Rural-Urban Disparities in Receipt of Surgery for Potentially Resectable Non-Small Cell Lung Cancer

Race and Sex Disparities in Metabolic/Bariatric Surgery over 20 Years: A Cohort Study

Objectives

To determine how rates of discussion of metabolic and bariatric surgery (MBS) between patients with class 2 obesity and higher and their healthcare providers as well as subsequent progression to MBS have varied by race and sex over the last 20 years.

Background

Obesity is a growing public health crisis. MBS remains the most effective treatment for long-term management of obesity.

Methods

Retrospective cohort study of electronic health records from a large tertiary academic health system using a previously validated natural language processing algorithm. The primary outcomes were discussion of MBS between eligible patients and providers and progression to surgery. Multivariable logistic regression was used to determine the association between sociodemographic factors, time, and discussion and receipt of MBS.

Results

Among 122,487 patients included in the analysis, 11,094 (9.1%) patients discussed MBS with their providers. Of these, 1348 (12.2%) progressed to MBS. Between 2000 and 2020 the annual fraction of patients who had a discussion of MBS with their providers rose from 3.2% to 10.0% (P < 0.001). Black people were equally likely to discuss MBS with providers as non-Black people (9.5 vs 9.0%, P = 0.09) but were less likely to progress to MBS (8.4 vs 12.6%, P < 0.001). These disparities in progression narrowed over the study period (P = 0.044). Men were less likely than women to both discuss (8.1% vs 9.6%, P < 0.001) and receive MBS (7.6% vs 14.6%, P < 0.001), and these disparities increased over the study period.

Conclusions

Interventions to reduce racial disparities in utilization of MBS should focus on progression from discussion to MBS. Interventions to increase the uptake of MBS among men are required across the care cascade.

Rurality predisposes departure from gold-standard care, leading to delayed or accelerated access to surgery: insights from a scoping review

BACKGROUND

Because tertiary centres are generally situated at urban sites, it is unclear whether patients in rural areas have the same access to surgical services that patients in urban areas do. We sought to map the North American evidence landscape of how rurality affects access to medically indicated surgeries and identify system-, patient-, and provider-level barriers that preclude urban-comparable care.

METHODS

We carried out a systematic search adhering to PRISMA for Scoping Reviews methodology across PubMed, MEDLINE, Scopus, and Web of Science, encompassing literature from the last 26 years (January 2023). Search terms included "rural population," "health care access," "surgical procedures," and "health disparities." We synthesized our findings using a narrative approach.

RESULTS

Of 13 897 identified studies, we included 71 publications, spanning a wide spectrum of surgical disciplines. Of these, 83% reported diminished and 17% reported accelerated access to surgery, and 30% reported an interaction between rurality with other social determinants of health, particularly age, sex and gender, and race and ethnicity. Of the studies that reported diminished access, top cited reasons included primary and specialist provider density, differences in patients' socioeconomic profiles, and provision of comparable counselling during surgical decisionmaking. Strikingly, a key driver of enhanced surgical access was an absence of specialized medical interventions leading to an overreliance on surgical alternatives.

CONCLUSION

Whether surgical access was diminished or accelerated, the net impact of rurality was a deviation from guideline-concordant care. A key implication of these findings is that reliance on surgical wait times alone can skew perception of surgical access, advocating for adoption of integrated quality-of-care metrics that better reflect access to comprehensive medical and surgical treatment programs.

CONTEXTE

Étant donné que les centres de soins tertiaires se trouvent généralement en milieu urbain, on peut se demander si l'accès aux services chirurgicaux est le même en région rurale qu'en milieu urbain. Nous avons voulu cartographier, preuve à l'appui, l'impact de la ruralité sur l'accès à des chirurgies médicalement indiquées en Amérique du Nord et identifier les obstacles, propres au système, à la patientèle et aux équipes soignantes, qui nuisent à la prestation des soins équivalents à ceux des milieux urbains. MÉTHODES: Nous avons procédé à une interrogation systématique (conforme à la Norme de réalisation de revue systématique de la littérature PRISMA) des bases de données PubMed, MEDLINE, Scopus et Web of Science regroupant la littérature des 26 dernières années (janvier 2023). Les mots clés de langue anglaise utilisés incluaient : « rural population », « health care access », « surgical procedures » et « health disparities ». Nous avons synthétisé nos observations au moyen d'une approche narrative. RÉSULTATS: Des 13 897 études recensées, nous avons retenu 71 publications abordant un vaste éventail de disciplines chirurgicales. Parmi ces publications, 83 % faisaient état d'un accès diminué, 17 % d'un accès plus rapide à la chirurgie, et 30 % d'un lien entre la ruralité et d'autres déterminants sociaux de la santé, notamment l'âge, le sexe et le genre, ainsi que la race et l'ethnicité. Selon les études ayant fait état d'un accès diminué, les principales raisons incluaient la densité des effectifs en médecine primaire et de spécialité, les différences de profils socioéconomiques de la patientèle et l'offre d'un counselling comparable lors du processus décisionnel concernant la chirurgie. À noter, l'un des principaux facteurs d'amélioration de l'accès aux soins chirurgicaux était l'absence d'interventions médicales spécialisées associées à une dépendance indue à l'endroit des solutions chirurgicales.

CONCLUSION

Que l'accès à la chirurgie ait été diminué ou accéléré, l'impact net de la ruralité a pris la forme d'un écart par rapport aux soins préconisés par les lignes directrices. Ces observations indiquent principalement que la dépendance à l'égard des temps d'attente en chirurgie seule peut fausser la perception quant à l'accès aux soins chirurgicaux, ce qui milite en faveur de l'adoption de paramètres de qualité de soins intégrés qui reflèteraient plus fidèlement l'accès à des programmes de traitements médicaux et chirurgicaux complets.

