Regionalization for health improvement: A systematic review

The Effect on Travel Distance of a Statewide Regionalization Policy for Initial Breast Cancer Surgery

PURPOSE

Reimbursement strategies to regionalize care can be effective for improving patient outcomes but may adversely affect access to care. We sought to determine the effect on travel distance for surgical treatment of a 2009 New York State (NYS) policy restricting Medicaid reimbursement for breast cancer surgery at low-volume hospitals.

PATIENTS AND METHODS

From a linked data set merging the NYS tumor registry with hospital discharge data, we identified women younger than 65 years with stage I-III first breast tumors from pre- and post-policy periods. We classified patients by urbanicity of their residence into four geographic areas (New York City, other large urban core, suburban/large town, and small town/rural). A multivariable difference-in-difference-in-differences model was used to estimate the policy effect on the distance traveled by Medicaid and non-Medicaid insured patients before and after the policy, by area of residence.

RESULTS

Among the 46,029 study sample, 13.5% were covered by Medicaid. Regardless of insurance, women treated more recently traveled longer distances to their surgical facility than those in the prepolicy period. Regardless of time period, Medicaid beneficiaries drove fewer miles to treatment than women with other insurance. Although all women traveled greater distances postpolicy, the increase was not significantly different by insurance status (Medicaid or not), except for those living in suburban areas in which Medicaid patients traveled further postpolicy (+7.7 miles compared with +3.4 miles for non-Medicaid; P = .007).

CONCLUSION

After a policy regionalizing surgical care, only suburban Medicaid patients experienced a statistically significant (albeit small) increase in travel distance compared with non-Medicaid patients. In the state of NY, regionalization of breast cancer care yielded improved outcomes with minimal decrease in access.

Using the Stratum-Specific Likelihood Ratio Method to Derive Outcome-Based Hospital Volume Categories for Total Knee Replacement

BACKGROUND

Evidence of higher hospital volume being associated with improved outcomes for patients undergoing total knee replacement (TKR) is mostly based on arbitrary distribution-based thresholds.

OBJECTIVE

We aimed to define outcome-based volume thresholds using data from a national database.

METHODS

We used the MedPAR Limited Data Set inpatient data from 2010-2015 to identify patients who had undergone primary TKR. Surgical and TKR specific complications occurring within the index hospitalization and all-cause readmission within 90 days were considered adverse events. We derived an average annual TKR case volume for each hospital and applied the stratum-specific likelihood ratio method to determine volume categories indicative of a similar likelihood of 90-day post-operative complications. Hierarchical multivariable logistic regression with a random intercept for hospital nested within study year and adjusted for patient and hospital characteristics was performed to determine if these volume thresholds were still associated with the odds of 90-day readmission for complications after adjustment.

RESULTS

SSLR analysis yielded 4 hospital volume categories based on the likelihood of 90-day postoperative complications: 1-31 (low), 32-127 (medium), 128-248 (high), and 429+ (very high) TKRs performed per year. The results of the hierarchical multivariable logistic regression showed significantly increased odds of 90-day complications at lower volume categories. Sensitivity analyses confirmed our main findings.

CONCLUSIONS

This study is the first to provide national-level volume categories that are evidence-based. Publicizing these thresholds may enhance quality measures available to patients, providers, and payors.

Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State

BACKGROUND

The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions.

METHODS

A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients.

RESULTS

During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization).

DISCUSSION

Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Characterizing Regionalization of Inflammatory Bowel Disease Hospitalizations and Operations in Washington State

BACKGROUND

Hospitalizations for inflammatory bowel disease (IBD) are a major contributor of healthcare utilization. We assessed IBD hospitalizations and surgical operations in Washington State to characterize regionalization patterns.

METHODS

We identified a cohort of hospitalizations for Crohn's disease (CD) or ulcerative colitis (UC) from 2008 to 2019 using Washington State's Comprehensive Hospital Abstract Reporting System (CHARS). Hospitalizations were characterized by emergent or elective acuity and whether an operation or endoscopic procedure was performed. Facility volume and distance travelled by patients were used to determine regionalization.

