Access to Quaternary Care: Studies Needed in Otolaryngology

Abstract

Although our health-care delivery system is changing, some of the goals behind health care reform over the last decade are likely to persist. One of these is the desire to increase access to care. So far, this has been attempted through control of health-care costs, insurance reform, and redesigning the health-care delivery system through not only payment reform but also the institution of accountable care organizations (ACOs). Accountable care organizations were started by the Center for Medicare and Medicaid Innovation and are responsible for the health of specific, assigned populations of patients. Payments for ACOs are adjusted based upon results measured months to a year after treatment and directed at assessing the costs and quality of care. The results of these assessments lead to bonuses for providers, or assessments requiring return of funds. Access to quaternary care is relatively limited. So, for efficiency and because quaternary care is naturally concentrated in quaternary care institutions such as universities, patients travel longer distances for quaternary care than they do for routine care. To the best of my knowledge, the association of long travel times and medical outcomes has not been studied in otolaryngology, but it has been studied in general surgery; and otolaryngologists probably have something to learn from the results. Mehaffey et al reviewed the outcomes of 17 582 patients treated at the University of Virginia, Charlottesville, Virginia. The median travel time of their patients was 65 minutes, with a median distance of 54 miles. Of all, 45.5% of their patients were considered local, traveling less than 1 hour; and 54.5% (9576) of the patients were considered regional, traveling more than 1 hour. The regional group had significantly higher rates of transfer, inpatient surgery, American Society of Anesthesiologists classifications greater than 2, and rates of several medical comorbidities. They also were more likely than local patients to have nonindependent functional status, ventilator dependence, and greater than 10% weight loss in the past 6 months. Moreover, the regional group had higher predicted risks of 30-day morbidity and mortality in comparison with the local group. Interestingly, the findings of the study were not entirely what one might have predicted. Despite the higher predicted risks of mortality and morbidity associated with increased preoperative risk factors, there was no difference in 30-day mortality associated with greater travel time. However, higher rates of prolonged ventilation, reoperation, and wound infection were noted, as were significantly higher health-care costs. Nevertheless, although 30-day survival statistics in regional patients were comparable to local patients, long-term mortality was not. Divergence between the groups occurred by 90 days and persisted over the 10 years of follow-up of some of the subjects. Although the study by Mehaffey et al was single center and retrospective, American College of Surgeons National Surgical Quality Improvement Program data were collected prospectively. Even though outcomes for regional and local patients were similar at 30 days, and although the divergence at 90 days and greater might be due to the severity of disease that led patients to travel longer distances, more information is needed to understand the implications of long travel to receive quaternary care, as well as to investigate ways to mitigate differences, possibly through improvements in local follow-up care, telemedicine follow-up, or other interventions. In addition, similar studies on otolaryngologic patients (perhaps especially patients with advanced head and neck cancer) should be encouraged.