Effect of regionalization of endometrial cancer care on site of care and patient travel

Abstract

Background: Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.

Objective: To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.

Study design: We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.

Results: We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both).

Conclusion: The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

Keywords: centralization of care; endometrial cancer; gynecologic cancer; rural disparities; travel distance.