Supportive Care Needs of Newly Diagnosed Cancer Patients in a Comprehensive Cancer Center: Identifying Care Profiles and Future Perspectives.

The prompt introduction of supportive care for patients with cancer leads to a better quality of life, potential survival benefits, and improvements in treatment safety. Considering that patients' needs vary, descriptive assessments could serve as a compass for an efficient and prompt healthcare response. The aim of this study was to identify supportive care needs in newly diagnosed patients according to cancer type. A retrospective study was conducted by collecting data from the case consultation and medical records of a comprehensive cancer center in France. Patients' needs were divided into twelve domains: nutrition, psychological support, psychiatric support, social care, physiotherapy, addictology, pain management, palliative care, pharmacology, complementary and alternative practice (CAM), sexual health, and speech therapy. Out of 6217 newly diagnosed patients of various cancer types who sought medical care at Gustave Roussy in 2021, 2541 (41%) required supportive cancer care (SCC), and of them, 1331 patients (52%) required two or more different SCC specialist interventions. The top five interventions were dietary (for 60% of patients), physiotherapy (33%), psychology (29%), social care (28%), and pain management (16%). Subgroup analysis according to cancer department highlighted additional specific needs: CAM for breast cancer patients (11%), speech specialist (27%) and addictologist (22%) interventions for ENT patients, psychiatry consultations for neurological patients (16%), and palliative care for dermatology patients (23%). The aforementioned data suggest that an early, multidisciplinary supportive care intervention should be required. Assembling human resources at the time of diagnosis within a dedicated day unit would be the next appropriate step in developing personalized care pathways related to the highlighted needs.

Are Nurse Coordinators Really Performing Coordination Pathway Activities? A Comparative Analysis of Case Studies in Oncology.

Patient Pathway Coordination (PPC) improves patient care quality and safety, particularly in oncology. PPC roles, such as nurse coordinators (NCs), have positively impacted the quality of patient care and reduced financial costs. However, NCs and their real activities in Health Care Organizations (HCOs) are unclear. Our aim was to identify, quantify, and compare all activities performed by NCs in oncology care settings from an organizational approach. Methods: We used qualitative and quantitative approaches based on case study principles. We accumulated 325 observation hours by shadowing and timing the activities of 14 NCs in four French HCO in oncology. Data analysis was conducted using an analytical framework to investigate the Activity of PAtient PAthway Nurse Coordinators in Oncology (APANCO). Results: Our research generated important findings: (1) NC roles and job titles are not standardized. (2) Non-coordination related activities are important in NC work content. Non-coordination times were consistent with distribution times between ward NCs and NCs in centralized structures. Ward NCs had higher non-coordination activities when compared with NCs in centralized structures. (3) PPC times varied for both ward NCs and NCs in centralized structures. Ward NCs performed less design coordination when compared with NCs in centralized structures, and this latter group also performed more external coordination than ward NCs. Conclusions: NCs do not just perform PPC activities. Their position in HCO structures, wards, or centralized structures, influence their work content. Centralized structures allow NCs to focus on their PPC roles. We also highlight different dimensions of NC work and training requirements. Our study could help managers and decision-makers develop PPC roles in oncology.

Motivation of patients with chronic cancer during COVID-19: a qualitative analysis.

PURPOSE: Motivation to treat cancer and prevent its negative impact has been largely explored in a non-pandemic context. However, little is known about the motivation to comply with the treatment, especially during a pandemic. To fill this gap, we have explored the individual and contextual factors impacting patients' motivation during the COVID-19 period using the integrated model. METHODS: We have conducted two qualitative studies before (study 1) and during the COVID-19 (study 2) period in a cancer centre. We respectively interviewed 30 and 22 patients with various chronic cancers in study 1 and also with COVID-19 in study 2. Data analysis was based on content analysis and grounded theory approach identifying the factors affecting patient motivations during both periods, and then comparing them. RESULTS: Our results show the mechanisms that allow patients to maintain their motivation despite the threats related to COVID-19. They underline the importance of respecting the rules and laws for patients' motivation. CONCLUSION: Compliance with legislation fuels the psychological need of protection in patients, which is a key determinant of motivation in the context of the pandemic. Considering patients' self-regulatory activities to assess motivational factors, going beyond clinical aspects, to include organisational and quality-of-life-related aspects throughout their care pathway is crucial.

