Median Travel Distance Research Articles

Human movement patterns of different racial-ethnic and economic groups in U.S. top 50 populated cities: What can social media tell us about isolation?

ABSTRACT Many studies have proven that human movement patterns are strongly impacted by individual socioeconomic and demographic background. While many efforts have been made on exploring the influences of age and gender on movement patterns using social media, this study aims to analyse and compare the movement patterns among different racial-ethnic and economic groups using social media (i.e. geotagged tweets) from the U.S. top 50 populated cities. Results show that there are significant differences in number of activity zones and median travel distance across cities and demographic groups, and that power-laws tend to be captured in both spatial and demographic aspects. Additionally, the analysis of outbound-city travels demonstrates that some cities have slightly stronger interaction with others, and that economically disadvantaged populations and racial-ethnic minorities are more restricted in long distance travels, indicating that their spatial mobility is more limited to the local scale. Lastly, an economically-segregated movement pattern is discovered – upper-class neighbourhoods are mostly visited by the upper-class, while lower-class neighbourhoods are mainly accessed by the lower-class – but some racial-ethnic groups can diversify this segregated pattern in the local scale.

Understanding the Tradeoffs Between Travel Burden and Quality of Care for In-center Hemodialysis Patients.

Renal dialysis is a lifesaving but demanding therapy, requiring 3 weekly treatments of multiple-hour durations. Though travel times and quality of care vary across facilities, the extent to which patients are willing and able to engage in weighing tradeoffs is not known. Since 2015, Medicare has summarized and reported quality data for dialysis facilities using a star rating system. We estimate choice models to assess the relative roles of travel distance and quality of care in explaining patient choice of facility. Using national data on 2 million patient-years from 7198 dialysis facilities and 4-star rating releases, we estimated travel distance to patients' closest facilities, incremental travel distance to the next closest facility with a higher star rating, and the difference in ratings between these 2 facilities. We fit mixed effects logistic regression models predicting whether patients dialyzed at their closest facilities. Median travel distance was 4 times that in rural (10.9 miles) versus urban areas (2.6 miles). Higher differences in rating [odds ratios (OR): 0.56; 95% confidence interval (CI): 0.50-0.62] and greater area deprivation (OR: 0.50; 95% CI: 0.48-0.53) were associated with lower odds of attending one's closest facility. Stratified models were also fit based on urbanicity. For rural patients, excess travel was associated with higher odds of attending the closer facility (per 10 miles; OR: 1.05; 95% CI: 1.04-1.06). Star rating differences were associated with lower odds of receiving care from the closest facility among urban (OR: 0.57; 95% CI: 0.51-0.63) and rural patients (OR: 0.18; 95% CI: 0.08-0.44). Most dialysis patients have higher rated facilities located not much further than their closest facility, suggesting many patients could evaluate tradeoffs between distance and quality of care in where they receive dialysis. Our results show that such tradeoffs likely occur. Therefore, quality ratings such as the Dialysis Facility Compare (DFC) Star Rating may provide actionable information to patients and caregivers. However, we were not able to assess whether these associations reflect a causal effect of the Star Ratings on patient choice, as the Star Ratings served only as a marker of quality of care.

