Why Do Long-Distance Travelers Have Improved Pancreatectomy Outcomes?

• Published in: Journal of the American College of Surgeons Vol. 225; no. 2; pp. 216 - 225
• Main Authors: Jindal, Manila, BS, Zheng, Chaoyi, MS, Quadri, Humair S., MD, Ihemelandu, Chukwuemeka U., MD, Hong, Young K., MD, Smith, Andrew K., BS, Dudeja, Vikas, MD, Shara, Nawar M., PhD, Johnson, Lynt B., MD, FACS, Al-Refaie, Waddah B., MD, FACS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-08-2017
• Subjects: Aged; Aged, 80 and over; Cohort Studies; Female; Health Services Accessibility - statistics & numerical data; Hospitals, High-Volume; Humans; Male; Middle Aged; Pancreatectomy - mortality; Pancreatectomy - statistics & numerical data; Pancreatic Neoplasms - surgery; Retrospective Studies; Surgery; Treatment Outcome; United States
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2017.04.003

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 behind this association remains largely unknown. We sought to unravel the relationships among travel distance, receiving pancreatectomy at high volume hospitals (HVH), 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 Data Base. 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 further adjustment of procedure volume affected this relationship overall and among rural patients. Results The median travel distance to undergo pancreatectomy increased from 16.5 to 18.7 miles (p for trend < 0.001). While longer travel distance was associated with delayed pancreatectomy, it was also related to higher odds of receiving pancreatectomy at HVH and lower post-operative 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 77% lower 30-day mortality rate than shortest travel among rural patients even when procedure volume is accounted for. Conclusions Our large national study showed that the beneficial effect of longer travel distance on mortality after pancreatectomy is mainly attributable to increase in procedure volume. However, it may have additional benefits on rural patients not explained by volume. Distance may represent a surrogate for rural populations.