Hybrid model: a promising type of public procurement in the healthcare sector of the European Union.

The management of health supplies in public hospitals has been a major concern of national and European institutions over time, often being a field of reforms and regulatory interventions. Health procurement systems constitute complex decision-making and supply chain management mechanisms of public hospitals, involving suppliers, health providers, administrators and political bodies. Due to this complexity, the first important decision to be taken when designing a procurement system, concerns the degree of centralization, namely to what extent the decision-making power on the healthcare procurement (what, how and when) will be transferred either to a central public authority established for this purpose, or to the competent local authorities. In this perspective, we attempt to analyse the types of public procurement in the healthcare sector of the European Union, in terms of degree of centralization. Employing a narrative approach that summarizes recent interdisciplinary literature, this perspective finds that the healthcare procurement systems of the EU Member States, based on the degree of centralization, are categorized into three types of organizational structures: Centralized, Decentralized and Hybrid procurement. Each structure offers advantages and disadvantages for health systems. According to this perspective, a combination of centralized and decentralized purchases of medical supplies represents a promising hybrid model of healthcare procurement organization by bringing the benefits of two methods together.

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP.

BACKGROUND AND AIMS: ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study performed a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers. METHODS: A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by one-way and two-way sensitivity analyses and probabilistic sensitivity analysis (PSA) using Monte Carlo simulations. RESULTS: In the baseline case, the ICER was -141,017€/year, due to the hypothetical scenario's lower costs and slightly higher QALYs. The model was most sensitive to changes in the transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%) but only transportation cost above 3,407€ changed the study outcome. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥ 92.4% vs. 89.3%) with much lower significant AEs (≤ 0.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the PSA. CONCLUSIONS: Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

Fiscal centralization and urban industrial pollution emissions reduction: Evidence from the vertical reform of environmental administrations in China.

The relationship between fiscal regimes and urban industrial pollution emissions is unclear. This paper aims to explore the effects and mechanisms of fiscal centralization on urban industrial pollution emissions and environmental quality. Using the vertical reform of environmental administrations (VREA) in China as a quasi-natural experiment of fiscal centralization, this study applies a staggered difference-in-differences (DID) model to explore the differences in industrial pollution emissions between centralization cities and decentralization cities. The main findings are: (1) VREA significantly inhibits regional industrial pollution emissions, and the reform effect increases over time. This conclusion still holds after considering a series of robustness issues. (2) Industrial sulfur dioxide (SO2) and solid particulate emissions in the fiscal centralization cities have decreased significantly by 0.3281% and 0.2240%, respectively. However, there is no significant change in industrial wastewater discharges. (3) Environmental regulations, environmental expenditures, and pollution control investments of local governments are the main channels through which VREA reduces industrial pollution emissions. (4) The effects of VREA are more significant in central and western cities and small cities. (5) Relative to decentralization cities, centralization cities have improved air and water quality by 0.0825% and 0.1628%, respectively. These findings help to accurately assess the effects of fiscal centralization on regional environmental governance and provide a decision-making reference for further deepening environmental centralization reform in China.

Centralisation of specialist cancer surgery: an assessment of patient preferences for location of care in the upper South Island of New Zealand.

BACKGROUND: A positive association between volume and outcome for certain operations has led to increasing centralization. The latter is associated with a greater travel burden for patients. This study investigated patient preferences for location of care for cancer surgery. METHODS: Two hundred and one participants were recruited from those who have had recent cancer surgery and from general practice or outpatient clinics in both urban and rural locations in the upper South Island of New Zealand. A questionnaire presented participants with a hypothetical scenario of needing cancer surgery and they were asked to indicate their preference of either a hospital 1 or 5 h away. Scenarios evolved in risk of mortality, complications and need for hospital transfer due to a complication. RESULTS: The majority of participants preferred surgery at the closer hospital when there was a negligible difference in risk. Preference shifted to the distant hospital in a linear relationship as the risk of mortality or complications at the closer hospital increased. Respondents were more likely to prefer the distant hospital from the outset if there was a risk of requiring transfer. CONCLUSION: The majority of participants preferred surgery at the closer hospital if risks were comparable but chose to travel as the risk increased and to avoid hospital transfer due to a complication. New Zealand's unique geography and population make it impossible to replicate centralization models from other countries. The drive for improved outcomes must take equity and patient values into consideration.

