Pawlik TM. Trends in the Geospatial Distribution of Inpatient Adult Surgical Services across the United States. Ann Surg 2021; 273:121-127. [PMID: 31090565 DOI: 10.1097/sla.0000000000003366] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to define trends in the geographic distribution of surgical services in the United States to assess possible geographic barriers and disparities in access to surgical care. SUMMARY BACKGROUND DATA Despite the increased need and utilization of surgical procedures, Americans often face challenges in gaining access to health care that may be exacerbated by the closure and consolidation of hospitals. Although access to surgical care has been evaluated relative to the role of insurance, race, and health literacy/education, the relationship of geography and travel distance to access has not been well studied. METHODS The 2005 and 2015 American Hospital Association annual survey was used to identify hospitals with surgical capacity; the data were merged with 2010 Census Bureau data to identify the distribution of the US population relative to hospital location, and geospatial analysis tools were used to examine a service area of real driving time surrounding each hospital. RESULTS Although the number of hospitals that provided surgical services slightly decreased over the time periods examined (2005, n = 3791; 2015, n = 3391; P<0.001), the number of major surgery hospitals increased from 2005 (n = 539) to 2015 (n = 749) (P<0.001). The geographic location of hospitals that provided surgical services changed over time. Specifically, although in 2005 852 hospitals were located in a rural area, that number had decreased to 679 by 2015 (P<0.001). Of particular note, from 2005 to 2015 there was an 82% increase in the number of people who lived further than 60 minutes from any hospital (P<0.001). However, the number of people who lived further than 60 minutes from a major surgery hospital decreased (P<0.001). CONCLUSIONS Although the number of rural hospitals decreased over the last decade, the number of large, academic medical centers has increased; in turn, there has been an almost doubling in the number of people who live outside a 60-minute driving range to a hospital capable of performing surgery.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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24
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Yee EK, Coburn NG, Davis LE, Mahar AL, Zuk V, Gupta V, Liu Y, Earle CC, Hallet J. Impact of Geography on Care Delivery and Survival for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis. J Natl Compr Canc Netw 2020; 18:1642-1650. [PMID: 33285520 DOI: 10.6004/jnccn.2020.7605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/18/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about how the geographic distribution of cancer services may influence disparities in outcomes for noncurable pancreatic adenocarcinoma. We therefore examined the geographic distribution of outcomes for this disease in relation to distance to cancer centers. METHODS We conducted a retrospective population-based analysis of adults in Ontario, Canada, diagnosed with noncurable pancreatic adenocarcinoma from 2004 through 2017 using linked administrative healthcare datasets. The exposure was distance from place of residence to the nearest cancer center providing medical oncology assessment and systemic therapy. Outcomes were medical oncology consultation, receipt of cancer-directed therapy, and overall survival. We examined the relationship between distance and outcomes using adjusted multivariable regression models. RESULTS Of 15,970 patients surviving a median of 3.3 months, 65.6% consulted medical oncology and 38.5% received systemic therapy. Regions with comparable outcomes were clustered throughout Ontario. Mapping revealed regional discordances between outcomes. Increasing distance (reference, ≤10 km) was independently associated with lower likelihood of medical oncology consultation (relative risks [95% CI] for 11-50, 51-100, and ≥101 km were 0.90 [0.83-0.98], 0.78 [0.62-0.99], and 0.77 [0.55-1.08], respectively) and worse survival (hazard ratios [95% CI] for 11-50, 51-100, and ≥101 km were 1.08 [1.04-1.12], 1.17 [1.10-1.25], and 1.10 [1.02-1.18], respectively), but not with likelihood of receiving therapy. Receipt of therapy seems less sensitive to distance, suggesting that distance limits entry into the cancer care system via oncology consultation. Regional outcome discordances suggest inefficiencies within and protective factors outside of the cancer care system. CONCLUSIONS These findings provide a basis for clinicians to optimize their practices for patients with noncurable pancreatic adenocarcinoma, for future studies investigating geographic barriers to care, and for regional interventions to improve access.
