Geographic Distribution of Radiation Oncologists in the United States

Revolutionizing Rural Oncology: Innovative Models and Global Perspectives

For individuals living in rural areas, access to cancer care can be difficult. Barriers to access cross international boundaries and have a negative impact on treatment outcomes. Current models to increase rural access in the United States are reviewed, as is a system-wide approach to this problem in Australia. Ongoing efforts to increase access to clinical trials for patients in rural areas are also discussed.

Radiation Oncology Training in the Philippines: Bridging Gaps for Improved Cancer Care in Low- and Middle-Income Countries

PURPOSE

Radiation oncology in the Philippines, a large lower- and middle-income country in Southeast Asia, is facing a critical shortage in manpower, with only 113 radiation oncologists (ROs) over 55 radiotherapy (RT) centers serving 100 million population. Paramount to workforce expansion is ensuring that training programs can produce adequately trained specialists. In this study, we describe the current state of radiation oncology training programs in the Philippines.

METHODS

This is a cross-sectional observational analysis of the nine radiation oncology residency training programs in the Philippines. Data were collected from a survey of the program directors, the Philippine Radiation Oncology Society database, and a PubMed literature search.

RESULTS

Eight of the nine programs are in the National Capital Region. Since program standardization in 2005, there have been 82 four-year residency graduates, with up to 18 new graduates annually. Faculty-to-trainee ratio ranges from 0.5 to 2.67. In terms of technology, all programs have intensity-modulated RT and high-dose-rate brachytherapy, but only six are equipped with computed tomography-based image guidance and stereotactic capabilities. Clinical education schemes vary per institution regarding curriculum implementation, resident activities, and methods of evaluation. Required resident case logs are not met for lung, GI, genitourinary, bone and soft tissue, and hematologic malignancies. In total, there are only 22 resident-led publications from 10 unique individuals in two training programs.

CONCLUSION

Program expansions are warranted to meet the projected demand for ROs in the Philippines, but training programs must first improve key aspects of staffing, technology, clinical education, and research. Addressing training challenges related to resource limitations necessitates local and international collaborations with higher-capacity centers to bridge gaps for continued quality improvement with the aim of ultimately delivering better overall cancer care.

Academic and Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2015-2022

PURPOSE

Little is known about how the academic and geographic employment outcomes of new radiation oncology (RO) graduates have changed over time. In this study, we sought to trace the evolution of these outcomes for all RO residents who graduated between 2015 and 2022.

METHODS AND MATERIALS

Using publicly available data sources, we identified the first permanent, clinical employment positions accepted by graduating members of the RO residency classes of 2015 to 2022. We additionally determined the medical school and residency program attended by each graduate. We then classified each clinical employment position by its rural-urban continuum code and core-based statistical area, and whether it was academic or nonacademic.

RESULTS

Of 1478 RO graduates identified, 1396 first accepted clinical positions in the United States after residency. A majority accepted positions in the largest metropolitan areas (N = 878, 62.9%) and in nonacademic settings (N = 719, 51.5%). The proportion of graduates who accepted academic positions climbed steadily from 2015 to 2020 before dropping by 31% in 2021 and partially rebounding in 2022. Women and graduates of large-sized academic programs were more likely to have accepted academic positions. In contrast, graduates of small-sized residency programs were more likely than those of large-sized residency programs to have accepted positions in nonmetropolitan areas. At least 288 of the examined individuals (20.6%) had switched jobs at least once at the time of this analysis.

CONCLUSIONS

Most new RO graduates in this study accepted clinical positions in large metropolitan areas. A slight majority accepted nonacademic positions. While the RO job market was able to absorb the vast majority of these new graduates between 2015 and 2022, there is no guarantee that this equilibrium will hold in the future. Additional studies aiming to refine projections of future RO demand are needed.

Forecasting Rural and Urban Otolaryngologists, Radiation Oncologists, and Oropharyngeal Carcinoma

OBJECTIVE

To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030.

METHODS

Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons.

RESULTS

Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96).

CONCLUSIONS

Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:136-142, 2024.

Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020

BACKGROUND

United States cancer death rates have been steadily declining since the early 1990s, but information on disparities in progress against cancer mortality across congressional districts is lacking. This study examined trends in cancer death rates, overall and for lung, colorectal, female breast, and prostate cancer by congressional district.

METHODS

County level cancer death counts and population data from the National Center for Health Statistics were used to estimate relative change in age-standardized cancer death rates from 1996-2003 to 2012-2020 by sex and congressional district.

RESULTS

From 1996-2003 to 2012-2020, overall cancer death rates declined in every congressional district, with most congressional districts showing a 20%-45% decline among males and a 10%-40% decline among females. In general, the smallest percent of relative declines were found in the Midwest and Appalachia, whereas the largest declines were found in the South along the East Coast and the southern border. As a result, the highest cancer death rates generally shifted from congressional districts across the South in 1996-2003 to districts in the Midwest and central divisions of the South (including Appalachia) in 2012-2020. Death rates for lung, colorectal, female breast, and prostate cancers also declined in almost all congressional districts, although with some variation in relative changes and geographical patterns.

CONCLUSIONS

Progress in reducing cancer death rates during the past 25 years considerably vary by congressional district, underscoring the need for strengthening existing and implementing new public health policies for broad and equitable application of proven interventions such as raising tax on tobacco and Medicaid expansion.

Building Better Patient Care in Mississippi Radiation Oncology: Why Mississippi Needs a Collaborative Quality Initiative

OBJECTIVES

Cancer is an insidious and devastating disease that affects many people. Progress in mortality rate has not been realized universally across the United States, and challenges remain in how to best make up the ground that has been lost in these areas, one of which is Mississippi. Radiation therapy is a significant contributor to cancer control rates and certain challenges exist specifically regarding this treatment modality.

METHODS

The challenges of radiation oncology in Mississippi have been reviewed and discussed, with the proposal of a potential collaboration between clinical practitioners and payors to provide optimal and cost-effective radiation therapy to patients in Mississippi.

RESULTS

A similar model to that proposed has been reviewed and evaluated. This model is discussed based on its potential validity and usefulness in Mississippi.

CONCLUSIONS

Significant barriers exist in the state of Mississippi to patients receiving a consistent standard of care, regardless of their location and socioeconomic status. A collaborative quality initiative has been shown to be a boon to this endeavor elsewhere and stands to have a similar impact in Mississippi.

Prospective 5-Year Analysis of the United States Radiation Oncology Job Market Using the ASTRO Career Center Website

PURPOSE

We provide 5-year results of prospectively collected radiation oncology (RO) job opportunities and a longitudinal assessment of RO graduate numbers within the United States.

METHODS AND MATERIALS

Full-time domestic RO job opportunities were collected and categorized using the American Society for Radiation Oncology (ASTRO) Career Center from July 1, 2016 to June 30, 2021. A chi-square test was used to compare regional job availability by city size and position type. The corresponding number of graduating United States (US) RO residents (2017-2021) was collected. US census and Medicare database resources were used as comparators for population and workforce estimates. Pearson's correlation coefficients were used to examine changes in data over time and a 2-tailed t test was used to assess for statistical significance.

RESULTS

Over the 5-year study period, 819 unique job offers were posted, compared with 935 RO graduates (0.88 total jobs-to-graduates ratio). Most jobs were nonacademic (57.6%), located in populated areas >1 million (57.1%; median: 1.57M), with the largest proportion of jobs seen in the South region (32.4%). One-third of academic jobs were located at satellites. Regional differences were seen between academic versus nonacademic job availability (P < .01), with the highest proportion of academic jobs seen in the Northeast (60.3%) and the lowest in the Midwest (34.5%). Differences between regions were also observed for jobs in areas >1 million versus ≤1 million (P < .01), with the most jobs in areas >1 million seen in the West (64.6%) and the least in the South (51.3%). Regional job availability over time did not differ by position type (academic vs nonacademic) or population area size (P = .11 and P = .27, respectively). Annual graduate numbers increased with time (P = .02), with the highest percentage of graduates trained in the South (30.8%). Regional distribution of jobs versus graduates significantly differed (P < .01) with the lowest jobs-to-graduates ratio observed in the Northeast (0.67) and highest ratio in the West (1.07). Regional RO workforce estimates based on the 4336 radiation oncologists who were Medicare providers in 2020 were compared with total jobs and graduates by region with no difference observed between the distributions of the workforce and jobs (P = .39), but comparisons between the workforce and graduates were proportionally different (P < .01). The number of total jobs (vs graduates) per 10 million population in the Northeast, South, Midwest, and West were 30.2 (45.1), 21.0 (22.7), 30.6 (33.4), and 22.6 (21.2), respectively.