The 2021 plan for hospital care centralization in Poland - When politics overwhelms the policy process.

The health system in Poland is characterized by oversized hospital infrastructure, with simultaneous deficits in the ambulatory and long-term care sectors. The main challenges of the hospital sector involve i.a. weak stewardship and fragmented governance with a concurrent problem of persistent hospital debts as well as huge workforce deficits. The objective of this paper is to present the government's 2021 plan for hospital care centralization. The reform project aimed i.a. at improving hospital service coordination by implementing a professional and centralized system for hospital sector supervision and effective restructuration processes. The proposed regulation project focused on three major issues: (1) adjusting the existing hospital network towards better concentration of specialized services; (2) launching an independent central agency responsible for monitoring public hospital financial standing as well as initiating and/or managing hospitals restructuration processes; and (3) introducing a formal certification of hospital managers competencies. The reform plans were developed in a relatively short time frame, with a top-down approach and strongly pushed towards the adoption in 2022. Many of the health system stakeholders were strongly opposed to the project which, in connection with new challenges faced by the health system in 2022 (the economic crisis) led the reform suspension. At the same time, a new restructuration and debt relief programme for public hospitals was announced.

Socioeconomic Status and Distance to Reference Centers for Complex Cancer Diseases: A Source of Health Inequalities? A Population Cohort Study Based on Catalonia (Spain).

The centralization of complex surgical procedures for cancer in Catalonia may have led to geographical and socioeconomic inequities. In this population-based cohort study, we assessed the impacts of these two factors on 5-year survival and quality of care in patients undergoing surgery for rectal cancer (2011-12) and pancreatic cancer (2012-15) in public centers, adjusting for age, comorbidity, and tumor stage. We used data on the geographical distance between the patients' homes and their reference centers, clinical patient and treatment data, income category, and data from the patients' district hospitals. A composite 'textbook outcome' was created from five subindicators of hospitalization. We included 646 cases of pancreatic cancer (12 centers) and 1416 of rectal cancer (26 centers). Distance had no impact on survival for pancreatic cancer patients and was not related to worse survival in rectal cancer. Compared to patients with medium-high income, the risk of death was higher in low-income patients with pancreatic cancer (hazard ratio (HR) 1.46, 95% confidence interval (CI) 1.15-1.86) and very-low-income patients with rectal cancer (HR 5.14, 95% CI 3.51-7.52). Centralization was not associated with worse health outcomes in geographically dispersed patients, including for survival. However, income level remained a significant determinant of survival.

Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands.

BACKGROUND: This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. MATERIALS AND METHODS: All patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. RESULTS: Over 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. CONCLUSION: With nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.

The centralization of bladder cancer care and its implications for patient travel distance.

OBJECTIVES: To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS: Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS: A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS: Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.

Clinical laboratory services for primary healthcare centers in urban cities: a pilot ACO model of ten primary healthcare centers.

