To examine the potential impact of a policy of selective referral to high-volume knee replacement hospitals on patients' travel distance to hospitals and access to care for patients seeking total knee replacement (TKR) in urban and rural settings.
The travel distance required for patients to reach their hospital of service and the additional travel distance required to reach the nearest high-volume hospital were analyzed using a 100% sample of Medicare fee-for-service patients undergoing TKR in 2001.
Of the 183,174 TKRs performed in the US during 2001, 95% of the patients selected underwent TKR at a hospital that was located within 50 miles of their residence. There were 11,550 patients who had their TKR performed at a low-volume hospital (LVH) where there was no nearer high-volume hospital. The impact of a policy that would direct patients to high-volume hospitals varied by region. In urban areas, the nearest high-volume hospital was a median of 3.8 miles further than the LVH of service. The patient factors race and poverty were associated with selection of LVHs in urban areas. In rural areas and urban clusters, 1,506 patients would have had to travel >50 miles and 259 patients would have had to travel >100 miles to reach a high-volume hospital.
A policy to direct patients away from LVHs could increase patients' travel time to hospitals in rural areas and restrict access for minority and low-income patients in urban areas. Any implementation of selective referral to high-volume centers should address access to hospitals for rural patients and urban minority and low-income patients.