Accessibility as a major determinant of radiotherapy underutilization: A population based study

Equity, Diversity, and Inclusion in Radiation Oncology: A Bibliometric Analysis and Critical Review

The promotion of equity, diversity, and inclusion (EDI) is being increasingly pursued in health care, both in general and within radiation oncology. Because bibliometrics is a powerful tool to reveal the scientific literature on a specific topic during a certain timespan, a systematic bibliometric analysis of the documents published on EDI in radiation oncology was performed, aiming at exploring common patterns in research and emerging trends, tracking collaborations and networks, and anticipating future directions in clinical research. Standard descriptive statistics and bibliometric techniques were used in the analysis. A collaboration network and thematic map were generated from the data. Four domains were represented: (1) motor themes, including themes well developed and important for the structuring of the research field; (2) niche themes, representing the isolated topics that do not share important external links with other themes; (3) emerging themes, referring to still weakly developed topics; and (4) basic themes, including the essential topics. EDI in the profession of radiation oncology is essential to ensure that the workforce delivering radiation oncology care both draws from the full talent pool of human capital and delivers the highest quality science and clinical care to all patients. The burgeoning literature on EDI in radiation oncology suggests that a large and growing cohort of scholars within radiation oncology are dedicated to addressing these important challenges.

A multicriteria decision analysis framework to measure equitable healthcare access during COVID-19

The ongoing novel coronavirus (COVID-19) pandemic has highlighted the need for individuals to have easy access to healthcare facilities for treatment as well as vaccinations. The surge in COVID-19 hospitalizations during 2020 also underscored the fact that accessibility to nearby hospitals for testing, treatment and vaccination sites is crucial for patients with fever or respiratory symptoms. Although necessary, quantifying healthcare access is challenging as it depends on a complex interaction between underlying socioeconomic and physical factors. In this case study, we deployed a Multi Criteria Decision Analysis (MCDA) approach to uncover the barriers and their effect on healthcare access. Using a least cost path (LCP) analysis we quantified the costs associated with healthcare access from each census block group in the Los Angeles metropolitan area (LA Metro) to the nearest hospital. Social vulnerability reported by the Centers for Disease Control and Prevention (CDC), the daily number of COVID-19 cases from the Los Angeles open data portal and built environment characteristics (slope of the street, car ownership, population density distribution, walkability, traffic collision density, and speed limit) were used to quantify overall accessibility index for the entire study area. Our results showed that the census block groups with a social vulnerability index above 0.75 (high vulnerability) had low accessibility owing to the higher cost of access to nearby hospitals. These areas were also coincident with the hotspots for COVID-19 cases and deaths which highlighted the inequitable exposure of socially disadvantaged populations to COVID-19 infections and how the pandemic impacts were exacerbated by the synergistic effect of socioeconomic status and built environment characteristics of the locations where the disadvantaged populations resided. The framework proposed herein could be adapted to geo-target testing/vaccination sites and improve accessibility to healthcare facilities in general and more specifically among the socially vulnerable populations residing in urban areas to reduce their overall health risks during future pandemic outbreaks.

Comparison between Accelerated Partial Breast Irradiation with multicatheter interstitial brachytherapy and Whole Breast Irradiation, in clinical practice

Purpose

The aim of this study was to compare accelerated partial breast irradiation (APBI) with multicatheter interstitial brachytherapy (BT) and whole breast irradiation (WBI), in terms of toxicity, aesthetic result, quality of life and survival, in clinical practice.

Materials and methods

A comparative study of two prospectively recorded cohorts of 76 breast cancer patients who complied with the recommendations of GEC-ESTRO for APBI was conducted. The main objective was toxicity, quality of life measured through validated questionnaires and the aesthetic results. Secondary objectives were overall survival and disease-free survival.

Results

Seventy-six stage I/II breast cancer patients, with a mean age of 66 years entered the study. APBI group showed less acute G1-2 dermatitis (51.4 vs 94.9%, p < 0.001) and late hyperpigmentation (0 vs 17.9%, p = 0.04). There were no differences in aesthetic results, both assessed by the patient herself and by the doctor. Statistically significant differences in measures of quality of life were observed in favour of the APBI, both in EORTC QLQ-BR23 and body image scale questionnaires. With a median follow-up of 72 months (6 years), the estimated overall survival at 5 and 10 years was 96.8 and 77.7%, respectively, and disease-free survival at 5 and 10 years was 91.1 and 69.4%, respectively, without statistically significant differences between groups.

Discussion

APBI is an attractive alternative in candidate patients with initial breast cancer, with benefits in acute toxicity and quality of life and fewer visits to the hospital, without compromising tumor control or survival.

