The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
Niveditta Ramkumar , Carrie Colla , Sandra L. Wong , Qianfei Wang , Gabriel A. Brooks
Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure was rurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days of surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR=1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR=0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. The association between rurality and 90-day outcomes differed by race/ethnicity (p-interaction=0.001 for surgical complications and mortality, see Table). Hispanics and other races had higher odds of 90-day surgical complications in non-metro versus metro areas but there was no notable difference for white patients. Likewise, compared to metro areas, racial/ethnic minorities had higher odds of 90-day mortality in small town/rural areas but white patients had lower odds. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and worse outcomes, especially among non-white patients. The compounded effect of sociodemographic factors should be further studied to develop targeted policies and improve care for rural cancer patients.
90-Day Outcome | Adjusted OR(95% CI) | |||
---|---|---|---|---|
Race/Ethnicity | ||||
White | Black | Hispanic | Other | |
SURGICAL COMPLICATIONS | ||||
Metropolitan | 1.00 (reference) | |||
Micropolitan | 1.05 (0.95-1.16) | 1.02 (0.68-1.54) | 2.35 (1.51-3.68) | 1.37 (0.77-2.43) |
Small Town/Rural | 1.06 (0.96-1.17) | 1.24 (0.83-1.86) | 1.29 (0.69-2.42) | 2.02 (1.20-3.42) |
MORTALITY | ||||
Metropolitan | 1.00 (reference) | |||
Micropolitan | 0.89 (0.78-1.01) | 1.44 (0.89-2.34) | 1.31 (0.67-2.56) | -- |
Small Town/Rural | 0.76 (0.78-0.87) | 1.68 (1.04-2.72) | -- | 1.22 (0.58-2.58) |
Disclaimer
This material on this page is ©2024 American Society of Clinical Oncology, all rights reserved. Licensing available upon request. For more information, please contact licensing@asco.org
Abstract Disclosures
2021 ASCO Quality Care Symposium
First Author: Niveditta Ramkumar
2021 ASCO Quality Care Symposium
First Author: Niveditta Ramkumar
2023 ASCO Genitourinary Cancers Symposium
First Author: Franklin Liu
2023 ASCO Quality Care Symposium
First Author: Jeffrey Franks