CONCLUSIONS

This multiyear quantitative assessment of the RO job market and graduates identified fewer job opportunities than graduates overall in most regions, most notably in the Northeast. Regional differences were seen between available job type (academic vs nonacademic) and population size (>1 million vs ≤1 million). The findings are worrisome for trainee oversupply and geographic maldistribution. The number and distribution of RO trainees and residency programs across the US should be evaluated to minimize job market imbalance for future graduates, promote workforce stability, and continue to meet the future societal needs of patients with cancer.

Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2021

PURPOSE

In light of the persistent disparity in the prevalence of radiation oncologists between rural and urban areas in the United States, we sought to characterize the geographic employment outcomes of the radiation oncology (RO) residency class of 2021.

METHODS AND MATERIALS

We identified the employment positions accepted by 2021 RO residency graduates using publicly available information. Then, we classified each position as academic or nonacademic and determined the rural-urban continuum code and core-based statistical area (CBSA) of each position, residency program, and medical school associated with the 2021 graduates. Last, we compared the geographic employment outcomes of the 2021 class with those of the 2019 class.

RESULTS

Most 2021 graduates accepted employment positions outside of the counties, CBSAs, and states in which they attended medical school or residency. A total of 116 graduates accepted nonacademic positions, and 65 graduates accepted academic positions. Nine graduates accepted fellowships and were excluded from this analysis. As with the class of 2019, most 2021 graduates (n = 104; 57.5%) accepted positions in the largest metropolitan areas, and few (n = 11; 6.1%) accepted positions in nonmetropolitan areas. Female residents were more likely to accept academic (48.9% vs 31.3%; P = .03) and academic main site (36.2% vs 21.6%; P = .05) positions than male residents. The distribution of jobs in both the 5 and 10 largest CBSAs was not significantly different from what would have been expected if jobs were equally distributed across the country on the basis of population (P = .81 and P = .87, respectively). However, the distribution was significantly different from what would have been expected if the distribution of such positions reflected the number of residents who graduated from residency programs in those CBSAs (P < .01 and P < .01, respectively).

CONCLUSIONS

As with the class of 2019, the majority of graduates in the class of 2021 accepted employment positions in large metropolitan areas. Relatively few graduates accepted positions in nonmetropolitan areas. How key RO stakeholders respond to the challenge of maintaining a stable supply of rural radiation oncologists while also ensuring that jobs available to graduating RO residents reflect their preferences will have a significant effect on the field going forward.

Rural-urban survival disparities for patients with surgically treated lung cancer

BACKGROUND

Nonsmall-cell lung cancer (NSCLC) is a common diagnosis among patients living in rural areas and small towns who face unique challenges accessing care. We examined differences in survival for surgically treated rural and small-town patients compared to those from urban and metropolitan areas.

METHODS

The National Cancer Database was used to identify surgically treated NSCLC patients from 2004 to 2016. Patients from rural/small-town counties were compared to urban/metro counties. Differences in patient clinical, sociodemographic, hospital, and travel characteristics were described. Survival differences were examined with Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

The study included 366 373 surgically treated NSCLC patients with 12.4% (n = 45 304) categorized as rural/small-town. Rural/small-town patients traveled farther for treatment and were from areas characterized by lower income and education(all p < 0.001). Survival probabilities for rural/small-town patients were worse at 1 year (85% vs. 87%), 5 years (48% vs. 54%), and 10 years (26% vs. 31%) (p < 0.001). Travel distance >100 miles (hazard ratio [HR] = 1.11, 95% confidence interval [CI]: 1.07-1.16, vs. <25 miles) and living in a rural/small-town county (HR = 1.04, 95% CI: 1.01-1.07) were associated with increased risk for death.

