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Scodari BT, Schaefer AP, Kapadia NS, Brooks GA, O'Malley AJ, Moen EL. The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach. Ann Surg Oncol 2024; 31:4349-4360. [PMID: 38538822 PMCID: PMC11176015 DOI: 10.1245/s10434-024-15195-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies. METHODS We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay. RESULTS We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25). CONCLUSIONS Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.
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Affiliation(s)
- Bruno T Scodari
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - A James O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
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Abstract
BACKGROUND Workforce experts predict a future shortage of cardiologists that is expected to impact rural areas more severely than urban areas. However, there is little research on how rural patients are currently served through clinical outreach. This study examines the impact of cardiology outreach in Iowa, a state with a large rural population, on participating cardiologists and on patient access. METHODS AND RESULTS Outreach clinics are tracked annually in the Office of Statewide Clinical Education Programs Visiting Medical Consultant Database (University of Iowa Carver College of Medicine). Data from 2014 were analyzed. In 2014, an estimated 5460 visiting consultant clinic days were provided in 96 predominantly rural cities by 167 cardiologists from Iowa and adjoining states. Forty-five percent of Iowa cardiologists participated in rural outreach. Visiting cardiologists from Iowa and adjoining states drive an estimated 45 000 miles per month. Because of monthly outreach clinics, the average driving time to the nearest cardiologist falls from 42.2±20.0 to 14.7±11.0 minutes for rural Iowans. Cardiology outreach improves geographic access to office-based cardiology care for more than 1 million Iowans out of a total population of 3 million. Direct travel costs and opportunity costs associated with physician travel are estimated to be more than $2.1 million per year. CONCLUSIONS Cardiologists in Iowa and adjoining states have expanded access to office-based cardiology care from 18 to 89 of the 99 counties in Iowa. In these 71 counties without a full-time cardiologist, visiting consultant clinics can accommodate more than 50% of office visits in the patients' home county.
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Affiliation(s)
- Thomas S Gruca
- Tippie College of Business, University of Iowa, Iowa City, IA
| | - Tae-Hyung Pyo
- School of Business, State University of New York, New Paltz, NY
| | - Gregory C Nelson
- Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa, Iowa City, IA
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Gruca TS, Pyo TH, Nelson GC. Improving Rural Access to Orthopaedic Care Through Visiting Consultant Clinics. J Bone Joint Surg Am 2016; 98:768-74. [PMID: 27147690 DOI: 10.2106/jbjs.15.00946] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients from rural areas tend to be older and less physically active and are more likely to be obese, increasing their need for orthopaedic services. However, few orthopaedic surgeons practice in rural areas. One approach to meeting the needs of rural patients is visiting consultant clinics (VCCs). In this study, we examined orthopaedic surgery outreach in Iowa, a state with a large rural population. We assessed the involvement of the 2014 Iowa orthopaedic surgery workforce in outreach activities for the geographically disadvantaged rural population and its effect on patient travel distances. METHODS The University of Iowa Carver College of Medicine annually tracks VCC locations and frequencies. Data from 2014 were used to estimate average trip length for participating orthopaedic surgeons and patients in all Iowa census tracts. Primary practice locations, visiting consultant clinic locations, and census tracts were classified according to the 2010 Rural-Urban Commuting Areas (RUCA) classifications. RESULTS In 2014, 4,596 VCC days were provided in 80 predominantly rural sites. Overall, as a result of VCCs staffed by orthopaedic surgeons in Iowa and adjoining states, the number of Iowan counties with an orthopaedic surgeon increased from 35 (at his/her primary practice location) to 88 (at a VCC or primary practice location) of 99. Forty-five percent of all Iowa-based orthopaedic surgeons participated in a VCC. Visiting orthopaedic surgeons drove a total of 32,496 mi (52,297 km) per month to conduct these clinics. The average driving distance to the nearest orthopaedic surgeon was reduced from 19.2 mi (30.9 km) to 8.4 mi (13.5 km) for rural Iowans as a result of monthly VCCs. Monthly VCCs improved access to orthopaedic surgeons for between 450,000 and 670,000 Iowans from a total population of approximately 3 million. CONCLUSIONS VCCs staffed by orthopaedic surgeons from Iowa and surrounding states improve access to orthopaedic care by reducing driving distances for rural patients.
