In the patient's shoes: The impact of hospital proximity and volume on stage I endometrial cancer care patterns and outcomes.

OBJECTIVE: To compare the impact of travel burden and hospital volume on care patterns and outcomes in stage I endometrial cancer. METHODS: This retrospective cohort study identified patients from the National Cancer Database with stage I epithelial endometrial carcinoma who underwent hysterectomy between 2012 and 2020. Patients were categorized into: lowest quartiles of travel distance and hospital surgical volume for endometrial cancer (Local) and highest quartiles of distance and volume (Travel). Primary outcome was overall survival. Secondary outcomes were surgery route, lymph node (LN) assessment method, length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. Results were stratified by tumor recurrence risk. Outcomes were compared using propensity-score matching. Propensity-adjusted survival was evaluated using Kaplan-Meier curves and compared using log-rank tests. Cox models estimated hazard ratios for death. Sensitivity analysis using modified Poisson regressions was performed. RESULTS: Among 36,514 patients, 51.4% were Local and 48.6% Travel. The two cohorts differed significantly in demographics and clinicopathologic characteristics. Upon propensity-score matching (p < 0.05 for all), more Travel patients underwent minimally invasive surgery (88.1%vs79.1%) with fewer conversions to laparotomy (2.0%vs2.6%), more sentinel (20.5%vs11.3%) and fewer traditional LN assessments (58.1vs61.7%) versus Local. Travel patients had longer intervals to surgery (≥30 days:56.7%vs50.1%) but shorter LOS (<2 days:76.9%vs59.8%), fewer readmissions (1.9%vs2.7%%), and comparable 30- and 90-day mortality. OS and HR for death remained comparable between the matched groups. CONCLUSIONS: Compared to surgery in nearby low-volume hospitals, patients with stage I epithelial endometrial cancer who travelled longer distances to high-volume centers experienced more favorable short-term outcomes and care patterns with comparable long-term survival.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer.

BACKGROUND: While utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist. OBJECTIVE: To evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer. STUDY DESIGN: Patients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race. RESULTS: Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery. CONCLUSIONS: Patients, particularly those of Black race, who lack local access to gynecologic oncologist specialty care benefit from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020.

This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.

Analysis of travel burden and travel support among patients treated at a comprehensive cancer center in the Southeastern United States.

INTRODUCTION: Travel burden leads to worse cancer outcomes. Understanding travel burden and the level and types of travel support provided at large cancer centers is critical for developing systematic programs to alleviate travel burden. This study analyzed patients who received travel assistance, including their travel burden, types and amount of travel support received, and factors that influenced these outcomes. METHODS: We analyzed 1063 patients who received travel support from 1/1/2021 to 5/1/2023 at Winship Cancer Institute, in which ~18,000 patients received cancer care annually. Travel burden was measured using distance and time to Winship sites from patients' residential address. Travel support was evaluated using the monetary value of total travel support and type of support received. Patients' sociodemographic and clinical factors were extracted from electronic medical records. Area-level socioeconomic disadvantage was coded by the Area Deprivation Index using patient ZIP codes. RESULTS: On average, patients traveled 57.2 miles and 67.3 min for care and received $74.1 in total for travel support. Most patients (88.3%) received travel-related funds (e.g., gas cards), 5% received direct rides (e.g., Uber), 3.8% received vouchers for taxi or public transportation, and 3% received combined travel support. Male and White had longer travel distance and higher travel time than female and other races, respectively. Patients residing in more disadvantaged neighborhoods had an increased travel distance and travel time. Other races and Hispanics received more travel support ($) than Black and White patients or non-Hispanics. Patients with higher travel distance and travel time were more like to receive travel-related financial support. CONCLUSION: Among patients who received travel support, those from socioeconomically disadvantaged neighborhoods had greater travel burden. Patients with greater travel burden were more likely to receive travel funds versus other types of support. Further understanding of the impact of travel burden and travel support on cancer outcomes is needed.

The association of travel burden with prenatal care utilization, what happens after provider-selection.

