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Lin CC, Hill CE, Kerber KA, Burke JF, Skolarus LE, Esper GJ, de Havenon A, De Lott LB, Callaghan BC. Patient Travel Distance to Neurologist Visits. Neurology 2023; 101:e1807-e1820. [PMID: 37704403 PMCID: PMC10634641 DOI: 10.1212/wnl.0000000000207810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/10/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. METHODS We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. RESULTS We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. DISCUSSION We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.
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Affiliation(s)
- Chun Chieh Lin
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT.
| | - Chloe E Hill
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Kevin A Kerber
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - James F Burke
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Lesli E Skolarus
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Gregory J Esper
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Adam de Havenon
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Lindsey B De Lott
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Brian C Callaghan
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
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Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
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Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
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