Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy
Abstract
:Simple Summary
Abstract
1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Study Objectives
- To quantify the phenomenon of patients’ mobility to receive pancreatic surgery in Italy, comparing the characteristics of migrating and non-migrating patients and evaluating the travel rate and the attraction rate of each region;
- To analyze the effect of mobility on patients’ outcome;
- To investigate the presence of geographical disparities in the delivery of pancreatic surgery, measuring the operative mortality in each region and the availability of adequate facilities.
2.3. Methods and Definitions
2.4. Statistical Analysis
3. Results
3.1. Patients’ Mobility
3.2. Mortality Analysis
3.3. Distribution of Facilities in Geographical Areas and Regions
3.4. Effect of Mobility on Outcome
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Area/Region | Resident Population | Resident Patients Undergoing Resection | Resections in the Region/Area Out of Overall Resections in Italy | Migrating Patients * from a Specific Area/Region (Escape Rate a) | Migrating Patients * to a Specific Area/Region (Attraction Rate b) | ||||
---|---|---|---|---|---|---|---|---|---|
N | ‰ | N | % | N | % | N | % | ||
Northern Italy | 27,774,970 | 6561 | 0.24 | 8023 | 63.4 | 75 | 1.1 | 1462 | 18.2 |
Piedmont | 4,341,375 | 987 | 0.23 | 905 | 7.1 | 155 | 15.7 | 73 | 8.1 |
Valle d’Aosta | 126,933 | 19 | 0.15 | 2 | 0.1 | 17 | 89.5 | 0 | 0 |
Lombardy | 10,103,969 | 2441 | 0.24 | 3037 | 24.0 | 193 | 7.9 | 789 | 26.0 |
Trentino A.A. | 1,074,819 | 210 | 0.20 | 165 | 1.3 | 53 | 25.2 | 8 | 4.8 |
Veneto | 4,907,704 | 1089 | 0.22 | 2275 | 18.0 | 51 | 4.7 | 1237 | 54.4 |
Friuli V.G. | 1,211,357 | 264 | 0.22 | 226 | 1.8 | 58 | 22.0 | 20 | 8.8 |
Liguria | 1,543,127 | 417 | 0.27 | 261 | 2.1 | 173 | 41.5 | 17 | 6.5 |
Emilia-Romagna | 4,467,118 | 1209 | 0.27 | 1152 | 9.1 | 214 | 17.7 | 157 | 13.6 |
Central Italy | 11,986,958 | 2663 | 0.22 | 2638 | 20.8 | 388 | 14.6 | 363 | 13.8 |
Tuscany | 3,722,729 | 1061 | 0.29 | 1096 | 8.7 | 118 | 4.1 | 153 | 14.0 |
Umbria | 880,285 | 217 | 0.25 | 176 | 1.4 | 62 | 28.6 | 21 | 0.7 |
Marche | 1,518,400 | 309 | 0.20 | 282 | 2.2 | 119 | 38.5 | 92 | 3.2 |
Lazio | 5,865,544 | 1076 | 0.18 | 1084 | 8.6 | 174 | 16.2 | 182 | 16.8 |
Southern Italy | 20,482,711 | 3290 | 0.16 | 2001 | 15.8 | 1326 | 40.3 | 37 | 1.8 |
Abruzzo | 1,305,770 | 272 | 0.21 | 155 | 1.2 | 143 | 52.6 | 26 | 16.8 |
Molise | 308,493 | 60 | 0.19 | 19 | 0.2 | 46 | 76.7 | 5 | 26.3 |
Campania | 5,785,861 | 771 | 0.13 | 468 | 3.7 | 323 | 41.9 | 20 | 4.3 |
Puglia | 4,008,296 | 669 | 0.17 | 481 | 3.8 | 240 | 35.9 | 52 | 10.8 |
Basilicata | 556,934 | 84 | 0.15 | 56 | 0.4 | 35 | 41.7 | 7 | 12.5 |
Calabria | 1,924,701 | 294 | 0.15 | 71 | 0.6 | 224 | 76.2 | 1 | 1.4 |
Sicily | 4,968,410 | 838 | 0.17 | 559 | 4.4 | 294 | 35.1 | 15 | 2.7 |
