Potential impact of a volume pledge on spatial access: A population-level analysis of patients undergoing pancreatectomy

Background. A minimum-volume policy restricting hospitals not meeting the threshold from performing complex operation may increase travel burden and decrease spatial access to operation. We aim to identify vulnerable populations that would be sensitive to an added travel burden. Methods. We performed a retrospective analysis of the database of the California Office of Statewide Health Planning and Development for patients undergoing pancreatectomy from 2005 to 2014. Number of hospitals bypassed was used as a metric for travel. Patients bypassing fewer hospitals were deemed to be more sensitive to an added travel burden. Results. There were 13,374 patients who underwent a pancreatectomy, of whom 2,368 (17.7%) were nonbypassers. On unadjusted analysis, patients > 80 year old travelled less than their younger counterparts, bypassing a mean of 10.9 +/- 9.5 hospitals compared with 14.2 +/- 21.3 hospitals bypassed by the 35-49 year old age group (P < .001). Racial minorities travelled less when compared with non Hispanic whites (P < .001). Patients identifying their payer status as self-pay (8.9 +/- 15.6 hospitals bypassed) and Medicaid (10.1 +/- 17.2 hospitals bypassed) also travelled less when compared with patients with private insurance (13.8 +/- 20.4 hospitals bypassed, P < .001). On multivariate analysis, advanced age, racial minority, and patients with self-pay or Medicaid payer status were associated independently with increased sensitivity to an added travel burden. Conclusion. In patients undergoing pancreatectomy, the elderly, racial minorities, and patients with self pay or Medicaid payer status were associated with an increased sensitivity to an added travel burden. This vulnerable cohort may be affected disproportionately by a minimum-volume policy.