Trends in medical oncology outreach clinics in rural areas

Associations Between Oncology Outreach and Patient-Sharing Measures of Care Coordination

BACKGROUND

Oncology outreach is a common strategy for addressing cancer workforce shortages, where traveling oncologists commute across clinical settings to extend their services. Despite its known benefits specifically for rural patients, oncology outreach reallocates physician resources to satellite clinics and may negatively impact the coordination of cancer care.

METHODS

In this retrospective study, we identified patients with incident breast, colorectal, and lung cancers from 2016-2019 nationwide Medicare claims and linked them to oncologists using Part B. We considered encounters occurring outside the physician's primary hospital service area as "outreach visits" and calculated the proportion of outreach visits by oncology specialty for contiguous US hospital referral regions (HRRs) using 2016-2017 claims. We constructed a nationwide physician patient-sharing network from 2018-2019 claims and computed median care density-a measure of physician team familiarity-and local transitivity-a measure of physician cohesion/clustering-for each HRR as proxies for care coordination. Generalized linear models were used to explore the associations between oncology outreach and care coordination measures at the HRR level.

RESULTS

We found that HRRs with high medical oncology outreach were associated with 16% decreases in care density (95% CI: 5-25) and 4% decreases in local transitivity (95% CI: 1-8) compared to HRRs with low medical oncology outreach. HRRs with high radiation and surgical oncology outreach were not associated with network-based measures of care coordination.

CONCLUSIONS

While medical oncology outreach increases access for underserved patient populations, it potentially fragments care delivery across clinical settings. Health systems may consider this trade-off to inform decisions concerning the implementation of outreach programs or policies aimed at hedging against fragmentation in markets with active outreach arrangements.

The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach

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.

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.

Characterizing the Traveling Oncology Workforce and Its Influence on Patient Travel Burden: A Claims-Based Approach

PURPOSE

Oncology outreach is a common strategy for extending cancer care to rural patients. However, a nationwide characterization of the traveling workforce that enables this outreach is lacking, and the extent to which outreach reduces travel burden for rural patients is unknown.

METHODS

This cross-sectional study analyzed a rural (nonurban) subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident breast, colorectal, and lung cancers. Surgical, medical, and radiation oncologists were linked to patients using Part B claims, and traveling oncologists were identified by observing hospital service area (HSA) transition patterns. We defined oncology outreach as the provision of cancer care by a traveling oncologist outside of their primary HSA. We used hierarchical gamma regression models to examine the separate associations between patient receipt of oncology outreach and one-way patient travel times to chemotherapy, radiotherapy, and surgery.

RESULTS

On average, 9,935 of 39,960 oncologists conducted annual outreach, where 57.8% traveled with low frequency (0-1 outreach visits/mo), 21.1% with medium frequency (1-3 outreach visits/mo), and 21.1% with high frequency (>3 outreach visits/mo). Oncologists provided surgery, radiotherapy, and chemotherapy to 51,715, 27,120, and 5,874 rural beneficiaries, respectively, of whom 2.5%, 6.9%, and 3.6% received oncology outreach. Rural patients who received oncology outreach traveled 16% (95% CI, 11 to 21) and 11% (95% CI, 9 to 13) less minutes to chemotherapy and radiotherapy than those who did not receive oncology outreach, corresponding to expected one-way savings of 15.9 (95% CI, 15.5 to 16.4) and 11.9 (95% CI, 11.7 to 12.2) minutes, respectively.

CONCLUSION

Our study introduces a novel claims-based approach for tracking the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to cancer care.

Availability of cancer care services and the organization of care delivery at critical access hospitals

INTRODUCTION

Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas.

METHODS

Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs.

RESULTS

Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine.

CONCLUSION

Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Geographic differences in community oncology provider and practice location characteristics in the central United States

PURPOSE

How care delivery influences urban-rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions.

METHODS

We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal-Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists.

FINDINGS

We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural-only, urban-only, and urban-rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists.

CONCLUSIONS

We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation-isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban-rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Identifying the Knowledge Structure and Trends of Outreach in Public Health Care: A Text Network Analysis and Topic Modeling

Outreach programs are considered a key strategy for providing services to underserved populations and play a central role in delivering health-care services. To address this challenge, knowledge relevant to global health outreach programs has recently been expanded. The aims of this study were to analyze the knowledge structure and understand the trends in aspects over time and across regions using text network analysis with NetMiner 4.0. Data analysis by frequency, time and region showed that the central keywords such as patient, care, service and community were found to be highly related to the area, target population, purpose and type of services within the knowledge structure of outreach. As a result of performing topic modeling, knowledge structure in this area consisted of five topics: patient-centered care, HIV care continuum, services related to a specific disease, community-based health-care services and research and education on health programs. Our results newly identified that patient-centered care, specific disease and population have been growing more crucial for all times and countries by the examination of major trends in health-care related outreach research. These findings help health professionals, researchers and policymakers in nursing and public health fields in understanding and developing health-care-related outreach practices and suggest future research direction.