Understanding the activity of oncology nurse coordinators: An elaboration of a framework based on an abductive approach.

Care coordination is a major health system issue, in particular for cancer patients where a lack of coordination may impact quality of care, lived experiences, and care costs. Consequently, new roles facilitating Patient Pathway Coordination (PPC) have been created (nurse coordinators, NC). However, despite their importance, core PPC activities remain unclear. Practices are often heterogeneous and may be far removed from coordination roles, thus posing issues for implementation of PPC policies. To address this, we generated an analytical framework to investigate the Activity of PAtient PAthway Nurse Coordinators in Oncology (APANCO) from an organizational perspective. We adopted an abductive approach, characterized by two phases: the first involved a preliminary theoretical framework confronted with empirical data from two ethnographic fieldwork scenarios. In the second, we confronted the updated framework with data from a care coordination literature review. The final APANCO framework comprised three main categories at micro-level and three at meso-level. The first categories were used to analyze real NC activity at the micro-level and accounted for activities related (or not) to PPC. Meso-level categories considered organizational contexts that might have influenced NC work content. APANCO provided invaluable information on NCs activities. The framework may be used for clinical and managerial skills training and for standardizing job descriptions. These elements are key for decision-makers and managers who implement PPC programs.

The Ambulatory Medical Assistance (AMA) programme during active-phase treatment in patients with haematological malignancies: A cost-effectiveness analysis.

CONTEXT: The need for patient navigator is growing, and there is a lack of cost evaluation, especially during survivorship. OBJECTIVE: The objective of this study is to evaluate the cost-effectiveness of an Ambulatory Medical Assistance (AMA) programme in patients with haematological malignancies (HM). DESIGN: A cost-effectiveness analysis of the AMA programme was performed compared to a simulated control arm. SETTING: An interventional, single-arm and prospective study was conducted in a French reference haematology-oncology centre between 2016 and 2020. PARTICIPANTS: Adult patients were enrolled with histologically documented malignant haematology, during their active therapy phase, and treated either by intravenous chemotherapy or oral therapy. METHODS: An extrapolation of the effectiveness was derived from a similar nurse monitoring programme (CAPRI study). Cost effectiveness of the programme was evaluated through adverse events of Grade 3 or 4 avoided in different populations. RESULTS: Included patient (n = 797) from the AMA programme were followed during 125 days (IQR: 0-181), and adverse events (Grade 3/4) were observed in 10.1% of patients versus 13.4% in the simulated control arm. The overall cost of AE avoided was estimated to €81,113, leading to an ICER of €864. CONCLUSION: The AMA programme was shown to be cost-effective compared to a simulated control arm with no intervention.

Digital remote monitoring plus usual care versus usual care in patients treated with oral anticancer agents: the randomized phase 3 CAPRI trial.

Strategies that individualize the care of cancer patients receiving oral anticancer agents offer opportunities to improve treatment adherence and patient care. However, the impact of digital remote monitoring systems in this setting has not been evaluated. Here, we report the results of a phase 3 trial (CAPRI, NCT02828462) to assess the impact of a nurse navigator-led program on treatment delivery for patients with metastatic cancer. Patients receiving approved oral anticancer agents were randomized (1:1) to an intervention combining a nurse navigator-led follow-up system and a web portal-smartphone application on top of usual care, or to usual symptom monitoring at the discretion of the treating oncologist, for a duration of 6 months. The primary objective included optimization of the treatment dose. Secondary objectives were grade ≥3 toxicities, patient experience, rates and duration of hospitalization, response and survival, and quality of life. In 559 evaluable patients the relative dose intensity was higher in the experimental arm (93.4% versus 89.4%, P = 0.04). The intervention improved the patient experience (Patient Assessment of Chronic Illness Care score, 2.94 versus 2.67, P = 0.01), reduced the days of hospitalization (2.82 versus 4.44 days, P = 0.02), and decreased treatment-related grade ≥3 toxicities (27.6% versus 36.9%, P = 0.02). These findings show that patient-centered care through remote monitoring of symptoms and treatment may improve patient outcomes and experience.

