Broadband Data Forensics: Spatiotemporal Variations of the Download/Upload Speed Metric Commonly Used to Evaluate Potential Telehealth Accessibility.

Introduction: The complicated task of evaluating potential telehealth access begins with the metrics and supporting datasets that seek toevaluate the presence and durability of broadband connections in a community. Broadband download/upload speeds are one of the popular metrics used to measure potential telehealth access, which is critical to health equity. An understanding of the limitations of these measures is important for drawing conclusions about the reality of the digital divide in telehealth access. The objective of this study was to assess spatiotemporal variations in broadband download/upload speeds. Method: We analyzed a sample of data from the Speedtest Intelligence Portal provided through the Ookla for Good initiative. Results: We found that variation is inherent across the states of Vermont, New Hampshire, Louisiana, and Utah. Conclusions: The variation suggests that when single measures of download/upload speeds are used to evaluate telehealth accessibility they may be masking the true magnitude of the digital divide.

Refining 2SVCA Method for Measuring Telehealth Accessibility of Primary Care Physicians in Baton Rouge, Louisiana.

Equity in health care delivery is a longstanding concern of public health policy. Telehealth is considered an important way to level the playing field by broadening health services access and improving quality of care and health outcomes. This study refines the recently developed "2-Step Virtual Catchment Area (2SVCA) method" to assess the telehealth accessibility of primary care in the Baton Rouge Metropolitan Statistical Area, Louisiana. The result is compared to that of spatial accessibility via physical visits to care providers based on the popular 2-Step Floating Catchment Area (2SFCA) method. The study shows that both spatial and telehealth accessibilities decline from urban to low-density and then rural areas. Moreover, disproportionally higher percentages of African Americans are in areas with higher spatial accessibility scores; but such an advantage is not realized in telehealth accessibility. In the study area, absence of broadband availability is mainly a rural problem and leads to a lower average telehealth accessibility than physical accessibility in rural areas. On the other side, lack of broadband affordability is a challenge across the rural-urban continuum and is disproportionally associated with high concentrations of disadvantaged population groups such as households under the poverty level and Blacks.

Pandemic Use of Telehealth by Oncology at a Rural Academic Medical Center.

Introduction: The COVID-19 pandemic resulted in an exponential increase in telehealth. In response to the pandemic, Dartmouth-Hitchcock Health (D-HH) and its Norris Cotton Cancer Center (NCCC) closed non-essential in-person services on March 17, 2020 and began reopening on April 27, 2020. We examined outpatient telehealth utilization at D-HH and NCCC in the peri-pandemic period and compared utilization to the Academic Medical Center (AMC) overall and to other service lines. Methods: Weekly outpatient volumes, percentage telehealth, percentage video versus audio-only, and percentage of new patients were examined for D-HH, for the AMC, and for selected AMC-based service lines from January 1 to October 31, 2020. Results: Compared with the AMC overall and with five other primarily non-surgical specialties, oncology was lower in the (1) proportion of outpatient visits performed via telehealth (example week 7/12/20: oncology = 11%; AMC = 21%; mean of 5 other specialties = 38%) and (2) percentage of telehealth involving video versus audio-only (7/12/20: oncology = 19%; AMC = 58%; mean of 5 others = 60%). Oncology more closely resembled the surgical specialty of orthopedics (7/12/20: 2% telehealth; 10% of telehealth involved video). Oncology also demonstrated (1) a high proportion of outpatient visits involving procedures (oncology = 22%; orthopedics = 12%) and (2) no difference between telehealth and in-person visits in terms of the percentage involving new patients. Conclusions: During the peri-pandemic period, our oncology service demonstrated a lower than average incorporation of telehealth overall into their outpatient practice and a lower proportion of telehealth performed by video. Further understanding these results and the drivers behind them will be integral for redesigning outpatient oncology care with optimal integration of telehealth.

Language and Sentiment Regarding Telemedicine and COVID-19 on Twitter: Longitudinal Infodemiology Study.