Access to Radiotherapy in Ghana: A Geospatial Analysis

Radiotherapy (RT) is a crucial component of comprehensive cancer care, but there are large global gaps in access. Within Ghana, a West African country with a population of 31 million, there are only 3 RT centers with 5 external-beam (EBRT) and 2 high-dose rate (HDR) brachytherapy (BT) machines located in 2 cities in the south. This study describes the gaps in RT capacity and geographic accessibility.A retrospective review of all RT centers in Ghana was done to determine the number of RT courses, EBRT fractions, and BT insertions for cervical cancer delivered annually between 2018-2020. Additional RT capacity required for optimal utilization was estimated from GLOBOCAN 2020 and the Collaboration for Cancer Outcomes Research and Evaluation radiotherapy utilization rate (RUR) model. A time-driven activity-based model was used to estimate the number of machines and centers required to deliver this capacity. Geospatial modeling was used to calculate current travel distances to access RT, and how access would improve with new RT centers strategically located throughout the country.In 2020, Ghana delivered 1,794 RT courses and 34,624 EBRT fractions for all cancers, and performed 497 HDR BT insertions for cervical cancer (2nd most common cancer in women in Ghana). Based on a RUR of 48%, an additional 9,730 RT courses, 188,948 EBRT fractions and 4,538 HDR BT insertions are required. With standard operational parameters, this translates to 5 additional RT centers, each with 4 EBRT units and 1 HDR BT afterloader. Based on current capacity and center locations, patients have a median one-way travel distance from their regional capital to the nearest RT center of 157 km, with 54% of patients traveling less than 100 km, 15% traveling 100-150 km, 9% traveling 150-200 km, and 22% traveling > 200 km. The North East, Upper East, and Upper West regions have the longest travel distances of 424 km, 533 km, and 439 km, respectively. Establishing a new RT center in Tamale in northern Ghana would decrease median one-way travel distance from the regional capitals to the nearest center to 145.5 km, and the proportion of the population with a travel distance > 200 km to 4%. Optimizing the location of other new centers is needed to further reduce travel distances.Ghana has a major national deficit of RT capacity, with significant geographic disparities among regions. Well-planned infrastructure scale-up that accounts for the population distribution can improve RT accessibility.

Association between distance to tertiary hospital and cardiovascular outcomes in coronary artery disease patients

Abstract Background The impact of distance from residence to Tertiary Referral Hospital and cardiovascular (CV) outcomes in patients with coronary artery disease (CAD) is unknow. Despite longer travel distances hinder access to healthcare and may worsen CV outcomes, we hypothesize that Mediterranean lifestyle and behaviors in distant rural areas may be associated with a reduced risk of CV death and events. Purpose To investigate the association between travel distance to Tertiary Hospital and mid-term cardiovascular outcomes in a population of CAD patients in Southern Spain. Methods Retrospective study including all patients discharged after percutaneous coronary intervention (PCI) at a high-volume center in Southern Spain during 2018. Those belonging to another healthcare area were excluded. One-way driving distances from residence to hospital were computed using Google Maps Distance Matrix API with R package “gmapsdistance”. Patients were stratified into tertiles according to travel distance (short, STD; intermediate, ITD; and long, LTD). Kaplan-Meier (KM) and Multivariable Cox regression (adjusted for age, sex, atrial fibrillation, cancer history, prior revascularization and clinical presentation) were used to assess the impact of travel distance on CV death and a composite outcome of MACE (Myocardial Infarction, unplanned PCI and CV death). Results Of 1005 patients discharged after PCI during the study period, 966 met the selection criteria. Flowchart and baseline characteristics by distance groups are presented in Figure 1. Median travel distance tertiles were 6.1 (STD), 41.7 (ITD) and 78.4 (LTD). During a median follow-up of 31 (IQR 28–35) months, 50 cardiovascular deaths [STD 27 (8.4%), ITD 13 (4%), LTD 10 (3.1%), p=0.006)] and 63 MACE occurred [STD 45 (13.9%), ITD 37 (11.5%), LTD 26 (8.1%), p=0.060)]. KM curves for the three distance groups are shown in Figure 2. In univariable and multivariable Cox models, longer travel distances were associated with better outcomes, as for every 10 Km increase, there was a 11% and 7% decrease in the hazards of CV death (HR adj: 0.89, CI 0.82–0.98, p=0.029) and of MACE (HR adj: 0.93, CI 0.87–0.99, p=0.025), respectively. Conclusion Travel distance was inversely associated with CV events in a population of CAD patients in Southern Spain. Patients in the first tertile of distance had a higher rate of CV death. Multicenter studies involving other Mediterranean regions are needed to confirm these findings and to look for explanations. Funding Acknowledgement Type of funding sources: None. Flowchart and baseline characteristicsSurvival curves by distance groups

771 IMPACT OF NATIONWIDE CENTRALIZATION OF ESOPHAGEAL, GASTRIC, AND PANCREATIC SURGERY ON TRAVEL DISTANCE AND EXPERIENCED BURDEN IN THE NETHERLANDS

Abstract This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with esophageal-, gastric-, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. Methods All patients who underwent surgery between 2006–2017 for esophageal-, gastric- and pancreatic cancer in the Netherlands were included. Travel distance between patient’s home address and hospital of surgery in kilometers was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. Results Over 23,838 patients were included, in whom median travel distance for surgical care increased for esophageal cancer (n = 9,217) from 18 to 28 km, for gastric cancer (n = 6,743) from 9 to 26 km and for pancreatic cancer (n = 7,878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to travelling extra kilometers. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. Conclusion With nationwide centralization, travel distance increased for patients undergoing esophageal-, gastric-, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale travel distances in the Netherlands remain limited.

