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

Background While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. Methods The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. Results Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital. Conclusion Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.