Disparities across the continuum of lung cancer care: a review of recent literature

PURPOSE OF REVIEW

Lung cancer remains the leading cause of cancer mortality worldwide. Health disparities have long been noted in lung cancer incidence and survival and persist across the continuum of care. Understanding the gaps in care that arise from disparities in lung cancer risk, screening, treatment, and survivorship are essential to guiding efforts to achieve equitable care.

RECENT FINDINGS

Recent literature continues to show that Black people, women, and people who experience socioeconomic disadvantage or live in rural areas experience disparities throughout the spectrum of lung cancer care. Contributing factors include structural racism, lower education level and health literacy, insurance type, healthcare facility accessibility, inhaled carcinogen exposure, and unmet social needs. Promising strategies to improve lung cancer care equity include policy to reduce exposure to tobacco smoke and harmful pollutants, more inclusive lung cancer screening eligibility criteria, improved access and patient navigation in lung cancer screening, diagnosis and treatment, more deliberate offering of appropriate surgical and medical treatments, and improved availability of survivorship and palliative care.

SUMMARY

Given ongoing disparities in lung cancer care, research to determine best practices for narrowing these gaps and to guide policy change are an essential focus of future lung cancer research.

Disparity of the Treatment of Unresectable Non-small Cell Lung Cancer Regarding Chemotherapy: A Systematic Review and Meta-Analysis

This study investigates disparities in chemotherapy treatment for unresectable non-small cell lung cancer (NSCLC) between urban and rural populations. Despite advancements in NSCLC treatments enhancing survival, significant inequities persist, notably in rural areas where access to care is often limited, resulting in poorer outcomes. Through a systematic review and meta-analysis, we analyzed data from selected studies that compare chemotherapy access and usage between these populations from 2010 to 2024. Our findings indicate that rural patients are consistently less likely to receive advanced chemotherapy treatments than urban counterparts, with a pooled odds ratio of 0.91 (95% confidence interval (CI): 0.83-1.00), suggesting a marginal but noticeable disparity. This highlights a crucial gap in healthcare provision, underscoring the need for policy interventions and improved healthcare practices to ensure equitable treatment access. This research calls for further investigation into socioeconomic and cultural factors contributing to these disparities to inform targeted improvement strategies.

Access to Guideline Concordant Care for Node-Positive Non-Small Cell Lung Cancer in the United States

BACKGROUND

This study sought to determine whether seeking care at multiple Commission on Cancer (CoC) hospitals is associated with different rates of receiving guideline-concordant care (GCC) among patients with non-small cell lung cancer (NSCLC).

METHODS

The National Cancer Database was queried for the years 2004 to 2018 for patients with margin-negative pT1 to pT3 N1 to N2 M0 noncarcinoid NSCLC without neoadjuvant therapy. GCC was defined as chemotherapy for pN1 disease and as chemotherapy with or without radiation for pN2 disease. Patients who received care at >1 facility were examined separately. Factors previously associated with barriers to care were compared between groups. Kaplan-Meier analysis with log-rank tests analyzed 5-year overall survival (OS). Propensity score matching was performed to compare the effect sizes of race, insurance status, and income.

RESULTS

In total 44,531 patients met inclusion criteria, 11,980 (26.9%) of whom sought care at >1 CoC institution. Among patients with pN1 disease, 5565 (76.7%) received GCC if they visited >1 facility vs 13,995 (68.5%) patients who sought care at 1 facility (P < .001). For patients with pN2 disease, 3991 (84.4%) received GCC if they visited >1 facility vs9369 (77.4%) patients receiving care at 1 facility (P < .001). Visiting >1 facility was associated with higher OS at 5 years (4784 [54.35%] vs 10,215 [45.62%]; P < .001).

CONCLUSIONS

Visiting >1 CoC institution is associated with higher rates of GCC for individuals with pN1 to pN2 lung cancer. Patients who received care at >1 facility had higher OS at 5 years. Further study is warranted to identify factors associated with the ability of patients to seek care at multiple facilities.

Evaluation of Nationwide Trends in Nodal Sampling Guideline Adherence for Gastric Cancer: 2005-2017

INTRODUCTION

Surgical resection is the primary curative treatment for localized gastric cancer. A multitude of research supports surgical nodal sampling guidelines. Though there are known disparities in adherence to nodal sampling, it is unclear how hospital program-level disparities have changed over time. The purpose of this study is to evaluate trends in program-level disparities in adherence to gastric cancer nodal sampling guidelines.

METHODS

Patients who underwent resection of gastric cancer from 2005 to 2017 were identified in the National Cancer Database. Patients treated at academic programs were compared to those treated at nonacademic programs, and rates and trends of adherence to nodal sampling guidelines (defined as ≥15 lymph nodes) were determined. Adjusted multivariable analysis was used to determine likelihood of nodal sampling adherence while controlling for sociodemographic, clinical, hospital, and travel distance characteristics.

RESULTS

A total of 55,421 patients were included with 27,201 (49.1%) of patients meeting adherence criteria for lymph node sampling. Academic programs treated 44.4% of the total cohort. Overall, lymph node sampling criteria were met in 59.2% of patients treated at high-volume academic programs and 37.0% of patients treated at low-volume nonacademic programs (incidence rate ratios 0.67, 95% confidence interval 0.63-0.72 versus high-volume academic programs). Adherence rates improved from 2005 to 2017 for both low-volume nonacademic programs (27.8% in 2005 to 50.1% in 2017) and high-volume academic programs (46.0% in 2005 to 69.8% in 2017, P < 0.001).

CONCLUSIONS

Though adherence rates have improved from 2005 to 2017, high-volume academic programs were more likely to adhere to lymph node sampling guidelines for gastric cancer.