Margaret E Smith1,2, Ushapoorna Nuliyalu3, Justin B Dimick4,3, Hari Nathan4,3. 1. Department of Surgery, University of Michigan, Ann Arbor, MI, USA. smargare@med.umich.edu. 2. Center for Healthcare Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Building 16, 016-122W, Ann Arbor, MI, 48105, USA. smargare@med.umich.edu. 3. Center for Healthcare Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Building 16, 016-122W, Ann Arbor, MI, 48105, USA. 4. Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
Abstract
BACKGROUND: Referring patients to high-quality hospitals for complex procedures may improve outcomes. This is most feasible within small geographic areas. However, access to specialized surgical procedures may be an implementation barrier. We sought to determine the availability of high-quality hospitals performing pancreatectomy and the potential benefit and travel burden of referral within small geographic areas. METHODS: We identified elderly Medicare beneficiaries undergoing pancreatectomy between 2012 and 2014. Hospitals were stratified into quintiles of quality based on postoperative complication rates. Patient risk was assessed by modeling the predicted risk of developing a postoperative complication. The geographic unit of analysis was Metropolitan Statistical Area (MSA). Hospitals were categorized into MSA by zip code. Travel distance was calculated using patient and hospital zip code. RESULTS: Among high-risk patients, 40.7% received care at the lowest-quality hospitals even though 80% had a high-quality hospital in the same MSA. Shifting these patients from low- to high-quality hospitals would decrease serious complications from 46.6 to 21.9% (P < 0.001) and mortality from 10.9 to 8.9% (P = 0.047). Three quarters of high-risk patients treated at low-quality hospitals could reach a high-quality hospital by extending their travel < 5 miles, and nearly 60% traveled farther to a low-quality hospital than was necessary to reach a high-quality hospital. CONCLUSIONS: High-risk pancreatectomy patients often receive care at low-quality hospitals despite the availability of high-quality hospitals in the area or within an acceptable distance. Referral of high-risk patients to high-quality hospitals within small geographic areas may be an effective strategy to improve outcomes following pancreatic surgery.
BACKGROUND: Referring patients to high-quality hospitals for complex procedures may improve outcomes. This is most feasible within small geographic areas. However, access to specialized surgical procedures may be an implementation barrier. We sought to determine the availability of high-quality hospitals performing pancreatectomy and the potential benefit and travel burden of referral within small geographic areas. METHODS: We identified elderly Medicare beneficiaries undergoing pancreatectomy between 2012 and 2014. Hospitals were stratified into quintiles of quality based on postoperative complication rates. Patient risk was assessed by modeling the predicted risk of developing a postoperative complication. The geographic unit of analysis was Metropolitan Statistical Area (MSA). Hospitals were categorized into MSA by zip code. Travel distance was calculated using patient and hospital zip code. RESULTS: Among high-risk patients, 40.7% received care at the lowest-quality hospitals even though 80% had a high-quality hospital in the same MSA. Shifting these patients from low- to high-quality hospitals would decrease serious complications from 46.6 to 21.9% (P < 0.001) and mortality from 10.9 to 8.9% (P = 0.047). Three quarters of high-risk patients treated at low-quality hospitals could reach a high-quality hospital by extending their travel < 5 miles, and nearly 60% traveled farther to a low-quality hospital than was necessary to reach a high-quality hospital. CONCLUSIONS: High-risk pancreatectomy patients often receive care at low-quality hospitals despite the availability of high-quality hospitals in the area or within an acceptable distance. Referral of high-risk patients to high-quality hospitals within small geographic areas may be an effective strategy to improve outcomes following pancreatic surgery.
Authors: Daniel J Gottlieb; Weiping Zhou; Yunjie Song; Kathryn Gilman Andrews; Jonathan S Skinner; Jason M Sutherland Journal: Health Aff (Millwood) Date: 2010-01-28 Impact factor: 6.301
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