BACKGROUND: Birthing people in the United States face numerous challenges when accessing adequate prenatal care (PNC), with transportation being a significant obstacle. Nevertheless, previous studies that relied solely on the distance to the nearest provider cannot differentiate the effects of travel burden on provider selection and care utilization. These may exaggerate the degree of inequality in access and fail to capture perceived travel burden. This study investigated whether travel distances to the initially visited provider, to the predominant PNC provider, and perceived travel burden (measured by the travel disadvantage index (TDI)) are associated with PNC utilization. METHODS: A retrospective cohort of people with live births were identified from South Carolina Medicaid claims files in 2015-2018. Travel distances were calculated using Google Maps. The estimated TDI was derived from local pilot survey data. PNC utilization was measured by PNC initiation and frequency. Repeated measure logistic regression test was utilized for categorical variables and one-way repeated measures ANOVA for continuous variables. Unadjusted and adjusted ordinal logistic regressions with repeated measure were utilized to examine the association of travel burdens with PNC usage. RESULTS: For 25,801 pregnancies among those continuously enrolled in Medicaid, birthing people traveled an average of 24.9 and 24.2 miles to their initial and predominant provider, respectively, with an average TDI of -11.4 (SD, 8.5). Of these pregnancies, 60% initiated PNC in the first trimester, with an average of 8 total visits. Compared to the specialties of initial providers, predominant providers were more likely to be OBGYN-related specialists (81.6% vs. 87.9%, p < .001) and midwives (3.5% vs. 4.3%, p < .001). Multiple regression analysis revealed that every doubling of travel distance was associated with less likelihood to initiate timely PNC (OR: 0.95, p < .001) and a lower visit frequency (OR: 0.85, p < .001), and every doubling of TDI was associated with less likelihood to initiate timely PNC (OR: 0.94, p = .04). CONCLUSIONS: Findings suggest that the association between travel burden and PNC utilization was statistically significant but of limited practical significance.

Impact of Travel Distance on Surgical Outcomes of Patients Surgically Treated for Non-Small Cell Lung Cancer: A Single-Center Study in Ehime, Japan.

Travel burden is a poor prognostic factor for many cancers worldwide because it hinders optimal diagnosis and treatment planning. Currently, the impact of travel burden on survival after surgery for non-small cell lung cancer (NSCLC) in Japan is largely unexplored. We examined the impact of travel distance on the postoperative outcomes of patients with NSCLC in Ehime Prefecture, Japan. The data of 1212 patients who underwent surgical resection for NSCLC were retrospectively reviewed. Patients were divided into quartiles based on the travel distance from their home to the hospital (≤ 13 km, 13-40 km, 40-57 km, and > 57 km) in Ehime Prefecture. We found no significant differences among the quartiles in baseline clinicopathological characteristics, including sex, smoking status, histology, surgical procedure, clinical stage, and pathological stage. Overall survival (OS) and relapse-free survival (RFS) also were not significantly different among the travel distance quartiles. We conclude that travel distance did not impact OS or RFS among patients with NSCLC who underwent surgical resection at our institution.

Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration.

BACKGROUND: Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers. OBJECTIVE: The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented. DESIGN: Retrospective, observational, utilizing administrative data. SUBJECTS: VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT). MAIN MEASURES: Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service. KEY RESULTS: In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices. CONCLUSIONS: Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District.

Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.

Impact of travel burden on clinical outcomes in lung cancer.

PURPOSE: Our study explores the influence of travel burden (measured as travel distance and travel time) on clinical outcomes in lung cancer patients. METHODS: A retrospective analysis of a single Bulgarian center was performed. A total of 9240 lung cancer patients were included in the study. Travel distance and travel time between patients' city of residence and the treating facility were calculated with an online tool to determine the shortest route for travel using the existing road network. The probability of survival was estimated using the Kaplan-Meier method, and differences in survival in each subgroup were evaluated with a log-rank test. RESULTS: About one third of all included patients were living in the same city as the treating facility (n = 2746, 29.7%). Overall survival in our patient population was significantly lower with increasing travel distance (p < 0.001, Mantel-Cox log rank) and travel time (p < 0.001, Mantel-Cox log rank). The 1-year OS rate according to travel distance was 27.1% in the same city group, 22.4% in < 50-km group, and 20.5% in ≥ 50-km group (p < 0.001). The corresponding values for the 5-year OS rate were 2.9%, 2.6%, and 1.4% (p < 0.001). CONCLUSION: In this retrospective study, we discovered significant differences in the overall survival of patients with lung cancer depending on travel distance and travel time to the treating oncological facility. Despite having similar clinical and pathological characteristics (age, sex, stage at initial diagnosis, histologic subtype), the median overall survival was significantly lower in those subgroups of patients with a higher travel burden.