Initial Surgical Treatment for Breast Cancer and the Distance Traveled for Care

BACKGROUND

Geography may influence the operative decision-making in breast cancer treatment. This study evaluates the relationship between distance to treating facility and the initial breast cancer surgery selected, identifying the characteristics of women who travel for surgery.

METHODS

Utilizing Florida state inpatient and ambulatory surgery databases, we identified female breast cancer patients who underwent surgical treatment from January 1 to December 31, 2013. Patients were subgrouped by distance to treatment facility. The primary outcome was the initial surgical treatment choice. Regression models were used to identify factors associated with greater distance to initial treatment.

RESULTS

The final sample included 12 786 patients who underwent lumpectomy, mastectomy alone, or mastectomy with reconstruction. Compared to women who traveled < 4.0 miles, women who traveled > 14.0 miles were younger (P < .001), more often identified as white with private insurance (P < .001) and were less likely to have three or more medical comorbidities (P < .001). With increased travel to treatment, the frequency of lumpectomy decreased (P < .001), while the frequency of mastectomy with reconstruction increased (P < .001). Increasing age in years (adjusted odds ratio (AOR) = .98 [95% CI = .98-.99]) and identifying as nonwhite with private (AOR = .70 [.61-.80]) or public insurance (AOR = .64 [.56-.73]) was associated with less frequently travelling for initial breast cancer surgery.

DISCUSSION

The relationship between the initial surgical treatment for breast cancer and the distance traveled for care highlights a disparity between those who can and cannot travel for treatment.

Telemedicine and Gynecologic Cancer Care

Patients with gynecologic cancers experience better outcomes when treated by specialists and institutions with experience in their diseases. Unfortunately, high-volume centers tend to be located in densely populated regions, leaving many women with geographic barriers to care. Remote management through telemedicine offers the possibility of decreasing these disparities by extending the reach of specialty expertise and minimizing travel burdens. Telemedicine can assist in diagnosis, treatment planning, preoperative and postoperative follow-up, administration of chemotherapy, provision of palliative care, and surveillance. Telemedical infrastructure requires careful consideration of the needs of relevant stakeholders including patients, caregivers, referring clinicians, specialists, and health system administrators.

Framework for Improving Governance and Quality of Rural Oncology Outreach Services

PURPOSE

Rural outreach is a common method for delivering oncology services closer to rural residents; however, there is no clear service framework for supporting its quality and governance. This work aimed to develop an agreed framework for improving the governance and quality of a rural oncology outreach service.

METHODS

A Six Sigma and participatory action approach was used. Key clinicians and managers identified project goals and scope, participated in several rounds of interviews and medical record audits, and discussed findings to reach consensus about a framework for quality outreach service delivery from one regional cancer center supporting two rural hospital sites (5-chair nurse-led oncology units).

RESULTS

Themes included strong investment by stakeholders in maintaining the outreach service for its importance for rural populations. The referral, treatment, and clinical governance processes were implicitly understood between stakeholders but not well documented. Medical record audits of treated patients identified important gaps in clinical information at rural sites. Through reflection and discussion, consensus was reached about a framework for quality service delivery. The participatory action planning cycle involving sites in regular discussions fostered information sharing, strong engagement, and uptake of the final framework.

CONCLUSION

The framework was applied to a memorandum of understanding for planning, governance, and outcomes monitoring and provides a basis for developing new and benchmarking existing oncology outreach services.

Access to specialty healthcare in urban versus rural US populations: a systematic literature review

Background

Access to healthcare is a poorly defined construct, with insufficient understanding of differences in facilitators and barriers between US urban versus rural specialty care. We summarize recent literature and expand upon a prior conceptual access framework, adapted here specifically to urban and rural specialty care.

Methods

A systematic review was conducted of literature within the CINAHL, Medline, PubMed, PsycInfo, and ProQuest Social Sciences databases published between January 2013 and August 2018. Search terms targeted peer-reviewed academic publications pertinent to access to US urban or rural specialty healthcare. Exclusion criteria produced 67 articles. Findings were organized into an existing ten-dimension care access conceptual framework where possible, with additional topics grouped thematically into supplemental dimensions.

