Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004–2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III–IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53–2.12), and cervical (aOR: 1.45,95% CI: 1.26–1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48–0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60–0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58–0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.

How patients interpret early signs of foot problems and reasons for delays in care: Findings from interviews with patients who have undergone toe amputations

Aims To describe how patients respond to early signs of foot problems and the factors that result in delays in care. Methods Semi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis. Results We interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) “sudden” and “unexpected” illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers. Conclusion A confluence of patient factors (e.g., not examining their feet regularly or thoroughly and/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient’s appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.

Rural Disparities in Early Childhood Well Child Visit Attendance

PurposeChildren should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, and if indicated treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes.Design and MethodsWe utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n=6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level.ResultsTwo of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance.ConclusionsYoung children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.

Patterns of Healthcare Access and Utilization among Nonurban Transgender and Nonbinary Patients at a Large Safety Net Health System in Colorado

Current research characterizing transgender and nonbinary (TNB) communities focuses on coastal, urban centers and inadequately recognizes intersections of geography and gender identity. This study evaluates demographics, health insurance, mental health, one-way distance to care, and types of care accessed for a cohort of nonurban TNB patients seeking care at a large, safety net health system in Denver, Colorado. Electronic medical record (EMR) data were used to identify this TNB patient cohort (n = 1,230) Characteristics of age, race/ethnicity, sex assigned at birth, gender identity, insurance, residence ZIP code, alcohol use disorder, tobacco use, marijuana use, depression, and anxiety were extracted. Chart review characterized utilization patterns among non-Denver TNB patients (n = 232). Denver TNB patients were more likely to have the following characteristics: black or Hispanic identity, marijuana use, commercial insurance, depression, anxiety; comparatively, non-Denver TNB patients were more likely to be white and have public insurance coverage. The non-Denver cohort traveled an average of 82.52 miles one-way. A majority of non-Denver patients accessed gender-affirming (99%), hormone-related (81%), primary (78%), and preventive (69%) care. A minority of these patients (23%) accessed surgical transition care. Proximity to care is one of many important factors for TNB patients seeking care. The number of non-Denver TNB traveling for healthcare likely reflects a lack of accessibility to local gender-affirming care, which should prompt nonurban medical providers to seek training that meets this need. Medical educators should improve teaching on gender-affirming healthcare, particularly for rural educational tracks.

Does Distance to Treatment Affect Mortality Rate for Surgical Oncology Patients?

Introduction Using the National Cancer Database (NCDB), we seek to analyze the relationship of patient distance to hospital of treatment on mortality trends after surgery, since patients often travel large distances to referral centers. Methods A retrospective cohort study of the NCDB from 2004 to 2013 was performed, and patients with gastrointestinal, melanoma, and head and neck primary site tumors who underwent surgery were included. We excluded cases with no recorded mortality status or distance from the hospital. A multivariable logistic regression was conducted with adjustments for population density, treating facility location, age, race, gender, education, income, insurance, comorbidities (Charlson-Deyo score), days from diagnosis to treatment, positive margin, tumor stage and grade, and lymph or vascular invasion. Results A total of 1 424 482 patients were included. Overall median distance to hospital was 9.7 miles (range 4.2-23.7 miles); 696 647 (48.91%) of the sample traveled a distance greater than 10 miles to the institution where the procedure was performed. The multivariable regression analysis demonstrated overall lower mortality for those patients travelling a longer distance to care for multiple tumor types, including: liver (OR .87, .77-.99, P = .032), pancreas (OR .82, .76-.89, P < .001), colon (OR .92, .89-.95, P < .001), rectum (OR .90, .83-.96, P = .003), melanoma (OR .83, .79-.88, P < .001), and tumors of the larynx (OR .80, .69-.94, P = .005). Discussion Increased distance traveled for surgical treatment has a significant correlation with decreased odds of mortality for multiple cancers, highlighting the importance of centralized referral patterns for oncology care.

Travel distance and time to adjuvant chemotherapy in veterans with colorectal cancer.

84 Background: Patients from rural areas have well described disparities in quality cancer care. We hypothesized that longer travel distance is associated with less chemotherapy acceptance and less timely treatment. Methods: We reviewed 705 electronic medical records of patients with colorectal surgeries from January 1, 2000 to December 31, 2015 at the Veterans Health Administration Tennessee Valley Healthcare System. Two trained abstractors reviewed standard elements (k = 0.79 – 0.92). The study sample included patients with pathological stage high risk II or III CRC and excluded those with metastatic disease or documented National Comprehensive Cancer Network (NCCN) defined medical exclusions from chemotherapy. Primary exposure was distance to care calculated from central zip code of residence to Nashville infusion center. Primary outcomes were receipt of any chemotherapy, and days from surgery to first treatment (truncated at 120 days). We analyzed 2 populations; chemotherapy received and a second sensitivity population who were eligible for, but did not receive, chemotherapy (no documentation of NCCN ineligibility or declined). Results: Of 705 colorectal resections, we excluded 262 for non-cancer, 220 for stage I or low risk stage II, and 46 for NCCN exclusion criteria, yielding 177 cases: 120 colon and 57 rectal. Most patients were male (98%) and white (85%); median age was 64 [Interquartile Range 60, 70]. Distribution by travel distance was 60/177 [33.9%] < 50 miles, 61/177 [34.5%] 50-99 miles, and 56/177 [31.6%] > 100 miles. Of all eligible patients, 123/177 [69.5%] patients received chemotherapy and 54/177 [30.5%] did not receive chemotherapy. Among receivers, median times to treatment were 52 days [40, 61] < 50 miles; 48.5 [40,61] 50-99 miles; and 54 [43,77] > 100 miles, p = 0.3. Patients not receiving chemotherapy varied by distance: 15/60 (25%) < 50 miles; 18/61 (30%) 50-99 miles; 21/56 (38%) > 100 miles, p = 0.3. Including non-receivers, median times to treatment were 58 days [43, 120] < 50 miles; 58.5 [46.5, 120] 50-99 miles; and 80 [48.5, 120] > 100 miles, p = 0.1. Conclusions: Distance to care may influence acceptability of chemotherapy. Understanding patient/provider reasons for omission merits exploration.