Acceptability of tDCS in treating stress-related mental health disorders: a mixed methods study among military patients and caregivers.

BACKGROUND: Noninvasive brain stimulation techniques like transcranial direct current stimulation (tDCS) offer potential new approaches to treat stress-related mental health disorders. While the acceptability of tDCS as a treatment tool plays a crucial role in its development and implementation, little is known about tDCS acceptability for users in mental healthcare, especially in the context of stress-related disorders. METHODS: Using a mixed-methods approach, we investigated tDCS acceptability among 102 active duty and post-active military patients with stress-related symptoms (posttraumatic stress disorder, anxiety and impulsive aggression) who participated in a 5-session tDCS intervention. Quantitative dropout and adverse effects data was collected for all patients involved in the sham-controlled tDCS intervention. We additionally explored perspectives on the acceptability of tDCS treatment via a theory-based semi-structured interview. A subgroup of patients as well as their caregivers were interviewed to include the views of both patients and mental healthcare professionals. RESULTS: Quantitative outcomes showed minimal tDCS-related adverse effects (mild itching or burning sensations on the scalp) and high tDCS treatment adherence (dropout rate: 4% for active tDCS, 0% for sham). The qualitative outcomes showed predominantly positive attitudes towards tDCS interventions for stress-related disorders, but only as complementary to psychotherapy. Remarkably, despite the perception that sufficient explanation was provided, patients and caregivers stressed that tDCS treatment comprehension was limited and should improve. Also, the travel associated with frequent on-site tDCS sessions may produce a significant barrier to care for patients with stress-related disorders and active-duty military personnel. CONCLUSIONS: Acceptability numbers and perspectives from military patients and caregivers suggest that tDCS is an acceptable complementary tool in the treatment of stress-related disorders. Critically, however, if tDCS is to be used beyond scientific studies, adequately educating users on tDCS working mechanisms is vital to further improve its acceptability. Also, the perceived potential barrier to care due to frequent travel may favor home-based tDCS solutions. TRIAL REGISTRATION: The tDCS intervention was part of a sham-controlled trial registered on 05-18-2016 at the Netherlands Trial Register with ID NL5709 .

Patterns of elective lobectomy for lung cancer.

BACKGROUND: Lobectomy is the recommended treatment for early-stage lung cancer. Little is known about variations of access to health service areas and hospital types for lobectomy overall and according to specific surgical techniques, such as the video-assisted thoracoscopic surgery (VATS). METHODS: The New York Statewide Planning and Research Cooperative System (2007-2012) was queried for lung cancer patients who underwent elective lobectomy. Hospitals were defined as nearest high-volume hospital (nHVH, reference), distant HVH (dHVH), close or distant low-volume hospital (cLVH or dLVH) using lobectomy volume and travel burden by the distance to nHVH. RESULTS: Utilization of hospitals within patients' health service areas ranged between 44% and 82% for three different geographic units. Approximately 26%, 34%, 31%, and 9% of the 9099 lobectomies were performed in nHVH, dHVH, cLVH, and dLVH, respectively. Patients in nHVH were older and more likely to have private insurance. Patients in dHVH were treated more with VATS and by higher volume surgeons, opposite of what observed in cLVH and dLVH. The use of dHVH was associated with more comorbidities and higher income. The use of dLVH was higher in Hispanics and non-Hispanic blacks than that in non-Hispanic whites. The odds of adverse postoperative events were higher in cLVH and dLVH but lower for patients treated with VATS and by high-volume surgeons. CONCLUSIONS: Multiple factors likely resulted in differences in patterns of elective lobectomy among lung cancer patients. These variations should be taken into account when accessing and planning specialized health care delivery services.

Distance as a Barrier to Cancer Diagnosis and Treatment: Review of the Literature.

