Impact of County Rurality and Urologist Density on Urological Cancer Mortality in Illinois

Differences in cancer presentation, treatment, and mortality between rural and urban patients diagnosed with kidney cancer in the United States

INTRODUCTION

Rural-urban discrepancies in care and outcomes for kidney cancer (KCa) in the United States remains poorly understood. Our study aims to improve our understanding of the influence of rurality on KCa outcomes in the United States by analyzing differences in presentation, treatment, and mortality between urban areas (UAs) and rural areas (RAs) in the Surveillance, Epidemiology, and End Results (SEERs) database.

METHODS

SEERs data was queried from 2000 to 2019 for KCa patients. Patient counties were classified as UAs, rural adjacent areas (RAAs), or rural nonadjacent areas (RNAs) using Rural Urban Continuum Codes. Demographic, tumor characteristics, and treatment variables were compared. Propensity score matching was performed to create matched UA-RAA and UA-RNA cohorts. Multivariate regression evaluated rural-urban status as a predictor of treatment selection. Multivariate cox regression assessed the predictive value of rural-urban status for overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier analysis was used to generate survival curves for OS and CSS.

RESULTS

179,509 KCa patients were identified (UA = 87.0%, RAA = 7.7%, RNA = 5.3%). Patients in RAs were more likely to present with tumors of higher grade and stage than UAs. Following multivariate analysis, rural residency predicted undergoing nephrectomy (RAA: OR = 1.177, RNA: OR = 1.210) but was a negative predictor of receiving partial nephrectomy (RAA: OR = 0.744, RNA: OR = 0.717), all P < 0.001. Multivariate cox regression demonstrated that RAA or RNA residency was predictive of overall and cause-specific mortality. After matching, median OS was 151, 124, and 118 months for UA, RAA, and RNA cohorts respectively; mean CSS was 152, 147, and 144 months for UA, RAA, and RNA cohorts, respectively, all P < 0.001. Stage-specific analysis of CSS demonstrated significantly poorer CSS among RNA patients for localized, regionalized, and distant KCa after matching. Only RAA patients with localized KCa experienced significantly lower CSS than UA patients.

CONCLUSIONS

Patients in RAs are more likely to present with advanced KCa at diagnosis compared to those in UAs and may also experience different treatment options including a lesser likelihood of undergoing partial nephrectomy. Rural patients with KCa also demonstrated significantly worse OS and CSS compared to their urban counterparts. Further patient-level studies are required to better understand the discrepancy in CSS between urban and rural patients diagnosed with KCa.

Policy Recommendations for Improving Rural Cancer Services in the United States

Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

Rural–Urban Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study

Background: We sought to evaluate rural–urban disparities in patient care experiences (PCEs) among localized prostate cancer (PCa) survivors at intermediate-to-high risk of disease progression. Methods: Using 2007–2015 Surveillance Epidemiology and End Results (SEER) data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, we analyzed survivors’ first survey ≥6 months post-diagnosis. Covariate adjusted linear regressions were used to estimate associations of treatment status (definitive treatment vs. none) and residence (large metro vs. metro vs. rural) with PCE composite and rating measures. Results: Among 3779 PCa survivors, 1798 (53.2%) and 370 (10.9%) resided in large metro and rural areas, respectively; more rural (vs. large metro) residents were untreated (21.9% vs. 16.7%; p = 0.017). Untreated (vs. treated) PCa survivors reported lower scores for doctor communication (ß = −2.0; p = 0.022), specialist rating (ß = −2.5; p = 0.008), and overall care rating (ß = −2.4; p = 0.006). While treated rural survivors gave higher (ß = 3.6; p = 0.022) scores for obtaining needed care, untreated rural survivors gave lower scores for obtaining needed care (ß = −7.0; p = 0.017) and a lower health plan rating (ß = −7.9; p = 0.003) compared to their respective counterparts in large metro areas. Conclusions: Rural PCa survivors are less likely to receive treatment. Rural–urban differences in PCEs varied by treatment status.