CONCLUSIONS

Rural and small-town patients with surgically treated NSCLC had worse survival outcomes compared to urban and metropolitan patients.

Disparities in Access to Radiation Therapy by Race and Ethnicity in the United States With Focus on American Indian/Alaska Native People

OBJECTIVES

Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic-minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality.

METHODS

The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility.

RESULTS

Median distance to nearest RT facility was 72 miles in AI/AN-majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN-majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas.

CONCLUSIONS

Cancer patients in block groups with AI/AN-majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care.

Evaluation of Radiation Oncologist And Trainee Opinions on Residency Expansion, Possible Actions, and Training Program Accreditation Changes in the United States

PURPOSE

To sample U.S. radiation oncologist and trainee opinions regarding residency expansion, what action(s) should be taken to limit residency supply, if any, and the proposed Accreditation Council for Graduate Medical Education (ACGME) changes.

MATERIALS AND METHODS

An online survey was distributed to 1048 attending radiation oncologists by email and ∼800 residents through their program coordinators. The survey asked respondents to rank how strongly they agreed with certain statements regarding residency supply, possible solutions to address any perceived oversupply, and the proposed ACGME changes on a 1-10 disagreement-to-agreement scale. The 16% response rate yielded 294 responses for analysis.

RESULTS

Of the respondents, 90 (30%) were residents, and 204 (70%) were attendings, of whom 117 (57%) were academic, and 87 (43%) were non-academic. 86% agreed that there is a residency oversupply issue, and 91% agreed that actions should be taken to limit residency expansion. On chi-square test, residents and attendings were similarly likely to agree that there is a residency oversupply issue (93% and 89%, p=0.27), although residents were more likely to agree that this oversupply should be acted upon compared to attendings (100% and 88%, p<0.01). Regarding possible solutions, respondents were most likely to agree that further expansion should be limited (90%), program requirements should be made more stringent (76%), and the use of the Supplemental Offer and Acceptance Program should be limited (SOAP) (69%). Proposed ACGME changes that respondents were most likely to agree with included requiring that programs have modern image guidance, stereotactic radiotherapy, and brachytherapy techniques (98%) and have 4+ faculty members and maintain a faculty-to-resident ratio of >1.5:1 (86%). Case log minimums most supported to be increased were 4 uterus (65%) and 11 postmastectomy breast (61%) simulations.

CONCLUSIONS

The majority of respondents agree that there is a residency oversupply issue and that actions should be taken to limit residency expansion and make program requirements more stringent.

Variable Impact of the COVID-19 Pandemic on U.S. Radiation Oncology Practices

Early in the pandemic, the American Society for Radiation Oncology (ASTRO) surveyed physician leaders at U.S. radiation oncology practices to understand how the field was responding to the outbreak of COVID-19. Surveys were repeated at multiple points during the pandemic, with a response rate of 43% in April 2020 and 23% in January 2021. To our knowledge, this is the only longitudinal COVID-19 practice survey in oncology in the U.S. The surveys indicate that patient access to essential radiation oncology services in the United States has been preserved throughout the COVID-19 pandemic. Safety protocols were universally adopted, telehealth was widely adopted and remains in use, and most clinics no longer deferred or postponed radiation treatments as of early 2021. Late-stage disease presentation, treatment interruptions, PPE shortages, and vaccination barriers were reported significantly more at community-based practices than academic practices, and rural practices appear to have faced increased obstacles. These findings provide unique insights into the initial longitudinal impact of the COVID-19 pandemic on the delivery of radiation therapy in the United States. Downstream lessons in service adaptation and improvement can potentially be guided by formal concepts of resilience, which have been broadly embraced across the U.S. economy.

Geographic differences in therapy for stage I non-small-cell lung cancer in older adults

BACKGROUND

Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States.

METHODS

Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.

RESULTS

Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05).

