Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care
BACKGROUND:
Prostate cancer is the most common cancer diagnosis and cause of cancer death among male Veterans, thus access to prostate cancer diagnosis and treatment resources is critical for optimal patient outcomes. However, travel distances, particularly for Veterans living in rural settings, coupled with variation in facility-level VA cancer care resources may create barriers to quality care. This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Investigators used VA's Central Cancer Registry to identify all men diagnosed with prostate cancer in calendar year 2008 (n=11,368). Based on a 2005 VA facility survey of oncology resources (138 facilities), investigators then assessed each facility according to characteristics that might influence selected measures of quality prostate cancer care (i.e., onsite radiation therapy; urologist, medical, and radiation oncology staffing). Evidence-based quality of prostate cancer care was ascertained through chart review, and was based on five measures, including appropriate biopsy, cancer staging, and high-risk prostate cancer management.
FINDINGS:
- Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Rural patients, especially those living more than 30 miles from their treating facility, were somewhat less likely to complete a full course of radiotherapy.
- Among rural compared with urban patients, there were no significant differences in tumor grade or stage - and minimal differences with respect to initial treatment and comorbidity.
- Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
LIMITATIONS:
- Other barriers to quality prostate cancer care were not considered, including mental and physical challenges that may compromise access and quality of care.
- Although many Veterans use VA transportation resources to overcome travel barriers, investigators did not have access to detailed transportation information (e.g., reimbursement).
IMPACT:
- Better understanding the degree to which facility factors, transportation resources, and telemedicine contribute to the quality of cancer care may assist VA and other organizations involved in rural healthcare delivery. As telemedicine for specialty care expands, Veterans with prostate cancer living in rural settings may benefit further by having to travel less without compromising care.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D and VA's Office of Analytics and Business Intelligence. Dr. Skolarus is part of HSR&D's Center for Clinical Management Research in Ann Arbor, MI and is supported by a VA HSR&D Career Development Award.
Skolarus T, Chan S, Shelton J, et al. Quality of Prostate Cancer Care among Rural Men in the Veterans Health Administration. Cancer July 30, 2013;Epub ahead of print.