Low Urologist Density Predicts High-Cost Surgical Treatment of Stone Disease

Introduction and Objectives: Lack of access to urologic specialists is approaching crisis levels as the number of urologists is decreasing, while the demand for urologic care is increasing. The financial implications of this have not been explored. The objective of this study is to examine the impact of access and other patient factors on cost to treat urolithiasis. We hypothesized that markers of poor access would associate with higher costs of surgical encounters for patients presenting with urolithiasis. Methods: A retrospective review of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) from September 2015 to July 2018 was conducted to investigate characteristics of surgical patients treated for urinary stone disease. Univariate analysis was performed using the Welch two-sample t-test. Multivariate analysis was performed using logistic regression. Statistical analysis was performed in R version 3.5. Results: When taking into account age, delayed presentation, procedure type, stone size >20 mm, American Society of Anesthesiologists (ASA) code, gender, race, income, distance, urologist density, body mass index, diabetes, infection, education, language, insurance, and stone complexity, patients undergoing percutaneous nephrolithotomy procedure (p < 0.001; odds ratio [OR] 12.9, confidence interval [CI] 4.05-48.5), urologist density in the bottom quartile (p = 0.014; OR 4.66, CI 1.40-16.9), diabetes (p = 0.018; OR 4.38, CI 1.32-15.6), and infection (p = 0.007; OR 4.51, CI 1.55-14.0) were the only variables statistically significant for association with top quartile of total cost. Conclusions: Surgical encounter costs are largely dictated by patient clinical factors, but low regional urologist density appears to independently predicted for high-cost stone surgery. Increasing patients' access to a urologist may prove to be financially beneficial in the longitudinal reduction in health care costs for stone disease.

Decomposing Urban and Rural Disparities of Preventable ED Visits Among Patients With Alzheimer's Disease and Related Dementias: Evidence of the Availability of Health Care Resources

PURPOSE

The purpose of this study was to examine the urban and rural differences in the frequency of preventable Emergency Department (ED) visits among Alzheimer's Disease and Related Dementias (ADRD) patients, with a focus on the availability of health care resources in urban and rural areas.

METHODS

Linked datasets of 2015 State Emergency Department Databases from the Healthcare Cost and Utilization Project and the Area Health Resource File were used. ED discharges of 7 states were included in our analysis. We performed a state fixed-effect multivariable logistic regression to estimate the variation of preventable EDs by urban and rural areas. Individual characteristics and county-level health care resources were included in the estimation. The Oaxaca decomposition was used to quantify the association of county-level health care resources and urban/rural disparities.

FINDINGS

Rural patients with ADRD had 1.23 higher adjusted odds (P < .001) of going to the ED for a preventable visit compared to urban counterparts. The decomposition results showed that the model specification explained 49.2% of the differences between urban and rural patients. Patient residence in a mental health professional shortage area is one of the driving factors (contributing to 27%-48%) that explained the urban and rural disparities.

CONCLUSIONS

Our study demonstrates the importance of improving health care resources in rural areas to improve health care quality and outcomes among ADRD patients who reside in rural areas. Future research and data collection on unobserved factors, such as health care quality, will be helpful in explaining the geographic differences.

Under Treatment of Prostate Cancer in Rural Locations

PURPOSE

Compared to urban populations, rural populations rank poorly on numerous health indicators, including cancer outcomes. We examined the relationship of rural residence with stage and treatment among patients with prostate cancer, the second most common malignancy in men.

MATERIALS AND METHODS

Using the Pennsylvania Cancer Registry we identified all men diagnosed with prostate cancer between 2009 and 2015. Patients were classified as residing in a rural area, a large town or an urban area using the Rural-Urban Commuting Area classification. Our primary outcomes included indicators of prostate cancer treatment and treatment types but we also examined disease stage and mortality. We used the chi-square tests to assess differences between groups and estimated multivariable logistic regression models to assess the association between rural residence and treatment.

RESULTS

We identified 51,024 men diagnosed with localized or metastatic prostate cancer between 2009 and 2015. The overall incidence of prostate cancer decreased during the study period from 416 to 304/100,000 men while the incidence of metastatic disease increased from 336 to 538/100,000. Rural residents were less likely to undergo treatment than urban residents even when stratified by low, intermediate and high risk disease (aOR 0.77, 95% CI 0.64-0.91; aOR 0.71, 95% CI 0.58-0.89; and aOR 0.68, 95% CI 0.53-0.89, respectively). Rural status did not affect the receipt of radiation therapy compared to other treatment types.

CONCLUSIONS

Prostate cancer treatment differs between urban and rural residents. Rural residents are less likely to receive treatment even when stratified by disease risk.

Continuous Rural-Urban Coding for Cancer Disparity Studies: Is It Appropriate for Statistical Analysis?