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Affiliation(s)
- Elliott K Yee
- 1Faculty of Medicine, University of Toronto, Toronto, Ontario.,2Cancer Program - Evaluative Clinical Sciences, and
| | - Natalie G Coburn
- 2Cancer Program - Evaluative Clinical Sciences, and.,3Department of Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario.,4Department of Surgery, University of Toronto, Toronto, Ontario.,5ICES, Toronto, Ontario
| | - Laura E Davis
- 6Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
| | - Alyson L Mahar
- 7Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba; and
| | - Victoria Zuk
- 2Cancer Program - Evaluative Clinical Sciences, and
| | - Vaibhav Gupta
- 2Cancer Program - Evaluative Clinical Sciences, and.,4Department of Surgery, University of Toronto, Toronto, Ontario
| | - Ying Liu
- 4Department of Surgery, University of Toronto, Toronto, Ontario
| | - Craig C Earle
- 2Cancer Program - Evaluative Clinical Sciences, and.,5ICES, Toronto, Ontario.,8Division of Medical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- 2Cancer Program - Evaluative Clinical Sciences, and.,3Department of Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario.,4Department of Surgery, University of Toronto, Toronto, Ontario.,5ICES, Toronto, Ontario
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25
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Diaz A, Pawlik TM. Insurance status and high-volume surgical cancer: Access to high-quality cancer care. Cancer 2020; 127:507-509. [PMID: 33084043 DOI: 10.1002/cncr.33234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Adrian Diaz
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
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Chou J, Somnay V, Woodwyk A, Munene G. The Volume-Outcome Relationship and Traveling for Hepatobiliary and Pancreatic Surgery: A Quantitative Analysis of Patient Perspectives. Cureus 2020; 12:e11023. [PMID: 33214951 PMCID: PMC7671299 DOI: 10.7759/cureus.11023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite the well-established relationship between volume and outcomes, patients continue to have procedures performed at low-volume hospitals. The factors patients use to make the complex decision of where to have hepatopancreaticobiliary (HPB) surgery remain poorly characterized. A novel survey instrument was administered to all patients who had undergone HPB surgery at two university-affiliated community hospitals. 76 patients participated in the study (89% response rate). The majority of patients were unaware of the volume-outcome relationship (58.8%). No demographic factors differed between patients who were or were not aware except for patient research. Physician factors were the most important selection category (64.4%). Only 28.9% of patients were willing to travel more than two hours to have an operation performed at a hospital with a high volume/improved quality. Despite many voices calling for regionalization, patient decision-making factors should be considered before any realistic implementation.
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Affiliation(s)
- Jesse Chou
- Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Vishal Somnay
- Radiology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Alyssa Woodwyk
- Biostatistics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Gitonga Munene
- Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
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Trends in the Geospatial Distribution of Adult Inpatient Surgical Cancer Care Across the United States. J Gastrointest Surg 2020; 24:2127-2134. [PMID: 31396841 DOI: 10.1007/s11605-019-04343-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/24/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The relationship and trends of geography and travel distance to access surgical cancer care has been poorly characterized. The objective of the study was to define the geographic distribution of access to hospital-based operative cancer care across the USA. METHODS A cohort analysis was performed using the 2005 and 2015 American Hospital Association Annual Survey, Census Bureau Data for 2010, and the American Community Survey 5-year estimates for 2011 to 2016. RESULTS The number of hospitals that provided surgical services with an approved American College of Surgeons (ACS) cancer program slightly increased over the time periods examined (2005, n = 1203 vs. 2015, n = 1284; p = 0.7210). Based on geospatial analysis, 18,214,994 (5.9%) people lived more than 60 min from a hospital with a cancer program in 2005 compared with 34,630,516 (11.2%) by 2015. Communities within a 60-min drive time were more likely to be composed of individuals who completed high school (85.9% vs. 84.2%), were employed (62.7% vs. 57.1%), had a higher median household income ($67.4 k vs. $53.2 k), and lived within states that had expanded Medicaid (62.5% vs. 48.9%) (all p < 0.0001). In contrast, communities outside of a 60-min drive time had a greater proportion of individuals below the federal poverty level (18.3% vs. 16.5%; p < 0.0001). CONCLUSIONS While the number of hospitals with ACS approved cancer program designation increased over the last decade, the number of people living greater than 60 min from an approved cancer programs nearly doubled. These data highlight worrisome geospatial trends that may make access to cancer care for certain patient populations increasingly challenging.
