Distance to surgery linked to complications, longer stays in children

About 1 in 8 children who underwent a routine inpatient operation in a 12-state analysis lived more than 60 miles from the treating hospital, and those children had higher adjusted odds of complications, longer hospital stays, and higher charges than peers who lived nearby, according to a study published November 10, 2026, in the Journal of the American College of Surgeons.¹ The association with complications, however, lost statistical significance after investigators accounted for differences between states.²

Lead author Reagan Collins, MD, a surgery resident at the University of Pennsylvania in Philadelphia, cautioned that the results should be read "not as evidence that travel itself causes worse outcomes."² She noted that the burden of distance depends partly on a family's state resources and extends to missed work, child care, and added costs.²

Travel distance and outcomes after common pediatric surgeries

The retrospective study used 2018–2021 data from the Healthcare Cost and Utilization Project State Inpatient Databases.² Investigators identified 71,451 children who underwent appendectomy, cholecystectomy, pyloric stenosis surgery, inguinal hernia repair, or feeding tube placement and compared outcomes by ZIP code–estimated distance from the treating hospital.¹˒²

Overall, 8,594 children (12%) lived more than 60 miles away.² Compared with children living within 30 miles, this group had 21% higher adjusted odds of complications, an approximately 13% longer length of stay, and approximately 9% higher hospital charges.² Children living 30 to 60 miles away had length of stay and charges each about 4% higher than the closest group.²

The farthest-traveling cohort differed at baseline: these children were younger (median age, 3 vs 10 years), more often rural (47% vs 5%), and more often transferred from another facility (39% vs 13%).² Results were generally consistent after excluding COVID-19 pandemic years and analyzing each procedure separately.²

Regionalization of pediatric surgical care and rural access

Routine pediatric surgery continues to shift toward larger hospitals and specialized children's hospitals.² An earlier Child Health Evaluation of Surgical Services analysis of 143,467 children undergoing 7 common procedures from 2002 to 2017 found that travel distance rose more steeply for rural than urban children.³ Rural residence (adjusted odds ratio [aOR], 6.55; 95% CI, 6.11–7.01), age younger than 5 years (aOR, 2.17; 95% CI, 1.92–2.46), and Medicaid coverage (aOR, 1.35; 95% CI, 1.26–1.45) were each associated with traveling more than 60 miles.³

Single-center data point the same way. At a quaternary pediatric surgical center with a large rural catchment area, patients living more than 120 minutes away had higher unadjusted odds of serious postoperative adverse events than those within 60 minutes (odds ratio, 1.97; 95% CI, 1.84–2.12).⁴

Interpreting the link between distance and pediatric surgical complications

Senior author Cornelia L. Griggs, MD, MPH, FACS, a pediatric surgeon at Mass General Brigham for Children in Boston, emphasized the financial strain on traveling families, particularly when parents lose work time or need care for siblings at home.² She said the data could inform questions about the pediatric surgical workforce and where hospitals should offer services.²

The authors noted that some children may be treated safely closer to home, whereas others benefit from referral to a specialized center.² They proposed stronger local-regional hospital partnerships, clearer referral criteria, and transportation, lodging, or telemedicine support when travel is unavoidable.²

Study limitations and next steps

The administrative database does not capture illness severity, surgical complexity, or pediatric services available at local hospitals, so excess complications among distant patients may reflect case mix rather than distance itself; children with complex needs may have been referred to specialized centers by design.² Distance was estimated from ZIP codes and may not reflect actual travel time.² The investigators plan future studies examining travel time and patient complexity.²

References

1. Collins RA, Mullens CL, Shnawa GN, et al. Association between travel distance and outcomes for common pediatric surgical procedures. J Am Coll Surg. Published online November 10, 2026. doi:10.1097/XCS.0000000000002208

2. American College of Surgeons. Children who travel farther for common surgery have more complications and longer hospital stays. News release. EurekAlert!. November 10, 2026. Accessed November 11, 2026. https://www.eurekalert.org/news-releases/1151358

3. Gadepalli SK, Leraas HJ, Flynn-O'Brien KT, et al. Changing landscape of routine pediatric surgery for rural and urban children: a report from the Child Health Evaluation of Surgical Services (CHESS) group. Ann Surg. 2023;278(4):530-537. doi:10.1097/SLA.0000000000005990

4. Cockrell H, Barry D, Dick A, Greenberg S. Geographic access to care and pediatric surgical outcomes. Am J Surg. 2023;225(5):903-908. doi:10.1016/j.amjsurg.2023.02.010