Barriers to surgical care delivery are harming our planet: a case for decentralized provider services

Background: Surgical care centralization in the U.S. delays access and increases carbon emissions. Global targets suggest patients live within 2-hours of a surgical facility. This study quantifies the environmental impact of travel for cataract surgery in rural Michigan and models the potential emissions reductions from decentralizing surgical and follow-up services. Methods: A retrospective, cross-sectional study analyzed electronic medical records from a rural Michigan ophthalmology practice (March-November 2023). We calculated travel distances using population-weighted centroids and estimated emissions using U.S. Department of Energy vehicle data. A k-means clustering model optimized additional facility placement, and a gradient analysis identified optimal numbers for decentralization points, for emissions reductions. Results: The 920 patients traveled a median of 55.45 km (IQR: 43.33-88.20 km) for surgery and 55.07 km (IQR: 43.54-87.82 km) for follow-up visits, generating Total Surgical Access Emissions (TSAE) of 57,168 kgCO2; (median of 59.20 kgCO2; IQR: 32.31-81.87) under the centralized model. The k-means decentralization model and gradient analysis identified 7 hospitals and 9 clinics, respectively, as the optimal expansion points, reducing emissions by 34.07% (19,475 kgCO2 saved) and 39.52% (22,590 kgCO2; saved). The Surgical Access Carbon Impact (SACI) model demonstrated that achieving two-hour access to clinic services reduced excess emissions by 54.7%. Sensitivity analyses using fuel-efficient vehicles (Toyota Prius and Tesla Model 3) or reducing follow-up visit frequency reduced emissions by 54.03% (30,888 kgCO2) and 25.83% (14,768 kgCO2), respectively. Conclusion: Decentralizing surgical services in rural U.S. settings could cut travel-related emissions by up to 40%, significantly reducing healthcare-related carbon footprints while improving timely access to care. The SACI metric provides a novel framework for integrating environmental sustainability into U.S. health policy and service planning