Nearly 40 years ago, Ross Mullner and Jack Goldberg published “Toward an outcome-oriented medical geography: an evaluation of the Illinois trauma/emergency medical services system” (Soc Sci Med 1978;12(2D):103-110). The underlying question was whether regionalization and optimal location of services actually made a difference in patient outcome, and the answer was “yes.” This led me, in some of my early research in the 1980s, to ask a similar question. I was interested in whether location of emergency medical service units (either BLS or ALS–that is, either EMT or paramedic units) made a difference in patient survival from cardiac arrest, and, in particular, ventricular fibrillation. My answer, too, using the Seattle Medic I program as an example, was also “yes.” Survival from out of hospital cardiac arrest dropped for each additional minute of delay. Thus, choosing the best strategic locations for these units actually mattered to survival.
In retrospect, both of these sets of articles were harbingers of the evidence-based medicine/comparative outcomes movements. I wanted to know whether the selection of location, in order to minimize aggregate response times, would benefit patients. In other words, did geography matter to outcomes?
There is other evidence that it does, at least in some contexts. Regionalization of specialized services can affect outcome, because of the well known volume-outcome relationships for procedures as diverse as coronary artery bypass grafting, aortic aneurysm surgery, the Whipple procedure for pancreatic cancers, burn services, neonatal intensive care, and others. In most centrally planned systems, regionalization is mandated and is taken for granted: complex procedures and services should be centralized and consolidated to maximize outcome and, sometimes, to minimize cost. In the US, these arrangements have been more haphazard. It is the norm for high level services for severe burns to be regionalized, as it is for highest order trauma, the most specialized neonatal intensive care units, and some organ transplantation services (cardiac transplantation and lung transplants are more consolidated than kidney transplant services). This regionalization is through a patchwork quilt of cooperative and voluntary arrangements, as well as some statutes. On the other hand, there is far less centralization and consolidation of cardiac surgery. Why? Because cardiac surgery tends to be a money maker for hospitals. Thus, in the Seattle metropolitan area, cardiac surgery is performed in between 6 and 8 hospitals, depending on the definition of the metropolitan area. This region has approximately 2.5 million people. In the UK, a similar area would be served by 1-2 institutions.
Logically, one would hope that services would be configured in a manner that best serves the patient–and not the hospitals. This is not always the case in the US–in fact, this happens far less frequently than one would hope. Of course, “benefit the patient” is a slippery term, because it can mean anything from “be most convenient for the patient” to “maximizes survival probability for the patient.” This is the case when considering whether a given service should be more dispersed, and therefore more accessible, or more centralized, which is less convenient to those at more distant locations. In the case of services for which the outcome depends in part on volume–the “practice makes perfect” orientation, a strong ethical argument can be made for greater centralization. That arrangement would be most beneficent, or at least non-maleficent, and these considerations are basic to contemporary medical ethics. In fact, it was exactly this set of considerations that led me to do a fellowship in medical ethics that led to my serving as Chief of the Clinical Ethics Consult Service at one of the Seattle area hospitals.
I see an ethically grounded outcome-orientation all too rarely in geographic studies of health services. I hope that one of our goals is to benefit “the patient” which, in the aggregate, means “to beneficent as many patients as possible.” In other words, this is the utilitarian philosophy that one sees in distributive justice considerations in medical ethics: to do the greatest good for the greatest number.
I hope that we can return to this outcome orientation in which the greatest good for the greatest number is a strong priority.