ABSTRACT & COMMENTARY
The Complexity of Health Care Disparity: The Geographic Effect
By Robert L. Coleman, MD
Professor, University of Texas; M.D. Anderson Cancer Center, Houston
Dr. Coleman reports no financial relationships relevant to this field of study.
SYNOPSIS: Barriers to guideline-adherent care for advanced ovarian cancer are impacted by geographic proximity to a high-volume hospital and travel distance. However, these geographic barriers disproportionately affect racial minorities and women of lower socioeconomic status.
SOURCE: Bristow RE, et al. Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status. Gynecol Oncol 2014;134:60-67.
Several factors are known to impact access to National Comprehensive Cancer Network (NCCN) guideline-compliant care for the management of advanced ovarian cancer. The current study interrogates geographic location and the impact of travel distance to care in relation to race and socioeconomic status (SES). Patients diagnosed with stage IIIC/IV epithelial ovarian cancer (1/1/9612/31/06) were identified from the California Cancer Registry, which captures 99% of the state’s index cases and has follow-up completion rates of more than 95%. Generalized additive models were created to assess the effect of spatial distributions of geographic location, proximity to a high-volume hospital (defined as treating 20 or more cases per year), distance traveled to receive care, race, and SES on adherence to NCCN guidelines. Of the 11,770 patients identified, 45.4% were treated according to NCCN guidelines. Black race (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.21-1.83), low-SES (OR, 1.46; 95% CI, 1.24-1.72), and geographic location more than 50 miles from a high-volume hospital (OR, 1.88; 95% CI, 1.61-2.19) were independently associated with an increased risk of non-adherent care, while high-volume hospital treatment (OR, 0.59; 95% CI, 0.53-0.66) and travel distance to receive care more than 20 miles (OR, 0.80; 95% CI, 0.69-0.92) were independently protective. SES was inversely associated with location over 50 miles from a high-volume hospital, ranging from 6.3% (high-SES) to 33.0% (low-SES) (P < 0.0001). White patients were significantly more likely to travel more than 20 miles to receive care (21.8%) compared to blacks (14.4%), Hispanics (15.9%), and Asian/Pacific Islanders (15.5%) (P < 0.0001). The study highlighted that geographic proximity to a high-volume hospital and travel distance to receive treatment are independently associated with NCCN guideline-adherent care for advanced-stage ovarian cancer.
Access to health care is a complex issue and involves several contexts that extend beyond availability of care.1 To this end, health care in the United States is largely available, but how it is gainfully accessed is profoundly and disproportionately limited by factors that include financial, organizational, social, and cultural barriers. These well-described factors define utilization; much effort has been expended to not only understand how these factors impact utilization, but also how health care services may be consumed under limitations of any one, or all, of these factors. This has been the center of the ongoing and highly contentious debate of the Affordable Health Care Act.2 One frequently cited example of disproportionate health care utilization is emergency department (ED) visits. The absence of regular primary health care access, which disproportionately affects minorities and lower socioeconomic classes, leads to higher utilization of the ED for routine care. At least one state, where more universal health care access has been enabled, has greatly altered the character and frequency of inappropriate utilization of the ED.
In the June 2013 issue of OB/GYN Clinical Alert, I presented a provocative article that demonstrated compliance with NCCN guidelines for ovarian cancer care was significantly related to access to a gynecologic oncologist.3 This was one of the first articles to also clearly demonstrate the impact of compliance on expected survivorship from the disease and included data on approximately 70% of all patients cared for in the United States. Other reports have also highlighted survivorship related to the hospitals in which these patients were cared for; higher ovarian cancer patient volume closely tracks with significantly higher compliance with NCCN guideline treatment and leads to improvement in overall survival.4 The correlation of hospitals with high ovarian cancer patient volume and access to a gynecologic oncologist is expectedly strong. The current study closely examines a new feature, geography. While the majority of people live in urban areas where highly specialized care can be accessed, Bristow and colleagues nicely demonstrate the disparity of non-adherent ovarian cancer care throughout the state of California based on geographical distance to high-volume centers. In addition, they demonstrate that geography disproportionately affects racial minorities (African American, Hispanic, and Asian/Pacific Islander). In this study, white patients were significantly more likely to travel over 20 miles to receive care in high-volume centers. So, while geographic proximity to high-volume hospitals significantly impacts the opportunity to receive the best appropriate care, this distance is disparate among racial minorities and patients of lower SES status.
This study, as the others, highlights that patients face significant barriers and challenges to receiving appropriate standard of care therapy. This is the case even with equal opportunity to access but is confounded even more by geographic factors. The solution to this problem is not simple, but has been tackled in other countries where universal health care is available. In these situations, a mandated and quality-controlled process of centralization of specialty services (centers of excellence) has been enacted. Removing geographical and financial barriers leads to higher compliance of treatment standards, which are significantly impacted by specialty care. In the case of ovarian cancer, surgical resection and pathology expertise are more disparate among high- and low-volume centers than the type of chemotherapy that can be delivered in these settings. Methodical evaluation of the critical factors impacting survivorship can help to define how to begin the process to harmonize effective care in ovarian cancer management.
- Gulliford M, et al. What does access to health care’ mean? J Health Serv Res Policy 2002;7:186-188.
- United States Congress House Committee on Oversight and Government Reform. Subcommittee on Health Care District of Columbia Census and the National Archives: Examining the impact of Obamacare on doctors and patients: Hearing before the Subcommittee on Health Care, District of Columbia, Census, and the National Archives of the Committee on Oversight and Government Reform, House of Representatives, One Hundred Twelfth Congress, second session, July 10, 2012. Washington, U.S. G.P.O.: For sale by the Supt. of Docs., U.S. G.P.O., 2012
- Bristow RE, et al. Disparities in ovarian cancer care quality and survival according to race and socioeconomic status. J Natl Cancer Inst 2013;105:823-832.
- Bristow RE, et al. High-volume ovarian cancer care: Survival impact and disparities in access for advanced-stage disease. Gynecol Oncol 2014;132:403-410.