Regionalization of Cardiac Surgery in the United States and Canada

Abstract

<h3>Objective.</h3> —To determine how regionalization of facilities for coronary artery bypass surgery (CABS) affects geographic access to CABS and surgical outcomes. <h3>Design.</h3> —Computerized hospital discharge records were used to measure hospital CABS volume and in-hospital post-CABS mortality rates. Relationships between surgical volume and age- and sex-adjusted mortality rates were compared using χ²tests. Small-area analysis of the association between CABS rates and distances to nearest CABS hospital was performed using multivariate linear regression methods. <h3>Setting.</h3> —All nonfederal hospitals in New York, California, Ontario, Manitoba, and British Columbia. <h3>Patients.</h3> —All adult residents of the five jurisdictions who underwent CABS in a hospital in their jurisdiction from 1987 through 1989. <h3>Results.</h3> —In New York and Canada, approximately 60% of all CABS operations took place in hospitals performing 500 or more CABS operations per year, compared with only 26% in California. The highest mortality rates were found among California hospitals performing fewer than 100 CABS operations per year (adjusted 14-day in-hospital mortality was 4.7% compared with 2.4% in high-volume California hospitals,<i>P</i>&lt;.001). The percentage of the population residing within 25 miles of a CABS hospital was 91% in California, 82% in New York, and less than 60% in Canada. Eliminating very low-volume (&lt;100 cases per year) CABS hospitals in California would increase travel distances to a CABS hospital only slightly for a small number of residents. The Canadian degree of regionalization was not associated with lower CABS rates within provinces for populations living at more remote distances from the nearest CABS hospital. <h3>Conclusion.</h3> —Regionalization of CABS facilities in New York and Canada largely avoids the problem of low-volume outlier hospitals with high postoperative mortality rates found in California. New York has avoided the redundancy of facilities that exists in California while still providing residents a geographically convenient selection of CABS hospitals. Stricter regionalization in Canada may leave residents with a more narrow choice of facilities, but does not disproportionately affect access to surgery for populations living at remote distances from CABS facilities. (<i>JAMA</i>. 1995;274:1282-1288)