BACKGROUND: Primary healthcare centers (PHC) ensure that patients receive comprehensive care from promotion and prevention to treatment, rehabilitation, and palliative care in a familiar environment. It is designed to provide first-contact, continuous, comprehensive, and coordinated patient care that will help achieve equity in the specialty healthcare system. The healthcare in Saudi Arabia is undergoing transformation to Accountable Care Organizations (ACO) model. In order for the Kingdom of Saudi Arabia (KSA) to achieve its transformational goals in healthcare, the improvement of PHCs' quality and utilization is crucial. An integral part of this service is the laboratory services. METHODS: This paper presents a pilot model for the laboratory services of PHC's in urban cities. The method was based on the FOCUS-PDCA quality improvement method focusing on the pre-analytical phase of the laboratory testing as well as the Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) gap analysis and readiness within the ten piloted primary healthcare centers. RESULTS: The Gap analysis, revealed in-consistency in the practice, lead to lower the quality of the service, which was seen in the low performance of the chosen key performance indicators (KPI's) (high rejection rates, lower turn-around times (TAT) for test results) and also in the competency of the staff. Following executing the interventions, and by using some of the ACO Laboratory strategies; the KPI rates were improved, and our results exceeded the targets that we have set to reach during the first year. Also introducing the electronic connectivity improved the TAT KPI and made many of the processes leaner. CONCLUSIONS: Our results revealed that the centralization of PHC's laboratory service to an accredited reference laboratory and implementing the national accreditation standards improved the testing process and lowered the cost, for the mass majority of the routine laboratory testing. Moreover, the model shed the light on how crucial the pre-analytical phase for laboratory quality improvement process, its effect on cost reduction, and the importance of staff competency and utilization.

Influence of the introduction of caseload requirements on indication for visceral cancer surgery in Switzerland.

BACKGROUND: In 2013 Swiss health authorities implemented annual hospital caseload requirements (CR) for five areas of visceral surgery. We assess the impact of the implementation of CR on indication for surgery in esophageal, pancreatic and rectal cancer. MATERIALS AND METHODS: Retrospective analysis of national registry data of all inpatient admissions between January 1st, 2005 and December 31st, 2015. Primary end-point was the age-adjusted resection rate for esophageal, pancreatic and rectal cancer among patients with at least one cancer-specific hospitalization per year. We calculated age-adjusted rate ratios for period effects before and after implementation of CR and odds ratios (OR) based on a generalized estimation equation. A relative increase of 5% in age-adjusted relative risk was set a priori as relevant from a health policy perspective. RESULTS: Age-adjusted resection rates before and after the implementation of CR were 0.12 and 0.13 (Relative Risk [RR] 1.08; 95%-Confidence Interval [CI] 0.85-1.36) in esophageal cancer, 0.22 and 0.26 (RR 1.17; 95%-CI 0.85-1.58) in pancreatic cancer and 0.38 and 0.43 (RR 1.14; 95%-CI 0.99-1.30) in rectal cancer. In adjusted models OR for resection after the implementation of CR were 1.40 (95%-CI 1.24-1.58) in esophageal cancer, 1.05 (95%-CI 0.96-1.15) in pancreatic cancer and 0.92 (95%-CI 0.87-0.97) in rectal cancer. CONCLUSION: Implementation of CR was associated with an increase of resection rates above the a priori set margins in all resections groups. In adjusted models, odds for resection were significantly higher for esophageal cancer, while they remained unchanged for pancreatic and decreased for rectal cancer.

Association between surgical volumes and real-world healthcare cost when using a mesh capturing device for pelvic organ prolapse: A 5-years comparison between single- versus multicenter use.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate whether high surgical volume at a single center was associated with lower healthcare costs compared to lower surgical volume in a multicenter setting. METHODS: All patients had symptomatic and anatomical apical prolapse (POP-Q ≥ stage II) with or without cystocele and were operated on by a standard surgical procedure using the Uphold mesh. Data on time of resource use in terms of surgery time, hospital stay and re-interventions across 5 years were compared between the single center (97 patients) and multicenter (173 patients, at 24 clinics). Unit costs for surgical time, inpatient and outpatient visits were extracted from the single-center hospital's operation analysis program and prime production cost. Total costs were estimated for primary surgery and during 5-year follow-up. RESULTS: Costs for primary surgery were comparable between the single and the multicenter ($13,561 ± 2688 and $13,867 ± 1177, P = 0.29). Follow-up costs 5 years after primary surgery were 2.8 times higher at the multicenter than single center ($3262 vs. $1149, P < 0.001). Mean cost per patient over 5 years was significantly lower at the single than multicenter [$14,710 (CI: 14,168-15,252) vs. $17,128 (CI: 16,952-17,305), P < 0.001)]. CONCLUSIONS: Using a mesh kit for apical pelvic organ prolapse in a high surgical volume center was associated with reduced healthcare costs compared with a lower volume multiple-site setting. The cost reduction at the high surgical volume center increased over time because of lower surgical and medical re-intervention rates for postoperative complications and recurrence.