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Diaz A, Chavarin D, Paredes AZ, Tsilimigras DI, Pawlik TM. Association of Neighborhood Characteristics with Utilization of High-Volume Hospitals Among Patients Undergoing High-Risk Cancer Surgery. Ann Surg Oncol 2020; 28:617-631. [PMID: 32699923 DOI: 10.1245/s10434-020-08860-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/02/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION As high-risk cancer surgery continues to become more centralized, it is important to understand the association of neighborhood characteristics relative to access to surgical care. We sought to determine the neighborhood level characteristics that may be associated with travel patterns and utilization of high-volume hospitals. METHODS The California Office of Statewide Health Planning database was used to identify patients who underwent pancreatectomy (PD), esophagectomy (ES), proctectomy (PR), or pneumonectomy (PN) for cancer between 2014 and 2016. Total minutes (m) traveled as well as whether a patient bypassed the nearest hospital that performed the operation to get to a higher-volume center was assessed. Data were merged with the Centers for Disease control social vulnerability index (SVI). RESULTS Overall, 26,937 individuals (ES: 4.7%; PN: 53.5% PD: 13.9% PR: 27.9%) underwent a complex oncologic operation. Median travel time was 16 m (interquartile range [IQR] 8.3-30.24) [ES: 21.8 m (IQR 10.6-46.9); PN: 14 m (IQR 7.8-27.0); PD: 21.2 m (IQR 10.6-42.6); PR: 15 m (IQR 8.1-28.4)]. Nearly three-quarter of patients (ES: 34%; PN: 73%; PD: 72%; LR: 81%) underwent an operation at a high-volume hospital. For all four operations, patients who resided in a county with a high overall SVI were less likely to have surgery at a high-volume hospital (ES: odds ratio [OR] 0.39, 95% confidence interval [CI] 0.24-0.65; PN: OR: 0.67, 95% CI 0.51-0.88; PD: OR 0.61, 95% CI 0.44-0.84; PR: OR 0.76, 95% CI 0.58-0.98). CONCLUSIONS Patients residing in communities of high social vulnerability were less likely to undergo high-risk cancer surgery at a high-volume hospital. The identification of society-based contextual disparities in access to complex surgical care should serve to inform targeted strategies to direct additional resources toward these vulnerable communities.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.,IHPI Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Chavarin
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Matthews KA, Kahl AR, Gaglioti AH, Charlton ME. Differences in Travel Time to Cancer Surgery for Colon versus Rectal Cancer in a Rural State: A New Method for Analyzing Time-to-Place Data Using Survival Analysis. J Rural Health 2020; 36:506-516. [PMID: 32501619 DOI: 10.1111/jrh.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Rectal cancer is rarer than colon cancer and is a technically more difficult tumor for surgeons to remove, thus rectal cancer patients may travel longer for specialized treatment compared to colon cancer patients. The purpose of this study was to evaluate whether travel time for surgery was different for colon versus rectal cancer patients. METHODS A secondary data analysis of colorectal cancer (CRC) incidence data from the Iowa Cancer Registry data was conducted. Travel times along a street network from all residential ZIP Codes to all cancer surgery facilities were calculated using a geographic information system. A new method for analyzing "time-to-place" data using the same type of survival analysis method commonly used to analyze "time-to-event" data is introduced. Cox proportional hazard model was used to analyze travel time differences for colon versus rectal cancer patients. RESULTS A total of 5,844 CRC patients met inclusion criteria. Median travel time to the nearest surgical facility was 9 minutes, median travel time to the actual cancer surgery facilities was 22 minutes, and the median number of facilities bypassed was 3. Although travel times to the nearest surgery facilities were not significantly different for colon versus rectal cancer patients, rectal cancer patients on average traveled 15 minutes longer to their actual surgery facility and bypassed 2 more facilities to obtain surgery. DISCUSSION In general, the survival analysis method used to analyze the time-to-place data as described here could be applied to a wide variety of health services and used to compare travel patterns among different groups.
