title: Access to Quaternary Care Surgery: Implications for Accountable Care Organizations.
abstract: BACKGROUND
  Accountable care organizations (ACOs) attempt to provide the most efficient and effective care to patients within a region. We hypothesized that patients who undergo surgery closer to home have improved survival due to proximity of preoperative and post-discharge care.
  
  
  METHODS
  All (17,582) institutional American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients with a documented ZIP code and predicted risk, who underwent surgery at our institution (2005 to 2014), were evaluated. Google Maps calculated travel times, and patients were stratified by 1 hour of travel (local vs regional). Multivariable logistic regression and Cox proportional hazard models were used to evaluate the NSQIP risk-adjusted effects of travel time on operative morbidity, mortality, and long-term survival.
  
  
  RESULTS
  Median travel time was 65 minutes, with regional patients demonstrating significantly higher rates of ascites, hypertension, diabetes, disseminated cancer, >10% weight loss, higher American Society of Anesthesiologists (ASA) score, higher predicted risk of morbidity and mortality, and lower functional status (all p < 0.01). After adjusting for ACS NSQIP-predicted risk, travel time was not significantly associated with 30-day mortality (odds ratio [OR] 1.06; p = 0.42) or any major morbidities (all p > 0.05). However, survival analysis demonstrated that travel time is an independent predictor of long-term mortality (OR 1.24; p < 0.001).
  
  
  CONCLUSIONS
  Patients traveling farther for care at a quaternary center had higher rates of comorbidities and predicted risk of complications. Additionally, travel time predicts risk-adjusted long-term mortality, suggesting a major focus of ACOs will need to be integration of care at the periphery of their region.
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA. Electronic address: JHM9T@virginia.edu.
authors.forename: J Hunter
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Hawkins
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Mullen
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Max O
authors.initials: MO
authors.lastname: Meneveau
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Bruce
authors.initials: B
authors.lastname: Schirmer
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Jones
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Peter T
authors.initials: PT
authors.lastname: Hallowell
mesh_terms: D060866:Accountable Care Organizations / Q000458:organization & administration* / Q000706:statistics & numerical data; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D020379:Risk Adjustment; D013514:Surgical Procedures, Operative / Q000401:mortality*; D014768:Virginia