Hospital-based health systems 20 years later: A taxonomy for policy research and analysis.

OBJECTIVE: Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. DATA SOURCES: The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). STUDY DESIGN: Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. DATA COLLECTION: Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. PRINCIPAL FINDINGS: Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. CONCLUSIONS: The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

Role of Digital Technology in Transforming Organizational Competencies Influencing Green Economy: Moderating Role of Product Knowledge Hiding.

Digital technology has gained momentum in the recent decade, with its relationships with digital entrepreneurship, digital economies, digital social interaction, green economies, etc. These have changed the perspective of business and hence digitalized the strategic policies through blockchains. The current study aims to identify such benefits that have changed the day-to-day life processes and procedures for carrying out different tasks due to the convenience of adopting digital technology. Those benefits have been classified as transparency, centralization, and access to new markets for the organizations considering their consequences, especially when using digital technology. When processes are taking place online, there are fair chances of hiding knowledge about certain products or procedures to gain particular benefits. Hence, this study has considered the moderating role of product knowledge hiding while interacting online. This study is a quantitative post-positivist cross-sectional study that has followed a survey technique for data collection. The population used in this study is the managerial staff of the telecom sector in the mainland in China. The sample size used in this study is 358. The software used in this study is Smart-PLS 3.3. The technique used in this study for data analysis is structural equation modeling with measurement modeling. The findings of this study show that digital technology has led to many benefits for organizations like centralization, access to the new markets, and transparency, which have been made possible remotely only because of the use of digital technology in business operations. However, the moderating role of product knowledge hiding has been found significant only for transparency. This research paper highlights the important benefits of the use of technological use in the corporate world. Also, it contributes to expanding the network of knowledge hiding, addressing the moderation of product knowledge hiding, and extending the known consequences of digital technology influencing knowledge hiding.

Population density and size facilitate interactive capacity and the rise of the state.

Radiocarbon summed probability distribution (SPD) methods promise to illuminate the role of demography in shaping prehistoric social processes, but theories linking population indices to social organization are still uncommon. Here, we develop Power Theory, a formal model of political centralization that casts population density and size as key variables modulating the interactive capacity of political agents to construct power over others. To evaluate this argument, we generated an SPD from 755 radiocarbon dates for 10 000-1000 BP from Central, North Central and North Coast Peru, a period when Peruvian political form developed from 'quasi-egalitarianism' to state levels of political centralization. These data are congruent with theoretical expectations of the model but also point to an artefactual distortion previously unremarked in SPD research. This article is part of the theme issue 'Cross-disciplinary approaches to prehistoric demography'.

Epidemias en los márgenes: la peste bubónica (1903-1905) y el covid-19 en el sur andino peruano / Epidemics on the Margins: The Bubonic Plague (1903­1905) and covid-19 Epidemics in the Peruvian South Andean Region / Epidemias marginais: a peste bubônica (1903-1905) e covid-19 no sul andino peruano

