INTRODUCTION: Increased facility surgical volume and care centralization are associated with improved surgical outcomes but can increase travel burden for patients. OBJECTIVE: To quantify travel distance based on surgical volume and assess hospital surgical volume’s association with prolapse retreatment. METHODS: We conducted a retrospective analysis of deidentified private payor insurance claims for services from October 2015 to 2024 in a single state. The cohort consisted of individuals undergoing hysterectomy for prolapse, identified by ICD-10-CM and CPT codes. Hospital Service Areas (HSAs) were identified based on both the individual’s home zip code and the facility zip code. Distance traveled was calculated between these zip codes using a SAS geodistance formula. High-volume facilities were defined as those in the top quintile of case volume within the cohort. The surgical outcome of interest was prolapse retreatment (repeat surgery or pessary use). A Cox proportional hazard model was used to adjust for patient/surgical attributes, e.g., age, comorbidities, concurrent gynecologic diagnoses, geographic factors, facility volume, subspecialty training, and concurrent prolapse procedure(s). Social vulnerability was assessed using both a composite score (Social Vulnerability Index) and individual components related to travel (transport and disability). RESULTS: We identified 4,978 hysterectomies that met inclusion criteria across 91 facilities and in 74 HSAs. The top quintile volume cut-point was 85 hysterectomies. Twenty-seven percent of HSAs had at least one high-volume facility, and 57% of individuals lived in an HSA with a high-volume facility. There were 47.6% who received care in their home HSA, and 65% of surgeries were performed in high-volume centers. For those who lived in an HSA with a high-volume facility, 62.4% stayed within that HSA for care and 77% received care at a high-volume center. The median distance traveled was 11.4 miles (IQR 5.8–21.4). Median travel distances for low- and high-volume centers were 10.6 miles (IQR 4.6–20.1) and 12.4 miles (IQR 6.3–22), respectively (P<0.001). For those who received care at a low-volume center, the nearest high-volume center was a median 19.6 miles away (IQR 8.65–34.5) (Table 1). This travel increased to a median 30.1 miles (IQR 20.8–48) for those who lived in an HSA without a high-volume center. HSAs without a high-volume center were associated with households without a vehicle (3.4% vs 2.5%) and individuals with disabilities (15.4% vs 12.6%) (p<0.001). Regarding outcomes, 4.97% (n=244) underwent subsequent prolapse retreatment. This rate for those who underwent care at a high-volume center was 3.9% (n=127) compared to 6.7% (n=117) for those who did not. High-volume centers were associated with a decreased hazard of retreatment (Table 2). Twenty-five individuals would need to receive care at a high-volume center to prevent 1 prolapse retreatment at 5 years after surgery. CONCLUSIONS: This analysis suggests that treatment at a high-volume center is associated with lower rates of retreatment but longer distances of travel. Policies and strategies around care centralization need to address social vulnerability as longer travel distances may especially affect those who lack transportation or who are disabled.Table 1Table 2
Latack et al. (Fri,) studied this question.