BACKGROUND: The COVID-19 pandemic has necessitated a rapid shift in how individuals interact with and receive fundamental services, including health care. Although telemedicine is not a novel technology, previous studies have offered mixed opinions surrounding its utilization. However, there exists a dearth of research on how these opinions have evolved over the course of the current pandemic. OBJECTIVE: This study aims to evaluate how the language and sentiment surrounding telemedicine has evolved throughout the COVID-19 pandemic. METHODS: Tweets published between January 1, 2020, and April 24, 2021, containing at least one telemedicine-related and one COVID-19-related search term ("telemedicine-COVID") were collected from the Twitter full archive search (N=351,718). A comparator sample containing only COVID-19 terms ("general-COVID") was collected and sampled based on the daily distribution of telemedicine-COVID tweets. In addition to analyses of retweets and favorites, sentiment analysis was performed on both data sets in aggregate and within a subset of tweets receiving the top 100 most and least retweets. RESULTS: Telemedicine gained prominence during the early stages of the pandemic (ie, March through May 2020) before leveling off and reaching a steady state from June 2020 onward. Telemedicine-COVID tweets had a 21% lower average number of retweets than general-COVID tweets (incidence rate ratio 0.79, 95% CI 0.63-0.99; P=.04), but there was no difference in favorites. A majority of telemedicine-COVID tweets (180,295/351,718, 51.3%) were characterized as "positive," compared to only 38.5% (135,434/351,401) of general-COVID tweets (P<.001). This trend was also true on a monthly level from March 2020 through April 2021. The most retweeted posts in both telemedicine-COVID and general-COVID data sets were authored by journalists and politicians. Whereas the majority of the most retweeted posts within the telemedicine-COVID data set were positive (55/101, 54.5%), a plurality of the most retweeted posts within the general-COVID data set were negative (44/89, 49.4%; P=.01). CONCLUSIONS: During the COVID-19 pandemic, opinions surrounding telemedicine evolved to become more positive, especially when compared to the larger pool of COVID-19-related tweets. Decision makers should capitalize on these shifting public opinions to invest in telemedicine infrastructure and ensure its accessibility and success in a postpandemic world.

Utilization of breast cancer screening with magnetic resonance imaging in community practice.

BACKGROUND: Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice. OBJECTIVE: To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications. DESIGN: Prospective cohort study conducted between 2007 and 2014. PARTICIPANTS: In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI. MAIN MEASURES: Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression. KEY RESULTS: Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7-2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9-14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0-60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%-84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1-37.9%) among women considered at low-to-average breast cancer risk. CONCLUSION: Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.

The Effect of Digital Breast Tomosynthesis Adoption on Facility-Level Breast Cancer Screening Volume.

OBJECTIVE: The purpose of this study was to determine whether digital breast tomosynthesis (DBT) adoption was associated with a decrease in screening mammography capacity across Breast Cancer Screening Consortium facilities, given concerns about increasing imaging and interpretation times associated with DBT. SUBJECTS AND METHODS: Facility characteristics and examination volume data were collected prospectively from Breast Cancer Screening Consortium facilities that adopted DBT between 2011 and 2014. Interrupted time series analyses using Poisson regression models in which facility was considered a random effect were used to evaluate differences between monthly screening volumes during the 12-month preadoption period and the 12-month postadoption period (with the two periods separated by a 3-month lag) and to test for changes in month-to-month facility-level screening volume during the preadoption and postadoption periods. RESULTS: Across five regional breast imaging registries, 15 of 83 facilities (18.1%) adopted DBT for screening between 2011 and 2014. Most had no academic affiliation (73.3% [11/15]), were nonprofit (80.0% [12/15]), and were general radiology practices (66.7% [10/15]). Facility-level monthly screening volumes were slightly higher during the postadoption versus preadoption periods (relative risk [RR], 1.09; 95% CI, 1.06-1.11). Monthly screening volumes remained relatively stable within the preadoption period (RR, 1.00 per month; 95% CI 1.00-1.01 per month) and the postadoption period (RR, 1.00; 95% CI, 1.00-1.01 per month). CONCLUSION: In a cohort of facilities with varied characteristics, monthly screening examination volumes did not decrease after DBT adoption.

Population-based geographic access to parent and satellite National Cancer Institute Cancer Center Facilities.

