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Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are largely unknown. We determined the extent of regionalization of care for adrenal surgery and the extent to which this centralization has evolved with time.Using 1996 to 2009 hospital discharge data from New York, New Jersey and Pennsylvania we identified all patients 18 years old or older treated with adrenalectomy. Hospital volume quintiles were created using 1996 hospital volumes. These cutoffs were then applied to subsequent years. Outcome variables were examined by hospital volume status with time using logistic regression models.A total of 8,381 patients underwent adrenalectomy from 1996 to 2009 with a significant 17% to 42% shift toward regionalization to very high volume hospitals, defined as 15 or greater procedures per year (p0.001). For each successive year the odds of having surgery performed at a very low volume hospital decreased by 13% (OR 0.87, 95% CI 0.84-0.89). There were significant differences in patient age, race and payer group for very low volume hospitals, defined as less than 1 procedure per year, compared to very high volume hospitals (p0.0001). Patients at very high volume hospitals were less likely to be 55 years old or older (OR 0.73, 95% CI 0.61-0.88), insured through Medicaid (OR 0.60, 95% CI 0.45-0.79) or uninsured (OR 0.34, 95% CI 0.17-0.70). When controlling for year treated, patients were less likely to die in the hospital if treated at a very high volume hospital (OR 0.38, 95% CI 0.19-0.75).These data reveal the increasing centralization of adrenalectomy to very high volume hospitals since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.

We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis.North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect.Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03).Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.

INTRODUCTION AND OBJECTIVES: Centralization of complex urologic oncology procedures to high volume centers has been proposed as a means of improving surgical quality of care. We hypothesized that performance of radical cystectomy has become increasingly regionalized to very high volume hospitals resulting in improved short term clinical and mortality outcomes. METHODS: Using 1996 to 2009 hospital discharge data from NY, NJ, and PA provided by Databay Resources, all patients 18 years with transitional cell carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of radical cystectomies performed on a per hospital basis in 1996; very low volume hospital: 0–2 (VLVH), low: 3–4 (LVH), moderate: 5–8 (MVH), high: 9–31 (HVH) and very high: 32 (VHVH). Changes in the relative proportion of procedures performed by hospital volume status were assessed over time, and patient characteristics were compared between groups. Outcome variables including discharge status, inpatient mortality, and hospital length of stay (HLOS) were examined by hospital volume status using logistic regression models. RESULTS: 14,404 patients undergoing cystectomy were included for analysis. From 1996 to 2009, there was a significant shift towards regionalization of care to VHVHs (21 to 38%, p 0.02) and away from VLVHs (20 to 9%, p 0.001). For each year increase (1996–2009), the odds of having surgery performed at a VHVH increased by 16% (OR 1.16 [CI 1.03, 1.31]). Stratified by hospital volume status, there were significant differences between groups in patient age (p 0.0001), race (p 0.0001), gender (p 0.0001), geographic location (p 0.0001), and payer group (p 0.0001). Independent of year treated, patients undergoing surgery at a VHVH were less likely to be African American (OR 0.50 [CI 0.32–0.79]) or insured through Medicaid (OR 0.67 [CI 0.47–0.95]) or Medicare (OR 0.84 [CI 0.76–0.95]). Controlling for year treated, median LOS was shorter (median difference 1.1 days [CI 1.12 to 1.06]) and patients were less likely to die during their hospital stay if treated at a VHVH compared to a VLVH (OR 0.30 [CI 0.17–0.52]). CONCLUSIONS: Since 1996, these data demonstrate that there has been extensive centralization of radical cystectomy to VHVHs, which has resulted in significant reductions in inpatient mortality rates and HLOS over time. Nevertheless, insurer and racial disparities preclude optimal access to care and these discrepancies must still be addressed.

Purpose Travel distances to care have increased substantially with centralization of complex cancer procedures at high-volume centers. We hypothesize that longer travel distances are associated with higher rates of postoperative readmission and poorer outcomes. Methods SEER-Medicare patients with bladder, lung, pancreas, or esophagus cancer who were diagnosed in 2001 to 2007 and underwent extirpative surgery were included. Readmission rates and survival were calculated using Kaplan-Meier functions. Multivariable negative binomial models were used to examine factors associated with readmission. Results Four thousand nine hundred forty cystectomies, 1,573 esophagectomies, 20,362 lung resections, and 2,844 pancreatectomies were included. Thirty- and 90-day readmission rates ranged from 13% to 29% and 23% to 43%, respectively, based on tumor type. Predictors of readmission were discharge to somewhere other than home, longer length of stay, comorbidities, higher stage at diagnosis, and longer travel distance (P < .001 for each). Patients who lived farther from the index hospital also had increased emergency room visits and were more likely to be readmitted to a hospital other than the index hospital (P < .001). Of readmitted patients, 31.9% were readmitted more than once. Long-term survival was worse and costs of care higher for patients who were readmitted (P < .001 for all). Conclusion The burden of readmissions after major cancer surgery is high, resulting in substantially poorer patient outcomes and higher costs. Risk of readmission was most strongly associated with length of stay and discharge destination. Travel distance also has an impact on patterns of readmission. Interventions targeted at higher risk individuals could potentially decrease the population burden of readmissions after major cancer surgery.

INTRODUCTION AND OBJECTIVE: Partial nephrectomy is an established standard for treatment of localized RCC. Unfortunately, NSS remains widely underutilized except at high-volume academic centers. We evaluated the potential impact of a patient’s primary insurance status as an independent variable predicting a patient’s likelihood of undergoing NSS using inpatient discharge data from New York (NY), New Jersey (NJ), and Pennsylvania (PA). METHODS: A database generated from discharge claims data of individual state agencies of NJ, NY, and PA, was queried for all patients =>18 years of age who underwent radical or partial nephrectomy from 2000 to 2006. We used multiple linear regressions to investigate effects of insurance status on likelihood of undergoing partial nephrectomy. RESULTS: 42,104 radical or partial nephrectomies were included in the analysis. The total number of procedures performed increased annually (Figure 1). On univariate analysis, likelihood of undergoing NSS was associated with age, gender, hospital procedure volume, socioeconomic status, payer, and rurality. In the multivariate analysis, older patients (p 65 (n= 26,600), patients with Medicare as the primary payer (n=18,811) were less likely to undergo NSS (OR=0.76, CI 0.70, 0.81) than patients who had a private provider as the primary payer (n=6,684; OR=1.00). CONCLUSIONS: Disparities in quality of care exist. By examining a large discharge claims database from NY, NJ, and PA, we were able to show that patients =>65 years of age with Medicare coverage were 24% less likely to undergo nephron sparing surgery for treatment of renal malignancy than patients whose primary payer was a private insurance carrier. Reasons for these findings require further investigation.