Far From Home: The Role of Travel Distance and Care Fragmentation in Surgical Outcomes for Inflammatory Bowel Disease

**Background:** Fragmented care for inflammatory bowel disease (IBD) is known to correlate negatively with outcomes, but it is unclear which aspects of care fragmentation are relevant and potentially modifiable. There is little data on the relationship between travel distance and the benefits of integrated care models. This study explored associations between integrated care, travel distance, and surgical outcomes for IBD patients undergoing abdominal surgery.

**Methods:** This was a single-center retrospective cohort study conducted at a tertiary referral center. Patients with an ICD diagnosis code for IBD who underwent intestinal surgery (colectomy, proctectomy, ostomy) between January 2015 and December 2020 were identified. Patients with incident IBD (disease duration <1 year) were excluded. The primary outcome was a composite of postoperative complications. Integrated GI care was defined as ≥2 outpatient medical GI encounters at the same institution in the year prior to surgery. Travel distance was calculated as straight-line distance between the hospital and patient residence using zip code centroids, with a cutoff of 75 miles. Multivariable logistic regression with backward stepwise elimination was used to identify factors independently associated with complications. A planned subgroup analysis examined the interaction between care integration and travel distance.

**Key Results:** Of 157 patients included, 82 (52.2%) had nonintegrated GI care and 84 (53.5%) lived >75 miles from the hospital. Overall, 60 patients (38.2%) had a complication. Complications were significantly more common among patients traveling >75 miles (47.6% vs 27.4%, P = .009). Integrated preoperative care was not significantly associated with complications on bivariate (34.7% integrated vs 41.5% nonintegrated, P = .381) or multivariable analysis. After adjustment, factors independently associated with complications were: open surgical approach (OR 3.15, 95% CI: 1.23–8.11), new ileostomy (OR 3.85, 95% CI: 1.79–8.30), and travel distance >75 miles (OR 2.17, 95% CI: 1.01–4.63). The c-statistic for model fit was 0.748. Among patients living <75 miles, complications occurred in 20.9% with integrated care vs 36.7% without (P = .138). For patients >75 miles, complication rates were 53.1% with integrated care vs 44.2% without (P = .428). The interaction term between travel distance and care integration was not statistically significant (P = .056). Sensitivity analyses using alternative outcome definitions (SSI/readmission composite) and different travel distance cutoffs (50 and 100 miles) yielded consistent results.

**Clinical Implications:** This study demonstrates that travel distance >75 miles is independently associated with a twofold increase in surgical complications after adjusting for other risk factors, including surgical acuity and complexity. Integrated preoperative GI care did not show a statistically significant protective effect, though a trend toward benefit was observed among patients living closer to the hospital. The findings suggest that as IBD care becomes increasingly specialized and concentrated in high-volume centers, the burdens of regionalization on remote patients must be considered. Remote patients had greater socioeconomic deprivation (P < .001), more preoperative anemia (P = .060), and higher comorbid disease burden (P = .091), suggesting that travel distance may function as a proxy for multiple risk factors. The authors note that with the observed complication proportions, the study had only 23% power to detect a difference based on care integration, and 383 patients per group would be needed for 80% power. Future efforts addressing continuity of care should consider tactics to mitigate the impact of travel distance, such as enhanced telemedicine capabilities or rural-based integrated care models.