Background: The dichotomization or categorization of rural-urban codes, as nominal variables, is a prevailing paradigm in cancer disparity studies. The paradigm represents continuous rural-urban transition as discrete groups, which results in a loss of ordering information and landscape continuum, and thus may contribute to mixed findings in the literature. Few studies have examined the validity of using rural-urban codes as continuous variables in the same analysis. Methods: We geocoded cancer cases in north central Florida between 2005 and 2010 collected by Florida Cancer Data System. Using a linear hierarchical model, we regressed the occurrence of late stage cancer (including breast, colorectal, hematological, lung, and prostate cancer) on the rural-urban codes as continuous variables. To validate, the results were compared to those from using a truly continuous rurality data of the same study region. Results: In term of associations with late-stage cancer risk, the regression analysis showed that the use of rural-urban codes as continuous variables produces consistent outcomes with those from the truly continuous rurality for all types of cancer. Particularly, the rural-urban codes at the census tract level yield the closest estimation and are recommended to use when the continuous rurality data is not available. Conclusions: Methodologically, it is valid to treat rural-urban codes directly as continuous variables in cancer studies, in addition to converting them into categories. This proposed continuous-variable method offers researchers more flexibility in their choice of analytic methods and preserves the information in the ordering. It can better inform how cancer risk varies, degree by degree, over a finer spectrum of rural-urban landscape.

Increasing Urologic Care Ratios: Implications of Male Patient Care in Florida

Ongoing trends have revealed an inverse relationship between population growth and the number of practicing urologists in the U.S. per capita, which threatens urologic care accessibility. Furthermore, different regions in the United States may be more negatively impacted due to higher population growth rates. The state of Florida witnessed over a 10% higher growth rate compared with national figures between 2000 and 2015. Coupled with data suggesting that since the 1980s, the number of U.S. urologists per capita has been decreasing, the foreseeable future presents many challenges regarding health equity and accessibility. This secondary analysis aimed to investigate the implications of forecasted urologic care decline within a growing population and how it can contribute to adverse male health outcomes. National- and state-level data were collected to calculate a series of urologic care ratios as defined by the number of urologists compared with population sizes. Analyses revealed that national-level urologic care ratios and prostate cancer incidence rates have a significant positive relationship, lending to the conclusion that with fewer urologists, the number of cases identified will decrease. State-level forecasted models indicated that the urologic care ratio will decrease approximately 30% in Florida from 6.23 per 100,000 in 2010 to 4.39 per 100,000 by the year 2030. As growth in demand for urologic care will increase in the next decade, a dire public health scenario is potentially unfolding. Future implications of undiagnosed prostate cancer due to the lack of access will drive an increase in mortality rates as well as health equity concerns for men.

Mapping rural-urban disparities in late-stage cancer with high-resolution rurality index and GWR

Effects of urban/rural residence on late-stage cancer have long been explored, but remained controversial. Spatial granularity of rural definition, temporal change of rurality, and local variability of such effects may contribute to inconsistent findings, but they have not been fully addressed. We proposed a spatially resolved and temporally comparable rurality index and a geographically weighted regression approach to re-examine this question. Taking Florida as an example, our analyses show that rural effects on late-stage cancer vary dramatically over locations (600-m cells). The odds ratios range from 0.9 to 1.10, and imply that one degree of rurality can increase/decrease local risk of late-stage cancer by up to 10%. Our study is an early attempt to explore local effects of rurality on cancer at a fine spatial scale, and reveals interesting patterns hidden by global multi-level analysis. The new framework and findings can better inform precision interventions to mitigate cancer disparities.

Effects of primary care physician density, urologist presence, and insurance status on stage of diagnosis for urologic malignancies

OBJECTIVE

To evaluate effects of PCP density, insurance status, and urologist presence on stage of diagnosis for urologic malignancies. Cancer stage at diagnosis is an important outcome predictor. Studies have shown an inverse relationship to primary care physician (PCP) density and insurance coverage with stage of cancer diagnosis.

METHODS

Data was obtained from OK2Share, an Oklahoma Central Cancer Registry, for bladder, kidney, and prostate cancer from 2000 to 2010. Physician data was obtained through the State Licensing Board. The 2010 national census was used for population data. High PCP density was defined as greater than or equal to the median value: 3.17 PCP/10,000 persons. Chi-square and multivariate logistic regressions were used to analyze effects of PCP density, insurance status, and urologist presence on advanced stage diagnosis.

RESULTS

27,086 patients were identified across 77 counties. As PCP density increased by 1 PCP/10,000 persons, the odds ratios (OR) of an advanced stage at diagnosis were 0.383, 0.468, 0.543 for bladder, kidney, and prostate cancer respectively. Compared to private insurance, being uninsured had OR of 1.61 and 2.45 respectively for kidney and prostate cancers. The OR of an advanced stage diagnosis for bladder and prostate cancer were 3.77 and 1.73, respectively, in counties with a urologist.

