With Michelle Mollica, PHD, MPH, RN, OCN, of the National Cancer Institute
By Sarah DiGiulio
Past research has suggested that patients with cancer who live in rural areas have a delay in accessing the cancer care services they need compared with patients with cancer who live in urban areas. But a new study that examined more recent data found that paradigm may be changing.
The new findings suggest that rural cancer survivors report more timely care than those in urban areas; but regardless of residence in an urban or rural area, individuals who were of a racial or ethnic minority still reported challenges accessing timely care (Cancer 2018; doi:10.1002/cncr.31541).
"After we controlled for key patient variables and cancer-related variables, we actually found a significant association between residence at diagnosis," stated Michelle Mollica, PhD, MPH, RN, OCN, Program Director in the Outcomes Research Branch of the Healthcare Delivery Research Program at the NCI, during an interview with Oncology Times. "Those that lived in urban areas rated their timeliness of care lower than those in rural areas. We did not see a significant interaction with the access to care measure.
"In the measure of access to care, rural non-Hispanic white respondents rated their access to care almost two points higher than those in urban areas. But we found a different trend for non-Hispanic black and Hispanic respondents—those in rural areas rated their access to care lower," Mollica explained.
For the study, researchers looked at patient experience survey data for 6,140 cancer survivors who identified as urban and 686 who identified as rural. All the individuals whose replies were part of the study were Medicare beneficiaries. The surveys were collected between 1998 and 2013 as part of the Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data during the patients' course of treatment and care.
The study examined replies to the surveys in which respondents ranked "Getting Needed Care" and "Getting Care Quickly" over the past 6 months of their care. It was the latter question that urban cancer survivors were more likely to rank lower than rural cancer survivors. And while there were no significant differences for "Getting Needed Care" between urban and rural cancer survivors, both people who were non-Hispanic black and Hispanic ranked that measure lower than others did.
Here's what else Mollica told Oncology Times about the findings and what they mean about how best to improve access to care for both urban and rural patients with cancer.
1. These new findings are somewhat different than what previous studies have shown. Were you surprised by that?
"Based on the literature and based on lots of previous work, we anticipated that there would be issues with access to care for those that lived in rural areas. We thought we would see a similar trend here. And we actually found the opposite.
"It's possible that reports of timeliness of care are due to ability to obtain a provider referral, identify a provider or availability of an appointment, or to get to the health care provider. So it's possible that urban residents experience barriers that rural residents in the sample did not.
"It's also possible that rural residents have different expectations. So, they perhaps may be willing to travel farther for their care. And also we have had some substantial advances in telehealth and technology that have improved care for rural residents—and perhaps for urban residents we have to consider that as well.
"The CAHPS survey itself has very specific measures in terms of timeliness of care, such as did you get the care when you thought you needed it, but we don't have questions on transportation and other sort of fine-grained aspects of accessing care.
"So we really feel like future work should look into this in a more specific way."
2. Does the data suggest access to care in rural areas has improved (given that other data suggests they had worse access to care)—or is that too simple a read on the findings?
"There are nuances to this story, but that's not to shortchange the fact that they have made several advances in telehealth and in technology in rural areas.
"I think that we need to also be considering those types of technologies for areas that are more urban. So it's very possible this is part of the story and perhaps lays the groundwork for future research.
"It's going to be really important to consider rural [versus urban residence], as well as race/ethnicity when looking at perceived access to care. We've seen lots of disparities among race/ethnicity in cancer incidence, among other things. But specifically, how we are addressing disparities and access to care is an important next step.
"We also need to be considering innovative cancer care delivery tools for those that are in urban areas. I think sometimes we forget that urban areas may have higher volume and longer wait times because there could be more people and more crowded clinics."
3. What would you say are the most important takeaways about this research for cancer care providers treating patients every day?
"I'm an oncology nurse as well as a researcher. I think that one of the things that oncology providers do a great job of is treating the whole patient. But in doing so I think it's important to consider barriers to access within urban areas, as well as rural areas. We may need to broaden our view to the barriers that people might be experiencing even in more populated areas."