Traveling to reach high-volume centers among patients undergoing hepatectomy: how far will you go?

Abstract

Presenter: Adrian Diaz MD, MPH | The Ohio State University 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 among patients undergoing hepatectomy 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 hepatectomy between 2005-2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed hepatectomy 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: Overall 13,379 adults underwent a hepatectomy in 229 hospitals; only 39 hospitals were considered high volume (15> cases/year). Median travel distance to a hospital that performed hepatectomy was 21 miles (IQR: 9.2-47.8) with a median travel time of 25 minutes (IQR: 13.1 – 52.0). The overwhelming majority of patients (92%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, 75% went to a high-volume hospital. Outcomes at hospitals with shorter travel distances versus destination hospitals varied (incidence of complications: 23% vs. 20%; failure-to-rescue: 11% vs. 7%; mortality 2.6% vs. 0.5%; all p<0.05). Care at a high-volume center for hepatectomy was associated with hospital bypass (OR=4.23 95%CI 3.68–4.89). Of note, African American (OR=0.55 95%CI 0.46 – 0.66) and Hispanic (OR=0.66 95%CI 0.59 – 0.74) patients, as well as individuals with Medicaid (OR=0.55 95%CI 0.47 – 0.63), were less likely to undergo care at a high-volume center or travel more than 25 minutes for care (AA: OR=0.41, 95%CI 0.35- 0.49; Hispanic: OR=0.61, 95%CI 0.55-0.68; Medicaid: OR=0.72 95%CI 0.63-0.83)(all p<0.05). Among the 3,703 patients who underwent hepatectomy at a low volume center, 2,126 (57.4%) patients had bypassed a high-volume hospital. Among the remaining 1,577 patients, 95% of these individuals would have needed to travel less than an additional hour to reach a high-volume center. Conclusion: Roughly one-quarter of patients who underwent hepatectomy received care at a low-volume center, with African-American, Hispanic, and patients on Medicaid particularly at risk. Nearly all of these patients either bypassed a high-volume hospital or would have needed to travel less than one additional hour to reach a high-volume center.