The central role of comorbidity in predicting ambulatory care sensitive hospitalizations.

BACKGROUND: Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions. METHODS: Using 1998-99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power. RESULTS: Flags for the presence of a few comorbid conditions-congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia-contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs. CONCLUSION: Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs.

Where do medical students turn? The role of the assigned mentor in the fabric of support during medical school.

BACKGROUND: The University of Washington School of Medicine implemented an assigned mentoring program in 2002. The College Mentors are assigned at matriculation, advise students throughout medical school, and teach and evaluate students in the 2nd-year Introduction to Clinical Medicine course. PURPOSE: The purpose of the study was to determine from whom students report they would seek advice and support for academic, professional, personal, and research issues. METHODS: A cross-sectional cohort survey asking students whom they would first contact about academic, personal, professional, and research issues was administered to three cohorts of students in 2007. RESULTS: Students reported that they would contact their College Mentor first for general academic progress (49.6%), personal issues (36.2%), and professional issues (64.1%) but not for research issues. CONCLUSIONS: Students identified their College Mentor as a primary contact for academic, professional, and personal issues, suggesting that neither the mentors' assigned status or evaluator role were barriers to the mentoring relationship.

The contribution of longitudinal comorbidity measurements to survival analysis.

BACKGROUND: Many clinical and health services research studies are longitudinal, raising questions about how best to use an individual's comorbidity measurements over time to predict survival. OBJECTIVES: To evaluate the performance of different approaches to longitudinal comorbidity measurement in predicting survival, and to examine strategies for addressing the inevitable issue of missing data. RESEARCH DESIGN: Retrospective cohort study using Cox regression analysis to examine the association between various Romano-Charlson comorbidity measures and survival. SUBJECTS: Fifty thousand cancer-free individuals aged 66 or older enrolled in Medicare between 1991 and 1999 for at least 1 year. RESULTS: The best fitting model combined both time independent baseline comorbidity and the time dependent prior year comorbidity measure. The worst fitting model included baseline comorbidity only. Overall, the models fit best when using the "rolling" comorbidity measures that assumed chronic conditions persisted rather than measures using only prior year's recorded diagnoses. CONCLUSIONS: Longitudinal comorbidity is an important predictor of survival, and investigators should make use of individuals' longitudinal comorbidity data in their regression modeling.

No pain, but no gain? The disappearance of angina hospitalizations, 1992-1999.

BACKGROUND: Hospitalization for angina is commonly considered an ambulatory care sensitive hospitalization and used as a measure of access to primary care. OBJECTIVE: To analyze time trends in angina-related hospitalizations and seek possible explanations for an observed, marked decline during 1992 to 1999. RESEARCH DESIGN: We analyzed Medicare claims of SEER-Medicare control subjects for occurrence of angina hospital discharges, using the Agency for Healthcare Research and Quality Prevention Quality Indicator (PQI) definition, along with occurrence of related events including angina admissions with revascularization, angina admissions discharged as coronary artery disease (CAD) or myocardial infarction, and overall ischemic heart disease discharges. SUBJECTS: Approximately 124,000 cancer-free Medicare beneficiary/ies, with subjects contributing data for 1 to 8 years. RESULTS: Angina PQI hospital discharges declined 75% between 1992 and 1999. CAD hospital discharges rose in a reciprocal pattern, while angina discharges with revascularization declined and discharges for myocardial infarction and ischemic heart disease were relatively constant during this time period. CONCLUSIONS: The marked decline in angina PQI hospital discharges during 1992-1999 does not appear to represent improvements in access to care or prevention of heart disease, but rather increased coding of more specific discharge diagnoses for CAD. Our findings suggest that angina hospitalization is not a valid measure for monitoring access to care and, more generally, demonstrate the need for careful, periodic re-evaluation of quality measures.

Premedical Student Exposure to Pharmaceutical Marketing: Too Much, Too Soon?