Acute Healthcare Utilization and Predictors of Admission for Sickle Cell Disease in Illinois

Background Sickle cell disease (SCD) is associated with acute healthcare utilization and an estimated annual cost of $2 billion that is primarily covered through public insurance. Understanding factors contributing to acute healthcare utilization among SCD patients is crucial to decrease costs associated with services. Our study describes trends of acute care utilization among Illinois (IL) residents with SCD over a 3 year period and examines factors associated with hospital admissions from the emergency department (ED). Methods We extracted ED visits and hospitalizations associated with an ICD-10 code for SCD from the Illinois Comparative Health Care and Hospital Data Reporting Services, a statewide hospital administrative data source for 154 IL non-federal hospitals. Visits from January 2016 to December 2018 were extracted. Variables of interest included patient sociodemographic variables (age, IL region, insurance, zip code poverty rate and area deprivation index and distance to care). Poverty was categorized based on the percent of residents in a zip code who are at or below the federal poverty level (FPL) as low (<10% of households ≤ FPL), medium (10-20% of households ≤ FPL) or high (>20% households ≤ FPL) using data from the 2017 Community American Survey. Composite socioeconomic opportunity was determined using 2015 state ranked patient zip code area deprivation index (ADI) and categorized as low (ADI<5), medium (ADI=5-7.99), or high (ADI≥8) with higher ADI levels indicating higher levels of socioeconomic disadvantage. For admissions, length of stay (LOS) and intensive care unit (ICU) care were examined. Health care facilities were categorized by number of SCD visits per year into low (< 50), medium (50 to 332) or high (≥333) volume. Poisson regression, adjusted for clustering within hospitals, was used to analyze the likelihood of hospital admission versus discharge from an ED visit. Results Trends of acute care utilization. There were 50,260 hospitalization and ED visits with SCD codes in the 36 month study period, averaging 1396 visits per month. The number of visits per year was stable during the study period (Table 1). Approximately 71% of the visits were associated with SCD as the primary diagnosis. The majority (64%) of visits occurred in Cook County, with 95% occurring within a 30 miles radius from the patient's zip code and 94% in facilities with more than 50 SCD visits annually. Most visits were covered under public insurance (50% Medicaid and 25% Medicare); 20% were covered by private insurance; and less than 5% were uninsured visits. The majority of visits were from patients living in medium (46%) or high (32%) ADI with only 19% from low ADI zip codes. Most (60%) visits were outpatient ED visits (average 832 visits per month) and 40% were hospital admissions (average 564 visits per months) with a mean LOS of 5 days and 12.8% requiring ICU level care. Approximately 80% of the hospital admissions were admissions from the ED. Factors associated with hospital admissions from the ED (Table 2). In the adjusted model, uninsured patients were less likely to be admitted (IRR=0.60; 95% CI 0.50-0.73) and Medicare patients were more likely to be admitted (IRR=1.57; 95% CI 1.38-1.81) compared to patients with private insurance. ED visits with patients travelling >30 miles (IRR=1.52, 95% CI 1.21-1.94) and visits at high volume hospitals (IRR=1.62; 95% CI 1.32-1.99) were more likely to result in admission compared to visits associated with shorter distances and visits at lower volume hospitals, respectively. Visits with patients from medium ADI zip codes (IRR=0.90; 95% CI 0.81-0.99) or high ADI zip codes (IRR=0.90; 95% CI 0.81-0.99) were less likely to result in admission than visits from low ADI zip codes. Biological sex, age, location of care, and zip code poverty level were not significantly associated with hospital admissions from the ED. Conclusions In the most recent 3 year period, SCD acute healthcare utilization in Illinois remained stable without significant reductions. Patients who were uninsured or had higher levels of socioeconomic disadvantage were less likely to be admitted from the ED whereas further distance to care and high SCD volume hospital were associated with higher rates of admission. Further research should explore whether the uninsured and highly disadvantaged were less likely to be admitted due to disease severity or system level factors such as poor access or poor preventative care. Disclosures No relevant conflicts of interest to declare.

Methodological Challenges When Studying Distance to Care as an Exposure in Health Research

Distance to care is a common exposure and proposed instrumental variable in health research, but it is vulnerable to violations of fundamental identifiability conditions for causal inference. We used data collected from the Botswana Birth Outcomes Surveillance study between 2014 and 2016 to outline 4 challenges and potential biases when using distance to care as an exposure and as a proposed instrument: selection bias, unmeasured confounding, lack of sufficiently well-defined interventions, and measurement error. We describe how these issues can arise, and we propose sensitivity analyses for estimating the degree of bias.