The path from big data analytics capabilities to value in hospitals: a scoping review.

BACKGROUND: As the uptake of health information technologies increased, most healthcare organizations have become producers of big data. A growing number of hospitals are investing in the development of big data analytics (BDA) capabilities. If the promises associated with these capabilities are high, how hospitals create value from it remains unclear. The present study undertakes a scoping review of existing research on BDA use in hospitals to describe the path from BDA capabilities (BDAC) to value and its associated challenges. METHODS: This scoping review was conducted following Arksey and O'Malley's 5 stages framework. A systematic search strategy was adopted to identify relevant articles in Scopus and Web of Science. Data charting and extraction were performed following an analytical framework that builds on the resource-based view of the firm to describe the path from BDA capabilities to value in hospitals. RESULTS: Of 1,478 articles identified, 94 were included. Most of them are experimental research (n=69) published in medical (n=66) or computer science journals (n=28). The main value targets associated with the use of BDA are improving the quality of decision-making (n=56) and driving innovation (n=52) which apply mainly to care (n=67) and administrative (n=48) activities. To reach these targets, hospitals need to adequately combine BDA capabilities and value creation mechanisms (VCM) to enable knowledge generation and drive its assimilation. Benefits are endpoints of the value creation process. They are expected in all articles but realized in a few instances only (n=19). CONCLUSIONS: This review confirms the value creation potential of BDA solutions in hospitals. It also shows the organizational challenges that prevent hospitals from generating actual benefits from BDAC-building efforts. The configuring of strategies, technologies and organizational capabilities underlying the development of value-creating BDA solutions should become a priority area for research, with focus on the mechanisms that can drive the alignment of BDA and organizational strategies, and the development of organizational capabilities to support knowledge generation and assimilation.

Current developments in delivering customized care: a scoping review.

BACKGROUND: In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care. METHODS: Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included "care customization", "personalized service and health care", individualized care" and "targeting population" in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers. RESULTS: We identified 70 articles published between 2008 and 2019. Most of the articles (n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles (n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles (n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation. CONCLUSIONS: There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care.

Unhealthy behaviors after breast cancer: Capitalizing on a teachable moment to promote lifestyle improvements.

BACKGROUND: This study assessed the prevalence and risk factors of unhealthy behaviors among survivors of early-stage breast cancer. METHODS: Women (n = 9556) from the CANcer TOxicity cohort (NCT01993498) were included. Physical activity (PA), tobacco and alcohol consumption, and body mass index were assessed at diagnosis and at years 1 and 2 after diagnosis. A behavior was defined as unhealthy if patients failed to meet PA recommendations (≥10 metabolic equivalent task hours per week), reduce/quit tobacco, or decrease alcohol consumption to less than daily, or if they gained substantial weight over time. Multivariable-adjusted generalized estimating equations explored associations with unhealthy behaviors. RESULTS: At diagnosis, 41.7% of patients were inactive, 18.2% currently used tobacco, 14.6% consumed alcohol daily, and 48.9% were overweight or obese. At years 1 and 2, unhealthy PA behavior was reported among 37.0% and 35.6% of patients, respectively, unhealthy tobacco use behavior was reported among 11.4% and 9.5%, respectively, and unhealthy alcohol behavior was reported among 13.1% and 12.6%, respectively. In comparison with the previous assessment, 9.4% and 5.9% of underweight and normal-weight patients had transitioned to the overweight or obese category at years 1 and 2, respectively, and 15.4% and 16.2% of overweight and obese patients had gained ≥5% of their weight at years 1 and 2, respectively. One in 3 current tobacco smokers and 1 in 10 daily alcohol users reported improved behaviors after diagnosis. Older women (5-year increment) were more likely to be inactive (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 1.01-1.05) and report unhealthy alcohol behavior (aOR, 1.28; 95% CI, 1.23-1.33) but were less likely to engage in unhealthy tobacco use (aOR, 0.81; 95% CI, 0.78-0.85). Being at risk for depression (vs not being at risk for depression) was associated with reduced odds of unhealthy tobacco use (aOR, 0.67; 95% CI, 0.46-0.97) and with a higher likelihood of unhealthy alcohol behavior (aOR, 1.58; 95% CI, 1.14-2.19). Women with a college education (vs a primary school education) less frequently reported an unhealthy PA behavior (aOR, 0.61; 95% CI, 0.51-0.73) and were more likely to report unhealthy alcohol behavior (aOR, 1.85; 95% CI, 1.37-2.49). Receipt of chemotherapy (vs not receiving chemotherapy) was associated with higher odds of gaining weight (aOR, 1.51; 95% CI, 1.23-1.87) among those who were overweight or obese at diagnosis. CONCLUSIONS: The majority of women were adherent to healthy lifestyle behaviors at the time of their breast cancer diagnosis, but a significant subset was nonadherent. Unhealthy behaviors tended to persist after the breast cancer diagnosis, having varying clinical, psychological, sociodemographic, and treatment-related determinants. This study will inform more targeted interventions to promote optimal health.