How far persons with diabetes travel for care? Spatial analysis from a tertiary care facility in Southern India

ABSTRACT Accessibility determines health care utilization among individuals with noncommunicable diseases as they need to visit health facilities frequently. Hence, we aimed to assess the road distance and travel time to the diabetes clinic of Persons with Diabetes (PWDs) seeking care at a public tertiary care facility in South India. PWDs house locations were geocoded using ArcGIS World Geocoding Services, and ArcGIS Pro Business Analyst Geoprocessing extension was used to conduct network analysis. A simple median regression analysis was done to compare the association of sociodemographic variables with distance and time. Of the total 2261 PWDs included, the mean (SD) age was 53.7 (11.5) years, and 49.4% were males and about 66.0% of the PWDs resided in rural areas. The median (IQR) travel distance of PWDs from their home to the diabetes clinic was 30.5 (7.6–78.5) km and the median (IQR) time spent in travelling was 77.9 (16.4–194.7) minutes. About 76% travelled more than 5 km to the diabetes clinic. About 85% of PWDs travelled farther than the nearest available public health facility to avail care from the diabetes clinic. Younger age group, male gender, PWDs from rural areas and the state of Tamil Nadu travelled significantly longer distance compared to their counterparts. To conclude, about three-fourth of the PWDs travelled more than 5 km for care at the diabetes clinic. Also, about 9 out of 10 travelled farther than the nearest available public health facility where diabetes care was available.

Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands

BackgroundThis study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. Materials and methodsAll patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. ResultsOver 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. ConclusionWith nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.

Association between travel distance and survival among women with locally advanced cervical cancer treated with radiotherapy

<h3>Objectives:</h3> Regionalization of care in which patients are selectively referred to specialized or high-volume centers has been associated with improved survival for many oncologic procedures. Given the increase in regionalization of cancer care, we sought to examine the effect of travel distance on outcomes of patients with locally advanced cervical cancer receiving radiation therapy. <h3>Methods:</h3> We used the National Cancer Database to identify women with stage IB2-IVA cervical cancer diagnosed from 2005-2016 who were treated with primary radiation. Patients who received <4500 Gy of radiation or initiated therapy >180 days after diagnosis were excluded. The linear distance from the centroid of each patient's zip code of residence to the radiation facility was calculated. Patients were divided based on travel distance into approximately four equal quartiles. Multivariable models were developed to determine factors associated with greater travel distance (fourth quartile). The association between travel distance and survival was estimated using Cox proportional hazards models. A sensitivity analysis comparing patients treated at low volume, local hospitals to those who traveled to high volume hospitals was performed. <h3>Results:</h3> Among 12,576 patients identified, the median travel distance was 9.6 miles. Patients in the highest quartile traveled ≥23.0 miles. Factors associated with increased travel (the highest quartile) included younger age, White race, higher neighborhood socioeconomic status and educational attainment, and residence in a rural area (P<0.05 for all). There was no association between grade, stage or histology and travel distance. There was no association between residence in a rural area and survival. After adjustment for clinical and demographic characteristics, there was no association between travel distance and overall survival. However, compared to women receiving treatment at a low volume, local hospital (lowest travel quartile), women who traveled to a high-volume center (highest travel quartile) had decreased mortality (HR=0.80; 95% CI, 0.68-0.95). <h3>Conclusions:</h3> Overall there was no association between distance travelled to receive radiation and survival for women with locally advanced cervical cancer. However, compared to patients who received care locally at a low volume center, survival is improved for women who travel a longer distance to a high-volume center.

Mobile ECMO retrieval of patients during the COVID-19 pandemic.

