map of rural counties around Wake Forest
Data courtesy Kathryn Weaver, Wake Forest Baptist Medical Center.

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When it comes to cancer care, where a patient lives makes a difference. But in some instances, distance could be an advantage.

By Stephanie Soucheray

All cancer care is not created equal. That’s the main message of two studies published in the most recent edition of the North Carolina Medical Journal.

Using provider data, Medicaid and Medicare enrollees and census information, researchers illustrated that where patients live and how their care is managed were major factors in the quality of care they received during cancer treatments.

Cancer cells in tissue culture from human connective tissue, at a magnification of 500x. Image source: National Cancer Institute

“Often [it’s] related to things outside of the biology of the disease,” said Stephanie Wheeler, an assistant professor in health policy and management at the Gillings School of Global Public Health at UNC-Chapel Hill.

There are “vast differences” in the quality of care, she said.

Wheeler studied publicly insured cancer patients being treated in so-called patient centered medical homes to measure the frequency and severity of chemotherapy-related adverse events.

“The majority of the Medicaid population in this time is enrolled in the medical home, but we don’t know the data in terms of outcomes,” she said. Medicaid provides coverage for about 1.6 million low-income children, pregnant women and people with disabilities in North Carolina.

Community Care of North Carolina (CCNC) is a medical-home program started in the 1990s that has long received national attention for its patient-centered care and positive outcomes for approximately 750,000 North Carolinians on Medicaid, most of whom are women and children.

Wheeler said studying this group was important because the Affordable Care Act has many medical-home provisions and more states will start relying on medical homes for managing the care of their Medicaid patients.

She and her colleagues looked at low-income women who received chemotherapy for early-stage breast cancer between 2003 and 2007. Those in the medical-home system had fewer inpatient admissions for adverse events.

However, patients enrolled in a medical home had no difference in outpatient and emergency room admissions.

Still, breast cancer is the most prevalent cancer among women in the state and the diagnosis makes up one-third of all new cancer diagnoses, Wheeler said. Any reduction in patient visits ends up reducing Medicaid costs.

Location, location, location

Wheeler also performed a second study which investigated the connection between rural and urban living and access to radiation. Patients receiving radiation therapy have to come to the hospital for treatment daily, which can be burdensome in terms of time and travel.

For this study, Medicare enrollees who were recommended to receive radiation therapy for cancer were followed for two years during and after treatment.

Medicare is the federally funded program for seniors and some people with disabilities. Almost everyone in the U.S. over the age of 65 years old is covered by Medicare, and data about these patients is available to researchers.

By geocoding the provider and patient’s addresses, Wheeler and her colleagues were able to determine how geographic settings encouraged or detracted patients from getting radiation therapy.

“The results were somewhat counterintuitive,” she declared.

“For urban patients, increased distance meant a lesser likelihood in receiving radiation,” Wheeler said. “For rural patients, those living less than 10 miles away from a provider were also less likely to receive [radiation therapy].”

Map of rural counties around Wake Forest Baptist Medical Center from which patients come to the hospital’s Comprehensive Cancer Center. Data courtesy Kathryn Weaver

But she found the patients most likely to comply with recommendations for radiation therapy were rural patients living 10 to 20 miles away from their provider.

“These patients are used to driving these distance of about a half hour,” said Wheeler. She said the disparity among urban patients could have to do with their reliance on public transportation, rather than having cars of their own.

“This study shows that where you live does matter,” she said.

Urban vs rural

The results in Wheeler’s studies both echo and complicate the results of a study published by Wake Forest Baptist Medical Center last year. In particular, that research looked at the health behaviors of about 7,600 adult cancer survivors in rural and urban settings throughout the country and found that these survivors had very different lifestyle factors. Her data came from the National Health Interview Survey, a population-based sample of adults, conducted by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.

Data courtesy Kathryn Weaver, Wake Forest Baptist Medical Center

Weaver, who practices at the Wake Forest Baptist Comprehensive Cancer Center said the center draws patients from the western half of the state, which is largely rural. “We needed to get a better sense of who our rural cancer survivors are and what they are facing.”

“We found that rural survivors were more likely to smoke and were more sedentary,” said Kathryn E. Weaver, assistant professor of social sciences and health policy at Wake Forest Baptist, author of the study, which was published in Cancer Causes and Control. “And survivors who smoked reported worse health and were more likely unemployed.”

Weaver said both smoking and being sedentary are health factors and behaviors that link cancer survivors to subsequent cancer diagnoses and survival rates. She said previous studies have showed that rural cancer patients were more likely to be uninsured, and said access to care is a considerable issue for this patient population.

“In my own clinical practice, I’ve seen patients who have to drive an hour to get to the Cancer Center,” said Weaver. “They routinely live more than 60 miles away.”

Weaver said she hopes her study can help open the conversation about meeting patients’ needs where they live. She said telecounseling for smoking cessation and at-home fitness routines should be part of post-cancer patient education for rural survivors.

“Meeting patients where they are has to be a priority,” she said.

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