BACKGROUND: Satellite facilities of National Cancer Institute (NCI) cancer centers have expanded their regional footprints. This study characterized geographic access to parent and satellite NCI cancer center facilities nationally overall and by sociodemographics. METHODS: Parent and satellite NCI cancer center facilities, which were geocoded in ArcGIS, were ascertained. Travel times from every census tract in the continental United States and Hawaii to the nearest parent and satellite facilities were calculated. Census-based population attributes were used to characterize measures of geographic access for sociodemographic groups. RESULTS: From the 62 NCI cancer centers providing clinical care in 2014, 76 unique parent locations and 211 satellite locations were mapped. The overall proportion of the population within 60 minutes of a facility was 22% for parent facilities and 32.7% for satellite facilities. When satellites were included for potential access, the proportion of some racial groups for which a satellite was the closest NCI cancer center facility increased notably (Native Americans, 22.6% with parent facilities and 39.7% with satellite facilities; whites, 34.8% with parent facilities and 50.3% with satellite facilities; and Asians, 40.0% with parent facilities and 54.0% with satellite facilities), with less marked increases for Hispanic and black populations. Rural populations of all categories had dramatically low proportions living within 60 minutes of an NCI cancer center facility of any type (1.0%-6.6%). Approximately 14% of the population (n = 43,033,310) lived more than 180 minutes from a parent or satellite facility, and most of these individuals were Native Americans and/or rural residents (37% of Native Americans and 41.7% of isolated rural residents). CONCLUSIONS: Racial/ethnic and rural populations showed markedly improved geographic access to NCI cancer center care when satellite facilities were included. Cancer 2017;123:3305-11. © 2017 American Cancer Society.

Disparities in the use of screening magnetic resonance imaging of the breast in community practice by race, ethnicity, and socioeconomic status.

BACKGROUND: Uptake of breast magnetic resonance imaging (MRI) coupled with breast cancer risk assessment offers the opportunity to tailor the benefits and harms of screening strategies for women with differing cancer risks. Despite the potential benefits, there is also concern for worsening population-based health disparities. METHODS: Among 316,172 women aged 35 to 69 years from 5 Breast Cancer Surveillance Consortium registries (2007-2012), the authors examined 617,723 negative screening mammograms and 1047 screening MRIs. They examined the relative risks (RRs) of MRI use by women with a <20% lifetime breast cancer risk and RR in the absence of MRI use by women with a ≥20% lifetime risk. RESULTS: Among women with a <20% lifetime risk of breast cancer, non-Hispanic white women were found to be 62% more likely than nonwhite women to undergo an MRI (95% confidence interval, 1.32-1.98). Of these women, those with an educational level of some college or technical school were 43% more likely and those who had at least a college degree were 132% more likely to receive an MRI compared with those with a high school education or less. Among women with a ≥20% lifetime risk, there was no statistically significant difference noted with regard to the use of screening MRI by race or ethnicity, but high-risk women with a high school education or less were less likely to undergo screening MRI than women who had graduated from college (RR, 0.40; 95% confidence interval, 0.25-0.63). CONCLUSIONS: Uptake of screening MRI of the breast into clinical practice has the potential to worsen population-based health disparities. Policies beyond health insurance coverage should ensure that the use of this screening modality reflects evidence-based guidelines.

Multilevel factors associated with long-term adherence to screening mammography in older women in the U.S.

In the U.S., guidelines recommend that women continue mammography screening until at least age 74, but recent evidence suggests declining screening rates in older women. We estimated adherence to screening mammography and multilevel factors associated with adherence in a longitudinal cohort of older women. Women aged 66-75years receiving screening mammography within the Breast Cancer Surveillance Consortium were linked to Medicare claims (2005-2010). Claims data identified baseline adherence, defined as receiving subsequent mammography within approximately 2years, and length of time adherent to guidelines. Characteristics associated with adherence were investigated using logistic and Cox proportional hazards regression models. Analyses were stratified by age to investigate variation in relationships between patient factors and adherence. Among 49,775 women, 89% were adherent at baseline. Among women 66-70years, those with less than a high school education were more likely to be non-adherent at baseline (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.65-2.33) and remain adherent for less time (hazard ratio [HR] 1.41; 95% CI 1.11-1.80) compared to women with a college degree. Women with ≥1 versus no Charlson co-morbidities were more likely to be non-adherent at baseline (OR 1.46; 95% CI 1.31-1.62) and remain adherent for less time (HR 1.44; 95% CI 1.24-1.66). Women aged 71-75 had lower adherence overall, but factors associated with non-adherence were similar. In summary, adherence to guidelines is high among Medicare-enrolled women in the U.S. receiving screening mammography. Efforts are needed to ensure that vulnerable populations attain these same high levels of adherence.

