Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

PURPOSE

Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.

METHODS

Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.

RESULTS

Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).

CONCLUSION

The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals

Background:

Rural patients experience worse cancer survival outcomes than urban patients despite similar incidence rates, due in part to significant barriers to accessing quality cancer care. Community hospitals in non-metropolitan/rural areas play a crucial role in providing care to patients who desire and are able to receive care locally. However, rural community hospitals typically face challenges to providing comprehensive care due to lack of resources. The University of Kentucky’s Markey Cancer Center Affiliate Network (MCCAN) is an effective complex, multi-level intervention, improving cancer care in rural/under-resourced hospitals by supporting them in achieving American College of Surgeons Commission on Cancer (CoC) standards. With the long-term goal of adapting MCCAN for other rural contexts, we aimed to identify MCCAN’s core functions (i.e., the components key to the intervention’s effectiveness/implementation) using theory-driven qualitative data research methods.

Methods:

We conducted eight semi-structured virtual interviews with administrators, coordinators, clinicians, and certified tumor registrars from five MCCAN affiliate hospitals that were not CoC-accredited prior to joining MCCAN. Study team members coded interview transcripts and identified themes related to how MCCAN engaged affiliate sites in improving care quality (intervention functions) and implementing CoC standards (implementation functions) and analyzed themes to identify core functions. We then mapped core functions onto existing theories of change and presented the functions to MCCAN leadership to confirm validity and completeness of the functions.

Results:

Intervention core functions included: providing expertise and templates for achieving accreditation, establishing a culture of quality-improvement among affiliates, and fostering a shared goal of quality care. Implementation core functions included: fostering a sense of community and partnership, building trust between affiliates and Markey, providing information and resources to increase feasibility and acceptability of meeting CoC standards, and mentoring and empowering administrators and clinicians to champion implementation.

Conclusion:

The MCCAN intervention presents a more equitable strategy of extending the resources and expertise of large cancer centers to assist smaller community hospitals in achieving evidence-based standards for cancer care. Using rigorous qualitative methods, we distilled this intervention into its core functions, positioning us (and others) to adapt the MCCAN intervention to address cancer disparities in other rural contexts.

Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers

Introduction: Uncontrolled bleeding is a preventable cause of death in rural trauma. Herein, we examined the appropriateness, effectiveness, and safety of tourniquet application for bleeding control in a rural trauma system.Methods: Medical records of adult patients admitted to our academic Level I trauma center between July 2015 and December 2018 were retrospectively reviewed. Demographics (age, gender), injury (Injury severity score, Glascow Coma scale, mechanism of injury), tourniquet (type, tourniquet application site, tourniquet duration, place of application and removal, indication), and outcome data (complications such as amputation, acute kidney injury, rhabdomyolysis, or nerve palsy and mortality) were collected. Tourniquet indications, effectiveness, and complications were evaluated. Data were compared to those in urban settings.Results: Ninety-two patients (94 tourniquets) were identified, of which 58.7% incurred penetrating injuries. Eighty-seven tourniquets (92.5%) were applied in the prehospital setting. Twenty tourniquets (21.3%) were applied to patients without an appropriate indication. Two of these tourniquets were applied in a hospital setting, while 18 occurred in the prehospital setting (p = 0.638). Patients with a non-indicated tourniquet presented with a higher hemoglobin level on admission, received less packed red blood cell units within the first 24 hours of hospitalization, and were less likely to require surgery for hemostasis. None of the non-indicated tourniquets led to a complication. Indicated tourniquets were deemed ineffective in seven cases (9.5%); they were all applied in the prehospital setting. The average tourniquet time was 123 min in rural vs. 48 min in urban settings, p < 0.001. There was no significant difference in mortality, amputation rates and incidence of nerve palsy between the rural and urban settings.Conclusion: Even with long transport times, early tourniquet application for hemorrhage control in rural settings is safe with no significant attributable morbidity and mortality compared to published studies on urban civilian tourniquet use. The observed rates of non-indicated and ineffective tourniquets indicate suboptimal tourniquet usage and application. Opportunity exists for standardized hemorrhage control training on the use of direct pressure and pressure dressings, indications for tourniquet use, and effective tourniquet application.

