Why Do Long-Distance Travelers Have Improved Pancreatectomy Outcomes?

Abstract

BACKGROUND Centralization of complex surgical care has led patients to travel longer distances. Emerging evidence suggested a negative association between increased travel distance and mortality after pancreatectomy. However, the reason for this association remains largely unknown. We sought to unravel the relationships among travel distance, receiving pancreatectomy at high-volume hospitals, delayed surgery, and operative outcomes. STUDY DESIGN We identified 44,476 patients who underwent pancreatectomy for neoplasms between 2004 and 2013 at the reporting facility from the National Cancer Database. Multivariable analyses were performed to examine the independent relationships between increments in travel distance mortality (30-day and long-term survival) after adjusting for patient demographics, comorbidity, cancer stage, and time trend. We then examined how additional adjustment of procedure volume affected this relationship overall and among rural patients. RESULTS Median travel distance to undergo pancreatectomy increased from 16.5 to 18.7 miles (p for trend < 0.001). Although longer travel distance was associated with delayed pancreatectomy, it was also related to higher odds of receiving pancreatectomy at a high-volume hospital and lower postoperative mortality. In multivariable analysis, difference in mortality among patients with varying travel distance was attenuated by adjustment for procedure volume. However, longest travel distance was still associated with a 77% lower 30-day mortality rate than shortest travel among rural patients, even when accounting for procedure volume. CONCLUSIONS Our large national study found that the beneficial effect of longer travel distance on mortality after pancreatectomy is mainly attributable to increase in procedure volume. However, it can have additional benefits on rural patients that are not explained by volume. Distance can represent a surrogate for rural populations.

Racial and Ethnic Disparities in Travel for Head and Neck Cancer Treatment and the Impact of Travel Distance on Survival

“…The association between travel distance and survival has been examined for other cancer sites and the current study findings are consistent with these prior studies . The survival benefit observed from increasing travel distance is partially a consequence of the regionalization of care to high‐volume centers with resultant improvements in oncologic outcomes, because patients in the current study who traveled a long distance for treatment were found to be significantly more likely to be treated at high‐volume and academic centers. In HNSCC, as in other malignancies, there is evidence to support a relationship between higher patient volumes and improved outcomes.…”

“…To the best of our knowledge, the reasons that African American and Hispanic patients are less likely to travel long distances for the treatment of HNSCC compared with white and non-Hispanic patients are not known but are likely multifactorial in nature. Racial and ethnic disparities in travel for cancer treatment have been documented for patients with non-HNSCC 12,22 ; the results of the current study add to the growing literature. Lack of insurance, lack of access to an automobile or someone to drive patients to treatment, and financial toxicity as well as cultural beliefs regarding health care have been shown to contribute toward racial and ethnic differences in travel patterns.…”

“…Treatment modality was categorized as surgery, surgery plus adjuvant therapy (radiotherapy [RT] or chemoradiation [CRT]), primary RT, and primary CRT. Hospital‐level covariates included treatment facility type and annual facility volume, which was grouped in quartiles (1‐9, >9 to 17, >17 to 43, and >43 cases/year) . Other categorical variables were grouped as previously described …”

“…Prior work has demonstrated the existence of racial disparities in travel for cancer care, 10,13 especially for travel to high-volume facilities. 12,14 The increasing travel requirements that have occurred contemporaneously with the progressive regionalization of cancer care may be creating another barrier to equitable, quality cancer care and contributing toward worsening racial and ethnic disparities in cancer outcomes. 14 However, to our knowledge, the prevalence of long travel distances for treatment by patients with HNSCC has not been described and the question of whether racial disparities in patterns of travel for HNSCC exist has not been investigated to date.…”

Accessing surgical care for pancreaticoduodenectomy: Patient variation in travel distance and choice to bypass hospitals to reach higher volume centers

“…Of note, other investigators have similarly noted that some patients may have a tendency to travel beyond high‐volume centers in favor of seeking surgery at low‐volume hospitals, despite a higher chance of surgery‐related mortality at these centers . Patients willingness to travel for higher level of care can improve both short‐ and long‐term outcomes, especially for patients with complex diseases such as liver and pancreatic cancer . The decision to where to have ones complex oncologic operation is certainly a complex one.…”