CONCLUSIONS

Increased PCP density and insurance coverage reduced the odds of an advanced diagnosis. Implementation of policies to improve access to healthcare including through increasing PCP density and reducing the number of uninsured patients should result in diagnosis at an earlier stage, which will likely improved cancer-related outcomes.

Impact of County Rurality and Urologist Density on the Practice of Inguinal Lymph Node Dissection and Mortality in Patients Diagnosed with Squamous Cell Carcinoma of the Penis

BACKGROUND

Inguinal lymphadenectomy (LND) is influential in reducing the mortality of squamous cell carcinoma of the penis (SCCP). We investigated the impact of urologic workforce density (UD) and rural residence (RR) on the practice of LND and mortality of SCCP (SCCP-RM).

MATERIALS AND METHODS

UD was determined from the 2014 to 2015 Area Health Resource File data, while RR was determined using the 2003 rural-urban continuum codes. All cases of SCCP within the surveillance, epidemiology, and end results 18 registry with known county codes were used for analysis (n = 2863).

RESULTS

Overall, 48.69% of cases lived in a county with less than the mean UD, 8.38% lived in counties with no urologists, 14.60% lived in a rural county, and 19.2% (n = 550) had LND performed. UD and RR had no impact on the prevalence of LND, number of lymph nodes examined, or the mean number of lymph nodes positive for SCCP (all p > 0.05). Adjusted analysis indicated that older patients and patients with regional stage of cancer were at a greater risk for post-LND SCCP-RM (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.28-2.21, and HR 4.32, 95% CI 3.09-6.06, respectively). There was no difference in the HR of SCCP-RM dependent on race, marital status, education, RR, UD, or LND.

CONCLUSION

While demand on the urologist workforce has increased in rural demographics, no impact of limited access to urologists on the practice of LND in SCCP could be identified in this study. In addition, there was no significant difference in the risk of SCCP-specific mortality related to lower UD or RR.

Does uneven geographic distribution of urologists effect bladder and prostate cancers mortality? National health insurance data in Korea from 2007-2011

The relationship between distribution of urologists and mortality of bladder and prostate cancers has not been clearly established. The aim of this study was to investigate the relationship between uneven distribution of urologists and urologic cancer specific mortality at country level. Data from the National Health Insurance Service and National Statistical Office in Korea from 2007 to 2011 were analyzed in this ecological study. Univariate and multivariable regression analyses were performed to determine risk factors for age standardized mortality rates (ASMR) of bladder and prostate cancers. Linear regression analysis showed a markedly (p < 0.001) uneven distribution of urologists between metropolitan and non-metropolitan areas. There was no significant difference in cancer specific ASMRs for either bladder cancer or prostate cancer. Univariate analysis after adjusting for time showed that country area, urologist density, and income were significant factors affecting bladder cancer incidence (p < 0.001, p = 0.013, and p < 0.001, respectively). It also showed that the number of training hospitals was a significant factor for prostate cancer incidence (p = 0.002). Although country area showed borderline significance (p = 0.056) for ASMR of bladder cancer, urologist density was not related to ASMR of bladder cancer or prostate cancer. Although there was a marked difference in urologist density between metropolitan and non-metropolitan areas for these years analyzed, mortality rates of bladder and prostate cancers were not significantly affected by country area or urologist density.

Kidney Cancer in Rural Illinois: Lower Incidence Yet Higher Mortality Rates

OBJECTIVE

To determine if rural status was associated with kidney and renal pelvis cancer (KCa) incidence and mortality in Illinois while controlling for known KCa risk factors and access to care variables.

MATERIALS AND METHODS

Age-adjusted KCa incidence rates from 1991 to 2010 were calculated from Illinois State Cancer Registry data. Age-adjusted KCa mortality rates were obtained from health statistics embedded within SEER*Stat. Rural Urban Continuum Codes designated Illinois' 102 counties as urban, rural adjacent to, and rural non-adjacent to a metropolitan area. County-level demographics and physician density were obtained from the Area Health Resource File. Behavioral Risk Factor Surveillance System data were used for smoking, obesity, and hypertension prevalence. Analysis of variance, correlation, and regression analyses were used.

RESULTS

The incidence of KCa was found to be higher among urban compared to rural counties after controlling for known risk factors (P < .01). A larger proportion of cases were diagnosed at a localized stage in urban counties (<0.01). Mortality rates were significantly higher in rural counties (P = .02). The final regression model found rural status, higher incidence rate, fewer with localized stage at diagnosis, and lower urologist density to be variables significantly associated with higher KCa mortality.