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Affiliation(s)
- Kevin A Matthews
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amanda R Kahl
- Department of Epidemiology, Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, Iowa
| | - Anne H Gaglioti
- National Center for Primary Care, Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Mary E Charlton
- Department of Epidemiology, Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, Iowa
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Diaz A, Paredes AZ, Hyer JM, Pawlik TM. Variation in value among hospitals performing complex cancer operations. Surgery 2020; 168:106-112. [PMID: 32409168 DOI: 10.1016/j.surg.2020.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND While variation in outcomes has driven centralization of complex cancer surgery, variation in cost and value remains unexplored. We evaluated outcomes relative to cost among hospitals performing esophageal and pancreatic resection for cancer. METHODS Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective esophagectomy and pancreatectomy for cancer from 2014 to 2016. Risk- and reliability-adjusted, price-standardized payments for the surgical episode from admission through 30 days post discharge, as well as risk- and reliability-adjusted complication rates for each hospital, were calculated. Hospitals were separated into quintiles relative to payments and outcomes. Highest-value hospitals were defined as hospitals in the top 2 quartiles for both cost and outcomes. RESULTS Among 11,586 Medicare beneficiaries who underwent a complex oncologic operation between 2014 and 2016, 66% had a pancreatic neoplasm, while 33% had an esophageal neoplasm. Overall, 31.1% patients underwent an operation at a high-value hospital. Among patients who underwent pancreatectomy, the risk-adjusted postoperative complication rate was 31.4% at the lowest-value hospitals vs 22.7% at highest-value hospitals (odds ratio: 0.57, 95% confidence interval 0.47-0.70). The esophagectomy, risk-adjusted postoperative complication rate was 48.3% at lowest-value hospitals versus 29.8% at highest-value hospitals (odds ratio: 0.36, 95% confidence interval 0.27-0.47). The average difference in episode cost of care for an esophagectomy at lowest- versus highest-value hospitals was $5,617; the difference for pancreatectomy was $2,748. CONCLUSION There was wide variation in complication rates and average costs among lowest- versus highest-value hospitals performing esophagectomy and pancreatectomy for cancer. Even among highest quality hospitals, wide variation in average episode costs was noted. Surgeons should seek to better understand practice variation to standardize care and decrease variation in outcomes, utilization, and costs.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Villano AM, Zeymo A, Houlihan BK, Bayasi M, Al-Refaie WB, Chan KS. Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes. J Surg Res 2020; 247:180-189. [DOI: 10.1016/j.jss.2019.07.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/24/2019] [Accepted: 07/07/2019] [Indexed: 02/07/2023]
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Diaz A, Burns S, D'Souza D, Kneuertz P, Merritt R, Perry K, Pawlik TM. Accessing surgical care for esophageal cancer: patient travel patterns to reach higher volume center. Dis Esophagus 2020; 33:doaa006. [PMID: 32100019 DOI: 10.1093/dote/doaa006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/06/2019] [Accepted: 01/24/2020] [Indexed: 12/11/2022]
Abstract
While better outcomes at high-volume surgical centers have driven the regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate the travel patterns among patients undergoing esophagectomy to assess willingness of patients to travel for surgical care. The California Office of Statewide Health Planning database was used to identify patients who underwent esophagectomy between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed esophagectomy to get to a higher volume center, was assessed. Overall 3,269 individuals underwent an esophagectomy for cancer in 154 hospitals; only five hospitals were high volume according to Leapfrog standards. Median travel time to a hospital that performed esophagectomy was 26 minutes (IQR: 13.1-50.7). The overwhelming majority of patients (85%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, only 36% went to a high-volume hospital. Of the 2,248 patients who underwent esophagectomy at a low-volume center, 1,491 patients had bypassed a high-volume hospital. Of the remaining 757 patients who did not bypass a high-volume hospital, half of the individuals would have needed to travel less than an additional hour to reach a high-volume center. Nearly two-thirds of patients undergoing an esophagectomy for cancer received care at a low-volume center; 85% of patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- VA/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
| | - Sarah Burns
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Desmond D'Souza
- The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Peter Kneuertz
- The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Robert Merritt
- The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kyle Perry
- 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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Segel JE, Lengerich EJ. Rural-urban differences in the association between individual, facility, and clinical characteristics and travel time for cancer treatment. BMC Public Health 2020; 20:196. [PMID: 32028942 PMCID: PMC7006189 DOI: 10.1186/s12889-020-8282-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background Greater travel time to cancer care has been identified as a potential barrier to care as well as associated with worse health outcomes. While rural cancer patients have been shown to travel farther for care, it is not known what patient, facility, and clinical characteristics may differentially be associated with greater roundtrip travel times for cancer patients by rurality of residence. Identifying these factors will help providers understand which patients may be most in need of resources to assist with travel. Methods Using 2010–2014 Pennsylvania Cancer Registry data, we examined the association between patient, facility, and clinical characteristics with roundtrip patient travel time using multivariate linear regression models. We then estimated separate models by rural residence based on the Rural-Urban Continuum Code (RUCC) of a patient’s county of residence at diagnosis to understand how the association of each factor with travel time may vary for patients separated into metro residents (RUCC 1–3); and two categories of non-metro residents (RUCC 4–6) and (RUCC 7–9). Results In our sample (n = 197,498), we document large differences in mean roundtrip travel time—mean 41.5 min for RUCC 1–3 patients vs. 128.9 min for RUCC 7–9 patients. We show cervical/uterine and ovarian cancer patients travel significantly farther; as do patients traveling to higher volume and higher-ranked hospitals. Conclusions To better understand patient travel burden, providers need to understand that factors predicting longer travel time may vary by rurality of patient residence and cancer type.