CONCLUSIONS

Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Diversity Trends by Sex and Underrepresented in Medicine Status Among US Radiation and Medical Oncology Faculty Over 5 Decades

Importance

It remains unclear how the historical exclusion of women and racial and ethnic minority groups from medical training, and therefore the oncologic subspecialties, has contributed to rates of faculty diversity among oncology departments over time. Oncologic faculty diversity is an important initiative to help improve care and address health disparities for an increasingly diverse US population with cancer.

Objectives

To report trends in academic faculty representation by sex and by race and ethnicity for radiation oncology (RO) and medical oncology (MO) departments and to describe comparisons with the general US population, medical students, RO and MO trainees, clinical department chairs, and faculty in other departments.

Design, Setting, and Participants

This cross-sectional analysis used data from the Association of American Medical Colleges to analyze trends by sex and by race and ethnicity among full-time US faculty in RO and MO departments from 1970 through 2019. Data were analyzed between October 2020 and April 2021.

Main Outcomes and Measures

Proportions of women and individuals from underrepresented in medicine (URM) racial and ethnic groups (Black, Hispanic, and Indigenous individuals) were calculated among RO and MO academic departments; trends were analyzed over 5 decades. These proportions were compared with cohorts already described. In addition, proportions of women and URM individuals were calculated by faculty rank among RO and MO departments.

Results

In 1970, there were 119 total faculty in RO (10 women [8.4%] and 2 URM [1.7%]) and 87 total faculty in MO (11 women [12.6%] and 7 URM [8.0%]). In 2019, there were 2115 total faculty in RO (615 women [29.1%] and 108 URM [5.1%]) and 819 total faculty in MO (312 women [38.1%] and 47 URM [5.7%]). Total faculty numbers increased over time in both RO and MO. Faculty representation of URM women proportionally increased by 0.1% per decade in both RO (95% CI, 0.005%-0.110%; P <. 001 for trend) and MO (95% CI, -0.03% to 0.16%; P = .06 for trend) compared with non-URM women faculty, which increased by 0.4% (95% CI, 0.25%-0.80%) per decade in RO and 0.7% (95% CI, 0.47%-0.87%) per decade in MO (P < .001 for trend for both). Faculty representation of URM men did not significantly change for RO (0.03% per decade [95% CI, -0.008% to 0.065%]; P = .09 for trend) or MO (0.003% per decade [95% CI, -0.13% to 0.14%]; P = .94 for trend). Representation of both women and URM individuals among both specialties was lower than their representation in the US population in both 2009 and 2019. Across all cohorts studied, RO faculty had the lowest URM representation in 2019 at 5.1%. At every rank in 2019, the number of total URM faculty represented among both MO and RO remained low (MO: instructor, 2 of 44 [5%]; assistant professor, 18 of 274 [7%]; associate professor, 13 of 177 [7%]; full professor, 13 of 276 [5%]; and RO: instructor, 9 of 147 [6%]; assistant professor, 57 of 927 [6%]; associate professor, 20 of 510 [4%]; full professor, 18 of 452 [4%]).

Conclusions and Relevance

This cross-sectional study suggests that RO and MO academic faculty have increased the representation of women over time, while URM representation has lagged. The URM trends over time need further investigation to inform strategies to improve URM representation in RO and MO.

Geographic Access to Radiation Therapy Facilities in the United States

BACKGROUND

The current distribution of radiation therapy (RT) facilities in the US is not well established. A comprehensive inventory of US RT facilities was last assessed in 2005, based on data from state regulatory agencies and dosimetric quality assurance bodies. We updated this database to characterize population-level measures of geographic access to RT and analyze changes over the past 15 years.

METHODS

We compiled data from regulatory and accrediting organizations to identify US facilities with linear accelerators used to treat humans in 2018-2020. Addresses were geocoded and analyzed with Geographic Information Services (GIS) software. Geographic access was characterized by assessing the Euclidian distance between zip code tabulation areas (ZCTA)/county centroids and RT facilities. Populations were assigned to each county to estimate the impact of facility changes at the population level. Logistic regressions were performed to identify features associated with increased distance to RT and associated with regions that gained an RT facility between the two time points studied.

