Travel Patterns among Patients Undergoing Hepatic Resection in California: Does Driving Further for Care Improve Outcomes?

backgroundBetter outcomes at high-volume surgical centers have driven regionalization of complex surgical care. In turn, access to high-volume centers often requires travel over longer distances. We sought to characterize travel patterns among patients who underwent a hepatectomy.

methodsThe California Office of Statewide Health Planning database was used to identify patients who underwent hepatectomy between 2005 and 2016. Total distance traveled and whether a patient bypassed the nearest hospital that performed hepatectomy to get to a higher-volume center were assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center.

resultsOverall, 13,379 adults underwent a hepatectomy in 229 hospitals; only 26 hospitals were high volume (> 15 cases/year). Median travel time to a hospital that performed hepatectomy was 25.2 min (IQR: 13.1-52.0). The overwhelming majority of patients (91.6%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, 75.5% went to a high-volume hospital. Outcomes at destination hospitals were improved compared with nearest hospitals (incidence of complications: 20.4% vs. 22.9% %; failure-to-rescue: 7.1% vs 10.9%; mortality 1.5% vs. 2.6%). Medicaid beneficiaries (OR 0.69, 95%CI 0.56-0.85) were less likely to bypass the nearest hospital to go to a high-volume hospital; additionally, Medicaid patients were less likely to undergo hepatectomy at a high-volume hospital independent of bypassing the nearest hospital (OR 0.60, 95%CI 0.48-0.76). Among the 3703 patients who underwent hepatectomy at a low-volume center, 2126 patients had actually bypassed a high-volume hospital. Among the remaining 1577 patients, 95% of individuals would have needed to travel less than 1 additional hour to reach a high-volume center.

conclusionRoughly, one-quarter of patients undergoing hepatectomy received care at a low-volume center; nearly all of these patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center. Travel distance needs to be considered in policies and healthcare delivery design to improve care of patients undergoing hepatic resection.