Effects of a reimbursement change and travel times on the delivery of private and public radiology services in Norway: a register-based longitudinal study of Norwegian claims data

BACKGROUND

The variation in the impact of the 2008 reimbursement change for Norwegian radiology providers, depending on the travel times to private and public providers in different municipalities, was examined. The activity-based fund allocation for radiology providers was reduced from approximately 50% to 40%, which was compensated by an increased basic grant. The hypothesis was that the Norwegian population would be affected by the reimbursement change unevenly depending on their distances to different types of the providers.

METHODS

The study of the effect of the reimbursement change and travel time difference between private and public radiology providers in Norway (Time_difference) on the number of the services was performed using fixed-effects regressions applied to panel data at the municipality level with monthly observations for the period 2007-2010.

RESULTS

After the reimbursement change, the number of private services decreased more than the number of public services. Private services declined after 2008, but the absolute value of the effect was smaller as the Time_difference became greater. The number of public services increased as the Time_difference grew. The total number of services decreased until the Time_difference was equal to 40 min and increased for time differences greater than 40 min.

CONCLUSIONS

The messages for policymakers are as follows. Populations that only had private providers nearby were more affected by the reimbursement change in terms of a reduced number of services. The reimbursement change contributed to the reallocation of patients from private to public providers. The difference between the centralities of municipalities in their consumption patterns was reduced and the difference between different Regional Health Authorities was increased due to the reimbursement change.

A Population-Based Study of Palliative Radiation Therapy for Bone Metastases in Patients Dying of Prostate Cancer

PURPOSE

Increasing the survival of patients with metastatic prostate cancer (PCa) may affect the demand for palliative radiation to bone (PRTB). Our aim was to characterize the use of PRTB in patients who died of PCa in British Columbia between 2003 and 2015.

METHODS AND MATERIALS

All patients with a diagnosis of PCa who died during the study period (n = 23,260) were identified from a population-based provincial registry. Patient and treatment characteristics were analyzed. PRTB utilization rate was calculated by year and location. Survival was calculated from the first and the last course of PRTB.

RESULTS

A total of 5701 patients died of PCa, with a median survival from diagnosis of 5.2 years. The overall PRTB utilization rate was 38.6%, with an increasing trend over time. Multiple courses of PRTB were frequent, with 51% of patients receiving ≥2 courses of PRTB. Of the patients who died of PCa (15.2% of the PRTB cohort), 5.4% received PRTB within the last 4 weeks of life, 60% of whom received multiple fractions. Rural areas had a lower referral rate and lower use of PRTB. Patients with longer survival tended to receive multiple courses of treatment. The median survival after the first course of PRTB increased from 8.2 months in 2003 to 2004 to 9.4 months in 2013 to 2014 (P = .04).

CONCLUSIONS

PRTB is only used in a minority of patients dying of PCa. The majority who die of PCa after PRTB do so within a year of their first course. The use of multifractionation was common in the last 4 weeks of life. Survival after first PRTB increased minimally over time, and additional research is required to identify its association with recent changes in practice. The referral rate and PRTB utilization rate differ between rural and nonrural locations, underlying the importance of accessibility and referral for utilization of PRTB. Investigating other barriers and ensuring equitable access to radiation are needed.

Location-allocation model for external beam radiotherapy as an example of an evidence-based management tool implemented in healthcare sector in Poland

BACKGROUND AND PURPOSE

External beam radiotherapy (EBRT) is one of three key treatment modalities of cancer patients. Its utilisation and outcomes depend on a plethora of variables, one of which is the distance a patient must travel to undergo the treatment. The relation between distance and utilisation is clearly visible in Poland. At the same time no strategic investment plan is observed. This work proposes a method of resolving these two issues.

MATERIALS AND METHODS

We propose a mixed-integer linear programming model that aims to optimise the distribution of linear accelerators among selected locations in such a way that a patient's journey to the nearest EBRT is as short as possible. The optimisation is done with observance of international guidelines concerning EBRT capacity. With the use of proposed theoretical framework, we develop a national, strategic plan for linear accelerator investments.

RESULTS

According to model assumptions decentralisation of EBRT, together with new equipment purchases, is required to ensure optimal access to EBRT.

CONCLUSIONS

The results were incorporated into Healthcare Needs Maps for Poland. The plan based on the results of this study, implemented by 2025, should deal with the most pressing concerns of Polish EBRT.

Healthcare-resource utilization associated with radiation to bone across eight European countries: Results from a retrospective study

Background

Bone metastases and lytic lesions due to multiple myeloma are common in advanced cancer and can lead to debilitating complications (skeletal-related events [SREs]), including requirement for radiation to bone. Despite the high frequency of radiation to bone in patients with metastatic bone disease, our knowledge of associated healthcare resource utilization (HRU) is limited.