RESULTS

In 2020, a total of 2,313 US RT facilities were reported compared to 1,987 in 2005, representing a 16.4% growth in facilities over nearly 15 years. Based on population attribution to ZCTA centroids, 77.9% of the US population lives within 12.5 miles of an RT facility, and 1.8% of the US population lives more than 50 miles from an RT facility. We found that increased distance to RT was associated with non-metro status, less insurance, older median age, and less populated regions. Between 2005 and 2020, the population living within 12.5 miles from an RT facility increased by 2.1 percentage points, while the population living furthest from RT facilities decreased 0.6 percentage points. Regions with improved geographic RT access are more likely to be higher income and better insured.

CONCLUSION

1.8% of the US population has limited geographic access to radiation therapy. We found that people benefiting from improved access to RT facilities are more economically advantaged, suggesting disparities in geographic access may not improve without intervention.

Disparities in Healthcare Services and Spatial Assessments of Mobile Health Clinics in the Border Regions of Thailand

Reducing the disparities in healthcare access is one of the important goals in healthcare services and is significant for national health. However, measuring the complexity of access in truly underserved areas is the critical step in designing and implementing healthcare policy to improve those services and to provide additional support. Even though there are methods and tools for modeling healthcare accessibility, the context of data is challenging to interpret at the local level for targeted program implementation due to its complexity. Therefore, the purpose of this study is to develop a concise and context-specific methodology for assessing disparities for a remote province in Thailand to assist in the development and expansion of the efficient use of additional mobile health clinics. We applied the geographic information system (GIS) methodology with the travel time-based approach to visualize and analyze the concealed information of spatial data in the finer analysis resolution of the study area, which was located in the border region of the country, Ubon Ratchathani, to identify the regional differences in healthcare allocation. Our results highlight the significantly inadequate level of accessibility to healthcare services in the regions. We found that over 253,000 of the population lived more than half an hour away from a hospital. Moreover, the relationships of the vulnerable residents and underserved regions across the province are underlined in the study and substantially discussed in terms of expansion of mobile health delivery to embrace the barrier of travel duration to reach healthcare facilities. Accordingly, this research study addresses regional disparities and provides valuable references for governmental authorities and health planners in healthcare strategy design and intervention to minimize the inequalities in healthcare services.

Changes in dermatology practice characteristics in the United States from 2012 to 2017

Background

Dermatology practice has recently seen multiple changes. A better understanding of trends pertaining to dermatology practice setups is necessary.

Objective

To analyze the recent changes in dermatology practice in terms of geography, practice size, and gender distribution as well as to analyze the availability of dermatologists based on zip codes’ income levels.

Methods

This was a cross-sectional study. We extracted data on the sex and billing addresses of dermatologists from Medicare provider utilization and payment data for 2012 and 2017. We used 2017 tax returns data to calculate the poverty level for each zip code.

Results

Between 2012 and 2017, the number of solo practitioners decreased, while that of dermatologists working in large groups increased. The southern region experienced the largest changes. The male-to-female ratio decreased. Dermatology practices mainly comprised mixed genders, with a higher proportion of all-male groups versus that of all-female groups, but this difference decreased over time. In the northeastern and western regions, more than one third of dermatologists were located in the wealthiest zip codes.

Limitations

The Medicare data may not be exhaustively representative of the dermatology workforce, and the zip codes of 489 dermatologists’ billing addresses were missing in the tax return dataset.

Conclusions

These findings provide an understanding of the recent changes pertaining to dermatology practice setups and of the substantial health care disparities based on geographic distribution.

Geographic access to brachytherapy services in the United States

PURPOSE

Disparities in geographic access to medical care exist in nearly all fields of medicine including radiation oncology. We aim to update knowledge of the geographic distribution of radiation oncologists in the United States.

METHODS AND MATERIALS

We used the Physician and Other Supplier Public Use File (PUF) from the Centers for Medicare & Medicaid Services (CMS) as well as the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) database to identify practices that either coded for or are marked as having access to brachytherapy services. Geographic analysis was performed on several levels including United States (US) Census region, Dartmouth Atlas Healthcare Referral Region, and the county level.