BACKGROUND AND OBJECTIVES: Direct pharmaceutical marketing to physicians by pharmaceutical representatives is effective in changing behavior of health care providers, resulting in less evidence-based prescribing. Although much has been written about pharmaceutical marketing exposures among medical students, less is known about direct marketing exposures before students matriculate. This study examined the types of pharmaceutical representative direct marketing exposures for premedical students and where they occurred. METHODS: From June to August of 2017, researchers surveyed students who accepted admission to US public medical schools. These prematriculated students completed our survey just prior to matriculation. The survey inquired about whether the students were exposed to pharmaceutical marketing directly from pharmaceutical salespeople, the types of marketing they observed or received, and where these interactions occurred. RESULTS: Survey participants included 911 prematriculated students from 14 of the 188 medical schools invited to participate. Seventy-one percent (646) of the participants received or observed someone receiving pharmaceutical marketing gifts, small meals or snacks, articles, or samples. The two most common contexts for direct pharmaceutical marketing exposures were during shadowing experiences (54%, 346) and during employment (50%, 323). CONCLUSIONS: The findings suggest that it may be common for medical students to have interacted directly with pharmaceutical salespeople or observed other health professionals in these interactions before they matriculate in medical school. Because many of these interactions occur during clinical experiences required by institutions for admission, medical schools and premedical associations should consider delivering conflict-of-interest education early in medical school education or before students matriculate.

MasterMind: Empower Yourself With Mental Health. A program for adolescents.

BACKGROUND: Teachers need classroom-based programs to develop and support mental health fitness in adolescents because this age group faces significant challenges to their mental health. There is a paucity of such ready-made programs. This article describes the development and proposed implementation of a low-cost, effective, adaptable, 6-week, classroom-based workshop entitled MasterMind: Empower Yourself With Mental Health. MasterMind provides students with a "toolbox for mental health" by creating a safe environment for discussion of mental health and emotionally charged topics, by increasing student knowledge of mental health issues, and by providing tools to develop and maintain mental health. Instructional materials address topics identified through needs assessments. The program combines instruction and written exercises with "peer-teaching-peer" group activities, individual assignments, and open discussion. Specific methods are included to allow students to ask questions anonymously and to build each other's self-esteem. METHODS: MasterMind was implemented as a pilot program to a Seattle, WA, middle school class of 30 students and addressed self-esteem, media literacy, school resources, relationships, emotions, stress and ways to de-stress, and future goals. RESULTS: The students' enthusiasm and participation increased throughout the program, and they gave high satisfaction ratings to the topics covered. Additionally, the host teacher continued selected program activities after MasterMind was completed. CONCLUSIONS: MasterMind educates all students in a class, not just those with identified emotional problems, and can potentially identify children with mental health needs not already evident. The pilot program implementation of MasterMind shows that such programs have potential for providing adolescents with tools to optimize mental health.

What Is the Impact of the Underserved Pathway Program on Graduates Entering an Underserved Family Medicine Residency? Five-Year Findings From the University of Washington School of Medicine.

PURPOSE: More primary care physicians are needed in underserved areas of the United States. Prior research indicates that medical student experiences in underserved settings increase the likelihood that they will practice in underserved areas; few studies have controlled for selection bias. This study aimed to estimate the effect of the University of Washington School of Medicine's (UWSOM's) longitudinal extracurricular experience, the Underserved Pathway (UP), on graduates' choice in entering a family medicine residency with underserved training opportunities. METHOD: The American Medical College Application Service application that all students submit to apply to UWSOM and a matriculation survey were used to collect demographic information for medical school graduates who subsequently entered family medicine residencies between 2010 and 2015. A given family medicine residency offered underserved training if it had a clinic or rotation at a federally qualified health center or if the admitting hospital was a critical access hospital. Multiple logistic regression was used to estimate the UP program's effect on graduates entering an underserved family medicine residency, adjusting for 26 covariates. RESULTS: Participants were 158 UWSOM graduates; 39 (25%) completed the UP program. UP completion was associated with a 3.58 odds ratio increase to matching to an underserved family medicine residency, compared with non-UP graduates. CONCLUSIONS: Completion of the UP was linked to a significant increase in program graduates matching to an underserved family medicine residency. Longitudinal extracurricular programs similar to the UP could be an important component in the pipeline to meeting the primary care needs of underserved populations.

Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery: understanding the volume-outcome relationship.

HYPOTHESIS: Although numerous studies have demonstrated an association between surgical volume and improved outcome in cancer surgery, the specific structures and mechanisms of care that are associated with volume and lead to improved outcomes remain poorly defined. We hypothesize that there are modifiable surgeon and hospital characteristics that explain observed volume-outcome relationships. DESIGN: Retrospective cohort study. SETTING: Surveillance, Epidemiology, and End Results cancer registry areas. PATIENTS: Patients aged 66 years and older, diagnosed and surgically treated for stage I, II, or III colon cancer between 1992 and 1996 (n = 22 672). MAIN OUTCOME MEASURES: Thirty-day postoperative mortality and 30-day postoperative procedural interventions, including reoperation and image-guided percutaneous procedures. RESULTS: Surgeon volume, but not hospital volume, is a significant predictor of postoperative procedural intervention (adjusted odds ratio for very high-volume surgeons vs low-volume surgeons, 0.79; 95% confidence interval, 0.64-0.98). In the unadjusted analyses, high hospital volume (odds ratio, 0.67; 95% confidence interval, 0.56-0.81) and very high hospital volume (odds ratio, 0.65; 95% confidence interval, 0.54-0.79) is associated with lower postoperative mortality. Postoperative procedural intervention is not a significant mediator of the relationship between hospital volume and mortality. A single variable-the presence of sophisticated clinical services-was the most important explanatory variable underlying the relationship between hospital volume and mortality. CONCLUSIONS: Very high surgeon volume is associated with a reduction in surgical complications. However, the association between increasing hospital volume and postoperative mortality appears to derive mainly from a full spectrum of clinical services that may facilitate the prompt recognition and treatment of complications.

Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education.

Medical students enter medical school hoping to have good relationships with their patients. Along with residents, however, they are exposed to a hidden curriculum that places the acquisition of biomedical knowledge above and at times at odds with development of the awareness and relationship skills important to the patient-physician relationship. Seasoned clinicians often enjoy the capacity for rich, healing relationships that are marked by reciprocal influence between them and their patients. The author argues that it is not necessary to relegate this recapturing of the human side of medicine to a midcareer epiphany, and the author calls for educational measures to encourage development of the communication and relationship-building skills throughout the medical education process. This will require a paradigm shift to a culture where teachers and learners are willing to consciously attend to their relationships and to work on self-awareness and mindfulness while they also master the biomedical knowledge required of the profession. Medical educators can facilitate and support continuous development of these skills throughout medical school and residency. Within the curriculum, there are many opportunities to teach how to reflect and to guide those reflections in ways that enhance our students' and residents' understanding of themselves as individuals and in the relationships they form with their patients. Using examples from narratives gathered in workshops and on work rounds with students and residents at the University of Washington School of Medicine, the author explores the concepts of relationship-centered care, self-awareness, and mindfulness as proposed cornerstones of a new foundation for medical education.

Student Perceptions About Benets From an Extracurricular Curriculum: A Qualitative Study of the Underserved Pathway.