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Affiliation(s)
- Joel E Segel
- Department of Health Policy and Administration, Pennsylvania State University, 504 S Ford Building, University Park, PA, 16802, USA. .,Penn State Cancer Institute, Hershey, PA, USA. .,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA.
| | - Eugene J Lengerich
- Penn State Cancer Institute, Hershey, PA, USA.,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Diaz A, Burns S, Paredes AZ, Pawlik TM. Accessing surgical care for pancreaticoduodenectomy: Patient variation in travel distance and choice to bypass hospitals to reach higher volume centers. J Surg Oncol 2019; 120:1318-1326. [PMID: 31701535 DOI: 10.1002/jso.25750] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. METHODS The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. RESULTS Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital. CONCLUSION Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Sarah Burns
- Ohio State University College of Medicine, Columbus, Ohio
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
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Villano AM, Zeymo A, McDermott J, Crocker A, Zeck J, Chan KS, Shara N, Kim S, Al-Refaie WB. Evaluating Dissemination of Adequate Lymphadenectomy for Gastric Cancer in the USA. J Gastrointest Surg 2019; 23:2119-2128. [PMID: 30788715 DOI: 10.1007/s11605-019-04138-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adequate lymphadenectomy (AL) of 15+ lymph nodes comprises an important component of gastric cancer surgical therapy. Despite endorsement by the National Comprehensive Cancer Network and the Committee on Cancer, initial adoption of this paradigm has been relatively slow. The current analysis sought to perform an adjusted time-trend evaluation of the factors associated with AL and its dissemination. METHODS Utilizing the 2004-2015 National Cancer Database, 28,985 patients were identified who underwent gastrectomy for adenocarcinoma. An adjusted time-trend analysis was performed to estimate the adoption of AL overall. Multivariable logistic regression was utilized to assess factors associated with these observed trends. Interactions and stratified models determined disparate effects in vulnerable populations (older adults, ethnic minorities, low socioeconomic status). RESULTS The adjusted time-trend analysis demonstrated an overall 30% increase (28.8 to 58.7%) in receipt of AL (OR 1.10 increase/year; 95%CI 1.09-1.10) from 2004 to 2015. This trend persisted even after stratifying the models by age, race/ethnicity, and income (OR 1.07-1.12; p < 0.05). Slowest rates of adoption were seen amongst hospitals in the Midwest census region (OR 1.08, CI 1.06-1.90) and comprehensive community hospitals (OR 1.08, CI 1.06-1.91) and with African-American patients (OR 1.09, CI 1.06-1.11) (all p < 0.05). CONCLUSION This multi-center evaluation demonstrates increased adoption of AL during gastric cancer surgery in the USA overall and amongst vulnerable populations, although regional and racial disparities were observed. Future studies are needed to investigate reasons underlying racial and regional differences in receipt of AL.
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Affiliation(s)
- Anthony M Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.,Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC, USA
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.,MedStar Health Research Institute, Hyattsville, MD, USA
| | - James McDermott
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA
| | - Andrew Crocker
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA
| | - Jay Zeck
- Department of Pathology, MedStar-Georgetown University Hospital, Washington, DC, USA
| | - Kitty S Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.,MedStar Health Research Institute, Hyattsville, MD, USA
| | - Nawar Shara
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC, USA.,Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | - Sunnie Kim
- Department of Hematology-Oncology, MedStar-Georgetown University Hospital, Washington, DC, USA
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA. .,Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC, USA. .,MedStar Health Research Institute, Hyattsville, MD, USA. .,Department of Surgery, MedStar Georgetown University Hospital and Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd., NW, PHC Building, 4th Floor, Washington, DC, 20007, USA.
