Hospital volume has been shown to be inversely correlated with surgical mortality rates in complex surgery. Since the popularization of its concept, there has been a push towards volume-based regionalization of pancreatectomy. This past year, three major health systems have imposed minimum- volume standards that will bar hospitals and surgeons not meeting the threshold from performing complex surgery, and are pushing for other health systems to pledge to the low-volume threshold mandate. However, the impact of such a regionalization strategy on patient preferences and access to care remains unclear. Pancreatectomy has demonstrated the most pronounced association between volume and mortality rates, and represents the procedure that stands to gain the most from such a policy. However, national data demonstrates that up to 70% of patients with early stage pancreatic cancer do not receive surgical intervention, of which racial minorities, patients on Medicaid and the uninsured make up the majority of this cohort. This was hypothesized to be secondary to nihilism towards the disease and the complexity of the operation needed for hopes of long-term survival. As such, a proposed low-volume threshold mandate may cause unintended consequences by exerting more constraints on patients to receive care. Preliminary data has demonstrated that the vulnerable cohort as described above tend to travel shorter distances for pancreatectomy, and often undergo the surgery at hospitals with poorer quality. The objective of this study is to assess the potential impact of the proposed low-volume threshold mandate on access to care in patients undergoing pancreatectomy. Specifically, we will quantitatively assess the impact on distance needed to travel by patients and overall mortality rates in a setting where all patients are redirected to high-volume centers, and a simulated setting where patients with lower likelihood of travelling do not receive care. Additionally, we will perform qualitative assessment of the facilitators and constraints that patients face to receive care. When completed, this study will provide novel data highlighting the impact of volume-based regionalization on access to care. Additionally, it will bring attention to reduce current disparities in health care quality and access with respect to vulnerable populations, and inform interventions to alleviate the issue, a core goal of the National Institute of General Medical Sciences. Lastly, our study will provide stimulus for research in more appropriate measures of quality than volume, as volume may be over-simplifying a complex issue and a dangerous metric to be incentivizing hospitals on.
While volume-based regionalization of a complex procedure like pancreatectomy may improve outcomes of patients receiving the procedure, it may have a detrimental impact on access to care. This study will attempt to quantify the impact of a proposed low- volume threshold mandate on access to care, and qualitatively assess facilitators and constraints patients face to access care to inform interventions and policy decisions that can alleviate this public health burden.
| Fong, Zhi Ven; Loehrer, Andrew P; Fernández-Del Castillo, Carlos et al. (2017) Potential impact of a volume pledge on spatial access: A population-level analysis of patients undergoing pancreatectomy. Surgery 162:203-210 |