INTRODUCTION: Too few medical graduates choose to care for underserved populations. This qualitative study explores medical student perceptions of the benefits of participating in the Underserved Pathway (UP), a 4-year extracurricular program designed to nurture interest in, and develop skills to serve vulnerable populations. METHODS: Fourteen of 28 graduating students in the class of 2013 who completed the UP were interviewed. Using conventional qualitative content analysis, an iterative process was used to code transcriptions until there was high concordance among the assigned codes. The research team analyzed the data for common themes, theme saturation, and unique perspectives. RESULTS: Four major thematic areas emerged: 1) the underserved curriculum scaffold, 2) influence on career choice, 3) influence on residency choice, and 4) capacity to match. Of all participants, 78.6% thought the UP influenced their career choice, 64.3% stated the UP played a role in residency choice and rank, and 85.7% thought participation in the UP would improve match success. No single curricular component of the UP was individually responsible for career or specialty choice, or as being most useful to student understanding of the underserved. CONCLUSIONS: Students noted that participation in the UP provided them with a scaffold to support their interest in underserved careers, and influenced their specialty and residency choice. They also perceived it as making them more competitive as residency applicants. This study provides medical educators with insight into the importance of building robust frameworks, even extracurricular ones, to support student interests in serving vulnerable communities.

Using the diffusion of innovations theory to assess socio-technical factors in planning the implementation of an electronic health record alert across multiple primary care clinics.

BACKGROUND: Adverse drug events (ADEs) are a leading cause of death in the United States. Patients with stage 3 and 4 chronic kidney disease (CKD) are at particular risk because many medications are cleared by the kidneys. Alerts in the electronic health record (EHR) about drug appropriateness and dosing at the time of prescription have been shown to reduce ADEs for patients with stage 3 and 4 CKD in inpatient settings, but more research is needed about the implementation and effectiveness of such alerts in outpatient settings. OBJECTIVE: To explore factors that might inform the implementation of an electronic drug-disease alert for patients with CKD in primary care clinics, using Rogers' diffusion of innovations theory as an analytic framework. METHODS: Interviews were conducted with key informants in four diverse clinics using various EHR systems. Interviews were audio recorded and transcribed. results Although all clinics had a current method for calculating glomerular filtration rate (GFR), clinics were heterogeneous with regard to current electronic decision support practices, quality improvement resources, and organizational culture and structure. CONCLUSION: Understanding variation in organizational culture and infrastructure across primary care clinics is important in planning implementation of an intervention to reduce ADEs among patients with CKD.

Community's voice in managing childhood asthma: the assessment phase of research.

This study was designed to investigate community beliefs about caring for childhood asthma and to elicit suggestions for interventions to improve asthmatic children's health. Focus groups were conducted with parents of children with asthma, children with asthma, school staff, and health care and childcare professionals. Data were analyzed for themes, such as disruption of normal living and having to work in a chaotic system, enabling researchers to posit a core belief for each group. These core beliefs, together with encompassed other, related beliefs held by group members, guide attitudes and actions about asthma. Interventions recommended by focus group participants included creating an asthma play, asthma education, and developing a clinic-based registry to standardize asthma documentation. The community's voice is important in assessment and design of health improvement projects. Incorporating the community's suggestions gives the community a sense of contributing to the health care of their children with asthma.

Another list or a grounding tool? Thoughts on the Q-List Manifesto.

Comments on the article by William B. Ventres (see record 2015-01771-001). This article discusses the Q-List Manifesto and how it differs from The Checklist Manifesto for procedural medicine. Is the question list any different from a checklist? What might it add and what pitfalls might it face if implemented? The Q-List can be useful for learners, from medical student to resident, a reminder to check in with patients, themselves and the domains, like Daily Reality, Patient Focus, and Practitioner Focus. It offers a framework along with concrete questions to explore with the patient, their families, and oneself.

Medical Student Participation in Family Medicine Department Extracurricular Experiences and Choosing to Become a Family Physician.

