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Original Contribution
November 26, 2003

Regionalization of High-Risk Surgery and Implications for Patient Travel Times

Author Affiliations

Author Affiliations: Departments of Surgery (Dr Birkmeyer) and Pediatrics (Dr Goodman), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH (Drs Birkmeyer and Goodman and Ms Marth); and Center for Outcomes Research and Evaluation, Maine Medical Center, Portland (Ms Siewers).

JAMA. 2003;290(20):2703-2708. doi:10.1001/jama.290.20.2703

Context Given the strong volume-outcome relationships observed with many surgical procedures, restricting some procedures to hospitals exceeding a minimum volume standard is advocated. However, such regionalization policies might cause unreasonable travel burdens for surgical patients.

Objective To estimate how minimum volume standards for esophagectomy and pancreatic resection would affect how long patients must travel for these procedures.

Design, Setting, and Patients Simulated trial based on Medicare claims and US road network data. All US hospitals in the 48 continental states were in the study if their surgical procedures included esophagectomy and pancreatic resection. Data from Medicare patients (N = 15 796) undergoing these 2 procedures for cancer between 1994 and 1999 were used.

Main Outcome Measure Additional travel time for patients required to change to higher-volume centers as a result of alternative hospital volume standards (procedures per year).

Results With low-volume standards (1/year for pancreatectomy; 2/year for esophagectomy), approximately 15% of patients would change to higher-volume centers, with negligible effect on their travel times. Most patients would need to travel less than 30 additional minutes (74% pancreatectomy; 76% esophagectomy). Many patients already lived closer to a higher-volume hospital (25% pancreatectomy; 26% esophagectomy). Conversely, with very high-volume standards (>16/year for pancreatectomy; >19/year for esophagectomy), approximately 80% of patients would change to higher-volume centers. More than 50% of these patients would increase their travel time by more than 60 minutes. Travel times would increase most for patients living in rural areas.

Conclusions Many patients travel past a higher-volume center to undergo surgery at a low-volume hospital. If not set too high, hospital volume standards could be implemented for selected operations without imposing unreasonable travel burdens on patients.