Sardinia | 1,630,474 | 302 | 0.19 | 192 | 1.5 | 112 | 37.1 | 2 | 1.0 |
Migrating Patients | Non-Migrating Patients | p | |
---|---|---|---|
Number of patients | 2603 (20.6%) | 10059 (79.4%) | |
Age > 70 | 706 (27.0%) | 4291 (42.7%) | <0.001 |
Male gender | 1377 (52.9%) | 5419 (53.9%) | 0.376 |
Charlson comorbidity index | <0.001 | ||
0 | 2404 (92.4%) | 8622 (85.7%) | |
1 | 185 (7.1%) | 1265 (12.6%) | |
≥2 | 14 (0.5%) | 172 (1.7%) | |
Type of resection | 0.041 | ||
Major (PD-TP) | 1767 (67.9%) | 7036 (69.9%) | |
Minor (others) | 836 (32.1%) | 3023 (30.1%) | |
Hospital volume | <0.001 | ||
Very low volume | 141 (5.4%) | 2232 (22.2%) | |
Low volume | 171 (6.6%) | 2259 (22.5%) | |
Medium volume | 290 (11.1%) | 2507 (24.9%) | |
High volume | 464 (17.8%) | 1762 (17.5%) | |
Very high volume | 1537 (59.0%) | 1299 (12.9%) | |
Private patients | <0.001 | ||
No | 2408 (92.5%) | 9786 (97.3%) | |
Yes | 195 (7.5%) | 273 (2.7%) | |
Diagnosis | 0.001 | ||
Pancreatic cancer and CP | 1661 (63.8%) | 6770 (67.3%) | |
Other | 942 (36.2%) | 3289 (32.7%) | |
Laparoscopy | 203 (7.8%) | 585 (8.5%) | 0.230 |
Multivisceral resection | 184 (7.1%) | 1313 (13.1%) | <0.001 |
Vascular resection | 140 (5.4%) | 734 (7.3%) | 0.001 |
Univariate Analysis | Multivariate Analysis | ||||||
---|---|---|---|---|---|---|---|
Variable | In-Hospital Mortality | OR | 95%CI | p-Value | OR | 95%CI | p-Value |
Age (years) | |||||||
≤70 | 341 (4.4%) | 1 | 1 | ||||
>70 | 448 (9.0%) | 2.115 | 1.83–2.45 | <0.001 | 1.923 | 1.66–2.23 | <0.001 |
Gender | |||||||
Male | 471 (6.9%) | 1 | 1 | ||||
Female | 318 (5.4%) | 0.770 | 0.66–089 | <0.001 | 0.784 | 0.87–0.91 | 0.001 |
Charlson comorbidity index | |||||||
0 | 646 (5.9%) | 1 | 1 | ||||
1 | 103 (7.1%) | 1.229 | 0.99–1.52 | 0.061 | 0.993 | 0.80–1.24 | 0.953 |
≥2 | 40 (21.5%) | 4.402 | 3.07–6.30 | <0.001 | 3.680 | 2.53–5.35 | <0.001 |
Hospital Volume | |||||||
Very low volume | 252 (10.6%) | 1 | 1 | ||||
Low volume | 170 (7.0%) | 0.633 | 0.52–0.78 | <0.001 | 0.632 | 0.51–0.78 | <0.001 |
Medium volume | 170 (6.1%) | 0.545 | 0.44–0.67 | <0.001 | 0.568 | 0.46–0.70 | <0.001 |
High volume | 110 (4.9%) | 0.438 | 0.35–0.55 | <0.001 | 0.516 | 0.40–0.66 | <0.001 |
Very high volume | 87 (3.1%) | 0.266 | 0.21–0.34 | <0.001 | 0.399 | 0.30–0.53 | <0.001 |
Geographical area (operating center) | |||||||
Northern Italy | 404 (5.0%) | 1 | 1 | ||||
Central Italy | 182 (6.9%) | 1.398 | 1.17–1.67 | <0.001 | 1.323 | 1.10–1.59 | 0.003 |
Southern Italy | 203 (10.1%) | 2.129 | 1.78–2.54 | <0.001 | 1.625 | 1.34–1.97 | <0.001 |
Geographical area (patient’s residence) | |||||||
Northern Italy | 370 (5.6%) | 1 | |||||
Central Italy | 177 (6.6%) | 1.206 | 1.01–1.45 | 0.048 | |||
Southern Italy | 239 (7.3%) | 1.327 | 0.12–1.57 | 0.001 | |||
Patient mobility | |||||||
Non-migrating patients | 709 (7.0%) | 1 | 1 | ||||
Migrating patients | 80 (3.1%) | 0.418 | 0.33–0.53 | <0.001 | 0.698 | 0.54–0.90 | 0.006 |