BACKGROUND AND OBJECTIVES: Many factors influence a medical student's decision to choose a family medicine career. The impact of participation in extracurricular programs sponsored by family medicine departments is currently unclear. Medical student participation in four University of Washington Department of Family Medicine-sponsored programs (Community Health Advancement Program, Family Medicine Interest Group, Rural Underserved Opportunity Program, and the Underserved Pathway) could be associated with becoming a family physician. METHODS: Demographic data, results from a matriculation career interest survey, records indicating participation in the four extracurricular programs, and Match lists showing the specialty of each graduate were linked. Based on responses to the matriculation survey, graduates were categorized into four levels of initial family medicine interest. Chi-square tests compared both demographic data with initial family medicine interest levels and initial family medicine interest levels with program participation. For residency-matched graduates, odds ratios of matching to family medicine versus other specialties for specific family medicine programs and number of programs were calculated, controlling for demographic variables and initial family medicine interest levels. RESULTS: Older age, female graduates, a rural upbringing, and high level of initial family medicine interest were independently and significantly associated with choosing family medicine. Participation in the Family Medicine Interest Group (OR 2.45) and the Underserved Pathway (OR 4.37) and two or more family medicine programs (OR 2.01--2.22) was significantly associated with entering family medicine. CONCLUSIONS: Certain demographic factors and high initial interest in family medicine is associated with entering the specialty. Some, but not all, family medicine department-sponsored extracurricular programs were associated with choosing family medicine.

Primary care residency choice and participation in an extracurricular longitudinal medical school program to promote practice with medically underserved populations.

PURPOSE: In 2006, the University of Washington School of Medicine (UWSOM) launched the Underserved Pathway (UP), an extracurricular longitudinal experience supporting student interest in caring for underserved populations. This study examined the association between UP participation and residency choice. METHOD: The study population was 663 UWSOM graduates who matched to a residency from 2008 to 2011; 69 were UP participants. Outcomes included matching to primary care residencies (family medicine, internal medicine, pediatrics, or medicine-pediatrics). The authors calculated graduate rates and odds of UP participants versus nonparticipants matching to primary care residencies overall and to residencies in individual primary care specialties. This analysis included all graduates and 513 graduates who had dual interest in primary care and underserved care at matriculation. Of 336 graduates matching to primary care, the authors calculated rates of entering the individual specialties with respect to UP participation. RESULTS: UP participants matched at significantly higher rates than nonparticipants to primary care (72.5% versus 48.1%, adjusted odds ratio [OR] 2.2) and family medicine residencies (33.3% versus 15.0%, adjusted OR 2.9). Of graduates with dual matriculation interest in primary care and underserved care, 73.4% of participants versus 53.5% of nonparticipants matched to primary care (adjusted OR 1.9), and 31.2% of participants versus 18.0% of nonparticipants matched to family medicine (adjusted OR 2.1). Of primary care matched graduates, 46.0% of participants versus 31.1% of nonparticipants entered family medicine. CONCLUSIONS: Supporting student interest in underserved careers is associated with higher rates of graduates entering primary care residencies, specifically family medicine.

Do primary care physicians lose contact with their colorectal cancer patients?

BACKGROUND: Primary care physicians and patients perceive that they lose contact with each other after a cancer diagnosis. The objective of this study was to determine whether colorectal cancer (CRC) patients are less likely to see their primary care physicians after cancer diagnosis. METHODS: This was a longitudinal cohort study using 1993 to 2001 Surveillance Epidemiology and End Results (SEER)-Medicare claims data. Eligible patients were those with stage 0 to 1 and 2 to 3 CRC aged 67 to 89 years at diagnosis. Main measures included the proportion of individuals with a face-to-face primary care visit and mean annual primary care visits per patient at baseline and during 5 years after treatment. RESULTS: Fewer than half of the cancer patients visited with a primary care physician at baseline. In the first year after treatment, patients with stage 0 to 1 CRC (48.9% vs 53.3%; P ≤ .001) and stage 2 to 3 CRC (43.6% vs 53.4%; P ≤ .001) significantly increased their likelihood of visiting a primary care physician from baseline. The proportion of patients with stage 0 to 1 CRC with a primary care visit remained relatively stable, and the proportion of patients with stage 2 to 3 CRC decreased somewhat between the first and fifth year after treatment. The findings for mean annual primary care visits per patient roughly paralleled those for the proportion of individuals with a primary care visit. CONCLUSIONS: Elderly patients with CRC, especially stage 2 to 3 CRC, increase rather than decrease contact with primary care providers after diagnosis. More work is needed to understand the care that different physician specialties provide cancer patients and to support their collaboration.