Introducción: la epidemia de covid-19 ha dejado en evidencia una serie de problemas de desigualdad en el acceso a la salud pública en Perú, especialmente en las provincias alejadas de la capital, donde se observa precariedad tanto en infraestructura como en personal sanitario. Este artículo analiza cómo el Gobierno y la población han hecho frente a epidemias en el sur de Perú, usando como casos de estudio el covid-19 y la peste bubónica ocurrida en 1903 y 1905, con el fin de entender continuidades en el manejo de la crisis epidémica y su respuesta a ellas. Desarrollo: se estudia la epidemia de la peste bubónica en las ciudades de Arequipa y Mollendo en 1903 y 1905 y el covid-19, con un enfoque en el funcionamiento del sistema de salud local y nacional, en la infraestructura sanitaria disponible para enfrentar epidemias y, finalmente, en las respuestas sociales de la población respecto al escepticismo de las medidas impuestas por las autoridades y al incremento de la automedicación. Conclusiones: la epidemia del covid-19 en el sur de Perú presenta importantes similitudes con la epidemia de peste bubónica que afectó a la región a inicios del siglo xx: desorden de responsabilidades, falta de previsión para hacer frente a enfermedades epidémicas, infraestructura precaria y una población con alto grado de desconfianza frente a las recomendaciones de las autoridades civiles y sanitarias

Introduction: The covid-19 epidemic has revealed a series of inequality problems in the access to public health services in Peru, especially in provinces far from the capital where precariousness in both infra-structure and sanitary personnel is observed. In this study, we analyzed how the population and author-ities in southern Peru faced epidemics, using covid-19 epidemic and bubonic plague in 1903 and 1905 as case studies to understand continuities in the management of epidemic crises and social response to them. Development: We studied the bubonic plague epidemic in the cities of Arequipa and Mollendo in 1903 and 1905 as well as the covid-19 epidemic, focusing on the functioning of local and national health systems, health infrastructure available to face epidemics, and finally, the social response of the population, paying particular attention to the skepticism of the population toward measures imposed by the authorities and increase in self-medication. Conclusions: The covid-19 epidemic in southern Peru pres-ents important similarities with the bubonic plague epidemic that affected the region at the beginning of the 20th century, including a disorder of responsibilities, lack of foresight to face epidemic diseases, insufficient infrastructure, and a population with a high degree of distrust in the recommendations given by the civil and health authorities

Introdução: a epidemia de covid-19 expôs uma série de problemas de desigualdade no acesso à saúde pública no Peru, especialmente nas províncias distantes da capital onde há precariedade tanto de infraestrutura quanto de pessoal de saúde. Este artigo analisa como o governo e a população têm enfren-tado epidemias no sul do Peru, utilizando o covid-19 e a peste bubônica ocorrida em 1903 e 1905 como estudos de caso, a fim de compreender as continuidades na gestão da crise epidêmica e suas respostas. Desenvolvimento: são estudadas as epidemias de peste bubônica nas cidades de Arequipa e Mollendo em 1903 e 1905 e a covid-19, enfocando no funcionamento do sistema de saúde local e nacional, a infraes-trutura de saúde disponível para enfrentar as epidemias e, por fim, as respostas da população, com particular atenção para o ceticismo em relação às medidas impostas pelas autoridades e ao aumento da automedicação. Conclusões: a epidemia de covid-19 no sul do Peru apresenta semelhanças importantes com a epidemia de peste bubônica que afetou a região no início do século XX: desordem de responsabili-dades, falta de previsão para enfrentar as doenças epidêmicas, infraestrutura precária e uma população com alto grau de desconfiança em relação às recomendações das autoridades civis e sanitárias

Competitive Conditions in Global Value Chain Networks: An Assessment Using Entropy and Network Analysis.

We investigated competitive conditions in global value chains (GVCs) for a period of fifteen years (2000-2014), focusing on sector structure, countries' dominance and diversification. For this purpose, we used data from the World Input-Output Database (WIOD) and examined GVCs as weighted directed networks, where countries are the nodes and value added flows are the edges. We compared the in-and out-weighted degree centralization of the sectoral GVC networks in order to detect the most centralized, on the import or export side, respectively (oligopsonies and oligopolies). Moreover, we examined the in- and out-weighted degree centrality and the in- and out-weight entropy in order to determine whether dominant countries are also diversified. The empirical results reveal that diversification (entropy) and dominance (degree) are not correlated. Dominant countries (rich) become more dominant (richer). Diversification is not conditioned by competitiveness.

Centralization of care in high volume hospitals and inequalities in access to care.