RESULTS

There were 20,494 IBD-related hospitalizations at 95 hospitals: 13,585 (66.3%) with CD and 6,909 (33.7%) with UC. Emergencies accounted for 78.2% of all IBD-related hospitalizations and did not differ between CD (78.3%) and UC (77.9%) (p = 0.54). Surgery was performed during 10.3% and endoscopy during 30.6% of emergent hospitalizations. 72.0% of emergent hospitalizations occurred at 22 facilities, while 71.1% of elective hospitalizations were concentrated at 9 facilities. Operations were performed during 78.5% of elective hospitalizations, and five hospitals performed 69% of all elective surgery. Laparoscopic surgery increased in both emergent (17% to 52%, p < 0.001) and elective operations (18% to 42%, p < 0.001) from 2008 to 2019.

CONCLUSIONS

In Washington State, most IBD hospitalizations were emergent, which were decentralized and typically non-operative. By contrast, most elective admissions involved surgery and were centralized at a few high-volume centers. Further understanding the drivers behind IBD hospitalizations may help optimize emergent medical and elective surgical care at a state level.

A Fuzzy BWM-TOPSIS Framework for Identifying and Prioritizing Measures to Overcome Obstacles to the Regionalization of Iranian Healthcare Services

Background

One of the most effective strategies to improve the access of community members to health services is to regionalize health services. The purpose of this study is to examine and prioritize measures that could help to counteract obstacles and problems in implementing the regionalization of healthcare in Iran.

Methods

The study relied on a mixed research method, including qualitative and quantitative phases. First, by conducting semi-structured interviews and analyzing them through qualitative content analysis, the obstacles and measures were identified. In the quantitative phase, the obstacles identified were weighted using the fuzzy best-worst method (FBWM), and the measures were then prioritized through the fuzzy TOPSIS (FTOPSIS) method.

Results

The obstacles were categorized into four main dimensions: "infrastructural," "political," "human resources," and "managerial." Among the 15 obstacles identified, "absence of performance guarantees" was the most important obstacle, while "insufficient education" was the least important obstacle to the regionalization of healthcare services in Iran. Meanwhile, the following eight measures that could help to overcome the obstacles were extracted from the interviews: "conducting a needs assessment," "providing clinical guidelines," "employing specialized human resources," "reinforcing the referral system," and "preparing electronic health records," "enhancing education and information dissimilation," "building executive support," and "providing cost-effective equipment and technology." "Employing specialized human resources" was also the most effective measure to overcome the obstacles.

Conclusions

Iranian healthcare policy-makers can use the empirical findings of this investigation to accelerate the implementation of Iran's regionalization plan to improve the access of community members to healthcare services.

Is there a relationship between surgical volume and outcome for total elbow arthroplasty? A systematic review

Purpose

Total elbow arthroplasty (TEA) is rarely performed compared to other arthroplasties. For many surgical procedures, literature shows better outcomes when they are performed by experienced surgeons and in so-called 'high-volume' hospitals. We systematically reviewed the literature on the relationship between surgical volume and outcomes following TEA.

Methods

A literature search was performed using the MEDLINE, EMBASE and CINAHL databases. The literature was systematically reviewed for original studies comparing TEA outcomes among hospitals or surgeons with different annual or career volumes. For each study, data were collected on study design, indications for TEA, number of included patients, implant types, cut-off values for volume, number and types of complications, revision rate and functional outcome measures. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale.

Results

Two studies, which included a combined 2301 TEAs, found that higher surgeon volumes were associated with lower revision rates. The examined complication rates did not differ between high- and low-volume surgeons. In one study, low-hospital volume is associated with an increased risk of revision compared to high-volume hospitals, but for other complication types, no difference was found.

Conclusions

Based on the results, the evidence suggests that high-volume centers have a lower revision rate in the long term. No minimum amount of procedures per year can be advised, as the included studies have different cut-off values between groups. As higher surgeon- and center-volume, (therefore presumably experience) appear to yield better outcomes, centralization of total elbow arthroplasty should be encouraged.

