Quality vs Convenience: Rural Cancer Patients Weigh Options for Surgical Care

While health care policies and programs strive to centralize cancer services and direct patients to high-volume hospitals, a new study suggests that factors beyond surgical volume, such as cancer complexity, patient quality of life, and satisfaction, must be considered to optimize outcomes and experiences.¹

Patients diagnosed with cancer in rural Pennsylvania counties often choose local hospitals for surgery, even though higher volume hospitals in urban areas are associated with better outcomes, according to the research published in JCO Oncology Practice by Haleh Ramian, PhD, a former postdoctoral researcher at Pitt Public Health, Lindsay Sabik, PhD, associate professor in Pitt Public Health’s Department of Health Policy and Management, and a team of investigators.

The decision-making process exemplifies the intricate balance between health care access, patient preferences, and quality metrics.

“Our study suggests that narrowly focusing on hospital volumes and tying that to insurance reimbursement might mask complexities and trade-offs in achieving the goal of optimizing patient outcomes and experiences,” Sabik said in a statement. “Not only are there cost and time burdens for rural patients who have to travel for care, but they are away from their local support networks, which can impact their quality of life.”²

To further understand the complexities surrounding surgical care for cancer patients residing in rural regions the investigators analyzed data obtained from the Pennsylvania Health Care Cost Containment Council, focusing on adult patients diagnosed with various types of cancer who underwent surgery between 2017 and 2020. The study distinguished between urban and rural counties and classified hospitals as "high-volume" based on their surgery numbers for specific cancer types.¹

Key findings of the study include:

• Complexity-Driven Decisions: Rural patients with cancers that require complex surgeries, such as pancreatic or esophageal cancers, were more likely than urban patients to choose high-volume hospitals, suggesting patients recognize the potential for better outcomes in such cases and actively seek these facilities.
• Balancing Trade-offs: Patients with less complex cancer surgeries tended to opt for local hospitals, indicating consideration of the trade-offs between convenience, local support networks, and known benefits associated with high-volume hospitals.
• Equity Concerns: While centralization policies align with high-volume hospitals, rural patients often have to travel longer distances for care, impacting their quality of life and straining support networks. Ensuring equitable access for underserved populations requires further attention, the study acknowledged.

Investigators emphasized the need for a comprehensive approach to health care policy. Focusing solely on hospital volume and insurance reimbursement can oversimplify the decision-making process, potentially neglecting patient-centric aspects and disparities in cancer care.

By considering factors beyond surgical volume, such as the complexity of cancer and its impact on patient well-being, policies can be designed to offer optimal care while addressing the unique challenges faced by rural patients.

“Future research should move beyond focusing primarily on the centralization of cancer surgery to improve outcomes and consider the consequences of centralization on quality of life and the continuum of cancer care including surgery as well as chemotherapy and radiation,” Sabik said. “Identifying and executing strategies that could help make cancer surgery more equitable for underserved populations could counter disparities in cancer care for all.”

Limitations acknowledged in the study included an inability to account for patients who declined surgery, the lack of analysis on surgeon volume, and the absence of data on decisions based on cancer stage or severity.

As cancer care policies evolve, the study noted these findings serve as a reminder that health care decisions are multi-faceted, influenced by medical, personal, and logistical factors, underscoring the importance of balancing quality metrics with patient experiences.

References

1. Ramian H, Sabik L, Sun Z, Yabes J, Jacobs B. Abstract PR004: Urban/rural differences in receiving cancer surgery at high-volume hospitals and sensitivity to hospital volume thresholds. Cancer Epidemiology, Biomarkers & Prevention. 2023;32(1_Supplement):PR004.

2. Policies favoring high-volume hospitals may disadvantage rural cancer patients. News release. University of Pittsburgh. August 17, 2023. Accessed August 17, 2023. https://medicalxpress.com/news/2023-08-policies-favoring-high-volume-hospitals-disadvantage.html#:~:text=Because%20high%2Dvolume%20hospitals%20are,patients%20living%20in%20urban%20areas.