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Effect of Minimum-Volume Standards on Patient Outcomes and Surgical Practice Patterns for Hysterectomy. Obstet Gynecol 2019; 132:1229-1237. [PMID: 30303921 DOI: 10.1097/aog.0000000000002912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To model the effect of implementing minimum-volume standards for women who underwent hysterectomy on patient outcomes and surgeon practice patterns. METHODS We conducted a retrospective cohort study using the New York Statewide Planning and Research Cooperative System to capture data for all women who underwent hysterectomy from 2010 to 2014. We estimated the number of hysterectomies performed by each patient's physician during the prior year. Multivariable models were used to estimate the ratio of observed to expected complications based on each surgeon's volume during the prior year. The mean observed/expected ratio of surgeons was then plotted by volume. The number of patients and surgeons who would be eliminated and the reduction in complications if minimum-volume standards (lowest fifth and 10th percentiles) were implemented were analyzed. Separate analyses were performed for each route of hysterectomy. RESULTS We identified a total of 127,202 patients. For abdominal hysterectomy, increasing surgeon volume was associated with a decreasing rate of complications (P<.001). Overall, 17.5% of surgeons (n=1,260) had a prior year volume of one abdominal hysterectomy. The mean observed/expected ratio of surgeons with a prior year abdominal hysterectomy volume of one was 1.47 (SD 2.71). Within this group of surgeons, 31.4% had an observed/expected ratio of 1 or greater, indicating a higher than expected complication rate, and 68.7% of the surgeons had a observed/expected ratio of less than 1, suggesting a lower complication rate than expected based on case mix. Selection of a prior year volume standard of one would restrict 12.5% of surgeons performing robotic-assisted, 16.8% of those performing laparoscopic, and 27.6% of surgeons performing vaginal hysterectomy. CONCLUSION Implementing minimum-volume standards for hysterectomy, for even the lowest volume physicians, would restrict a significant number of gynecologic surgeons, including many with outcomes that are better than predicted.
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Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics? Ann Surg 2019; 274:e220-e229. [PMID: 31425294 DOI: 10.1097/sla.0000000000003553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. SUMMARY BACKGROUND DATA Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. METHODS Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4). RESULTS Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. CONCLUSIONS Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.
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Geographic Distribution of Adult Inpatient Surgery Capability in the USA. J Gastrointest Surg 2019; 23:1652-1660. [PMID: 30617771 DOI: 10.1007/s11605-018-04078-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/28/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Access to timely, quality, and affordable surgical services is an important component of health care systems. A better understanding of the geographic distribution of surgical services in the USA may help identify disparities in access to surgery. METHODS Using the 2015 American Hospital Association Annual Survey, the 2010 Census Bureau Data, and the American Community Survey 5-year estimates from 2011 to 2016, all hospitals with surgical capabilities were geocoded with 30 straight-line mile service areas around each hospital using geospatial analysis. Major surgical hospitals were defined as meeting three of the four following criteria: bed size ≥ 45, ≥ 8600 operations per year, ≥ 12 operating rooms, and academic medical center. The distribution of the US population based on proximity to a hospital capable of performing adult inpatient surgery and a major surgical hospital was then analyzed and compared. RESULTS Overall, 3409 hospitals were identified that had the capacity to perform adult inpatient surgery of which 1373 were defined as major surgical hospitals. Based on geospatial analysis, 10% of the US population was found to reside outside of a linear 30-mile radius of a surgical hospital. Younger age (OR 0.97, CI 0.96-0.97), female sex (OR 4.6, CI 4.3-5), African-American race (OR = 5.4, CI 4.7-6.2), Hispanic/Latino race (OR 5.5, CI 4.8-6.3), having completed high school or greater (OR = 3.6, CI 3-4.2), being employed (OR 4.8, CI 4.6-4.9), and having any type of health insurance were significantly associated with living in a service area. CONCLUSION A significant proportion of the US population lives greater than 30 straight-line miles from a major surgical hospital. Common demographic and socioeconomic factors highlight disparities in access to surgical care.
