Rural-Urban Differences in Esophagectomy for Cancer

Background: Patients who are socioeconomically disadvantaged or in rural areas may not pursue surgery at high-volume centers, where outcomes are better for some complex procedures. The objective of this study was to determine and compare rural and urban patient differences and outcomes after undergoing esophagectomy for cancer. Study Design: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS) database was performed, capturing adult patients with esophageal cancer who underwent esophagectomy. Patients were stratified into rural or urban groups by the National Center for Health Statistics Urban-Rural Classification Scheme. Demographics, hospital variables, and outcomes were compared. Results: A total of 2,877 patients undergoing esophagectomy for esophageal cancer were captured by the database, with 228 (7.92%) rural and 2,575 (89.50%) urban patients. The rural and urban groups had no difference in age, race, insurance status, and many common comorbidities. Major outcomes of mortality and length of stay were similar for both rural and urban patients (3.95% versus 4.27%, p=0.815) and (15.75±13.22 versus 15.55±14.91 days, p=0.828), respectively. There was a trend for rural patients to be more likely to discharge home (35.96% versus 29.79%, OR 0.667 [95%CI 0.479-0.929]; p=0.0167). Conclusions: This retrospective administrative database study indicates that rural and urban patients receive equivalent postoperative care after undergoing esophagectomy. The findings are reassuring as there does not appear to be a disparity in major outcomes depending on the location of residence, but further studies are necessary to assure equitable treatment for rural patients.

Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

<b><i>Objective:</i></b> The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system. <b><i>Methods:</i></b> We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients’ initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort. <b><i>Results:</i></b> Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with <i>p</i> = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001) for the DS versus BM cohort, respectively. <b><i>Conclusions:</i></b> Modeled EMS prehospital triage of ELVO patients’ results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia

Background A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income. Methods We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA. Results On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient’s stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking. Conclusions These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient’s overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

Study of awareness, attitude, and utilization of Complementary and Alternative Medicine among patients visiting urban and rural health centers

Worldwide there is a recent increase in the usage of Complementary and Alternative Medicine (CAM), which has been defined as a group of diverse medical and healthcare systems, practices and products that are presently not considered to be a part of conventional medicine. The objectives were to assess and to compare the awareness, perspective, and utilization of CAM among urban and rural patients. A cross-sectional study was conducted among 200 out-patients attending the urban and rural health centers with a standardized questionnaire. MS Excel and Epi Info were used for data entry and analysis. The awareness of CAM was 71% of urban patients and 63% of rural patients. Despite the awareness of CAM, the urban patient either liked CAM (32%) or apathetic towards CAM (32%) and rural patients mostly apathetic towards CAM (47%). Both areas of patients (41%) used CAM, of which 36% were urban patients and 46% were rural patients. There is a higher proportion of aware patients in rural areas (73%) used CAM when compared to the usage of CAM by aware patients in the urban area (51%). Despite the usage of CAM, both areas of patients preferred Allopathy. In summary, this study demonstrated that most patients are aware of CAM, but patients were mostly apathetic towards CAM. Around half of the patients utilized alternative medicine.

The Rural Tax: Out-of-Pocket Costs for Patient Travel in British Columbia

Background: A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are downloaded to patients and their families. Methods: Online retrospective provincial survey seeking to estimate the out-of-pocket (OOP) costs and associated experiences of rural patients traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Results: On average, costs for respondents were $777 and $674 for transport and accommodation, respectively. Patient perspectives obtained from this survey expressed a number of related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking. Conclusions: These key findings highlight the existing inequities between rural and urban patient access to health care. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

Abstract 261: Improving Hypertension Control Among an Underserved Urban Patient Population

Needs and Objectives: Poorly-controlled hypertension is associated with increased risk of adverse cardiovascular outcomes and thus is an important healthcare quality metric for primary care practices. Yet achieving blood pressure goals among socially-complex, economically-disadvantaged patient populations can be challenging due to cost-related non-adherence, poor health literacy and other social determinant barriers. Indeed, by early 2019, only 59% of hypertensive patients at our inner-city community health clinic had a blood pressure less than 140/90. The goal of this resident-driven quality improvement (QI) project was to increase blood pressure control among our hypertensive patients to a network target of 75% over 6 months. Setting and Participants: Our project was implemented at the Ryan Adair Center, a Federally Qualified Health Center located in Central Harlem that serves as a primary care practice site for Internal Medicine residents. The patient population consists predominantly of Black and Latino patients, most of whom are on Medicaid and live well below the federal poverty line. Our target population was hypertensive patients. Intervention: We used the Plan-Do-Study-Act method to carry out our clinic-based project. PGY1’s at the site served as the QI project leaders with faculty oversight. Cycle 1 focused on nurse education regarding proper blood pressure measurement. Cycle 2 focused on home blood pressure monitoring including patient education on proper technique and the importance of maintaining a daily log. Cycle 3 focused on assessment of health literacy via a patient questionnaire. Cycle 4 focused on provider education by ensuring that our patients were prescribed an appropriate medication regimen based on ACC/AHA Guidelines. Cycle 5 focused on referring patients with continued poor control to community health coaches to identify barriers like nutrition, medication access, and health literacy. Evaluation: Using our clinic’s online hypertensive registry (DRVS), we tracked on a monthly basis the percentage of hypertensive patients who had controlled blood pressure (<140/90). Percent of patients at goal went from 59% in February 2019 to 73% in July 2019. Discussion/lessons learned: Through this project, we demonstrated a meaningful improvement in hypertensive control among an economically-disadvantaged, racially diverse urban patient population. Accurate nurse measurements, engagement of patients in self-management, and resident education on evidence-based medication standards have all contributed to this success. Future directions will explore the impact of community health coaches in hypertension control and use of standard questionnaire to assess health literacy.