Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009.

OBJECTIVES: To assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma. MATERIALS AND METHODS: Using 1996-2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥ 18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0-2 (VLVH), low: 3-4 (LVH), moderate: 5-8 (MVH), high: 9-31 (HVH), and very high: ≥ 32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups. RESULTS: A total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04-1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39-0.91]), or insured through Medicaid (OR 0.65 [CI 0.50-0.84]) or Medicare (OR 0.84 [CI 0.75-0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference -0.89 days [CI -1.12 to -0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22-0.49]). CONCLUSIONS: There has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.

Trends in regionalization of adrenalectomy to higher volume surgical centers.

PURPOSE: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are largely unknown. We determined the extent of regionalization of care for adrenal surgery and the extent to which this centralization has evolved with time. MATERIALS AND METHODS: Using 1996 to 2009 hospital discharge data from New York, New Jersey and Pennsylvania we identified all patients 18 years old or older treated with adrenalectomy. Hospital volume quintiles were created using 1996 hospital volumes. These cutoffs were then applied to subsequent years. Outcome variables were examined by hospital volume status with time using logistic regression models. RESULTS: A total of 8,381 patients underwent adrenalectomy from 1996 to 2009 with a significant 17% to 42% shift toward regionalization to very high volume hospitals, defined as 15 or greater procedures per year (p <0.001). For each successive year the odds of having surgery performed at a very low volume hospital decreased by 13% (OR 0.87, 95% CI 0.84-0.89). There were significant differences in patient age, race and payer group for very low volume hospitals, defined as less than 1 procedure per year, compared to very high volume hospitals (p <0.0001). Patients at very high volume hospitals were less likely to be 55 years old or older (OR 0.73, 95% CI 0.61-0.88), insured through Medicaid (OR 0.60, 95% CI 0.45-0.79) or uninsured (OR 0.34, 95% CI 0.17-0.70). When controlling for year treated, patients were less likely to die in the hospital if treated at a very high volume hospital (OR 0.38, 95% CI 0.19-0.75). CONCLUSIONS: These data reveal the increasing centralization of adrenalectomy to very high volume hospitals since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.

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

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.