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Clark JM, Boffa DJ, Meguid RA, Brown LM, Cooke DT. Regionalization of esophagectomy: where are we now? J Thorac Dis 2019; 11:S1633-S1642. [PMID: 31489231 DOI: 10.21037/jtd.2019.07.88] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert A Meguid
- Division of Thoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
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Abstract
OBJECTIVE Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy. BACKGROUND The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy. METHODS The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia. RESULTS In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016). CONCLUSIONS Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.
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Wright JD, Huang Y, Melamed A, Tergas AI, St. Clair CM, Hou JY, Khoury-Collado FMD, Ananth CV, Neugut AI, Hershman DL. Potential Consequences of Minimum-Volume Standards for Hospitals Treating Women With Ovarian Cancer. Obstet Gynecol 2019; 133:1109-1119. [PMID: 31135724 PMCID: PMC6548333 DOI: 10.1097/aog.0000000000003288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the potential effects of implementing minimum hospital volume standards for ovarian cancer on survival and access to care. METHODS We used the National Cancer Database to identify hospitals treating women with ovarian cancer from 2005 to 2015. We estimated the number of patients treated by each hospital during the prior year. Multivariable models were used to estimate the ratio of observed/expected 60-day, and 1-, 2- and 5-year mortalities. The mean predicted observed/expected ratio of hospitals was plotted based on prior year volume. The number of hospitals that would be restricted if minimum-volume standards were implemented was modeled. RESULTS A total of 136,196 patients treated at 1,321 hospitals were identified. Increasing hospital volume was associated with decreased 60-day (P=.004), 1-year (P<.001), 2-year (P<.001) and 5-year (P=.008) mortality. In 2015, using a minimum-volume cutpoint of one case in the prior year would eliminate 144 (13.6%) hospitals (treated 2.6% of all patients); a cutpoint of three would eliminate 364 (34.5%) hospitals (treated 7.7% of the patients). The mean observed/expected ratios for hospitals with a prior year volume of 1 was 1.14 for 60-day mortality, 1.06 for 1-year mortality, 1.12 for 2-year mortality, and 1.08 for 5-year mortality. Among hospitals with a prior year volume of one, 49.2% had an observed/expected ratio for 2-year mortality of at least 1 (indicating worse than expected performance), and 50.8% had an observed/expected ratio of less than 1 (indicating better than expected performance). The mean observed/expected ratios for hospitals with a prior year volume of two or less were 1.11 for 60-day mortality, 1.09 for 1-year mortality, 1.08 for 2-year mortality, and 1.07 for 5-year mortality. Implementing a minimum-volume standard of one case in the prior year would result in one fewer death for every 198 patients at 60 days, for every 613 patients at 1 year, and for every 62 patients at 5 years. CONCLUSION Implementation of minimum hospital volume standards could restrict care at a significant number of hospitals, including many centers with better-than-predicted outcomes.
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Affiliation(s)
- Jason D. Wright
- Columbia University College of Physicians and Surgeons
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons
| | | | - Ana I. Tergas
- Columbia University College of Physicians and Surgeons
- Joseph L. Mailman School of Public Health, Columbia University
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - Caryn M. St. Clair
- Columbia University College of Physicians and Surgeons
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - June Y. Hou
- Columbia University College of Physicians and Surgeons
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - Fady MD Khoury-Collado
- Columbia University College of Physicians and Surgeons
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - Cande V. Ananth
- Joseph L. Mailman School of Public Health, Columbia University
- Rutgers Robert Wood Johnson Medical School
- Environmental and Occupational Health Sciences Institute (EOHSI)
| | - Alfred I. Neugut
- Columbia University College of Physicians and Surgeons
- Joseph L. Mailman School of Public Health, Columbia University
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
| | - Dawn L. Hershman
- Columbia University College of Physicians and Surgeons
- Joseph L. Mailman School of Public Health, Columbia University
- Herbert Irving Comprehensive Cancer Center
- New York Presbyterian Hospital
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Matthews KA, Gaglioti AH, Holt JB, Wheaton AG, Croft JB. Using spatially adaptive floating catchments to measure the geographic availability of a health care service: Pulmonary rehabilitation in the southeastern United States. Health Place 2019; 56:165-173. [PMID: 30776768 PMCID: PMC6452632 DOI: 10.1016/j.healthplace.2019.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/15/2019] [Accepted: 01/28/2019] [Indexed: 11/15/2022]
Abstract
A spatially adaptive floating catchment is a circular area that expands outward from a provider location until the estimated demand for services in the nearest population locations exceeds the observed number of health care services performed at the provider location. This new way of creating floating catchments was developed to address the change of spatial support problem (COSP) by upscaling the availability of the service observed at a provider location to the county-level so that its geographic association with utilization could be measured using the same spatial support. Medicare Fee-for-Service claims data were used to identify beneficiaries aged ≥ 65 years who received outpatient pulmonary rehabilitation (PR) in the Southeastern United States in 2014 (n = 8798), the number of PR treatments these beneficiaries received (n = 132,508), and the PR providers they chose (n = 426). The positive correlation between PR availability and utilization was relatively low, but statistically significant (r = 0.619, p < 0.001) indicating that most people use the nearest available PR services, but some travel long distances. SAFCs can be created using data from health care systems that collect claim-level utilization data that identifies the locations of providers chosen by beneficiaries of a specific health care procedure.