Type of resection | |||||||
Minor (others) | 141 (3.7%) | 1 | 1 | ||||
Major (PD-TP) | 648 (7.4%) | 2.095 | 1.74–2.52 | <0.001 | 1.770 | 1.46–2.14 | <0.001 |
Diagnosis | |||||||
Pancreatic cancer and CP | 522 (6.2%) | 1 | |||||
Other | 267 (6.3%) | 1.021 | 0.88–1.19 | 0.794 | |||
Laparoscopy | |||||||
No | 781 (6.7%) | 1 | 1 | ||||
Yes | 8 (0.8%) | 0.105 | 0.05–0.21 | <0.001 | 0.150 | 0.07–0.30 | <0.001 |
Private patient | |||||||
No | 779 (6.4%) | 1 | 1 | ||||
Yes | 10 (2.1%) | 0.320 | 0.17–0.60 | <0.001 | 0.385 | 0.20–0.73 | 0.003 |
Vascular resection | |||||||
No | 742 (6.3%) | 1 | |||||
Yes | 47 (5.4%) | 0.846 | 0.62–1.15 | 0.280 | |||
Multivisceral resection | |||||||
No | 680 (6.1%) | 1 | |||||
Yes | 109 (7.3%) | 1.211 | 0.98–1.49 | 0.074 |
Mortality of Resections Performed in Each Area/Region | Mortality According to the Area/Region of Patients’ Residence | Mortality of Migrating Patients According to the Area/Region Where They Received Surgery | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Migrating Patients * | Non-Migrating Patients ° | |||||||||||||||
Area/Region | No. of Resections | Observed Mortality | RSMR | No. of Resections | Observed Mortality | RSMR | No. of Resections | Observed Mortality | RSMR | No. of Resections | Observed Mortality | RSMR | ||||
No. | % | % | No. | % | % | No. | % | % | No. | % | % | |||||
Northern Italy | 8023 | 404 | 5.0 | 5.1 | 75 | 2 | 2.7 | 1.4 | 6561 | 368 | 5.6 | 6.0 | 1462 | 36 | 2.5 | 1.3 |
Piedmont | 905 | 62 | 6.8 | 6.1 | 100 | 1 | 3.0 | 1.6 | 887 | 59 | 6.7 | 6.7 | 61 | 5 | 8.2 | 3.4 |
Lombardy | 3037 | 151 | 5.0 | 5.1 | 108 | 2 | 1.9 | 1.0 | 2333 | 124 | 5.3 | 6.0 | 725 | 22 | 3.0 | 1.7 |
Trentino AA | 165 | 6 | 3.6 | 3.5 | 34 | 3 | 8.8 | 5.3 | 175 | 5 | 2.9 | 3.2 | 7 | 2 | 28.5 | 13.3 |
Veneto | 2275 | 68 | 3.0 | 3.2 | 38 | 2 | 5.2 | 3.1 | 1051 | 51 | 4.9 | 5.5 | 1121 | 17 | 1.5 | 0.9 |
Friuli | 226 | 9 | 4.0 | 3.7 | 56 | 0 | 0 | 0 | 208 | 8 | 3.9 | 3.9 | 9 | 0 | 0 | 0 |
Liguria | 261 | 33 | 12.6 | 12.2 | 165 | 8 | 4.8 | 2.3 | 252 | 33 | 13.1 | 14.4 | 11 | 1 | 9.1 | 3.9 |
Emilia-Romagna | 1152 | 75 | 6.5 | 6.3 | 184 | 3 | 1.6 | 0.9 | 1025 | 69 | 6.7 | 7.2 | 140 | 6 | 4.3 | 2.3 |
Central Italy | 2638 | 182 | 6.9 | 7.0 | 388 | 12 | 3.1 | 1.7 | 2275 | 165 | 7.3 | 7.9 | 363 | 17 | 4.7 | 2.5 |
Tuscany | 1096 | 80 | 7.3 | 7.3 | 110 | 3 | 2.7 | 1.5 | 951 | 75 | 7.9 | 8.7 | 144 | 7 | 4.5 | 2.8 |
Umbria | 176 | 13 | 7.4 | 6.7 | 58 | 1 | 1.7 | 1.0 | 159 | 12 | 7.5 | 7.7 | 11 | 1 | 9.1 | 5.6 |
Marche | 282 | 14 | 5.0 | 5.1 | 112 | 6 | 5.4 | 3.1 | 197 | 14 | 7.1 | 8.0 | 89 | 0 | 0 | 0 |
Lazio | 1084 | 75 | 6.9 | 7.2 | 162 | 3 | 1.9 | 1.0 | 914 | 63 | 6.9 | 8.1 | 174 | 11 | 6.3 | 3.4 |
Southern Italy | 2001 | 203 | 10.1 | 9.9 | 1326 | 38 | 2.9 | 1.5 | 1964 | 201 | 10.2 | 10.8 | 37 | 2 | 5.4 | 2.6 |
Abruzzo | 155 | 12 | 7.7 | 7.0 | 134 | 8 | 6.0 | 3.4 | 138 | 12 | 8.7 | 9.0 | 20 | 0 | 0 | 0 |