Methods

This retrospective study estimated HRU following radiation to bone in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden and Switzerland. Eligible patients were ≥ 20 years old, had bone metastases secondary to breast, lung or prostate cancer, or bone lesions associated with multiple myeloma, and had received radiation to bone between 1 July 2004 and 1 July 2009. HRU data were extracted from hospital patient charts from 3.5 months before the index SRE (radiation to bone preceded by a SRE-free period of ≥ 6.5 months) until 3 months after the last SRE that the patient experienced during the study period.

Results

In total, 482 patients were included. The number of inpatient stays increased from baseline by a mean of 0.52 (standard deviation [SD] 1.17) stays per radiation to bone event and the duration of stays increased by a mean of 7.8 (SD 14.8) days. Outpatient visits increased by a mean of 4.24 (SD 6.57) visits and procedures by a mean of 8.51 (SD 7.46) procedures.

Conclusion

HRU increased following radiation to bone across all countries studied. Agents that prevent severe pain and delay the need for radiation have the potential to reduce the burden imposed on healthcare resources and patients.

Spatial barriers impact upon appropriate delivery of radiotherapy in breast cancer patients

Radiotherapy (RT) is the standard treatment for breast cancer patients after conserving surgery or mastectomy when patients are at high risk of relapse. Major obstacles to appropriate RT delivery are journey times. Since studies on access to RT were carried out mostly in large countries, this study investigated factors in an Italian region and the influence of RT delivery on survival. A total of 4735 female candidates for RT were included in the study. A geographic information system calculated journey times from patients' homes and surgery hospitals to RT centers. Logistic regression analyzed the influence of journey times, socioeconomic status, and other factors on RT delivery. Survival probabilities and excess mortality were assessed in 4364 propensity score-matched patients. Journey times of 40 min or less from residence and from surgery hospital to RT center played a major role in access to RT. A large survival difference emerged between treated and untreated breast cancer patients. The excess mortality for untreated patients compared with propensity score-matched women receiving RT was 3.1 (95% CI: 2.2-4.3). Expansion of RT facilities during the 11-year study period improved RT delivery and outcomes by increasing availability but mainly by shortening journey times.

Estimating radiotherapy demands in South East Asia countries in 2025 and 2035 using evidence-based optimal radiotherapy fractions

BACKGROUND AND PURPOSE

As about 50% of cancer patients may require radiotherapy, the demand of radiotherapy as the main treatment to treat cancer is likely to rise due to rising cancer incidence. This study aims to quantify the radiotherapy demand in countries in Southeast Asia (SEA) in 2025 and 2035 using evidence-based optimal radiotherapy fractions.

MATERIALS AND METHODS

SEA country-specific cancer incidence by tumor site for 2015, 2025 and 2035 was extracted from the GLOBOCAN database. We utilized the optimal radiotherapy utilization rate model by Wong et al. (2016) to calculate the optimal number of fractions for all tumor sites in each SEA country. The available machines (LINAC & Co-60) were extracted from the IAEA's Directory of Radiotherapy Centres (DIRAC) from which the number of available fractions was calculated.

RESULTS

The incidence of cancers in SEA countries are expected to be 1.1 mil cases (2025) and 1.4 mil (2035) compared to 0.9 mil (2015). The number of radiotherapy fractions needed in 2025 and 2035 are 11.1 and 14.1 mil, respectively, compared to 7.6 mil in 2015. In 2015, the radiotherapy fulfillment rate (RFR; required fractions/available fractions) varied between countries with Brunei, Singapore and Malaysia are highest (RFR > 1.0 - available fractions > required fractions), whereas Cambodia, Indonesia, Laos, Myanmar, Philippines, Timor-Leste and Vietnam have RFR < 0.5. RFR is correlated to GDP per capita (ρ = 0.73, P = 0.01). To allow RFR ≥1 in 2025 and 2035, another 866 and 1177 machines are required, respectively. The number are lower if longer running hours are implemented.

CONCLUSION

With the optimal number of radiotherapy fractions, estimation for number of machines required can be obtained which will guide acquisition of machines in SEA countries. RFR is low with access varied based on the economic status.

Understanding variations in the use of hypofractionated radiotherapy and its specific indications for breast cancer: A mixed-methods study

BACKGROUND AND PURPOSE

Radiation oncology guidelines favour hypofractionated whole-breast radiotherapy (HWBRT) over more conventional schemes in the conservative treatment of breast cancer, but its adoption still varies in clinical practice. This study assessed the patterns of HWBRT adoption in Catalonia (Spain).

MATERIAL AND METHODS

We used a mixed-methods approach based on an explanatory sequential design, first collecting and analysing quantitative data on HWBRT use (>2.5Gy per fraction) in 11 public radiotherapy centres (2005-2015) and then performing 25 semi-structured interviews with all department heads and reference radiation oncologist/s.

