Centralization of cancer surgery: implications for patient access to optimal care

Abstract

Purpose: The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly centralized and that this centralization has resulted in increased travel burden for patients.

Patients and methods: Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled.

Results: Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization.

Conclusion: There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.

Fig 1.

Procedure volume over time. (A) Median procedure volume. Values should be interpreted as volume for the 50th percentile of all cases. For example, in 1996, half of all resections for esophageal cancer were performed at a hospital that did ≤ 5 such procedures that year. In contrast, in 2006, half of all esophageal cancer resections were performed at a hospital that did ≥ 26 resections. (B) Distribution of procedures among volume categories based on 1996 quintile cut points.

Fig 2.

Number of available high- or very high–volume hospitals. Total number of hospitals meeting 1996 quintile cut points for high- or very high–volume hospitals.

Fig 3.

Travel distance over time. Median straight-line distance from patient zip code to treating facility in miles.

Fig 4.

Difference between actual distances traveled and distances to nearest high volume hospital. Comparison of actual distances traveled to reach treating facility and distances to nearest high or very high volume hospital in 2006 for patients from NJ, NY, and PA who underwent surgery at a low or very low volume hospital in the study area. Dashed line represents median. Box represents interquartile (IQ) range. Outliers (values > 75th percentile + 1.5 × IQ range) were omitted from the graphic for ease of interpretation.