The burden of travel from a patient's residence to health care providers is an important issue that can influence access to diagnosis and treatment of cancer. Although several studies have shown that the travel burden can result in delays in diagnosis and treatment of many common cancers, its role appears underestimated in the treatment of patients in clinical practice. Therefore, we performed a review of the published data on the role of travel burden influencing four items: delay of diagnosis, adequate treatment of cancer, outcome, and quality of life of cancer patients. Forty-seven studies published up to December 2014 were initially identified. Twenty studies were excluded because they did not regard specifically the four items of our review. Twenty-seven studies formed the basis of our study and involved 716,153 patients. The associations between travel burden and (a) cancer stage at diagnosis (12 studies), (b) appropriate treatment (8 studies), (c) outcome (4 studies), and (d) quality of life (1 study) are reported. In addition, in two studies, the relation between travel burden and compliance with treatment was examined. The results of our review show that increasing travel requirements are associated with more advanced disease at diagnosis, inappropriate treatment, a worse prognosis, and a worse quality of life. These results suggest that clinical oncologists should remember the specific travel burden problem for cancer patients, who often need health care services every week or every month for many years.

Choreographed expansion of services results in decreased patient burden without compromise of outcomes: An assessment of the Ontario experience.

Background: Neuro-oncology care in Ontario, Canada has been historically centralized, at times requiring significant travel on the part of patients. Toward observing the goal of patient-centered care and reducing patient burden, 2 additional regional cancer centres (RCC) capable of neuro-oncology care delivery were introduced in 2016. This study evaluates the impact of increased regionalization of neuro-oncology services, from 11 to 13 oncology centers, on healthcare utilization and travel burden for glioblastoma (GBM) patients in Ontario. Methods: We present a cohort of GBM patients diagnosed between 2010 and 2019. Incidence of GBM and treatment modalities were identified using provincial health administrative databases. A geographic information system and spatial analysis were used to estimate travel time from patient residences to neuro-oncology RCCs. Results: Among the 5242 GBM patients, 79% received radiation as part of treatment. Median travel time to the closest RCC was higher for patients who did not receive radiation as part of treatment than for patients who did (P = .03). After 2016, the volume of patients receiving radiation at their local RCC increased from 62% to 69% and the median travel time to treatment RCCs decreased (P = .0072). The 2 new RCCs treated 35% and 41% of patients within their respective catchment areas. Receipt of standard of care, surgery, and chemoradiation (CRT), increased by 11%. Conclusions: Regionalization resulted in changes in the healthcare utilization patterns in Ontario consistent with decreased patient travel burden for patients with GBM. Focused regionalization did not come at the cost of decreased quality of care, as determined by the delivery of a standard of care.

Shared-Care in Complex Malignant Hematology: An Integrative Review Using the RE-AIM Evaluation Framework.

Complex malignant hematology (CMH) shared-care programs have been established to support patients with access to care closer to home. This integrative review examined what is known about CMH shared-care using the RE-AIM evaluation framework. We searched five electronic databases for articles published until 16 January 2024. Articles were included if they were qualitative or quantitative studies, reviews or discussion papers, and reported on an experience with shared-care (defined as a reciprocal, ongoing patient-sharing relationship between a specialist centre and community hospital) for patients with hematological malignancies, and examined one or more aspects of the RE-AIM framework. The search yielded 6523 articles; 10 articles describing eight shared-care experiences. Indicators of reach were reported for 65% of the programs, and emphasized some patient eligibility criteria. Effectiveness indicators were reported for 28% of programs, and suggested favourable survival outcomes within a shared-care model; however, health system impact and quality of life studies were lacking. Indicators of adoption and implementation were reported for 56% and 42% of programs, respectively, and emphasized multidisciplinary teams, infrastructure support, and communication strategies. Maintenance was not reported. Common elements contribute to the implementation of existing CMH shared-care programs; however, a formal evaluation remains an area of need.

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis.

PURPOSE: Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. METHODS: Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden. RESULTS: A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5 years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income. CONCLUSION: Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

Access to inflatable penile prosthesis surgery as indicated by distances traveled among US men with Medicare.