Campania | 468 | 75 | 16.0 | 16.4 | 320 | 8 | 2.5 | 1.4 | 451 | 74 | 16.4 | 18.8 | 20 | 3 | 15 | 8.7 |
Puglia | 481 | 41 | 8.5 | 8.2 | 239 | 5 | 2.1 | 1.3 | 430 | 37 | 8.6 | 9.3 | 44 | 4 | 9.1 | 4.8 |
Basilicata | 56 | 7 | 12.5 | 11.0 | 27 | 0 | 0 | 0 | 57 | 6 | 10.5 | 10.5 | 4 | 0 | 0 | 0 |
Calabria | 71 | 7 | 9.9 | 9.1 | 224 | 10 | 4.5 | 2.4 | 70 | 7 | 10 | 10.4 | 1 | 0 | 0 | 0 |
Sicily | 559 | 45 | 8.1 | 8.2 | 294 | 8 | 2.7 | 1.5 | 544 | 44 | 8.1 | 9.4 | 15 | 1 | 6.7 | 2.9 |
Sardinia | 192 | 11 | 5.7 | 4.9 | 112 | 1 | 0.9 | 0.5 | 190 | 11 | 5.8 | 5.6 | 2 | 0 | 0 | 0 |
Area/Region | Overall Hospitals Performing Pancreatic Surgery | Minimum Volume ≥ 10 Resections/Year | Minimum Volume ≥ 10 Resections/Year and Mortality ≤ 10% | Minimum Volume ≥ 10 Resections/Year and Mortality ≤ 5% | ||
---|---|---|---|---|---|---|
No. | Rate Per Million Inhabitants | No. | Rate Per Million Inhabitants | |||
Northern Italy | 185 | 55 | 46 | 1.65 | 32 | 1.15 |
Piedmont | 27 | 5 | 4 | 0.92 | 3 | 0.69 |
Valle d’Aosta | 1 | 0 | 0 | 0 | 0 | 0 |
Lombardy | 79 | 23 | 17 | 1.68 | 13 | 1.28 |
Trentino AA | 4 | 3 | 3 | 2.8 | 2 | 1.87 |
Veneto | 27 | 8 | 8 | 1.63 | 7 | 1.42 |
Friuli | 18 | 3 | 3 | 2.48 | 2 | 1.65 |
Liguria | 9 | 2 | 1 | 0.64 | 0 | 0 |
Emilia-Romagna | 20 | 11 | 10 | 2.24 | 5 | 1.12 |
Central Italy | 85 | 17 | 15 | 1.25 | 5 | 0.42 |
Tuscany | 28 | 5 | 4 | 1.07 | 0 | 0 |
Umbria | 9 | 2 | 2 | 2.27 | 0 | 0 |
Marche | 9 | 2 | 2 | 1.31 | 1 | 0.66 |
Lazio | 39 | 8 | 7 | 1.19 | 4 | 0.68 |
Southern Italy | 126 | 20 | 14 | 0.68 | 7 | 0.34 |
Abruzzo | 12 | 1 | 1 | 0.77 | 1 | 0.77 |
Molise | 3 | 0 | 0 | 0 | 0 | 0 |
Campania | 32 | 5 | 1 | 0.17 | 0 | 0 |
Puglia | 27 | 4 | 3 | 0.75 | 1 | 0.25 |
Basilicata | 3 | 1 | 0 | 0 | 0 | 0 |
Calabria | 10 | 1 | 1 | 0.52 | 0 | 0 |
Sicily | 31 | 6 | 6 | 1.21 | 4 | 0.80 |
Sardinia | 8 | 2 | 2 | 1.23 | 1 | 0.61 |
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Share and Cite
Balzano, G.; Guarneri, G.; Pecorelli, N.; Partelli, S.; Crippa, S.; Vico, A.; Falconi, M.; Baglio, G. Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy. Cancers 2023, 15, 2429. https://doi.org/10.3390/cancers15092429
Balzano G, Guarneri G, Pecorelli N, Partelli S, Crippa S, Vico A, Falconi M, Baglio G. Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy. Cancers. 2023; 15(9):2429. https://doi.org/10.3390/cancers15092429
Chicago/Turabian StyleBalzano, Gianpaolo, Giovanni Guarneri, Nicolò Pecorelli, Stefano Partelli, Stefano Crippa, Augusto Vico, Massimo Falconi, and Giovanni Baglio. 2023. "Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy" Cancers 15, no. 9: 2429. https://doi.org/10.3390/cancers15092429
APA StyleBalzano, G., Guarneri, G., Pecorelli, N., Partelli, S., Crippa, S., Vico, A., Falconi, M., & Baglio, G. (2023). Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy. Cancers, 15(9), 2429. https://doi.org/10.3390/cancers15092429