What matters to patients? A mixed method study of the importance and consideration of oncology patient demands.

BACKGROUND: A patient-centred approach is increasingly the mandate for healthcare delivery, especially with the growing emergence of chronic conditions. A relevant but often overlooked obstacle to delivering person-centred care is the identification and consideration of all demands based on individual experience, not only disease-based requirements. Mindful of this approach, there is a need to explore how patient demands are expressed and considered in healthcare delivery systems. This study aims to: (i) understand how different types of demands expressed by patients are taken into account in the current delivery systems operated by Health Care Organisations (HCOs); (ii) explore the often overlooked content of specific non-clinical demands (i.e. demands related to interactions between disease treatments and everyday life). METHOD: We adopted a mixed method in two cancer centres, representing exemplary cases of organisational transformation: (i) circulation of a questionnaire to assess the importance that breast cancer patients attach to every clinical (C) and non-clinical (NC) demand identified in an exploratory inquiry, and the extent to which each demand has been taken into account based on individual experiences; (ii) a qualitative analysis based on semi-structured interviews exploring the content of specific NC demands. RESULTS: Further to the way in which the questionnaires were answered (573 answers/680 questionnaires printed) and the semi-structured interviews (36) with cancer patients, results show that NC demands are deemed by patients to be almost as important as C demands (C = 6.53/7 VS. NC = 6.13), but are perceived to be considered to a lesser extent in terms of pathway management (NC = 4.02 VS C = 5.65), with a significant variation depending on the type of non-clinical demands expressed. Five types of NC demands can be identified: demands relating to daily life, alternative medicine, structure of the treatment pathway, administrative and logistic assistance and demands relating to new technologies. CONCLUSIONS: This study shows that HCOs should be able to consider non-clinical demands in addition to those referring to clinical needs. These demands require revision of the healthcare professionals' mandate and transition from a supply-orientated system towards a demand-driven approach throughout the care pathway. Other sectors have developed hospitality management, mass customisation and personalisation to scale up approaches that could serve as inspiring examples.

Nurse navigators' telemonitoring for cancer patients with COVID-19: a French case study.

PURPOSE: The Gustave Roussy Cancer Institute implemented a patient-reported outcome platform (CAPRI-COVID) for cancer patients with coronavirus disease 2019 (COVID-19) to quarantine patients at home while ensuring monitoring of COVID-related symptoms and securing the care pathway. In this study, we described the CAPRI-COVID intervention, evaluated its use, and presented results of the tracking indicators with a focus on the nurse navigators' (NNs) activities and the experience of patients. METHODS: Data of 130 cancer patients with COVID-19 diagnosed from March 23 to June 5, 2020, were collected. Six COVID-related symptoms were monitored daily, either by the patient via the CAPRI mobile application (CAPRI App) or by NNs via telemonitoring. In the cases of worsening or new-onset symptoms, an automated alert was sent to the platform, and NNs could immediately consult an emergency physician for future course of action. RESULTS: All 130 patients (median age: 59 years; 59.2% female) were monitored during the study period. There were no deaths or admissions to the intensive care unit attributable to COVID-19; 7.8% of patients were hospitalized (excluding scheduled hospitalization), and 17.1% were admitted to the emergency department at least once during the monitoring period. NNs carried out 1412 regular monitoring calls (average of 10.9 calls per patient), while 55% of the patients downloaded the CAPRI App. CONCLUSIONS: Most patients monitored with CAPRI-COVID were quarantined during the first wave of the pandemic. In addition to the CAPRI App, which helped limit phone calls, NNs played an essential role in patient management.