Results

Despite geographic and demographic differences, many access facilitators and barriers were common to both populations; only three dimensions did not contain literature addressing both urban and rural populations. The most commonly represented dimensions were availability and accommodation, appropriateness, and ability to perceive. Four new identified dimensions were: government and insurance policy, health organization and operations influence, stigma, and primary care and specialist influence.

Conclusions

While findings generally align with a preexisting framework, they also suggest several additional themes important to urban versus rural specialty care access.

Public Transportation Environment and Medical Choice for Chronic Disease: A Case Study of Gaoyou, China

Current research on the built environment and medical choice focuses mainly on the construction and optimization of medical service systems from the perspective of supply. There is a lack of in-depth research on medical choice from the perspective of patient demand. Based on the medical choice behaviour of patients with chronic diseases, this article identifies the spatial distribution and heterogeneity characteristics of medical choice and evaluates the balance between medical supply and demand in each block. On this basis, we explored the mechanism of patient preferences for different levels of medical facilities by considering the patient's socioeconomic background, medical resource evaluation, and other built environment features of the neighbourhood by referring to patient questionnaires. In addition to socioeconomic characteristics, the results show that public transportation convenience, medical accessibility, and medical institution conditions also have significant influences on patient preferences, and the impact on low-income patients is more remarkable. The conclusions of the study provide a reference for the promotion and optimization of the functions of urban medical resources and the guidance of relevant public health policies.

Utilizing telemedicine in oncology settings: Patient favourability rates and perceptions of use analysis using Chi-Square and neural networks

BACKGROUND

Telemedicine is an alternative to traditional face-to-face doctor-patient office visits. Although telemedicine is becoming more prevalent, few studies have looked at the perceived favorability rate among patients utilizing telemedicine over the traditional office visit to a provider's office considering data samples from more than 5 clinics in northern Louisiana.

OBJECTIVE

This study aims to measure patient favorability of using telemedicine to receive care. This study looks at the perceived positive and negative favorability rates of patients in the oncology settings. The researchers analyzed how age, income level, and education level influenced the perceived patient favorability rates and their willingness to utilize telemedicine.

METHODS

The investigators used Chi-Square analysis to identify favorability with respect to age education and income levels. In addition to this Artificial Neural Networks were used to identify the threshold for favorability with respect to age, income, and education.

RESULTS

Chi-Square tests of association showed that of the variables analyzed, only education level had a statistically significant relationship with a patient's favorability rate of telemedicine utilization. While our neural network analysis indicated that the threshold for income, age, and education are $34,999, 66 years, and a college degree.

CONCLUSION

In this article the investigators have successfully demonstrated the use of Artificial Neural Networks in identifying favorability of telemedicine used in addition to the traditional statistical methods such as Chi-Square. Thereby, creating a path for future research using advanced computational techniques like Artificial Neural Networks in analyzing human behavior.

Evaluating the urban-rural paradox: The complicated relationship between distance and the receipt of guideline-concordant care among cervical cancer patients

OBJECTIVE

Urban-rural health disparities are often attributed to the longer distances rural patients travel to receive care. However, a recent study suggests that distance to care may affect urban and rural cancer patients differentially. We examined whether this urban-rural paradox exists among patients with cervical cancer.

METHODS

We identified individuals diagnosed with cervical cancer from 2004 to 2013 using a statewide cancer registry linked to multi-payer, insurance claims. Our primary outcome was receipt of guideline-concordant care: surgery for stages IA1-IB1; external beam radiation therapy (EBRT), concomitant chemotherapy, and brachytherapy for stages IB2-IVA. We estimated risk ratios (RR) using modified Poisson regressions, stratified by urban/rural location, to examine the association between distance to nearest facility and receipt of treatment.

RESULTS

62% of 999 cervical cancer patients received guideline-concordant care. The association between distance and receipt of care differed by type of treatment. In urban areas, cancer patients who lived ≥15 miles from the nearest surgical facility were less likely to receive primary surgical management compared to those <5 miles from the nearest surgical facility (RR: 0.77, 95% CI: 0.60-0.98). In rural areas, patients living ≥15 miles from the nearest brachytherapy facility were more likely to receive treatment compared to those <5 miles from the nearest brachytherapy facility (RR: 1.71, 95% CI: 1.14-2.58). Distance was not associated with the receipt of chemotherapy or EBRT.