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Affiliation(s)
- Kevin A Matthews
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, United States.
| | - Anne H Gaglioti
- National Center for Primary Care and Department of Family Medicine, Morehouse School of Medicine, United States
| | - James B Holt
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, United States
| | - Anne G Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, United States
| | - Janet B Croft
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, United States
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Abstract
This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.
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Affiliation(s)
- Stephanie Lumpkin
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA.
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Gabriel E, Narayanan S, Attwood K, Hochwald S, Kukar M, Nurkin S. Disparities in major surgery for esophagogastric cancer among hospitals by case volume. J Gastrointest Oncol 2018; 9:503-516. [PMID: 29998016 DOI: 10.21037/jgo.2018.01.18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of this study was to characterize disparities among centers performing major surgery for esophageal or gastric cancer stratified by case volume. Methods The National Cancer Data Base (NCDB) was queried for cases of esophagectomy or total gastrectomy. Centers were compared based on number of cases during 2004-2013: low volume [1-99], middle [100-200], and high [>200]. Results For esophagectomy, 17,547 patients were included; 73.5% were treated in low volume centers, 14.6% in middle, and 11.9% in high. For gastrectomy, 20,059 patients were included, with 87.5%, 8.3%, and 4.3%, respectively. Patients treated at low volume centers were more likely to be of racial/ethnic minorities, uninsured, and have lower socioeconomic status. Overall survival (OS) was superior for patients treated at high volume centers. On multivariable analysis for either procedure, a higher number of disparate factors was identified in the low and middle volume centers compared to the high volume centers, which were associated with poorer OS. Conclusions This study identified higher numbers of disparate patient factors associated with low/middle volume centers compared to high volume centers, which were associated with worse OS, and further makes the case for performance of esophagectomy and total gastrectomy at high volume centers.
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Affiliation(s)
- Emmanuel Gabriel
- Department of Surgery, Section on Surgical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Sumana Narayanan
- Department of Surgical Oncology, Roswell Park Cancer Institute Buffalo, Buffalo, NY, USA
| | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Cancer Institute Buffalo, Buffalo, NY, USA
| | - Steven Hochwald
- Department of Surgical Oncology, Roswell Park Cancer Institute Buffalo, Buffalo, NY, USA
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Cancer Institute Buffalo, Buffalo, NY, USA
| | - Steven Nurkin
- Department of Surgical Oncology, Roswell Park Cancer Institute Buffalo, Buffalo, NY, USA
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Warshaw AL. Appropriate Surgical Care: Who Decides?: The I. Ridgeway Trimble Lecture. Ann Surg 2018; 267:S52-S54. [PMID: 28885507 DOI: 10.1097/sla.0000000000002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew L Warshaw
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
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Are patients willing to travel for better ovarian cancer care? Gynecol Oncol 2018; 148:42-48. [DOI: 10.1016/j.ygyno.2017.10.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/10/2017] [Accepted: 10/14/2017] [Indexed: 11/22/2022]
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Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes. Dis Colon Rectum 2017; 60:1250-1259. [PMID: 29112560 DOI: 10.1097/dcr.0000000000000924] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection. OBJECTIVE The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers. DESIGN This was a population-based study. SETTINGS The National Cancer Database was queried for patients with rectal cancer. PATIENTS Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included. MAIN OUTCOME MEASURES The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival. RESULTS A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group. LIMITATIONS We lacked data regarding patient and physician decision making and surgeon-specific factors. CONCLUSIONS Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at http://links.lww.com/DCR/A446.
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