How to Design a Remote Patient Monitoring System? A French Case Study.

BACKGROUND: Remote Patient Monitoring Systems (RPMS) based on e-health, Nurse Navigators (NNs) and patient engagement can improve patient follow-up and have a positive impact on quality of care (by limiting adverse events) and costs (by reducing readmissions). However, the extent of this impact depends on effective implementation which is often restricted. This is partly due to the lack of attention paid to the RPMS design phase prior to implementation. The content of the RPMS can be carefully designed at this stage and various obstacles anticipated. Our aim was to report on an RPMS design case to provide insights into the methodology required in order to manage this phase. METHODS: This study was carried out at Gustave Roussy, a comprehensive cancer centre, in France. A multidisciplinary team coordinated the CAPRI RPMS design process (2013-2015) that later produced positive outcomes. Data were collected during eight studies conducted according to the Medical Research Council (MRC) framework. This project was approved by the French National Data Protection Authorities. RESULTS: Based on the study results, the multidisciplinary team defined strategies for resolving obstacles prior to the implementation of CAPRI. Consequently, the final CAPRI design includes a web app with two interfaces (patient and health care professionals) and two NNs. The NNs provide regular follow-up via telephone or email to manage patients' symptoms and toxicity, treatment compliance and care packages. Patients contact the NNs via a secure messaging system. Eighty clinical decision support tools enable NNs to prioritise and decide on the course of action to be taken. CONCLUSION: In our experience, the RPMS design process and, more generally, that of any complex intervention programme, is an important phase that requires a sound methodological basis. This study is also consistent with the notion that an RPMS is more than a technological innovation. This is indeed an organizational innovation, and principles identified during the design phase can help in the effective use of a RPMS (e.g. locating NNs if possible within the care organization; recruiting NNs with clinical and managerial skills; defining algorithms for clinical decision support tools for assessment, but also for patient decision and orientation).

[Entre dynamique d'amélioration de la qualité des soins et conformisme administratif : comportements des établissements de santé français face au paiement à la performance (P4P)].

Le paiement à la performance (P4P) continue de se développer dans les systèmes de santé des pays industrialisés, malgré des preuves encore assez limitées de son efficacité. Cette étude propose de comprendre le comportement des établissements de santé face à ce nouveau mode de paiement en se basant sur l'expérimentation de P4P hospitalier conduite en France. Nous avons, pour cela, combiné une approche quantitative basée sur un questionnaire auprès des établissements participants et une analyse qualitative dans neuf établissements afin de mieux identifier les processus à l'œuvre. L'étude montre que des actions correctives ont été réalisées dans certains établissements mais que les effets du programme sur l'organisation restent en fait assez limités puisqu'ils s'opèrent davantage à la marge. Les comportements semblent être essentiellement le reflet d'une volonté de conformation des organisations aux attentes de la tutelle, sans transformations organisationnelles majeures. Il sera toutefois intéressant de voir comment des perceptions différentes structurent ces comportements sur le long terme.

Does size matter? The impact of caseload and expertise concentration on AMI 30-day mortality-A comparison across 10 OECD countries.

OBJECTIVE: To examine the variability of hospital performance within and across countries, using 30-day acute myocardial infarction (AMI) mortality, and to study the impact of hospital characteristics on performance. STUDY SETTING: Hospital-level adjusted risk standardized mortality rates (RSMR) and hospital characteristics were collected from 10 OECD and two collaborating countries including 1,163 hospitals. STUDY DESIGN: Associations between RSMR and hospital characteristics were studied using univariate and multivariate linear regressions. Clusters of hospitals were created using hierarchical clustering and mortality compared using linear regression. FINDINGS: Wide variation between countries was found for RSMR and hospital characteristics. Regression models showed large country effects. A high volume of AMI admission was associated with lower RSMR in a model using a restricted number of hospital characteristics (-0.83, p < 0.001) but not in a model using all characteristics (-1.03, p = 0.06). Analysis within countries supported this association. Hospital clusters showed clear differences in characteristic distributions but no difference in RSMR. CONCLUSIONS: The effect of volume may support policies toward a concentration of services within the hospital sector. The effect of other hospital characteristics was inconclusive and suggests the importance of system-wide characteristics or pathways of care (i.e. timeliness and nature of initial response and during transportation to a hospital, transfers between hospitals, post-discharge organization) in explaining variation.