RESULTS

Of the 34,859 patients fulfiling the study criteria over the study period, just 12% were hypofractionated, reaching a percentage of 29% in 2015 (p<0.001). Our analysis showed a narrowing age gap between patients receiving conventional fractionation and hypofractionation in centres leading adoption. However, there were important differences in clinicians' interpretation of evidence (e.g. regarding the perceived risk of long-term toxicity) and selection of patients for specific indications, both within and between departments.

CONCLUSIONS

Differences observed in the rate of adoption of HWBRT could not be tackled only using a rational, evidence-based approach. Factors related to the management of radiotherapy departments play a major role in the diffusion of therapeutic strategies.

Measuring inequality in physician distributions using spatially adjusted Gini coefficients

Objective

To measure inequality in physician distributions using Gini coefficient and spatially adjusted Gini coefficients.

Design

Measurements were based on the distribution of physician data from the Taiwan National Health Insurance Research Database (NHIRD) and population data from the Ministry of the Interior in Taiwan.

Settings

The distribution of population and physicians in Taiwan from 2001 to 2010.

Participants

This study considered 35 000 physicians who are registered in Taiwan.

Main Outcome Measures

To calculate the Gini coefficient and spatially adjusted Gini coefficients in Taiwan from 2001 to 2010.

Results

The Gini coefficient for each year, from 2001 to 2010, ranged from 0.5128 to 0.4692, while the spatially adjusted Gini coefficients based on travel time and travel distance ranged, respectively, from 0.4324 to 0.4066 and from 0.4408 to 0.4178. We found that, in each year, irrespective of the type of spatial adjustment, the spatially adjusted Gini coefficient was smaller than the Gini coefficient itself. Our empirical findings support that the Gini coefficient may overestimate the maldistribution of physicians.

Conclusions

Our simulations demonstrate that increasing the number of physicians in medium-sized cities (such as capitals of counties or provinces), and/or improving the transportation time between medium-sized cities and rural areas, could be feasible solutions to mitigate the problem of geographical maldistribution of physicians.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Accessing doctors at times of need-measuring the distance tolerance of rural residents for health-related travel

BACKGROUND

Poor access to doctors at times of need remains a significant impediment to achieving good health for many rural residents. The two-step floating catchment area (2SFCA) method has emerged as a key tool for measuring healthcare access in rural areas. However, the choice of catchment size, a key component of the 2SFCA method, is problematic because little is known about the distance tolerance of rural residents for health-related travel. Our study sought new evidence to test the hypothesis that residents of sparsely settled rural areas are prepared to travel further than residents of closely settled rural areas when accessing primary health care at times of need.

METHODS

A questionnaire survey of residents in five small rural communities of Victoria and New South Wales in Australia was used. The two outcome measures were current travel time to visit their usual doctor and maximum time prepared to travel to visit a doctor, both for non-emergency care. Kaplan-Meier charts were used to compare the association between increased distance and decreased travel propensity for closely-settled and sparsely-settled areas, and ordinal multivariate regression models tested significance after controlling for health-related travel moderating factors and town clustering.

RESULTS

A total of 1079 questionnaires were completed with 363 from residents in closely-settled locations and 716 from residents in sparsely-settled areas. Residents of sparsely-settled communities travel, on average, 10 min further than residents of closely-settled communities (26.3 vs 16.9 min, p < 0.001), though this difference was not significant after controlling for town clustering. Differences were more apparent in terms of maximum time prepared to travel (54.1 vs 31.9 min, p < 0.001). Differences of maximum time remained significant after controlling for demographic and other constraints to access, such as transport availability or difficulties getting doctor appointments, as well as after controlling for town clustering and current travel times.

CONCLUSIONS

Improved geographical access remains a key issue underpinning health policies designed to improve the provision of rural primary health care services. This study provides empirical evidence that travel behaviour should not be implicitly assumed constant amongst rural populations when modelling access through methods like the 2SFCA.

Examining Determinants of Radiotherapy Access: Do Cost and Radiotherapy Inconvenience Affect Uptake of Breast-conserving Treatment for Early Breast Cancer?

AIMS

Radiotherapy utilisation is likely affected by multiple factors pertaining to radiotherapy access. Radiotherapy is an integral component of breast-conserving treatment (BCT) for early breast cancer. We aimed to determine if stepwise improvements in radiotherapy access in regional Australia affected the uptake of BCT and thus radiotherapy.

MATERIALS AND METHODS

Breast cancer operations in the Central Coast of New South Wales between January 2010 and March 2014 for T1-2N0-1M0 invasive or in situ (≤5 cm) disease in female patients eligible for BCT were examined. BCT uptake was calculated for three 1 year periods: period 1 (local radiotherapy available at cost to user or out of area radiotherapy with travel cost and inconvenience); period 2 (as per period 1 + publicly funded transport and radiotherapy at out of area facilities at no cost to user); period 3 (as per period 1 + publicly funded local radiotherapy at no cost to user).