Is the closest facility the one actually used? An assessment of travel time estimation based on mammography facilities.

BACKGROUND: Characterizing geographic access depends on a broad range of methods available to researchers and the healthcare context to which the method is applied. Globally, travel time is one frequently used measure of geographic access with known limitations associated with data availability. Specifically, due to lack of available utilization data, many travel time studies assume that patients use the closest facility. To examine this assumption, an example using mammography screening data, which is considered a geographically abundant health care service in the United States, is explored. This work makes an important methodological contribution to measuring access--which is a critical component of health care planning and equity almost everywhere. METHOD: We analyzed one mammogram from each of 646,553 women participating in the US based Breast Cancer Surveillance Consortium for years 2005-2012. We geocoded each record to street level address data in order to calculate travel time to the closest and to the actually used mammography facility. Travel time between the closest and the actual facility used was explored by woman-level and facility characteristics. RESULTS: Only 35% of women in the study population used their closest facility, but nearly three-quarters of women not using their closest facility used a facility within 5 min of the closest facility. Individuals that by-passed the closest facility tended to live in an urban core, within higher income neighborhoods, or in areas where the average travel times to work was longer. Those living in small towns or isolated rural areas had longer closer and actual median drive times. CONCLUSION: Since the majority of US women accessed a facility within a few minutes of their closest facility this suggests that distance to the closest facility may serve as an adequate proxy for utilization studies of geographically abundant services like mammography in areas where the transportation networks are well established.

Costs of diagnostic and preoperative workup with and without breast MRI in older women with a breast cancer diagnosis.

BACKGROUND: Breast cancer in the U.S. - estimated at 232,670 incident cases in 2014 - has the highest aggregate economic burden of care relative to other female cancers. Yet, the amount of cost attributed to diagnostic/preoperative work up has not been characterized. We examined the costs of imaging and biopsy among women enrolled in Medicare who did and did not receive diagnostic/preoperative Magnetic Resonance Imaging (MRI). METHODS: Using Surveillance, Epidemiology and End Results (SEER)- Medicare data, we compared the per capita costs (PCC) based on amount paid, between diagnosis date and primary surgical treatment for a breast cancer diagnosis (2005-2009) with and without diagnostic/preoperative MRI. We compared the groups with and without MRI using multivariable models, adjusting for woman and tumor characteristics. RESULTS: Of the 53,653 women in the cohort, within the diagnostic/preoperative window, 20 % (N = 10,776) received diagnostic/preoperative MRI. Total unadjusted median costs were almost double for women with MRI vs. without ($2,251 vs. $1,152). Adjusted costs were higher among women receiving MRI, with significant differences in total costs ($1,065), imaging costs ($928), and biopsies costs ($138). CONCLUSION: Costs of diagnostic/preoperative workups among women with MRI are higher than those without. Using these cost estimates in comparative effectiveness models should be considered when assessing the benefits and harms of diagnostic/preoperative MRI.

Development of the Rural Perception Scale (RPS-18).

BACKGROUND: People living in rural areas often experience limited access to health resources, slow knowledge diffusion, and geographical isolation, and tend to be at higher risk for poor physical and mental health outcomes compared with nonrural populations. It is unclear, yet, how the concept of "rural" shapes observed differences from nonrural populations. We aim to develop a psychometrically sound scale to assess key dimensions that constitute individual-level perceived rurality. METHODS: We first conducted a broad literature review to identify a priori concepts related to rurality and adapted survey items measuring relevant constructs, such as loneliness, attitudes toward people living in rural areas, and perceived social membership. We used these conceptual constructs and measures to develop a survey questionnaire focused on rural perceptions. We recruit residents in 3 rural states: Kentucky, New Hampshire, and Vermont. Using the explorative factor analysis and second-order measurement model in the structural equation model framework, we developed a rural perception scale consisting of 18 items. RESULTS: We recruited 1,384 participants (n = 686 from KY; n = 698 from NH/VT) using Amazon Mechanical Turk (n = 897, 64.8%) and social media paid ads (n = 487, 35.2%). The average age of participants was 41 years old (SD = 15); 54.7% of respondents had less than college graduate education, and 94.2% reported their race as non-Hispanic White. Majority of the participants were from Rural Urban Commuting Area (RUCA)-designated urban areas (n = 798, 57.7%), followed by RUCA-designated large rural areas (257, 18.6%), RUCA-designated rural areas (n = 174, 12.6%) and RUCA-designated isolated areas (n = 133, 9.6%). Our final model revealed 4 latent constructs: "belonging" (Cronbach's α = 0.896), "attitudes toward rural life" (Cronbach's α = 0.807), "loneliness" (Cronbach's α = 0.898), and "community social ties to people in their community" (Cronbach's α = 0.846). CONCLUSIONS: We identified 4 subfactors of the umbrella concept of rurality that explain how people in rural regions may perceive being in rural environments and having rural lifestyles.

