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.
J Surg Oncol. 2019 Dec;120(8):1318-1326. doi: 10.1002/jso.25750. Epub 2019 Nov 7.
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.
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.
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.
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.
虽然高容量手术中心更好的结果推动了复杂手术治疗的区域化，但获得高容量中心的机会往往需要长途旅行。我们试图评估胰腺癌患者接受胰十二指肠切除术（PD）的旅行模式，以评估患者对手术治疗的意愿。
使用加利福尼亚州全州卫生规划数据库，确定 2005 年至 2016 年间接受 PD 的患者。评估总旅行距离，以及患者是否绕过进行 PD 的最近医院前往更高容量的中心。使用多变量分析确定与绕过当地医院前往更高容量中心相关的因素。
在接受 PD 的 23014 名患者中，个人平均旅行距离为 18.0 英里，到达进行 PD 的医院。绝大多数（84%）患者绕过最近的提供医院，并平均额外行驶 16.6 英里到达目的地医院。在绕过最近医院的患者中，13269 人（68.6%）是为了前往高容量的目的地医院。具体来说，最近的“绕过”和最终目的地医院的平均 PD 年手术量分别为 29.6 例和 56 例。绕过和目的地医院的结果不同（并发症发生率：39.2% vs 32.4%；抢救失败：14.5% vs 9.1%）。在高容量中心进行 PD 与死亡率降低相关（OR=0.46，95%CI：0.22-0.95）。高容量 PD（>20 例）预测医院旁路（OR=3.8，95%CI：3.3-4.4）。在接受低容量中心手术的患者中，近 20%绕过了高容量医院。此外，在没有绕过高容量医院的患者中，三分之一的人只需再额外行驶 30 英里或更少即可到达最近的高容量医院。
大多数接受 PD 的患者绕过最近的提供医院，在更高容量的医院接受治疗。虽然这些数据反映了复杂手术治疗的区域化程度增加，但仍有近 1/5 的患者在低容量中心接受 PD。