RESULTS

In total, 574 cases met eligibility criteria. BCT declined with increasing distance to publicly funded radiotherapy (P = 0.035). BCT rates for periods 1, 2 and 3 were 63% (113/180), 61% (105/173) and 71% (156/221). There were no statistically significant differences in BCT between periods 1 and 2 in the whole cohort or within age, histology or tumour size subgroups. Overall, there was a 9% increase in BCT in the whole cohort in period 3 compared with periods 1 and 2 (P = 0.031). This increase was statistically significant for women over 70 years (19% increase, P = 0.034), for women with ductal carcinoma in situ (25% increase, P = 0.013) and for women with primary tumours that were ≤10 mm (21% increase, P = 0.016).

CONCLUSIONS

Improving the affordability of radiotherapy through publicly funded transport and radiotherapy at out of area facilities did not improve BCT uptake in a region where radiotherapy was locally available, albeit at cost to the user. Improving both affordability and convenience through the provision of local publicly funded radiotherapy increased BCT uptake. Service availability and affordability have long been recognised as important determinants of radiotherapy access. Our findings suggest that inconvenience may also influence radiotherapy utilisation.

International patterns of radiotherapy practice for non-small cell lung cancer

Radiotherapy is an important treatment modality for non-small cell lung cancer (NSCLC). There are models of radiotherapy utilization that estimate the proportion of patients with NSCLC who have an evidence-based indication for radiotherapy. These estimates range from 46%-68% for radiotherapy utilization at diagnosis and 64%-75% overall. However, actual radiotherapy utilization throughout much of the world is lower than this, ranging from 28%-53%, with the largest differences between actual and estimated radiotherapy utilization seen in stage III NSCLC. Some of this discrepancy is attributable to the assumptions in the models that are based on broad factors such as stage and performance status. Characteristics of the population with underlying lung cancer that often has comorbidities or compromised respiratory function also influence the ability to deliver radiotherapy safely. Sociodemographic factors such as race and income have been found to affect access to radiotherapy in certain jurisdictions. The type of clinician or medical setting the patient presents to initially can also influence radiotherapy use in NSCLC. Potential solutions to improve appropriate radiotherapy utilization for NSCLC include restructuring models of care to ensure that all patients with lung cancer are managed within a multidisciplinary team including a radiation oncologist.

Management of rectal cancers in relation to treatment guidelines: a population-based study comparing Italian and French patients

BACKGROUND

Few studies have investigated rectal cancer management at the population level. We compared how rectal cancers diagnosed in Italy (2003-2005) and France (2005) were managed, and evaluated the extent to which management adhered to European guidelines.

METHODS

Samples of 3938 Italian and 2287 French colorectal cancer patients were randomly extracted from 8 and 12 cancer registries respectively. Rectal cancer patients (860 Italian, 559 French) were analysed. Logistic regression models estimated odds ratios (ORs) of being treated with curative intent, receiving sphincter-saving surgery, and receiving preoperative radiotherapy.

RESULTS

Similar proportions of Italian and French patients were treated with curative intent (70% vs. 67%; OR=0.92 [0.73-1.16]); the respective proportions receiving sphincter-saving surgery were 21% and 33% (OR=1.15 [0.86-1.53]). In about 50% of those treated with curative intent, ≥ 12 lymph nodes were harvested in both countries. The proportion receiving postoperative radiotherapy was higher in Italy than in France (25% vs. 11%, p<0.01), but French patients were more likely to receive preoperative radiotherapy (52% vs. 21%; OR=4.06 [2.79-5.91]).

CONCLUSION

The proportions of patients receiving preoperative radiotherapy and the numbers of lymph nodes sampled were low in both countries. Centralising treatment and potentiating screening would be practical ways of improving outcomes and adhering to guidelines.

Evaluation of resource allocation and supply-demand balance in clinical practice with high-cost technologies

RATIONALE, AIMS AND OBJECTIVES

Japan has one of the highest numbers of high-cost medical devices installed relative to its population. While evaluations of the distribution of these devices traditionally involve simple population-based assessments, an indicator that includes the demand of these devices would more accurately reflect the situation. The purpose of this study was to develop an indicator of the supply-demand balance of such devices, using examples of magnetic resonance imaging scanners (MRI) and extracorporeal shockwave lithotripters (ESWL), and to investigate the relationship between this indicator, personnel distribution statuses and operating statuses at the prefectural level.

METHODS

Using data from nation-wide surveys and claims data from 16 hospitals, we developed an indicator based on the ratio of the supplied number of device units to the number of device units in demand for MRI and ESWL. The latter value was based on patient volume and utilization proportion. Correlation analyses were conducted between the supply-demand balances of these devices, personal distribution and operating statuses.