In 2018, the French National Health Insurance proposed to increase the minimum volume threshold for breast cancer and to set a specific threshold for ovarian cancer in order to get an authorization to treat these patients. Using an exhaustive nationwide data set, the aim of this study is to evaluate the impact of the application of minimum volume thresholds for breast cancer and ovarian cancer in France on socioeconomic and spatial inequalities in patient access to care, taking into account patient preferences for their preferred provider. Our findings indicate that it would increase spatial inequalities and introduce socioeconomic inequalities in access to specialized care in terms of travel distance and will contribute to the medical desertification in rural areas that already have less access to non-specialized care. Our results underline that ignoring patient preferences when assessing the impact of such policies drastically underestimate the deterioration in patient access to care.

Simulating the impact of centralization of prostate cancer surgery services on travel burden and equity in the English National Health Service: A national population based model for health service re-design.

INTRODUCTION: There is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment. Using prostate cancer surgery as an example, this national study analysis aims to simulate the effect of different centralization scenarios on the number of center closures, patient travel times, and equity in access. METHODS: We used patient-level data on all men (n = 19,256) undergoing radical prostatectomy in the English National Health Service between January 1, 2010 and December 31, 2014, and considered three scenarios for centralization of prostate cancer surgery services A: procedure volume, B: availability of specialized services, and C: optimization of capacity. The probability of patients travelling to each of the remaining centers in the choice set was predicted using a conditional logit model, based on preferences revealed through actual hospital selections. Multivariable linear regression analysed the impact on travel time according to patient characteristics. RESULTS: Scenarios A, B, and C resulted in the closure of 28, 24, and 37 of the 65 radical prostatectomy centers, respectively, affecting 3993 (21%), 5763 (30%), and 7896 (41%) of the men in the study. Despite similar numbers of center closures the expected average increase on travel time was very different for scenario B (+15 minutes) and A (+28 minutes). A distance minimization approach, assigning patients to their next nearest center, with patient preferences not considered, estimated a lower impact on travel burden in all scenarios. The additional travel burden on older, sicker, less affluent patients was evident, but where significant, the absolute difference was very small. CONCLUSION: The study provides an innovative simulation approach using national patient-level datasets, patient preferences based on actual hospital selections, and personal characteristics to inform health service planning. With this approach, we demonstrated for prostate cancer surgery that three different centralization scenarios would lead to similar number of center closures but to different increases in patient travel time, whilst all having a minimal impact on equity.

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

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.

Volume-Cost Relationship in Neurosurgery: Analysis of 12,129,029 Admissions from the National Inpatient Sample.

BACKGROUND/OBJECTIVE: Several studies have documented improved outcomes at high-volume hospitals for neurosurgery. However, the relationship between neurosurgical volume and costs remains poorly understood. METHODS: Using neurosurgery-specific Diagnosis-Related Groups (DRG) codes, we identified adult neurosurgical admissions in the National Inpatient Sample from 2002 to 2014. We stratified hospitals by annual neurosurgical volume as high-volume (top 20%) or low-volume centers (bottom 80%). We performed survey-weighted regression analyses to examine the impact of case volume on inpatient costs. RESULTS: A total of 12,129,029 admissions underwent neurosurgery from 2002 to 2014, with 59.6% treated at high-volume hospitals. Patients at high-volume centers were more likely to have private insurance, higher risk of mortality scores, and higher DRG weight procedures than those at low-volume centers (P < 0.001). High-volume hospital admissions were on average 9% or $1791 more expensive than their low-volume counterparts. However, after adjustment for patient, hospital, and case-mix differences, high-volume hospitals were 4.3% less expensive than low-volume centers ($21,825 vs. $22,924; P < 0.01). The southern United States, which had the biggest volume, showed the highest savings (6.5%). CONCLUSIONS: High-volume hospitals provide more cost-effective neurosurgical care. Centralization of care at high-volume neurosurgical institutions may be a promising strategy to delivering higher-value care, achieving better outcomes at lower costs.