Cardiac arrest centres: what, who, when, and where?

PURPOSE OF REVIEW

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions.

RECENT FINDINGS

CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer.

SUMMARY

Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Association between hospital treatment volume and major complications in ovarian hyperstimulation syndrome

OBJECTIVE

An inverse relationship between hospital volume and adverse patient outcomes has been established for many conditions, but has not yet been examined in ovarian hyperstimulation syndrome (OHSS). Given the rarity of severe OHSS, but potential for high morbidity, this study aimed to elucidate the effect of hospital volume on inpatient OHSS-related complications.

METHODS

This is a retrospective observational study querying the National Inpatient Sample, 1/2001-12/2011. Study population was 11,878 patients with OHSS treated at 735 hospitals. Annualized hospital OHSS treatment volume was grouped as: low-volume (1 case/year), mid-volume (>1 but < 3.5 cases/year), and high-volume (≥3.5 cases/year). Main outcome measure was major complication rates stratified by hospital treatment volume, assessed by multinomial regression and binary logistic regression models.

RESULTS

A total of 2,415 (20.3%) patients were treated at low-volume centers, 5,023 (42.3%) at mid-volume centers, and 4,440 (37.4%) at high-volume centers. Patients treated at high-volume centers were more likely to be older and less comorbid with higher incomes and lower body mass index (P < 0.05). High-volume hospitals were more likely to be urban-teaching centers with large bed capacity (P < 0.001). Overall, 1,624 (13.7%) patients experienced a major complication during hospitalization. Patients treated at high-volume hospitals had lower rates of major complications (high: 11.0%, mid: 15.2%, low: 15.6%, P < 0.001). On multivariable analysis, treatment at high-volume hospitals was independently associated with a nearly 20% lower rate of major complications (odds ratio 0.82, 95% confidence interval 0.70-0.97, P = 0.021).

CONCLUSION

Our study suggests that higher hospital treatment volume for OHSS may be associated with improved outcomes.

Optimizing the delivery of genetic and advanced diagnostic testing in the province of Ontario: challenges and implications for laboratory technology assessment and management in decentralized healthcare systems

AIMS

The Canadian province of Ontario provides full coverage for its residents (pop.14.8 M) for hospital-based diagnostic testing. Historical governance of the healthcare system and a legacy scheme of health technology assessment (HTA) and financing has led to a suboptimal approach of adopting advanced diagnostic technology (i.e. protein expression, cytogenetic, and molecular/genetic) for guiding therapeutic decisions. The aim of this research is to explore systemic barriers and provide guidance to improve patient and care provider experiences by reducing delays and inequity of access to testing, while benefitting laboratory innovators and maximizing system efficiency.

MATERIALS AND METHODS

A mixed-methods approach including literature review, semi-structured interviews, and a multi-stakeholder forum involving patient representatives (n = 1), laboratory leaders (n = 6), physicians (n = 5), Ministry personnel (n = 4), administrators (n = 3), extra-provincial experts, and researchers (n = 7), as well as pharmaceutical (n = 5) and diagnostic companies (n = 2). The forum considered evidence of good practices in adoption, implementation, and financing laboratory services and identified barriers as well as feasible options for improving advanced diagnostic testing in Ontario.

RESULTS

Overarching challenges identified included: barriers to define what is needed; need for a clear approach to adoption; and the need for more oversight and coordination. Recommendations to address these included a shift to an anticipatory system of test adoption, creating a fit-for-purpose system of health technology management that consolidates existing evaluation processes, and modernizing the governance and financing of testing so that it is managed at a care-delivery level.

CONCLUSIONS

The proposals for change in Ontario highlight the role that HTA, governance, and financing of health technology play along the continuum of a health technology life cycle within a healthcare system where decision-making is highly decentralized. Resource availability and capacity were not a concern - instead, solutions require higher levels of coordination and system integration along with innovative approaches to HTA.

Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect?

INTRODUCTION

The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques.

MATERIAL AND METHODS

A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012.

RESULTS

The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year.

CONCLUSIONS

The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.