Causes of Childhood Cancer: A Review of the Recent Literature: Part I-Childhood Factors.

PURPOSE: To review the childhood risk factors for pediatric cancer (diagnosis before age 20). METHODS: We conducted literature searches using Ovid Medline and Scopus to find primary research studies, review articles, and meta-analyses published from 2014 to 3 March 2021. RESULTS: Strong evidence indicates that an array of genetic and epigenetic phenomena, structural birth defects, and chromosomal anomalies are associated with an increased risk of various childhood cancers. Increased risk is also associated with prior cancer, likely due to previous treatment agents and therapeutic ionizing radiation. Convincing evidence supports associations between several pediatric cancers and ionizing radiation, immunosuppression, and carcinogenic virus infection both in healthy children and in association with immune suppression following organ transplantation. Breastfeeding and a childhood diet rich in fruits and vegetables appears to reduce the risk of pediatric leukemia but the evidence is less strong. Childhood vaccination against carcinogenic viruses is associated with a lower risk of several cancers; there is less strong evidence that other childhood vaccinations more broadly may also lower risk. Ultraviolet (UV) radiation is associated with increased melanoma risk, although most melanomas following childhood UV exposure occur later, in adulthood. Evidence is weak or conflicting for the role of body mass index, other childhood infections, allergies, and certain treatments, including immunomodulator medications and human growth therapy.

The interaction of rurality and rare cancers for travel time to cancer care.

PURPOSE: Geographic access to cancer care is known to significantly impact utilization and outcomes. Longer travel times have negative impacts for patients requiring highly specialized care, such as for rare cancers, and for those in rural areas. Scant population-based research informs geographic access to care for rare cancers and whether rurality impacts that access. METHODS: Using Medicare data (2014-2015), we identified prevalent cancers and cancer-directed surgeries, chemotherapy, and radiation. We classified cancers as rare (incidence <6/100,000/year) or common (incidence ≥6/100,000/year) using previously published thresholds and categorized rurality from ZIP code of beneficiary residence. We estimated travel time between beneficiaries and providers for each service based on ZIP code. Descriptive statistics summarized travel time by rare versus common cancers, service type, and rurality. FINDINGS: We included 1,169,761 Medicare beneficiaries (21.9% in nonmetropolitan areas), 87,399; 7.5% had rare cancers, with 9,133,003 cancer-directed services. Travel times for cancer services ranged from approximately 29 minutes (25th percentile) to 68 minutes (75th percentile). Travel times were similar for rare and common cancers overall (median: 45 vs 43 minutes) but differed by service type; 13.4% of surgeries were >2 hours away for rare cancers, compared to 8.3% for common cancers. Increasing rurality disproportionately increased travel time to surgical care for rare compared to common cancers. CONCLUSIONS: Travel times to cancer services are longest for surgery, especially among rural residents, yet not markedly longer overall between rare versus common cancers. Understanding geographic access to cancer care for patients with rare cancers is important to delivering specialized care.

From active treatment to surveillance: how the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients.