RESULTS

Comparisons between our indicator and conventional population-based indicators revealed that 15% and 30% of prefectures were at risk of underestimating the availability of MRI and ESWL, respectively. The numbers of specialist personnel/device units showed significant, negative correlations with our indicators in both devices.

CONCLUSIONS

Utilization-based analyses of health care resource placement and utilization status provide a more accurate indication than simple population-based assessments, and can assist decision makers in reviewing gaps between health policy and management. Such an indicator therefore has the potential to be a tool in helping to improve the efficiency of the allocation and placement of such devices.

Urbanization and the utilization of outpatient services under National Health Insurance in Taiwan

OBJECTIVES

This study aims to investigate the relationship between the level of urbanization and the utilization of outpatient services under the National Health Insurance (NHI) program in Taiwan.

METHODS

We adopted a two-part model using data from the 2001 National Health Interview Survey (NHIS) and the 2001 National Health Insurance Research Database (NHIRD) in Taiwan. Data for a total of 20,640 individuals were obtained for subsequent analysis in this study.

RESULTS

The results of the first part, the contact analysis, indicate that individuals residing in areas with lower urbanization levels are less likely to use outpatient services compared to those residing in areas with the highest urbanization levels. The second part of the frequency analysis revealed that, for those individuals that had previously utilized outpatient services, those residing in areas with lower urbanization levels tended to utilize outpatient services less than individuals residing in areas with higher levels of urbanization.

CONCLUSIONS

Our empirical results show that differences between urbanization levels are a major contributory factor associated with the probability and frequency of outpatient utilization in Taiwan.

The impact of geographic proximity to transplant center on outcomes after allogeneic hematopoietic stem cell transplantation

Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) need access to specialized care. We hypothesized that access to the transplant center after HSCT may be challenging for patients living in geographically distant areas, and that this would have an adverse effect on their outcome. We analyzed 1912 adult patients who underwent allogeneic HSCT at the Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) between 1996 and 2009 and who resided within 6 hours driving time of the institution. Driving time from primary residence to DF/BWCC based on zipcode was determined using geographic information systems. The median driving time (range) to DF/BWCC was 72 (2-358) minutes. When patients were stratified by driving time quartile, overall survival (OS) after HSCT was similar in the first year but worse after 1 year in patients in the top quartile (≥ 160 minutes driving time). In a landmark analysis of the 909 patients alive and free of disease at 1 year, 5-year OS was 76% and 65% for patients in the first (≤ 40 minutes) and fourth (≥ 160 minutes) quartiles, respectively (P = .027). This was confirmed in a multivariable analysis. The difference appeared to be mostly because of an increase in nonrelapse mortality. The number of visits to the transplant center between day 100 and 365 after HSCT declined significantly with increasing driving time to the transplant center, which was independently associated with worse survival. Long driving time to the transplant center is associated with worse OS in patients alive and disease-free 1 year after HSCT, independently of other patient-, disease-, and HSCT-related variables. This may be in part related to the lower frequency of post-HSCT visits in patients living farther away.

Breast cancer care compared with clinical Guidelines: an observational study in France

Background

Great variability in breast cancer (BC) treatment practices according to patient, tumour or organisation of care characteristics has been reported but the relation between these factors is not well known. In two French regions, we measured compliance with Clinical Practice Guidelines for non-metastatic BC care management and identified factors associated with non-compliance at clinical and organisational levels.

Methods

Eligible patients had invasive unilateral BC without distant metastases and at least two contacts with one of the two regional healthcare systems (2003-2004) in the first year after diagnosis. Medical data were collected from patient medical records in all public and private hospitals (99 hospitals).

The care process was defined by 20 criteria: clinical decisions for treatment and therapeutic procedures. Each criterion was classified according to level of compliance ("Compliant", "Justifiable" and "Not Compliant") and factors of non-compliance were identified (mixed effect logistic regression).

Results

926 women were included. Non-compliance with clinical decisions for treatment was associated with older patient age (OR 2.1; 95%CI: 1.3-3.6) and region (OR 3.0; 95%CI: 1.2-7.4). Non-compliance with clinical decisions for radiotherapy was associated with lymph node involvement or the presence of peritumoural vascular invasion (OR 1.5; 95%CI: 1.01-2.3) and non-compliance with overall treatment (clinical decisions for treatment + therapeutic procedures) was associated with the presence of positive lymph nodes (OR 2.0; 95%CI: 1.2-3.3), grade III versus grade I (OR 2.9; 95%CI: 1.4-6.2), and one region of care versus another (OR 3.5; 95%CI: 1.7-7.1). Finally, heterogeneity of compliance in overall treatment sequence was identified between local cancer units (p < 0.05).

Conclusion

This study provides interesting insights into factors of non-compliance in non-metastatic BC management and could lead to quality care improvements.

