Access to Quaternary Care Surgery: Implications for Accountable Care Organizations

Abstract

Background Accountable Care Organizations (ACO) attempt to provide the most efficient and effective care to patients within a region. We hypothesize that patients who undergo surgery closer to home have improved survival due to proximity of preoperative and post-discharge care. Study Design All (17,582) institutional American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients with a documented zip code and predicted risk who underwent surgery at our institution (2005–2014) were evaluated. Travel times were calculated by Google Maps, and patients were stratified by 1 hour of travel (local vs regional). Multivariable logistic regression and Cox Proportional Hazard models were used to evaluate the NSQIP risk-adjusted effects of travel time on operative morbidity, mortality, and long-term survival. Results Median travel time was 65 minutes with regional patients demonstrating significantly higher rates of ascites, hypertension, diabetes, disseminated cancer, >10% weight-loss, higher ASA, higher predicted risk of morbidity and mortality and lower functional status (all p<0.01). After adjusting for ACS NSQIP predicted risk, travel time was not significantly associated with 30-day mortality (OR 1.06, p=0.42) or any major morbidities (all p>0.05). However, survival analysis demonstrated travel time is an independent predictor of long-term mortality (OR 1.24, p<0.001) Conclusions Patients traveling farther for care at a quaternary center had higher rates of comorbidities and predicted risk of complications. Additionally, travel time predicts risk-adjusted long-term mortality, suggesting a major focus of ACOs will need to be integration of care at the periphery of their region.

Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis

“…However, community level factors are critical to understand when assessing the impact of SES on clinical outcomes 11 12. Community level factors include availability of in home health support, access to primary care, as well as travel distance to higher level or complex care 13 14. Currently there is no composite measure of community level SES to identify regions at highest risk for postoperative complications related to community level socioeconomic distress.…”

A model for geographic and sociodemographic access to care disparities for adults with congenital heart disease

“…When resources are limited—in this case, access to comprehensive ACHD care centers—disparities, often compounding each other, are bound to exist. We know that chronic disease patients and postoperative patients have better outcomes when they live closer to care, just as we know that receiving care at an ACHD center decreases mortality . In Europe, it is estimated that only 7.1% of ACHD patients receive care at ACHD centers; it is not known if the United States does any better …”

“…We know that chronic disease patients and postoperative patients have better outcomes when they live closer to care, just as we know that receiving care at an ACHD center decreases mortality. [14][15][16][17]29 In Europe, it is estimated that only 7.1% of ACHD patients receive care at ACHD centers; it is not known if the United States does any better. 30 ACHD patients historically remained with their pediatric cardiologists who understand congenital cardiac physiology, but they lack experience with general internal medicine practices and age-related cardiovascular disease.…”

“…Increased distance to a cardiac care center has been shown to be associated with poorer survival in pediatric CHD . Similarly, longer travel time to care correlates with poorer disease control in cystic fibrosis as well as increased morbidity and long‐term mortality in adult surgery patients . However, improvement in timely follow‐up has been shown after enrollment in programs that help eliminate transportation and cost barriers to care for socioeconomically disadvantaged adolescents with diabetes …”

“…15 Similarly, longer travel time to care correlates with poorer disease control in cystic fibrosis as well as increased morbidity and long-term mortality in adult surgery patients. 14,16,17 However, improvement in timely follow-up has been shown after enrollment in programs that help eliminate transportation and cost barriers to care for socioeconomically disadvantaged adolescents with diabetes. 18 This study was designed to contribute to the body of work on specific challenges in access to ACHD care.…”