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Affiliation(s)
- Thomas S Gruca
- Tippie College of Business (T.S.G.) and Office of Statewide Clinical Education Programs, Carver College of Medicine (G.C.N.), University of Iowa, Iowa City, Iowa
| | - Tae-Hyung Pyo
- School of Business, State University of New York, New Paltz, New York
| | - Gregory C Nelson
- Tippie College of Business (T.S.G.) and Office of Statewide Clinical Education Programs, Carver College of Medicine (G.C.N.), University of Iowa, Iowa City, Iowa
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Ward MM, Ullrich F, Matthews K, Rushton G, Tracy R, Bajorin DF, Goldstein MA, Kosty MP, Bruinooge SS, Hanley A, Lynch CF. Access to chemotherapy services by availability of local and visiting oncologists. J Oncol Pract 2014; 10:26-31. [PMID: 24443731 DOI: 10.1200/jop.2013.001217] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Geographic disparities have raised important questions about factors related to treatment choice and travel time, which can affect access to cancer care. PATIENTS AND METHODS Iowa residents who received chemotherapy regardless of where they were diagnosed or treated were identified through the Iowa Cancer Registry (ICR), a member of the SEER program. Oncologists and their practice locations, including visiting consulting clinics (VCCs), were tracked through the Iowa Physician Information System. Oncologists, VCCs, and patients were mapped to hospital service areas (HSAs). RESULTS Between 2004 and 2010, 113,885 newly diagnosed invasive cancers were entered into ICR; among patients in whom these cancers were diagnosed, 31.6% received chemotherapy as a first course of treatment. During this period, 106 Iowa oncologists practiced in 14 cities, and 82 engaged in outreach to 85 VCCs in 77 rural communities. Of patients receiving chemotherapy, 63.0% resided in an HSA that had a local oncologist and traveled 21 minutes for treatment on average. In contrast, 29.3% of patients receiving chemotherapy resided in an HSA with a VCC, and 7.7% resided in an HSA with no oncology provider. These latter two groups of patients traveled 58 minutes on average to receive chemotherapy. Availability of oncologists and VCCs affected where patients received chemotherapy. The establishment of VCCs increased access to oncologists in rural communities and increased the rate that chemotherapy was administered in rural communities from 10% to 24%, a notable increase in local access. CONCLUSION Access to cancer care is dependent on the absolute number of providers, but it is also dependent on their geographic distribution.
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Affiliation(s)
- Marcia M Ward
- University of Iowa, Iowa City, IA; Memorial Sloan-Kettering Cancer Center, New York, NY; Beth Israel Deaconess Medical Center, Boston, MA; Scripps Clinic, La Jolla, CA; and American Society of Clinical Oncology, Alexandria, VA
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Gruca TS, Nam I, Tracy R. Reaching rural patients through otolaryngology visiting consultant clinics. Otolaryngol Head Neck Surg 2014; 151:895-8. [PMID: 25281751 DOI: 10.1177/0194599814553398] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Providing otolaryngology care to rural populations is a major challenge. In this study, we focus on rural outreach by the otolaryngology workforce in Iowa, a state with a high proportion of rural residents. Using data from 2013, we find that almost half (46%) of Iowa-based otolaryngologists participate in outreach. Along with colleagues from adjoining states, Iowa otolaryngologists staffed more than 2100 in-person clinic days in 76 mainly rural sites. This system of rural outreach has expanded access from 20 to 85 of the 99 counties in Iowa. These efforts improve access for more than 1 million residents out of a total population of 3 million. However, this improved level of access comes at a cost as visiting otolaryngologists drove an estimated 17,000 miles per month. This established approach to serving rural patients may be negatively impacted by changes under the Affordable Care Act.
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Affiliation(s)
- Thomas S Gruca
- Tippie College of Business, University of Iowa, Iowa City, Iowa, USA
| | - Inwoo Nam
- College of Business and Economics, Chung-Ang University, Seoul, South Korea
| | - Roger Tracy
- Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Patterson PD, Probst JC, Moore CG. Expected Annual Emergency Miles per Ambulance: An Indicator for Measuring Availability of Emergency Medical Services Resources. J Rural Health 2006; 22:102-11. [PMID: 16606420 DOI: 10.1111/j.1748-0361.2006.00017.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT To ensure equitable access to prehospital care, as recommended by the Rural and Frontier Emergency Medical Services (EMS) Agenda for the Future, policymakers will need a uniform measure of EMS infrastructure. PURPOSE AND METHODS This paper proposes a county-level indicator of EMS resource availability that takes into consideration existing EMS resources (ambulances), population health and demographics, and geographic factors. The indicator, the EXpected annual emergency miles per AMBulance (EXAMB), provides a basis for comparing ambulance availability across counties within states. A method for calculating the EXAMB indicator is demonstrated using data from 5 states. FINDINGS The EXAMB indicator was negatively correlated with ambulance availability per 100,000 population in 4 of the 5 states in the study. The indicator was positively correlated with rurality in 3 states. In Mississippi, South Carolina, and Wyoming, whole-county health professional shortage areas had median EXAMB values 45%-81% higher than those of the non-health professional shortage areas counties. CONCLUSIONS Future research should explore the relationship of the EXAMB to EMS outcomes, with the ultimate goal of developing a nationally recognized indicator of "adequate" EMS resource availability.
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Affiliation(s)
- P Daniel Patterson
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Abstract
This article describes why rural residents migrate or travel outside their local market area for specialty physician care. Data were collected through a random mail survey of persons residing in Iowa's rural counties. The results imply that migration for specialty care is not simply a function of a low perceived availability of local specialty physicians. Managers of rural and urban health care systems may need to rethink the extent to which specialty physician services should be distributed across rural markets.
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Affiliation(s)
- T F Borders
- School of Medicine, Texas Tech University HSC, Lubbock, Texas, USA.
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