Abstract：
BACKGROUND: We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations.
METHODS: The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners\' Loan Corporation grades (A: \'Best\'; B: \'Still Desirable\'; C: \'Definitely Declining\'; and D: \'Hazardous/Redlined\'). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance.
RESULTS: Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the \'Best\', whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1-14.4) and travel time was 16.1 min (IQR 10.7-25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44-2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH.
CONCLUSIONS: Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.
METHODS: The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners\' Loan Corporation grades (A: \'Best\'; B: \'Still Desirable\'; C: \'Definitely Declining\'; and D: \'Hazardous/Redlined\'). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance.
RESULTS: Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the \'Best\', whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1-14.4) and travel time was 16.1 min (IQR 10.7-25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44-2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH.
CONCLUSIONS: Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.
摘要：
背景：我们试图确定历史重新调整对接受复杂癌症手术的患者的旅行方式和高容量医院（HVHs）利用的影响。
方法：使用加州卫生保健部门获取和信息数据库来识别接受食道切除术（ES）的患者，全肺切除术(PN),胰腺切除术(PA),或2010年至2020年之间的癌症直肠切除术（PR）。患者邮政编码被分配给房屋所有者\'贷款公司等级(A:\'最佳\';B:\'仍然理想\';C:\'绝对递减\';和D:\'危险/加红\')。聚类多变量回归用于评估患者在HVH接受手术的可能性，绕过最近的HVH,和总的实际驾驶时间和旅行距离。
结果：在14,944例接受高风险癌症手术的患者中（ES：4.7％，n=1216;PN:57.8%,n=8643;PD:14.4%,n=2154；PR：23.1％，n=3452),782人（5.2%）居住在“最佳”，而3393人(22.7%)居住在红线区域。中位行驶距离为7.8英里（四分位距[IQR]4.1-14.4），行驶时间为16.1分钟（IQR10.7-25.8）。总的来说,10,763例（ES：17.4％；PN：76.0％；PA：63.5％；PR：78.4％）患者在HVH下接受了手术。在多元回归中，居住在带红线区域的患者在HVH下接受手术的可能性较小(比值比[OR]0.67,95%置信区间[CI]0.54~0.82),并且更有可能绕过最近的医院(OR1.80,95%CI1.44~2.46).值得注意的是,医疗补助保险,少数民族地位,英语语言能力有限，和教育水平调节了获得HVH的差距。
结论：历史红线区域的患者在获得HVH方面的手术差异在很大程度上是由保险和少数民族地位等社会决定因素介导的。
方法：使用加州卫生保健部门获取和信息数据库来识别接受食道切除术（ES）的患者，全肺切除术(PN),胰腺切除术(PA),或2010年至2020年之间的癌症直肠切除术（PR）。患者邮政编码被分配给房屋所有者\'贷款公司等级(A:\'最佳\';B:\'仍然理想\';C:\'绝对递减\';和D:\'危险/加红\')。聚类多变量回归用于评估患者在HVH接受手术的可能性，绕过最近的HVH,和总的实际驾驶时间和旅行距离。
结果：在14,944例接受高风险癌症手术的患者中（ES：4.7％，n=1216;PN:57.8%,n=8643;PD:14.4%,n=2154；PR：23.1％，n=3452),782人（5.2%）居住在“最佳”，而3393人(22.7%)居住在红线区域。中位行驶距离为7.8英里（四分位距[IQR]4.1-14.4），行驶时间为16.1分钟（IQR10.7-25.8）。总的来说,10,763例（ES：17.4％；PN：76.0％；PA：63.5％；PR：78.4％）患者在HVH下接受了手术。在多元回归中，居住在带红线区域的患者在HVH下接受手术的可能性较小(比值比[OR]0.67,95%置信区间[CI]0.54~0.82),并且更有可能绕过最近的医院(OR1.80,95%CI1.44~2.46).值得注意的是,医疗补助保险,少数民族地位,英语语言能力有限，和教育水平调节了获得HVH的差距。
结论：历史红线区域的患者在获得HVH方面的手术差异在很大程度上是由保险和少数民族地位等社会决定因素介导的。