Accessibility to health care facilities in Montreal Island: an application of relative accessibility indicators from the perspective of senior and non-senior residents

BACKGROUND

Geographical access to health care facilities is known to influence health services usage. As societies age, accessibility to health care becomes an increasingly acute public health concern. It is known that seniors tend to have lower mobility levels, and it is possible that this may negatively affect their ability to reach facilities and services. Therefore, it becomes important to examine the mobility situation of seniors vis-a-vis the spatial distribution of health care facilities, to identify areas where accessibility is low and interventions may be required.

METHODS

Accessibility is implemented using a cumulative opportunities measure. Instead of assuming a fixed bandwidth (i.e. a distance threshold) for measuring accessibility, in this paper the bandwidth is defined using model-based estimates of average trip length. Average trip length is an all-purpose indicator of individual mobility and geographical reach. Adoption of a spatial modelling approach allows us to tailor these estimates of travel behaviour to specific locations and person profiles. Replacing a fixed bandwidth with these estimates permits us to calculate customized location- and person-based accessibility measures that allow inter-personal as well as geographical comparisons.

DATA

The case study is Montreal Island. Geo-coded travel behaviour data, specifically average trip length, and relevant traveller's attributes are obtained from the Montreal Household Travel Survey. These data are complemented with information from the Census. Health care facilities, also geo-coded, are extracted from a comprehensive business point database. Health care facilities are selected based on Standard Industrial Classification codes 8011-21 (Medical Doctors and Dentists).

RESULTS

Model-based estimates of average trip length show that travel behaviour varies widely across space. With the exception of seniors in the downtown area, older residents of Montreal Island tend to be significantly less mobile than people of other age cohorts. The combination of average trip length estimates with the spatial distribution of health care facilities indicates that despite being more mobile, suburban residents tend to have lower levels of accessibility compared to central city residents. The effect is more marked for seniors. Furthermore, the results indicate that accessibility calculated using a fixed bandwidth would produce patterns of exposure to health care facilities that would be difficult to achieve for suburban seniors given actual mobility patterns.

CONCLUSIONS

The analysis shows large disparities in accessibility between seniors and non-seniors, between urban and suburban seniors, and between vehicle owning and non-owning seniors. This research was concerned with potential accessibility levels. Follow up research could consider the results reported here to select case studies of actual access and usage of health care facilities, and related health outcomes.

A nationwide audit of the use of radiotherapy for rectal cancer in Italy

BACKGROUND

There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated.

METHODS

We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis.

RESULTS

Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients corresponding to 58% of rectal cancers operated by SICCR members in 2005. Radiotherapy was used in 307/682 (45.0%) patients. Preoperative radiotherapy was used in 236/682 (34.6%), postoperative radiotherapy in 71/682 (10.4%) cases and no radiotherapy in 375 (55.0%) cases. Of the 236 patients who underwent preoperative radiotherapy, only 24 (10.2%) received short-course radiotherapy, while 212 (89.8%) received long-course radiotherapy. Of the 339 stage II-III patients, 159 (47%) did not receive any radiotherapy. Radiotherapy was more frequently used in younger patients (P < 0.0001), in patients undergoing abdominoperineal resection (APR) (P < 0.01) and in the north and center of Italy (P < 0.001). Preoperative radiotherapy was more frequently used in younger patients (P < 0.001), in large volume centers (P < 0.05), in patients undergoing APR (P < 0.005) and in the north-center of Italy (P < 0.05).

CONCLUSION

Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.

Patterns of practice in palliative radiotherapy for painful bone metastases: impact of a regional rapid access clinic on access to care

PURPOSE

External beam radiotherapy (RT) is commonly indicated for the palliation of symptomatic bone metastases, but there is evidence of underutilization of this treatment modality in palliative care for cancer populations. This study was conducted to investigate factors that influenced the use of palliative RT services at a regional comprehensive cancer center.

METHODS AND MATERIALS

A cohort of patients with radiographically confirmed bone metastases and first-time users of palliative RT between 2003 and 2005 was retrospectively reviewed from the time of initial diagnosis of bone metastases to death or last follow-up. Type of radiation treatment service provider used (rapid access or routine access) and patient-, tumor-, and treatment-related factors were analyzed for their influences on the number of treatment courses given over the duration of disease.

RESULTS

A total of 887 patients received 1,354 courses of palliative RT for bone metastases at a median interval of 4.0 months between courses. Thirty-three percent of patients required more than one RT course. Increased age and travel distance reduced the likelihood and number of treatment courses, while service through a rapid access clinic was independently associated with an increase in subsequent use of palliative RT.

CONCLUSIONS

A rapid access service model for palliative RT facilitated access to RT. Travel distance and other factors remained substantial barriers to use of palliative RT services. The pattern of practice suggests an unmet need for symptom control in patients with bone metastases.