Receipt of general medical care by colorectal cancer patients: a longitudinal study.

BACKGROUND: cancer diagnosis has the potential to overshadow patients' general medical care needs. This study examined changes in general medical care among elderly patients with colorectal cancer (CRC), from before diagnosis through long-term survival. METHODS: this longitudinal cohort study used 1993 to 1999 Surveillance, Epidemiology, and End Results and 1991 to 2001 Medicare claims data for 22,161 patients with stage 0 to 3 CRC and 81,669 controls aged 67 to 89 years. Outcomes were preventive services (influenza vaccination, mammography) and, among diabetics, HgbA1c and lipid testing in the phase before diagnosis, the phase after initial treatment, the surveillance phase, and the survival care phase. Logistic regression provided adjusted relative risks of care receipt for patients with stage 0 to 1 cancer, stage 2 to 3 cancer, and no cancer. RESULTS: in the phase before diagnosis through the surveillance phase, patients with stage 0 to 1 CRC had the highest annual preventive service rates. Patients with stage 2 to 3 CRC made substantial gains in preventive service use, especially mammography, after diagnosis (influenza vaccination, 46.4% before diagnosis to 50.2% after initial treatment; mammography, 31.4% before diagnosis to 40.2% after initial treatment) but not in diabetes care (eg, HgbA1c, 53.4% before diagnosis to 54.9% after initial treatment). CONCLUSIONS: CRC diagnosis seems to facilitate receipt of preventive services but not diabetes care for elderly, later-stage patients. Additional strategies such as strengthening partnerships between cancer patients, primary care physicians, and cancer care physicians are needed to improve care for a chronic disease like diabetes.

Survival benefits and trends in use of adjuvant therapy among elderly stage II and III rectal cancer patients in the general population.

BACKGROUND: This study examined elderly stage II and III rectal cancer patients' adjuvant chemoradiation therapy adherence, trends in adherence over time, and the relation of levels of adherence to mortality. METHODS: The authors studied 2886 stage II and III rectal cancer patients who had surgical resection and who appeared in 1992-1999 linked SEER-Medicare claims data. The authors compared measures of adjuvant radiation and chemotherapy receipt and completion between stage II and III patients. Adjusted risk of cancer-related 5-year mortality was calculated by multivariate logistic regression for different levels of chemoradiation adherence among stage II and III patients. RESULTS: Of the 2886 patients, 45.4% received both adjuvant radiation and chemotherapy. Stage III patients were more likely to receive chemoradiation than stage II patients. The receipt of chemoradiation by stage II patients increased significantly from 1992 to 1999. Stage III patients were more likely to complete radiation therapy (96.6%), chemotherapy (68.2%), and both modalities (67.5%) than stage II patients (91.5%, 49.8%, 47.6%, respectively). Only a complete course of both radiation and chemotherapy for both stage II (relative risk [RR] 0.74; 95% CI, 0.54, 0.97) and III (RR 0.80; 95% CI, 0.65, 0.96) decreased the adjusted 5-year cancer mortality risk compared with counterparts with no adjuvant therapy. CONCLUSIONS: Even though stage II rectal cancer patients were less likely than stage III patients to receive and complete adjuvant chemoradiation, both patient groups in the general population had lower cancer-related mortality if they completed chemoradiation. These patients deserve support and encouragement to complete treatment.

Access to cancer services for rural colorectal cancer patients.

CONTEXT: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.