Hawkins Robert B, Byler Matthew, Fonner Clifford, Kron Irving L, Yarboro Leora T, Speir Alan M, Quader Mohammed A, Ailawadi Gorav, Mehaffey J Hunter
Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
Virginia Cardiac Surgery Quality Initiative, Falls Church, Virginia.
J Card Surg. 2019 Oct;34(10):1044-1048. doi: 10.1111/jocs.14199. Epub 2019 Aug 2.
Evidence in other surgical subspecialties suggests patients traveling farther to undergo surgery have worse outcomes. We sought to determine the impact of travel distance and travel beyond closest center on outcomes after valve surgery.
Patients who underwent valve surgery ±CABG with a Society of Thoracic Surgeons (STS) predicted risk and zip code were extracted from a statewide STS database (2011-016). Patients were stratified by those receiving care greater than or equal to 20 miles from the closest surgical center (Traveler) or at the closest center (Non-Traveler). Multivariate logistic regression assessed the effects of travel distance and traveler status on mortality and major morbidity adjusted for STS predicted risk, median income by zip code, and payer status.
Median travel distance for all patients (n = 4765) was 19 miles and after risk-adjustment increasing distance was associated with reduced operative mortality (odds ratio [OR], 0.94 [0.89-1.00], P = .049) with no impact on major morbidity. Travelers (445 patients, 9.3%) had lower median income, higher self-pay and reoperative status, but similar urgent/emergent status and STS risk as Non-Travelers. Travelers had lower operative mortality (1.6% vs 4.3%, P = .005) which remained statistically lower after risk-adjustment (OR, 0.32 [0.14-0.75], P = .009). This mortality difference was particularly pronounced in patients with postoperative complications (3.1% vs 7.9%, P = .005).
Contrary to other surgical subspecialties, farther travel distance and bypassing the nearest surgical center were associated with lower rates of operative mortality and failure to rescue. Either referral patterns or financials reasons may result in Travelers ending up at high performing centers that prevent escalation of complications.
其他外科亚专业的证据表明，前往更远的地方接受手术的患者预后较差。我们试图确定瓣膜手术后旅行距离和前往距离最近中心以外的地方旅行对预后的影响。
从全州范围的胸外科医师协会（STS）数据库（2011 - 2016年）中提取接受瓣膜手术±冠状动脉旁路移植术（CABG）且有STS预测风险和邮政编码的患者。患者按距离最近手术中心大于或等于20英里接受治疗的患者（旅行者）或在最近中心接受治疗的患者（非旅行者）进行分层。多因素逻辑回归评估旅行距离和旅行者状态对死亡率和主要并发症的影响，并对STS预测风险、邮政编码中位数收入和付款人状态进行调整。
所有患者（n = 4765）的中位旅行距离为19英里，风险调整后，距离增加与手术死亡率降低相关（比值比[OR]，0.94[0.89 - 1.00]，P = 0.049），对主要并发症无影响。旅行者（445例患者，9.3%）的中位数收入较低，自费和再次手术比例较高，但与非旅行者的紧急/急诊状态和STS风险相似。旅行者的手术死亡率较低（1.6%对4.3%，P = 0.005），风险调整后仍在统计学上较低（OR，0.32[0.14 - 0.75]，P = 0.009）。这种死亡率差异在术后并发症患者中尤为明显（3.1%对7.9%，P = 0.005）。
与其他外科亚专业相反，更远的旅行距离和绕过最近的手术中心与较低的手术死亡率和未能挽救成功率相关。转诊模式或财务原因可能导致旅行者最终在高绩效中心接受治疗，从而防止并发症升级。