ECMO support is particularly resource‐intensive and should be provided in highly specialized centers. Occasionally, ECMO needs to be initiated in non‐ECMO centers by mobile ECMO retrieval teams. Subsequently, patients must be transferred on ECMO to the ECMO center. We report single‐center data from out‐of‐center initiations of ECMO during the COVID‐19 pandemic. From March 2020 through February 2021, nine patients were connected to ECMO before transfer to our center. Median travel distance (IQR) from the referring hospital to our center was 66 km (20‐92), median land travel time (IQR) was 51 minutes (26‐92). Personal protective equipment was available for all team members and used throughout the missions. No infections of team members with SARS‐CoV‐2 occurred. Three patients survived until hospital discharge. Median duration of ECMO (IQR) was 18 days (2‐78) in survivors and 19 days (9‐42) in non‐survivors, respectively. Out‐of‐center initiation of ECMO during the COVID‐19 pandemic was feasible and safe for patients and staff.

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion

Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance. To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance. This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020. Median travel distance by car to the nearest abortion facility. US county abortion rate per 1000 female residents of reproductive age. Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, -0.05 [95% CI, -0.07 to -0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, -0.73 [95% CI, -0.80 to -0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age). These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.

The centralization of bladder cancer care and its implications for patient travel distance

ObjectivesTo evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. MethodsUsing SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. ResultsA total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). ConclusionsOver time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.

Single institution experience with telemedicine for pediatric urology outpatient visits: Adapting to COVID-19 restrictions, patient satisfaction, and future utilization

IntroductionWidespread utilization of telemedicine in our practice to date has been limited to the evaluation of certain post-surgical patients. The COVID-19 pandemic acutely stressed our established system and required us to enhance our utilization of telemedicine. We hypothesized that expansion of telemedicine to new and follow up patient visits for pediatric urology could be done effectively in a way that satisfied patient and parental expectations.Materials and methodsUsing a pre-COVID-19 established telemedicine program based in our electronic medical record (EMR), patients and providers transitioned to primarily virtual visits when clinically appropriate. Guidelines were formulated to direct patient scheduling, provider and staff education was provided, including a process map designed for multiple providers to complete video visits (VV), and the EMR was redesigned to incorporate telehealth terminology. The number of VV per provider was recorded using the electronic medical record, and patient reported outcomes (PRO) were measured using a standardized questionnaire.ResultsA total of 631 VV met inclusion criteria during the period of May 2018–April 2020. This included 334 follow up, 172 new, and 125 postoperative visits. The median age of patients at time of visit was 7 years (IQR 2–12 years), median visit time was 20 min (IQR 15–30 min), and the median travel distance saved by performing a VV was 12.2 miles (IQR 6.3–26.8 miles). Diagnoses were varied and included the entire breadth of a standard pediatric urology practice. The PRO questionnaire was completed for 325 of those patient visits. Families reported a high overall satisfaction with the video visits (median score of 10 out of 10) and felt that the visit met their child's medical needs. 90% stated that they would strongly recommend a telehealth visit to other families. Patients and parents reported benefits of VV including decreased travel costs and less time taken off from work and school.ConclusionThe EMR enabled nimble redirection of clinical care in the setting of a global pandemic. The enhanced use of telemedicine has proved to be an alternative method to provide care for pediatric urology patients. Families indicate a high degree of satisfaction with this technology in addition to significant time and cost savings. Telemedicine should remain a key aspect of medical care and expanded from post-operative visits to new patient and follow up visits, even as we return to our normal practices as the pandemic restrictions soften.Summary figureProgram map depicting the sequence of a video visit (VV). The process begins with our scheduling team which provides the necessary information to the family and ensures that they can be scheduled properly. The family is encouraged to conduct the visit in a quiet place with at least one parent and the child present. Relevant records, imaging, and laboratory studies should be uploaded prior to the visit. In addition, pictures and/or videos uploaded by the family prior to the visit can facilitate the examination portion of the visit. VV = video visit; AVS = after visit summary.Summary figure

Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study.

Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns. Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression. 22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86). There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care.