[New modes of payment for the process of care]. / Nouveaux modes de rémunération pour la prise en charge médicale.

NEW MODES OF PAYMENT FOR THE PROCESS OF CARE. Paying for quality and bundled payment appear in France, and in other countries, as complements to existing payments that have encouraged the volume of activity. Quality payment has already been implemented for several years while bundled payment is more recent, in an experimental phase, mainly in the frame of the Article 51 of the Sécurité sociale financing act for 2019. This article describes the main principles of these payments, provides a critical analysis, and lays the foundations for a coherent strategy of their developments. While these payments can improve quality and reduce costs, they require evaluation studies for a better understanding of their effectiveness, and should not represent objectives in themselves, but means to improve the organization of the continuum of care.

NOUVEAUX MODES DE RÉMUNÉRATION POUR LA PRISE EN CHARGE MÉDICALE. Les modes de rémunération à la qualité et au parcours apparaissent en France, et ailleurs, comme des compléments aux rémunérations existantes qui ont principalement incité à augmenter l'activité. Le paiement à la qualité est déjà implanté depuis plusieurs années tant en ville qu'à l'hôpital alors que le paiement au parcours est plus récent, en phase expérimentale, principalement dans le cadre de l'article 51 de la loi de financement de la Sécurité sociale pour 2019. Cet article décrit les grands principes de ces nouveaux modes de rémunération, porte une analyse critique, et jette les bases d'un emploi cohérent. Si ces paiements peuvent inciter à une amélioration de la qualité et à des parcours coordonnés (avec des conséquences aussi en matière de réduction des gaspillages), ils nécessitent de nombreux travaux d'évaluation afin d'optimiser leur impact, et ne doivent pas perdre de vue qu'ils ne sont pas des objectifs en eux-mêmes, mais des moyens au service d'une meilleure organisation des parcours de patients.

Transforming health care delivery: An imperative for healthcare systems.

The ways in which patient care is organized, managed and delivered are changing dramatically. As these changes continue to unfold, the organizational arrangements within which they take place - the production process - need to be redesigned. Redesign is always challenging, as peoples' routines, habits and expectations are frequently disrupted, and need to be modified or replaced by new ones. However, it should be a priority, as the need for change is only going to increase over time.

Geographic Variations of Stroke Hospitalization across France: A Diachronic Cluster Analysis.

BACKGROUND: This study evaluates the clustering of hospitalization rates for stroke and compares this clustering with two different time intervals 2009-2010 and 2012-2013, corresponding to the beginning of the French National Stroke Plan 2010-2014. In addition, these data will be compared with the deployment of stroke units as well as socioeconomic and healthcare characteristics at zip code level. METHODS: We used the PMSI data from 2009 to 2013, which lists all hospitalizations for stroke between 2009 and 2013, identified on the most detailed geographic scale allowed by this database. We identify statistically significant clusters with high or low rates in the zip code level using the Getis-Ord statistics. Each of the significant clusters is monitored over time and evaluated according to the nearest stroke unit distance and the socioeconomic profile. RESULTS: We identified clusters of low and high rate of stroke hospitalization (23.7% of all geographic codes). Most of these clusters are maintained over time (81%) but we also observed clusters in transition. Geographic codes with persistent high rates of stroke hospitalizations were mainly rural (78% versus 17%, P < .0001) and had a least favorable socioeconomic and healthcare profile. CONCLUSION: Our study reveals that high-stroke hospitalization rates cluster remains the same during our study period. While access to the stroke unit has increased overall, it remains low for these clusters. The socioeconomic and healthcare profile of these clusters are poor but variations were observed. These results are valuable tools to implement more targeted strategies to improve stroke care accessibility and reduce geographic disparities.