RESULTS

We identified 327 providers that billed for a brachytherapy code during the calendar year 2018 and 564 facilities providing brachytherapy. Within the 306 HRRs in the US, 149 have access to brachytherapy. This represents 247.5 million people based on 2018 estimates of population from the US Census Bureau. This implies that 76.7% of people within the US live in an HRR with access to brachytherapy, and, conversely, that 75.3 million people (23.3%) do not. Numerically, counties in metropolitan areas were more likely to have access to brachytherapy than those outside of a metropolitan area.

CONCLUSIONS

Geographic disparities exist in access to brachytherapy; metropolitan counties are more likely to have access than non-metropolitan counties. We support continued development of databases of brachytherapy providers and programs that may support travel and lodging costs to minimize these disparities.

The Geography of Employment Outcomes for Radiation Oncology Graduates in 2019

PURPOSE

The geographic distribution of practicing radiation oncologists is of concern for multiple stakeholders within the field. Employment outcomes of graduating residents can affect that distribution, and they are of major concern to current residents. Data investigating employment outcomes of recent graduates are sparse. We aimed to analyze the employment outcomes of the radiation oncology residency class of 2019.

METHODS AND MATERIALS

Using publicly available information, we identified the employment of 179 of 183 graduating residents in the class of 2019. For each, the place of employment, residency program, and medical school were geocoded using Google Maps. We used the rural-urban continuum code (RUCC) published by the United States Department of Agriculture to determine the rurality of each location and compared employment outcomes by RUCC and program size.

RESULTS

Two thirds of graduates (66%) took a position in a county within a metropolitan area with a population greater than 1,000,000 people; only 3.4% took a position in a county outside of a metropolitan area. Graduates of smaller programs (≤6 residents) and those in smaller metropolitan areas were more likely to take positions in smaller metropolitan areas or nonmetropolitan areas. The geographic distance between location of employment and residency program did not significantly vary by program size or size of metropolitan area where a residency program was located.

CONCLUSIONS

Among the class of 2019, a small proportion took positions in nonmetropolitan areas. Smaller programs and those in smaller metropolitan areas may be more likely to produce graduates that practice in similar settings, but those graduates might not do so locally. We advocate for a centralized, prospective data collection of employment outcomes for graduating residents to refine these analyses and to reduce employment prospect information asymmetry for trainees.

Travel Time to Radiation Oncology Facilities in the United States and the Influence of Certificate of Need Policies

PURPOSE

Radiation therapy often requires weeks of daily treatment making travel distance a known barrier to care. However, the full extent and variability of travel burden, defined by travel time, across the nation is poorly understood. Additionally, some states restrict radiation oncology (RO) services through Certificate of Need (CON) policies, but it is unknown how this affects travel times to care. Therefore, we aim to evaluate travel times to US RO facilities and assess the association with CON policies.

METHODS AND MATERIALS

RO facilities were identified from the 2018 National Plan and Provider Enumeration System (n = 2302). Travel times from populated US census tracts to nearest facility were calculated; differences by rurality, area deprivation, and region were computed. Multivariable linear regression was used to estimate adjusted differences in travel time by area characteristics. Logistic regression was used to assess the association of state CON laws with travel time >1 hour.

RESULTS

Among 72,471 census tracts, 92.4% were within 1 hour of the nearest radiation facility. Among the 12,453 rural tracts, 34.4% were >1 hour. On adjusted analysis, the 3054 isolated rural tracts had an estimated 58-minute (95% confidence interval [CI] 57, 59; P < .001) longer travel time than urban tracts. CON laws decreased rural travel time overall, but the association varied by region with decreased odds of prolonged travel in the South (P < .001), increased odds in the Northeast and Midwest (P < .001), and no association in the West (P = NS).

CONCLUSIONS

Isolated rural US census tracts, accounting for 9.4 million Americans, have nearly 1-hour longer adjusted travel time to the nearest RO facility, compared with urban tracts. CON laws had region-dependent associations with prolonged travel.