The index of rural access: an innovative integrated approach for measuring primary care access

BACKGROUND

The problem of access to health care is of growing concern for rural and remote populations. Many Australian rural health funding programs currently use simplistic rurality or remoteness classifications as proxy measures of access. This paper outlines the development of an alternative method for the measurement of access to primary care, based on combining the three key access elements of spatial accessibility (availability and proximity), population health needs and mobility.

METHODS

The recently developed two-step floating catchment area (2SFCA) method provides a basis for measuring primary care access in rural populations. In this paper, a number of improvements are added to the 2SFCA method in order to overcome limitations associated with its current restriction to a single catchment size and the omission of any distance decay function. Additionally, small-area measures for the two additional elements, health needs and mobility are developed. By utilising this improved 2SFCA method, the three access elements are integrated into a single measure of access. This index has been developed within the state of Victoria, Australia.

RESULTS

The resultant index, the Index of Rural Access, provides a more sensitive and appropriate measure of access compared to existing classifications which currently underpin policy measures designed to overcome problems of limited access to health services. The most powerful aspect of this new index is its ability to identify access differences within rural populations at a much finer geographical scale. This index highlights that many rural areas of Victoria have been incorrectly classified by existing measures as homogenous in regards to their access.

CONCLUSION

The Index of Rural Access provides the first truly integrated index of access to primary care. This new index can be used to better target the distribution of limited government health care funding allocated to address problems of poor access to primary health care services in rural areas.

Appropriateness of early breast cancer management in relation to patient and hospital characteristics: a population based study in Northern Italy

Administrative data may provide valuable information for monitoring the quality of care at population level and offer an efficient way of gathering data on individual patterns of care, and also to shed light on inequalities in access to appropriate medical care. The aim of the study was to investigate the role of patient and hospital characteristics in the initial treatment of early breast cancer using administrative data. Incident breast cancer patients were identified from hospital discharge records and linked to the radiotherapy outpatient database during 2000-2004 in the Piedmont region of Northwestern Italy. Women treated with breast-conserving surgery followed by radiotherapy (BCS + RT) were compared to those treated with BCS without radiotherapy (BCS w/o RT) or mastectomy using multinomial logistic regression models. Out of 16,022 incident cases, 46.2% received BCS + RT, 20.3% received BCS w/o RT, and 33.5% received a mastectomy. Compared to BCS + RT, the factors associated with BCS w/o RT were: increased age (OR = 1.54; 95% CI = 1.29-1.85, for ages 70-79 vs. <50), being unmarried (1.24; 1.13-1.36), presence of co-morbidities (1.32; 1.10-1.58), being treated at hospitals with low surgical volume (1.31; 1.07-1.60 for hospitals with less than 50 vs. > or =150 interventions/year), and living far from radiotherapy facilities (1.75; 1.39-2.20 for those at a distance of >45 min). These same factors were also associated with mastectomy. During the 5-year period observed, there was a trend of reduced probability of receiving a mastectomy (0.70; 0.56-0.88 for 2004 vs. 2000). The presence or absence of nodal involvement was positively associated with mastectomy (2.28; 1.83-2.85) and negatively associated with BCS w/o RT (0.65; 0.56-0.76). After adjustment for potential confounders, education level did not show any association with the type of treatment. Social and geographical factors, in addition to hospital specialization, should be considered to reduce inappropriateness of care for breast cancer.

Evidence-based estimation and radiotherapy utilisation rate in Andalusia

INTRODUCTION

The objective of this study was to estimate the theoretical needs -based on evidence- of radiotherapy treatments (RDT) in Andalusia, compare these needs with actual use of RDT in 2006 and analyse their evolution from 2003.

MATERIALS AND METHODS

Correlation between quantitative variables was analysed with Pearson's correlation coefficient. This dealt with differences between administered/estimated treatments and treatments carried out in years with the Student's t-distribution, and the Xi2 test among qualitative variables.

RESULTS

In Andalusia, the evidence-based rate of cancer irradiation is 55%. Eighty-five percent of theoretical treatments were administered in 2006. From this group, 107% were in gynaecological tumours, 100% in breast cancer cases, 71% in head and neck cancer and 48% in lung cancers; differences in the last two conditions were significant (p<0.01). As for regional distribution, differences were reported with reference to irradiation rates (p<0.0002) and resource distribution. In the last three years, an increment of 17% was observed in treatments conducted in public hospitals. The rate increased from 61% (with regard to optimal values) to 85% in 2006; in a parallel way, an increment was seen in therapy units (from 22 to 26) and radiation oncologists (from 57 to 69).

CONCLUSIONS

Despite the increment of irradiation rates seen in the last years, there is still a serious underutilisation of RDT for some cancer types (lung, head and neck cancer), as well as a great variability in the use of RDT between hospitals.