PURPOSE: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery, and the opportunity for telehealth in cancer survivorship is examined. METHODS: We conducted a mixed-methods study in Vermont and New Hampshire to characterize perceptions of rural cancer providers and survivors regarding survivorship transitions in care, consisting of (a) key informant interviews with primary care and oncology clinicians, (b) a broader survey of clinicians, and (c) surveys and focus group discussions with cancer survivors. In these interactions, we also explored the use of a shared telehealth survivorship care planning appointment between oncology clinicians, primary care clinicians, and survivors. RESULTS: Results from surveys and interviews clustered around several themes, namely (1) infrequent care transitioning back to primary care, (2) lack of mental health services, (3) lack of side effect education, (4) low perceived utility of survivorship care plans, (5) clinicians exclusively communicate using the EMR and finding it imperfect, and (6) clinicians and survivors reported conflicting perceptions regarding survivors' access to telehealth options. CONCLUSIONS: Our results suggest that telehealth has the potential to augment the delivery of survivorship care planning; however, key technical and logistical concerns need to be addressed, particularly enhanced coordination across clinician scheduling and ensuring payment parity for various telehealth implementation strategies. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery. There is an opportunity for the application of telehealth for supportive care in survivorship care planning, which should be a focus of further research.

Factors Influencing Telemedicine Use at a Northern New England Cancer Center During the COVID-19 Pandemic.

PURPOSE: To characterize the use of telemedicine for oncology care over the course of the COVID-19 pandemic in Northern New England with a focus on factors affecting trends. METHODS: We performed a retrospective observational study using patient visit data from electronic health records from hematology-oncology and radiation-oncology service lines spanning the local onset of the pandemic from March 18, 2020, through March 31, 2021. This period was subdivided into four phases designated as lockdown, transition, stabilization, and second wave. Generalized linear mixed regression models were used to estimate the effects of patient characteristics on trends for rates of telemedicine use across phases and the effects of visit type on patient satisfaction and postvisit ER or hospital admissions within 2 weeks. RESULTS: A total of 19,280 patients with 102,349 visits (13.1% audio-only and 1.4% video) were studied. Patient age (increased use in age < 45 and 85 years and older) and urban residence were associated with higher use of telemedicine, especially after initial lockdown. Recent cancer therapy, ER use, and hospital admissions in the past year were all associated with lower telemedicine utilization across pandemic phases. Provider clinical department corresponded to the largest differences in telemedicine use across all phases. ER and hospital admission rates in the 2 weeks after a telehealth visit were lower than those in in-person visits (0.7% v 1.3% and 1.2% v 2.7% for ER and hospital use, respectively; P < .001). Patient satisfaction did not vary across visit types. CONCLUSION: Telemedicine use in oncology during the COVID-19 pandemic varied according to the phase and patient, medical, and health system factors, suggesting opportunities for standardization of care and need for attention to equitable telemedicine access.

Adoption of Telemedicine in a Rural US Cancer Center Amid the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: The COVID-19 pandemic necessitated a rapid shift to telemedicine to minimize patient and provider exposure risks. While telemedicine has been used in a variety of primary and specialty care settings for many years, it has been slow to be adopted in oncology care. Health care provider and administrator perspectives on factors affecting telemedicine use in oncology settings are not well understood, and the conditions associated with the COVID-19 pandemic offered the opportunity to study the adoption of telemedicine and the resulting provider and staff perspectives on its use. OBJECTIVE: The aim of this paper is to study the factors that influenced telemedicine uptake and sustained use in outpatient oncology clinics at a US cancer center to inform future telemedicine practices. METHODS: We used purposive sampling to recruit a mix of oncology specialty providers, practice managers, as well as nursing and administrative staff representing 5 outpatient oncology clinics affiliated with the Dartmouth Cancer Center, a large regional cancer center in the northeast of United States, to participate in semistructured interviews conducted over 6 weeks in spring 2021. The interview guide was informed by the 5 domains of the Consolidated Framework for Implementation Research, which include inner and outer setting factors, characteristics of the intervention (ie, telemedicine modality), individual-level factors (eg, provider and patient characteristics), and implementation processes. In total, 11 providers, 3 leaders, and 6 staff participated following verbal consent, and thematic saturation was reached across the full sample. We used a mixed deductive and inductive qualitative analysis approach to study the main influences on telemedicine uptake, implementation, and sustainability during the first year of the COVID-19 pandemic across the 5 settings. RESULTS: The predominant influencers of telemedicine adoption in this study were individual provider experiences and assumptions about patient preference and accessibility. Providers' early telemedicine experiences, especially if negative, influenced preferences for telephone over video and affected sustained use. Telemedicine was most favorably viewed for lower-acuity cancer care, visits less dependent on physical exam, and for patient and caregiver education. A lack of clinical champions, leadership guidance, and vision hindered the implementation of standardized practices and were cited as essential for telemedicine sustainability. Respondents expressed anxiety about sustaining telemedicine use if reimbursements for telephonic visits diminished or ceased. Opportunities to enhance future efforts include a need to provide additional guidance supporting telemedicine use cases and evidence of effectiveness in oncology care and to address provider concerns with communication quality. CONCLUSIONS: In a setting of decentralized care processes, early challenges in telemedicine implementation had an outsized impact on the nature and amount of sustained use. Proactively designed telemedicine care processes with attention to patient needs will be essential to support a sustained role for telemedicine in cancer care.