Accuracy and Clinical Utility of Reports from Outside Hospitals for CT of the Cervical Spine in Blunt Trauma

BACKGROUND AND PURPOSE

Multidetector CT is the workhorse for detecting blunt cervical spine injury. There is no standard of care for re-interpretation of radiology images for patients with blunt trauma transferred to a higher level of care. The clinical impact of discrepancies of cervical spine CT reads remains unclear. We evaluated the discordance between primary (from referring hospitals) and secondary radiology interpretations (from a receiving level I tertiary trauma center) of cervical spine CT scans in patients with blunt trauma and assessed the clinical implications of missed cervical spine fractures.

MATERIALS AND METHODS

Medical records of patients with blunt trauma transferred to our institution between 2008 and 2015 were reviewed. Primary and secondary interpretations were compared and categorized as concordant and discordant. Two senior neuroradiologists adjudicated discordant reports. The benefit of re-interpretation was determined. For discordant cases, outcomes at discharge, injury severity pattern, treatment, and arrival in a cervical collar were assessed.

RESULTS

Six hundred fifty patients were included; 608 (94%) presented with concordant reports: 401 (61.7%) with fractures and 207 (31.8%) with no fractures. There were 42 (6.5%) discordant reports; 18 (2.8%) were cervical spine injuries undetected on the primary interpretation. Following adjudication, the secondary interpretation improved the sensitivity (99.3% versus 95.7%) and specificity (99.1% versus 91.7%) in detecting cervical spine fractures compared with the primary interpretation alone (P < .001).

CONCLUSIONS

There was an overall 6.5% discordance rate between primary and secondary interpretations of cervical spine CT scans. The secondary interpretation of the cervical spine CT increased the sensitivity and specificity of detecting cervical spine fractures in patients with blunt trauma transferred to higher-level care.

Rural comprehensive cancer care: A qualitative analysis of current challenges and limitations

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Background: Providing comprehensive and coordinated cancer care in rural settings can be difficult due to limited resources. Meeting cancer care standards established by the American Society of Clinical Oncology Quality Oncology Practice Initiative or the American College of Surgeons Commission on Cancer is also challenging due to limited resources; the vast majority of certified or accredited practices/hospitals are in metropolitan areas. It is critical to describe barriers faced by rural providers so models can be developed to facilitate high quality cancer care. Qualitative interviews were conducted to elicit current challenges and barriers among rural Iowa cancer care providers, with the goal of identifying strategies that could facilitate high quality cancer care in rural areas. Methods: Eleven cancer providers associated with 10 (out of 12) Iowa hospitals that diagnose or treat > 100 cancer patients annually and are in non-metropolitan/rural counties (Rural-Urban Continuum Code: 4-9) were interviewed via telephone or video conference. Questions focused on services offered, perceived patient- and system-level barriers to cancer care, perceived strengths and challenges in providing and assessing quality cancer care, challenges to meeting standards of cancer care set forth by national organizations, and referral experiences. Results: The major identified strength of rural hospitals was their geographic proximity to rural patients. Most hospitals provided outpatient chemotherapy, and a minority provide radiation oncology services. Common reasons for referral outside rural hospital networks were lack of specialized diagnostic procedures and complex surgical resections more commonly available at tertiary institutions. Other reasons for referrals include 1) lack of advanced technologies and treatments; 2) lack of certification secondary to inadequate staffing to support data infrastructure for quality improvement or to meet accreditation standards of national organizations; and 3) lack of ancillary patient services such as navigation, survivorship programs, genetic counseling, and education. A final important cause of referral is limited access to clinical trials, an impediment to rural patient participation in investigational treatments. Identified benefits of strengthening collaborations with larger urban/academic cancer centers were access to educational opportunities, tumor boards, shared resources and strategies for data management, clinical trials, patient navigation services and survivorship programs. Conclusions: Rural cancer care providers identified a number of challenges that could be addressed through resource sharing from larger cancer centers. Further research is needed to develop models and approaches that extend resources, services and expertise to rural providers to facilitate high-quality cancer care for all rural patients.