RICHMOND, Va-To help improve cancer care in rural areas of Virginia,
we developed a strategic alliance, known as the Rural Cancer
Outreach Program (RCOP), a network of an academic center providing
tertiary oncology services with rural hospitals needing new services,
to meet the needs of both parties.
One quarter of Americans live in rural areas, and these areas
have higher cancer mortality time trends than do urban and suburban
areas. Rural areas are often medically underserved, and the
population often has poor access to both primary and specialty
A number of socioeconomic factors also play a role in excess cancer
morality in rural areas, including unemployment, poor education,
poor health habits, especially cigarette smoking, and lack of
Options for rural cancer patients are limited. Healthier, wealthier
patients can travel to urban centers for both primary and specialty
care. Each patient typically makes 6 to 12 trips to the academic
center for treatment, traveling 100 miles each way at a cost of
$60 per visit.
Those unable to make the trip due to lack of money or poor health,
or unwilling to seek care due to outdated beliefs about cancer
therapy , may encounter a rural system with insufficient experience
to provide state-of-the-art care.
In general, rural health care is pro-vided by older general practitioners
and hospitals of variable quality [5-8]. The socio-economic characteristics
of rural populations mentioned above have also been strongly correlated
with poor outcomes of medical care .
Massey Cancer Center-Medical College of Virginia Hospital (MCC-MCVH)
is the Rural Cancer Outreach Program's academic center. Located
in an urban community, this 1,100-bed hospital has full oncologic
The three rural oncology clinics are situated in 80- to 100-bed
hospitals that each serve three to five counties with a population
of 50,000 to 80,000. The Massey Cancer Center nurses and physicians
travel every 2 weeks to the sites, each located about 100 miles
An intense training program, given at the beginning of the program,
includes a week-long course for rural oncology nurses. The rural
nurses come to the academic center to learn "hands on"
the care of cancer patients.
Tumor boards held at least once a month allow the oncologists
the opportunity to review with the rural physicians the treatment
of common cancers and complications of treatment. In addition,
we use the technique of "academic detailing," or providing
information on a one-to-one basis to the physicians who request
The rural physicians provide care in between the oncologists'
visits, using standard MCC-MCVH practice guidelines, policies,
and procedures. An MCC-MCVH physician and nurse are on call 24
hours a day to answer any telephone consultations.
In practice, cancer diagnoses are made at the rural hospital by
a family physician or surgeon. Staging is done after telephone
consultation between the oncology nurse at the rural site and
the oncologists at the Massey Cancer Center, or by standard protocol.
An outpatient oncology consultation takes place during the oncologist's
biweekly visit, to finalize the diagnosis and treatment plan.
The rural nurse administers chemotherapy and does much of the
intermediate care, with the MCC-MCVH nurse providing support for
approximately 75% of all patient visits. The rural physicians
manage complaints in between the oncologist's visits and have
now assumed responsibility for nearly all palliative care.
We audited charts at the first RCOP site after 3 years of operation
(post-RCOP) and compared results to those from 2 years pre-RCOP.
We audited morphine consumption from 1985 to the present at one
RCOP site, and performed a financial analysis of patients from
two RCOP sites.
We reviewed care of patients pre- and post-RCOP at one rural site
for three important clinical indicators: (1) breast cancer treatment,
since variation is common and important [10,11]; (2) clinical
trial accrual for adjuvant therapy; and (3) pain management, since
is often poorly done [12,13].
The number of patients who have tumor size recorded has improved
by a dramatic 100% (from 29% to 59%). Breast conservation has
increased from 20% to 70%, and the percentage of patients with
stage I or II breast cancer at diagnosis has gone up (from 59%
Clinical trial accrual has increased. The percentage of patients
receiving all their therapy at the rural sites has increased to
nearly 100%. Compliance with adjuvant chemotherapy is essentially
100%. Virtually all palliative care is given at the rural site,
as is 100% of chemotherapy for Hodgkin's and non-Hodgkin's lym-phoma
and testicular cancer.
Morphine consumption at the rural hospital was audited as an example
of palliative care. In the years prior to RCOP, there were no
inhospital prescriptions written for oral or intravenous morphine.
In the subsequent 5 years, there has been a 500% to 700% increase
in oral and IV morphine use, from none to adequate levels.
The program has increased the number of cancer patients at MCC-MCVH
by 330% and noncancer patients by 9%. The number of patient visits
from the rural areas to MCC-MCVH has dropped from 4.7 to 2.1,
a 45% decrease.
The total revenue increase for MCC-MCVH has been only 6% on a
volume increase of 330%, because of declining reimbursement at
the academic center as well as the shift of services to the outpatient
area. However, the contribution margin, or amount the program
generates toward program expenses, has increased by 32%; net profits
have increased by 68%.
For each rural hospital, the number of patients has increased
by a substantial amount, to about 100 new patients each year.
The rural hospitals have generated substantial revenues, profits
of approximately $500,000 per hospital per year. This has been
used to support other less financially viable activities and is
a critical component of the hospitals' financial structure.
Most striking is the reduction in cost to society. Using estimated
reimbursement as an index of cost to the health-care system, the
cost of taking care of a patient in the strategic alliance network
has decreased significantly.
The hospital charge of a rural cancer patient admitted to MCC-MCVH
has dropped by 40%. During this same time period, the hospital
charge of an urban cancer patient admission increased by 2%, and
overall hospital charge per cancer admission increased by 52%.
The cost per patient has decreased by 62%, from $10,233 to $3,862.
The reasons for the financial benefit of the RCOP include a shift
to outpatient services and more efficient care, as documented
by the 40% decline in charges per admission. Much of the reduction
has been achieved by shifting care from the higher priced urban
site to the lower cost rural site. In addition, there are more
primary care and nurse visits and fewer expensive specialist visits.
The RCOP improves access to state-of-the-art curative and palliative
care. Care is less expensive and is delivered more efficiently.
Provider and patient satisfaction with the program is high. Since
the program began, the quality of care for index conditions has
increased dramatically. Referrals have increased for both the
academic center and the rural sites.
The RCOP is profitable for the rural hospitals, revenue-neutral
for the academic center, and cost-saving for society. As an example
of a strategic alliance, the RCOP experience has shown that such
an arrangement can benefit all participants in the network.
Others who contributed to this report are Michael A. Grasso,
Michael J. McCue, Kay Grasso, and Debra Buonaiuto, Virginia Commonwealth
University School of Health Administration; Mary E. Johantgen,
the Agency for Health Care Policy and Research, Rockville , Maryland;
and Mary Helen Hackney, James E. Shaw, and Cynthia J. Simonson,
the Virginia Commonwealth University Massey Cancer Center.
Supported by grants from the Jessie Ball du Pont Fund, Jacksonville
, Florida, Agency for Health Care Policy and Research (RO1 HS
0659-01A1) (TJS, CED), and Office of Cancer Communications, NCI
(RFP CO 94388-63 (TIS), and by a Career Development Award from
the American Cancer Society (TJS).
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