The influence of travel time on breast cancer characteristics, receipt of primary therapy, and surveillance mammography.

Travel time has been shown to influence some aspects of cancer characteristics at diagnosis and care for women with breast cancer, but important gaps remain in our understanding of its impact. We examined the influence of travel time to the nearest radiology facility on breast cancer characteristics, treatment, and surveillance for women with early-stage invasive breast cancer. We included 1,012 women with invasive breast cancer (stages I and II) who had access to care within an integrated health care delivery system in western Washington State. The travel times to the nearest radiology facility were calculated for all the U.S. Census blocks within the study area and assigned to women based on residence at diagnosis. We collected cancer characteristics, primary and adjuvant therapies, and surveillance mammography for at least 2.5 years post diagnosis and used multivariable analyses to test the associations of travel time. The majority of women (68.6%) lived within 20 min of the nearest radiology facility, had stage I disease (72.7%), received breast conserving therapy (68.7%), and had annual surveillance mammography the first 2 years after treatment (73.7%). The travel time was not significantly associated with the stage or surveillance mammography after adjusting for covariates. Primary therapy was significantly related to travel time, with greater travel time (>30 min vs. ≤ 10 min) associated with a higher likelihood of mastectomy compared to breast conserving surgery (RR = 1.53; 95% CI, 1.16-2.01). The travel time was not associated with the stage at diagnosis or surveillance mammography receipt. The travel time does seem to influence the type of primary therapy among women with breast cancer, suggesting that women may prefer low frequency services, such as mastectomy, if geographic access to a radiology facility is limited.

Incorporating broadband durability in measuring geographic access to health care in the era of telehealth: A case example of the 2-step virtual catchment area (2SVCA) Method.

The COVID-19 (coronavirus disease 2019) pandemic has expanded telehealth utilization in unprecedented ways and has important implications for measuring geographic access to healthcare services. Established measures of geographic access to care have focused on the spatial impedance of patients in seeking health care that pertains to specific transportation modes and do not account for the underlying broadband network that supports telemedicine and e-health. To be able to measure the impact of telehealth on healthcare access, we created a pilot augmentation of existing methods to incorporate measures of broadband accessibility to measure geographic access to telehealth. A reliable measure of telehealth accessibility is important to enable policy analysts to assess whether the increasing prevalence of telehealth may help alleviate the disparities in healthcare access in rural areas and for disadvantaged populations, or exacerbate the existing gaps as they experience "double burdens."

Alcohol retail density and demographic predictors of health disparities: a geographic analysis.

OBJECTIVES: We examined whether the geographic density of alcohol retailers was greater in geographic areas with higher levels of demographic characteristics that predict health disparities. METHODS: We obtained the locations of all alcohol retailers in the continental United States and created a map depicting alcohol retail outlet density at the US Census tract level. US Census data provided tract-level measures of poverty, education, crowding, and race/ethnicity. We used multiple linear regression to assess relationships between these variables and retail alcohol density. RESULTS: In urban areas, retail alcohol density had significant nonlinear relationships with Black race, Latino ethnicity, poverty, and education, with slopes increasing substantially throughout the highest quartile for each predictor. In high-proportion Latino communities, retail alcohol density was twice as high as the median density. Retail alcohol density had little or no relationship with the demographic factors of interest in suburban, large town, or rural census tracts. CONCLUSIONS: Greater density of alcohol retailers was associated with higher levels of poverty and with higher proportions of Blacks and Latinos in urban census tracts. These disparities could contribute to higher morbidity in these geographic areas.