Objectives:Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care.Methods:A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment.Results:Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded “yes” to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor’s diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%).Conclusion:This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Variation in Eligible Patients’ Agreeing to and Receiving Lung Cancer Screening: A Cohort Study

Little is known about how clinicians make low-dose computed tomography lung cancer screening decisions in practice. Investigators assessed the factors associated with real-world decision making, hypothesizing that lung cancer risk and comorbidity would not be associated with agreeing to or receiving screening. Though these factors are key determinants of the benefit of lung cancer screening, they are often difficult to incorporate into decisions without the aid of decision tools. This was a retrospective cohort study of patients meeting current national eligibility criteria and deemed appropriate candidates for lung cancer screening on the basis of clinical reminders completed over a 2-year period (2013-2015) at 8 Department of Veterans Affairs medical facilities. Multilevel mixed-effects logistic regression models (conducted in 2019-2020) assessed predictors (age, sex, lung cancer risk, Charlson Comorbidity Index, travel distance to facility, and central versus outlying decision-making location) of primary outcomes of agreeing to and receiving lung cancer screening. Of 5,551 patients (mean age=67 years, 97% male, mean lung cancer risk=0.7%, mean Charlson Comorbidity Index=1.14, median travel distance=24.2 miles), 3,720 (67%) agreed to lung cancer screening and 2,398 (43%) received screening. Lung cancer risk and comorbidity score were not strong predictors of agreeing to or receiving screening. Empirical Bayes adjusted rates of agreeing to and receiving screening ranged from 22% to 84% across facilities and from 19% to 85% across clinicians. A total of 33.7% of the variance in agreeing to and 34.2% of the variance in receiving screening was associated with the facility or the clinician offering screening. Substantial variation was found in Veterans agreeing to and receiving lung cancer screening during the Veterans Affairs Lung Cancer Screening Demonstration Project. This variation was not explained by differences in key determinants of patient benefit, whereas the facility and clinician advising the patient had a large impact on lung cancer screening decisions.

Expanding Access to COVID-19 Tests through US Postal Service Facilities.

Widespread, convenient access to COVID-19 testing has been challenging in the United States. We make a case for provisioning COVID-19 tests through the United States Postal Service (USPS) facilities and demonstrate a simple method for selecting locations to improve access. We provide quantitative evidence that even a subset of USPS facilities could provide broad access, particularly in remote and at-risk communities with limited access to health care. Based on daily travel surveys, census data, locations of USPS facilities, and an established care-seeking model, we estimate that more than 94% of the US population would be willing to travel to an existing USPS facility if warranted. For half of the US population, this would require traveling less than 2.5 miles from home; for 90%, the distance would be less than 7 miles. In Georgia, Illinois, and Minnesota, we estimate that testing at USPS facilities would provide access to an additional 4.1, 3.1, and 1.3 million people and reduce the median travel distance by 3.0, 0.8, and 1.2 miles, respectively, compared with existing testing sites per 28 July 2020. We also discuss the option of distributing test-at-home kits via USPS instead of private carriers. Finally, our proposal provides USPS an opportunity to increase revenues and expand its mission, thus improving its future prospects and relevance.

Are Volume Pledge Standards Worth the Travel Burden for Major Abdominal Cancer Operations?

The study objective is to determine the association between travel distance and surgical volume on outcomes after esophageal, pancreatic, and rectal cancer resections. "Take the Volume Pledge" aims to centralize esophagectomies, pancreatectomies, and proctectomies to hospitals meeting minimum volume standards. The impact of travel, and possible care fragmentation, on potential benefits of centralized surgery is not well understood. Using the National Cancer Database (2004-2016), patients who underwent esophageal, pancreatic, or rectal resections at far HVH meeting volume standards versus local intermediate (IVH) and low-volume (LVH) hospitals were identified. Perioperative outcomes and 5-year OS were compared. Of 49,454 patients, 17,544 (34.5%) underwent surgery at far HVH, 11,739 (23.7%) at local IVH, and 20,171 (40.8%) at local LVH. The median (interquartilerange) travel distances were 77.1 (51.1-125.4), 13.2 (5.8-27.3), and 7.8 (3.1-15.5) miles to HVH, IVH, and LVH, respectively. By multivariable analysis, LVH was associated with increased 30-day mortality for all resections compared to HVH, but IVH was associated with mortality only for proctectomies [odds ratio 1.90, 95% confidence interval (CI) 1.31-2.75]. Compared to HVH, both IVH (hazard ratio 1.25, 95% CI 1.19-1.31) and LVH (hazard ratio 1.35, 95% CI 1.29-1.42) were associated with decreased 5-year OS. Compared to far HVH, 30-day mortality was higher for all resections at LVH, but only for proctectomies at IVH. Five-year OS was consistently worse at local LVH and IVH. Improving long-term outcomes at IVH may provide opportunities for greater access to quality cancer care.