CONCLUSIONS

Among cervical cancer patients, there is evidence supporting the urban-rural paradox, i.e., geographic distance to cancer care facilities is not consistently associated with treatment receipt in expected or consistent ways. Healthcare systems must consider the diverse and differential barriers encountered by urban and rural residents to improve access to high quality cancer care.

Health care eligibility and availability and health care reform: Are we addressing rural women's barriers to accessing care?

BACKGROUND

Rural populations in the U.S. face numerous barriers to health care access. The Patient Protection and Affordable Care Act (PPACA) was developed in part to reduce health care access barriers. We report rural women's access barriers and the PPACA elements that address these barriers as well as potential gaps.

METHODS

For this qualitative study, we analyzed two datasets using a common framework. We used content analysis to understand rural, focus group participants' access barriers prior to PPACA implementation. Subsequently, we analyzed the PPACA text.

RESULTS

Participants described health care access barriers in two domains: availability and eligibility. The PPACA proposes solutions within each domain, including health care workforce training, Medicaid expansion, and employer-based health care provisions. However, in rural settings, access barriers likely persist.

DISCUSSION

While elements of the PPACA address some health care access barriers, additional research and policy development are needed to comprehensively and equitably address persistent access barriers for rural women.

Reasons why specialist doctors undertake rural outreach services: an Australian cross-sectional study

BACKGROUND

The purpose of the study is to explore the reasons why specialist doctors travel to provide regular rural outreach services, and whether reasons relate to (1) salaried or private fee-for-service practice and (2) providing rural outreach services in more remote locations.

METHODS

A national cross-sectional study of specialist doctors from the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2014 was implemented. Specialists providing rural outreach services self-reported on a 5-point scale their level of agreement with five reasons for participating. Chi-squared analysis tested association between agreement and variables of interest.

RESULTS

Of 567 specialists undertaking rural outreach services, reasons for participating include to grow the practice (54%), maintain a regional connection (26%), provide complex healthcare (18%), healthcare for disadvantaged people (12%) and support rural staff (6%). Salaried specialists more commonly participated to grow the practice compared with specialists in fee-for-service practice (68 vs 49%). This reason was also related to travelling further and providing outreach services in outer regional/remote locations. Private fee-for-service specialists more commonly undertook outreach services to provide complex healthcare (22 vs 14%).

CONCLUSIONS

Specialist doctors undertake rural outreach services for a range of reasons, mainly to complement the growth and diversity of their main practice or maintain a regional connection. Structuring rural outreach around the specialist's main practice is likely to support participation and improve service distribution.

Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance

PURPOSE

Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy.

PATIENTS AND METHODS

Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics.

RESULTS

Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03).

CONCLUSION

Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.

The State of Cancer Care in America, 2015: A Report by the American Society of Clinical Oncology

In this second annual State of Cancer Care in America report, ASCO provides background and context to help understand what is happening today in cancer care and describes trends in the cancer care workforce that may affect cancer care in the coming years.

Overcoming the distance barrier in relation to treatment for haematology patients: Queensland findings

Objective The aim of the present study was to document the financial and psychosocial impact of relocation for specialist haematology treatment in Queensland. Methods This study was a qualitative exploratory study comprising 45 in-depth interviews with haematology patients supported by the Leukaemia Foundation of Queensland. Results The findings indicate that decentralisation of treatment is assisting haematology patients to overcome the profound difficulties associated with travelling to the metropolitan area for treatment. Conclusion Fostering specialist outreach and building capacity in regional cancer centres are service delivery strategies that are greatly appreciated by regional, rural and remote haematology patients who are stressed by the many challenges associated with leaving home to travel distances for specialist treatment. It is the hope and expectation that these findings will make a contribution to informing future health policy and service delivery planning. What is known about the topic? Internationally, there is evidence of the benefits of visiting specialists and the development of local specialist services for cancer patients in regional and rural areas, but there is limited research on the topic in Australia. What does this paper add? The findings herein make a contribution to this area of research through an up-to-date, in-depth consumer perspective on non-metropolitan oncology hospital services for haematology patients in Queensland. The evidence indicates that the opportunity to avoid travel to the metropolitan treating hospitals for regional, rural and remote haematology patients is increasingly an option in Queensland and greatly appreciated by many of those who have this option. What are the implications for practitioners? The findings applaud the work of the health professionals providing the opportunity for regional specialist care for haematology patients. With regard to service delivery and health policy decision making, it is important to note that for patients positive about access to local treatment, psychosocial concerns (e.g. remaining at home, connection with family, avoidance of financial hardship) predominate in their reasoning about benefit. Thus, it is important that regional, rural and remote patients are offered greater choice in treatment options and have more involvement in decision making about specialist care.