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Outreach Program Improves Oncologic Care for Rural Population, Reduces Cost

Outreach Program Improves Oncologic Care for Rural Population, Reduces Cost

ABSTRACT: Medical College of Virginia-Virginia Commonwealth University, and Virginia Commonwealth University School of Health Administration. This article, in which Drs. Smith and Desch describe a program that brought quality oncologic services to rural residents and lowered the cost of care, is the first in an occasional series entitled Innovations in Care. We invite physicians involved in innovative, cost-saving programs for delivery of oncologic care to contact us about a possible article for this series.

RICHMOND, Va-To help improve cancer care in rural areas of Virginia, we developed a strategic alliance[1], 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[2]. Rural areas are often medically underserved, and the population often has poor access to both primary and specialty care.

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 health-care insurance[3].

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Those unable to make the trip due to lack of money or poor health, or unwilling to seek care due to outdated beliefs about cancer therapy [4], may encounter a rural system with insufficient experience to provide state-of-the-art care.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 [9].

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 capability.

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 away.

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 consultations.

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 it
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% to 79%).

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.

Financial Analysis

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.

Summing Up

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).

References

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2. Pickle LW, Mason TJ, Howard N, et al: Atlas of U.S. Cancer Mortality Among Whites: 1950-1980. DHHS Publ. No. NIH 87-2900, US Govt Printing Office, 1987.

3. Desch CE, Smith TJ, Briendel CA, et al: Cancer treatment in rural areas. Hosp Health Services Admin 37:449-463, 1992.

4. Loehrer PJ Sr, Greger HA, Weinberger M, et al: Knowledge and beliefs about cancer in a socioeconomically disadvantaged population. Cancer 68:1665-1671, 1991.

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9. Cella DF, Orav EJ, Kornblith AB, et al: Socioeconomic status and cancer survival. J Clin Oncol 9:1500-1509, 1991.

10. Farrow DC, Hunt WC, Samet JM: Geographic variation in the treatment of localized breast cancer. N Engl J Med 326:1097-1101, 1992.

11. Nattinger AB, Gottlieb MS, Veum J, et al: Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 326:1102-1107, 1992.

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13. United States Dept of Health and Human Services Agency for Health Care Policy and Research: Clinical Practice Guidelines: Management of Cancer Pain, No. 9, March 1994.

 
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