Use of a rapid access multidisciplinary bone metastases clinic to decrease financial toxicity for patients undergoing single-fraction palliative radiation.

24 Background: A rapid access bone metastases clinic (RABC) was instituted at MD Anderson Cancer Center (MDACC) to allow outpatient consult, simulation and radiation treatment (RT) initiation in &lt; 6 hours for patients with painful bone metastases. Patients underwent multidisciplinary evaluation with orthopedics and radiation oncology. One aspect of financial toxicity is distress due to out-of-pocket (OOP) cost associated with a treatment. We hypothesized the RABC would decrease financial toxicity for MDACC patients over traditional RT. Methods: RABC patients surveyed between April 2018 and January 2020 were included. Patients were asked to estimate OOP cost for RT (including travel and treatment cost) and perceived cost burden of treatment. Travel distance was hometown distance to MDACC. Subset analyses were performed for patients receiving single fraction (1fx) and 2-5 fractions (2-5fx). Estimated OOP cost (1fx: RABCN= 34, nonRABCN= 20; 2-5fx: RABCN= 4, nonRABCN= 22), perceived cost burden (1fx: RABCN= 32, nonRABCN= 27; 2-5fx: RABCN= 7, nonRABCN= 38) and travel distance (1fx: RABCN= 34, nonRABCN= 28; 2-5fx: RABCN= 7, nonRABCN= 38) were compared using a Mann-Whitney U Test. Travel distance was also compared to OOP cost. Patients treated with 6+ fractions were excluded. Results: Median estimated OOP cost was significantly lower for 1fx RABC patients vs. 1fx non-RABC patients ($450 [IQR $187.5-$1,050] vs. $2,000 [$625-$4,000]; p = 0.008), but there was no significant difference for 2-5fx ($1,900 vs. $1,375; p = 0.593). Overall patient satisfaction with cost burden was high regardless of treatment setting (1fx: 10 [8-10]; 2-5fx: 10 [8-10]). Median travel distance was not significantly different between clinics (1fx: 245 [39.8-351.5] vs. 262.5 [83-879.3], p = 0.3651; 2-5fx: 274 [36-1293] vs. 176 [25-626], p = 0.2721). Travel distance was directly correlated with out of pocket cost for single fraction (1fx: R2= 0.125, p = 0.0109; 2-5fx: R2= 0.037, p = 0.3433). Conclusions: The establishment of a RABC at MDACC significantly decreased financial toxicity for 1fx patients receiving palliative RT, but not in the 2-5fx cohort. Increased financial toxicity was associated with longer travel distance for 1fx palliative radiation. Implementation of a similar model in local community centers may decrease financial toxicity for patients receiving palliative radiation.

Theoretical Model for Delivery of Congenital Heart Surgery in the United States

Over 150 hospitals perform congenital heart surgery (CHS) in the United States. Many hospitals are close together, with a median patient travel distance of 38.5 miles. We began with a theoretical blank slate and used objective methodology guided by population density and volume thresholds to estimate the optimal number and locations of hospitals to provide CHS in the United States. Guided by published data, we estimated the number of CHS operations in the United States in to be 32,500 per year. We distributed patients geographically based on population density. Metropolitan Statistical Areas (population centers and surrounding areas with close economic/social ties) were used as potential hospital locations. Patients were assigned to the closest hospital location such that all hospitals had a CHS volume of ≥300 operations. We estimated 57 hospitals could serve the contiguous United States. Median theoretical hospital volume after regionalization was 451 operations (interquartile range, 366-648). Median patient travel distance was 35.1 miles. Some patients (6396/31,895, 20%) traveled more than 100 miles. Our model suggests the United States could be served by approximately 100 fewer CHS hospitals than currently exist. With hospitals optimally placed, patient travel burden would decrease. This model serves as a platform to improve care delivery by regionalization of CHS.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers.

The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some. The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers. The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small. While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.