Health System Integration and Cancer Center Access for Rural Hospitals

BACKGROUND

Cancer centers provide superior care but are less accessible to rural populations. Health systems that integrate a cancer center may provide broader access to quality surgical care, but penetration to rural hospitals is unknown.

METHODS

Cancer center data were linked to health system data to describe health systems based on whether they included at least one accredited cancer center. Health systems with and without cancer centers were compared based on rural hospital presence. Bivariate tests and multivariable logistic regression were used with results reported as P-values and odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

Ninety percent of cancer centers are in a health system, and 72% of health systems (434/607) have a cancer center. Larger health systems (P = .03) with more trainees (P = .03) more often have cancer centers but are no more likely to include rural hospitals (11% vs 6%, P = .43; adjusted OR .69, 95% CI .28-1.70). The minority of cancer centers not in health systems (N = 95) more often serve low complexity patient populations (P = .02) in non-metropolitan areas (P = .03).

DISCUSSION

Health systems with rural hospitals are no more likely to have a cancer center. Ongoing health system integration will not necessarily expand rural patients' access to surgical care under existing health policy infrastructure and incentives.

Potentially inappropriate medications in geriatric blood or marrow transplantation (BMT) survivors: A BMT Survivor Study report

BACKGROUND

Blood or marrow transplantation (BMT) is increasingly offered to older individuals with hematologic malignancies. The high prevalence of chronic health conditions in such individuals necessitates use of multiple medications. Beers Criteria represent a list of potentially inappropriate medications (PIMs) shown to increase the risk of health problems in the elderly. We sought to determine the prevalence and predictors of PIM use in older BMT survivors and identify associations with health problems.

METHODS

Study participants were drawn from the BMT Survivor Study, a cohort study of patients transplanted at three US transplant centers between 1974 and 2014 and surviving ≥2 years. For this report, the survivors were aged ≥65 years. Siblings served as a comparison group. Participants self-reported sociodemographics, chronic health conditions, and medication use. Logistic regression analyses identified predictors of PIM use and associations with health problems.

RESULTS

Overall, PIM use was comparable between BMT survivors (49.4%) and siblings (49.3%) (odds ratio [OR] = 0.9; 95% CI, 0.7-1.2); however, BMT survivors were more likely to use >1 PIM (17.4% vs. 12.4%; OR = 1.5; 95% CI, 1.01-2.4) and central nervous system-related PIMs (8.3% vs. 4.3%; OR = 2.18; 95% CI, 1.17-4.09). Predictors of PIM use included presence of severe/life-threatening chronic health conditions (OR = 1.5; 95% CI, 1.1-2.0), and chronic graft versus host disease (OR = 1.7; 95% CI, 1.1-2.7). Survivors taking >1 PIM reported more issues with vertigo (OR = 2.3; 95% CI, 1.1-4.7), balance (OR = 2.6; 95% CI, 1.7-4.1), faintness/dizziness (OR = 2.8; 95% CI, 1.8-4.6), and personal care (OR = 4.5; 95% CI, 1.4-14.8).

CONCLUSIONS

This study shows the health problems associated with PIM use and identifies vulnerable populations at higher risk for PIM use, providing evidence for caution in using PIMs in high-risk populations.

Clinical use of intrapulmonary heparin

Of 16 patients treated with intrapulmonary heparin at doses between 10,000 and 20,000 U/week for 1592 patient days, or 4.3 years, only one rethrombosed. This patient has a congenital antithrombin III deficiency. However, the use of intrapulmonary heparin, even in this particular patient, has remarkably decreased her thrombotic events as manifested by studying her history of deep vein thrombosis and pulmonary embolism prior to starting intrapulmonary heparin. This represents a failure rate of 4.2% in the total of 1592 patient days of therapy, or a rethrombosis rate of 1.4% per year. This recurrence rate is far superior to that reported for warfarin-type therapy or for platelet suppressive therapy. From this limited experience, it appears that heparin is an extremely safe and highly effective mode of outpatient prophylaxis for deep vein thrombosis and thromboembolic disease. The ultimate aim of this study is to determine the possibility of calcium heparin being placed into a hand-held aerosol nebulizer that a patient can use at home on a weekly basis. This would provide a highly convenient, safe, and apparently very efficacious mode of therapy for the long-term outpatient prophylaxis of deep vein thrombosis and thromboembolic disease.

Helping supervisors step into the educator's role

Supervisors who lack the skills of the educator rarely visualize training as an integral part of their jobs. Consequently, new employees suffer from poor instruction and supervisors miss out on a potentially rewarding aspect of their duties. Seeking to remedy this situation, the University of Texas Medical Branch Department of Sterile Processing and Central Supply and the Personnel Office tailored a train-the-trainer program to meet the specific needs of their supervisors.