CONCLUSION

KCa incidence was higher in urban counties whereas mortality was higher in rural counties. The higher number of KCa cases diagnosed at a localized stage in urban counties and lower urologist density in rural counties suggest that poorer access to care may contribute to higher KCa mortality in rural Illinois. Telemedicine may be an opportunity to improve this disparity.

Telemedicine in Urology: State of the Art

Whereas telemedicine is recognized as one of the fastest-growing components of the healthcare system, the status of telemedicine use in urology is largely unknown. In this narrative review, we detail studies that investigate the use of televisits and teleconsultations for urologic conditions. Moreover, we discuss current regulatory and reimbursement policies. Finally, we discuss the significant barriers to widespread dissemination and implementation of telemedicine and reasons why the field of urology may be positioned to become a leader in the provision of telemedicine services.

Rural vs. urban disparities in association with lower urinary tract symptoms and benign prostatic hyperplasia in ageing men, NHANES 2001-2008

OBJECTIVE

The objective of this study was to investigate rural/urban and socio-demographic disparities in lower urinary tract symptoms and benign prostatic hyperplasia (LUTS/BPH) in a nationally representative population of men.

METHODS

Data on men age ≥40 years (N = 4,492) in the 2001-2008 National Health and Nutrition Examination Surveys were analysed. Self-report of physician-diagnosed enlarged prostate and/or BPH medication use defined recognised LUTS/BPH. Urinary symptoms without BPH diagnosis/medications defined unrecognised LUTS/BPH. Rural-Urban Commuting Area Codes assessed urbanisation. Unadjusted and multivariable associations (odds ratios (OR)) between LUTS/BPH and covariates were calculated using logistic regression.

RESULTS

Recognised and unrecognised LUTS/BPH weighted-prevalence estimates were 16.5% and 9.6%. There were no significant associations between LUTS/BPH and rural/urban status. Significant predisposing factors for increased adjusted odds of recognised and unrecognised LUTS/BPH included age, hypertension (OR=1.4;1.4), analgesic use (OR=1.4;1.4) and PSA level >4 ng/mL (OR=2.3;1.9) when adjusted for rural/urban status, race, education, income, alcohol, health insurance, health care and proton pump inhibitor (PPI) use (all p ≤ 0.1). Restricting to urban men only (N = 3,371), healthcare use (≥4visits/year) and PPI's increased adjusted odds of recognised LUTS/BPH (OR=2.0;1.6); no health insurance and <high school education decreased odds (OR=0.5;0.6) after adjusting for variables listed above, antidepressant and calcium channel blocker use (p ≤ 0.1). Also among urban men, adjusted odds of unrecognised LUTS/BPH increased for blacks (OR=1.9), Hispanic/Other (OR=1.9) and income<$34,999 (OR=1.6). Among rural men only (N = 1,121), adjusted odds of recognised and unrecognised LUTS/BPH increased for age, hypertension (OR=1.9;1.7) and analgesic use (OR=2.0;1.5) when adjusting for race, CRP, antidepressant and dyslipidaemic use (p ≤ 0.1).

CONCLUSION

Rural/urban status was not associated with significantly increased adjusted odds of either recognised or unrecognised LUTS/BPH.

Geographic Distribution of Urologists in Korea, 2007 to 2012

The adequacy of the urologist work force in Korea has never been investigated. This study investigated the geographic distribution of urologists in Korea. County level data from the National Health Insurance Service and National Statistical Office was analyzed in this ecological study. Urologist density was defined by the number of urologists per 100,000 individuals. National patterns of urologist density were mapped graphically at the county level using GIS software. To control the time sequence, regression analysis with fitted line plot was conducted. The difference of distribution of urologist density was analyzed by ANCOVA. Urologists density showed an uneven distribution according to county characteristics (metropolitan cities vs. nonmetropolitan cities vs. rural areas; mean square=102.329, P<0.001) and also according to year (mean square=9.747, P=0.048). Regression analysis between metropolitan and non-metropolitan cities showed significant difference in the change of urologists per year (P=0.019). Metropolitan cities vs. rural areas and non-metropolitan cities vs. rural areas showed no differences. Among the factors, the presence of training hospitals was the affecting factor for the uneven distribution of urologist density (P<0.001). Uneven distribution of urologists in Korea likely originated from the relatively low urologist density in rural areas. However, considering the time sequencing data from 2007 to 2012, there was a difference between the increase of urologist density in metropolitan and non-metropolitan cities.