Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma

[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]

BACKGROUND

The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement.

OBJECTIVE

The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany.

MATERIAL AND METHODS

In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis.

RESULTS

Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted.

CONCLUSION

The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

Geographic impact on access to care and survival for non-curative esophagogastric cancer: a population-based study

BACKGROUND

Among patients not undergoing curative-intent therapy for esophagogastric cancer, access to care may vary. We examined the geographic distribution of care delivery and survival and their relationship with distance to cancer centres for non-curative esophagogastric cancer, hypothesising that patients living further from cancer centres have worse outcomes.

METHODS

We conducted a population-based analysis of adults with non-curative esophagogastric cancer from 2005 to 2017 using linked administrative healthcare datasets in Ontario, Canada. Outcomes were medical oncology consultation, receipt of chemotherapy, and overall survival. Using geographic information system analysis, we mapped locations of cancer centres and outcomes across census divisions. Bivariate choropleth maps identified regional outcome discordances. Multivariable regression models assessed the relationship between distance from patient residence to the nearest cancer centre and outcomes, adjusting for demographic, clinical, and socioeconomic factors.

RESULTS

Of 10,228 patients surviving a median 5.1 months (IQR: 2.0-12.0), 68.5% had medical oncology consultation and 32.2% received chemotherapy. Certain distances (reference ≤ 10 km) were associated with lower consultation [relative risk 0.79 (95% CI 0.63-0.97) for ≥ 101 km], chemotherapy receipt [relative risk 0.67 (95% CI 0.53-0.85) for ≥ 101 km], and overall survival [hazard ratio 1.07 (95% CI 1.02-1.13) for 11-50 km, hazard ratio 1.13 (95% CI 1.04-1.23) for 51-100 km].

CONCLUSION

A third of patients did not see medical oncology and most did not receive chemotherapy. Outcomes exhibited high geographic variability. Location of residence influenced outcomes, with inferior outcomes at certain distances > 10 km from cancer centres. These findings are important for designing interventions to reduce access disparities for non-curative esophagogastric cancer care.

Impact of Geography on Care Delivery and Survival for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

BACKGROUND

Little is known about how the geographic distribution of cancer services may influence disparities in outcomes for noncurable pancreatic adenocarcinoma. We therefore examined the geographic distribution of outcomes for this disease in relation to distance to cancer centers.

METHODS

We conducted a retrospective population-based analysis of adults in Ontario, Canada, diagnosed with noncurable pancreatic adenocarcinoma from 2004 through 2017 using linked administrative healthcare datasets. The exposure was distance from place of residence to the nearest cancer center providing medical oncology assessment and systemic therapy. Outcomes were medical oncology consultation, receipt of cancer-directed therapy, and overall survival. We examined the relationship between distance and outcomes using adjusted multivariable regression models.

RESULTS

Of 15,970 patients surviving a median of 3.3 months, 65.6% consulted medical oncology and 38.5% received systemic therapy. Regions with comparable outcomes were clustered throughout Ontario. Mapping revealed regional discordances between outcomes. Increasing distance (reference, ≤10 km) was independently associated with lower likelihood of medical oncology consultation (relative risks [95% CI] for 11-50, 51-100, and ≥101 km were 0.90 [0.83-0.98], 0.78 [0.62-0.99], and 0.77 [0.55-1.08], respectively) and worse survival (hazard ratios [95% CI] for 11-50, 51-100, and ≥101 km were 1.08 [1.04-1.12], 1.17 [1.10-1.25], and 1.10 [1.02-1.18], respectively), but not with likelihood of receiving therapy. Receipt of therapy seems less sensitive to distance, suggesting that distance limits entry into the cancer care system via oncology consultation. Regional outcome discordances suggest inefficiencies within and protective factors outside of the cancer care system.

CONCLUSIONS

These findings provide a basis for clinicians to optimize their practices for patients with noncurable pancreatic adenocarcinoma, for future studies investigating geographic barriers to care, and for regional interventions to improve access.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time–related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients’ home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1–107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.