Background: The significance of geographic barriers to receiving inflatable penile prosthesis (IPP) treatment is uncertain according to the existing medical literature. Aim: To describe the travel patterns of men with erectile dysfunction (ED) in the United States who underwent IPP surgery. Methods: This retrospective cohort study utilized data from the 100% Medicare Standard Analytical Files. Men aged ≥65 years with an ED diagnosis who underwent IPP surgery between January 2016 and December 2021 were identified from the database. Federal Information Processing Series codes from the National Bureau of Economic Research's County Distance Database were used to determine geographic distances from patients' homes to the facilities at which surgery was performed. Outcomes: Evaluations included the proportions of men who traveled outside their county of residence or state for IPP treatment and the average distances in miles traveled. Results: Among 15 954 men with ED undergoing IPP treatment, 56.4% received care out of their county for IPP, at a mean distance of 125.6 miles (range, 3.8-4935.0). Although patients aged ≥80 years were less likely to travel outside their county as compared with men aged 65 to 69 years (48.1% vs 57.1%, P < .001), if they traveled, they were likely to travel farther (mean, 171.8 vs 117.7 miles; P < .001). South Dakota had the highest proportion of men traveling outside their county for IPP treatment (91.3%; mean, 514.2 miles), while Vermont had the highest proportion traveling outside their home state (73.7%). Clinical Implications: By unveiling disparities in access, this study will potentially lead to tailored interventions that enhance patient care and health outcomes. Strengths and Limitations: Strengths include the uniqueness in (1) evaluating the proportions of patients who travel out of their county of residence or home state for IPP treatment and (2) quantifying the average distances that patients traveled. An additional strength is the large sample size due to the retrospective design and database used. The analysis did not capture all Medicare enrollees; however, it did encompass all traditional Medicare enrollees, representing approximately half of all men in the US aged ≥65 years. Limitations include not being generalizable to entire population of the US, as the study examined only Medicare enrollees. In addition, the study period includes the pandemic, which could have affected travel patterns. Furthermore, the coding and accuracy of the data are limitations of using administrative claims data for research. Conclusion: Study findings showed that many men with Medicare and ED traveled from their home geographic location for IPP treatment.

Travel burden for patients with multimorbidity - Proof of concept study in a Dutch tertiary care center.

Objectives: To explore travel burden in patients with multimorbidity and analyze patients with high travel burden, to stimulate actions towards adequate access and (remote) care coordination for these patients. Design: A retrospective, cross-sectional, explorative proof of concept study. Setting and Participants: Electronic health record data of all patients who visited our academic hospital in 2017 were used. Patients with a valid 4-digit postal code, aged ≥18 years, had >1 chronic or oncological condition and had >1 outpatient visits with >1 specialties were included. Methods: Travel burden (hours/year) was calculated as: travel time in hours × number of outpatient visit days per patient in one year × 2. Baseline variables were analyzed using univariate statistics. Patients were stratified into two groups by the median travel burden. The contribution of travel time (dichotomized) and the number of outpatient clinic visits days (dichotomized) to the travel burden was examined with binary logistic regression by adding these variables consecutively to a crude model with age, sex and number of diagnosis. National maps exploring the geographic variation of multimorbidity and travel burden were built. Furthermore, maps showing the distribution of socioeconomic status (SES) and proportion of older age (≥65 years) of the general population were built. Results: A total of 14 476 patients were included (54.4% female, mean age 57.3 years ([± standard deviation] = ± 16.6 years). Patients travelled an average of 0.42 (± 0.33) hours to the hospital per (one-way) visit with a median travel burden of 3.19 hours/year (interquartile range (IQR) 1.68 - 6.20). Care consumption variables, such as higher number of diagnosis and treating specialties in the outpatient clinic were more frequent in patients with higher travel burden. High travel time showed a higher Odds Ratio (OR = 578 (95% Confidence Interval (CI) = 353 - 947), p < 0.01) than having high number of outpatient clinic visit days (OR = 237, 95% CI = 144 - 338), p < 0.01) to having a high travel burden in the final regression model. Conclusions and implications: The geographic representation of patients with multimorbidity and their travel burden varied but coincided locally with lower SES and older age in the general population. Future studies should aim on identifying patients with high travel burden and low SES, creating opportunity for adequate (remote) care coordination.

Trends of travel burdens to access cancer care among children with cancer: analysis of a population-based cancer registry data in Aichi, Japan.

Centralization of childhood cancer treatment in specialized hospitals is necessary for quality treatment and care, but imposes a time and cost burden for patients and their families. We investigated the 20-year trend in the patients' car travel burden to reach cancer-care hospitals in Aichi Prefecture, Japan. From the Aichi population-based cancer registry data, 1,741 cases diagnosed in 1998-2017 under 15 years of age were extracted and assigned to three treatment groups: invasive treatment (n = 697), radiotherapy (n = 371), or chemotherapy groups (n = 1,462), allowing for duplicate assignment. Their travels to access each treatment hospital were estimated and summarized as the estimated travel times (ETT), estimated travel distances (ETD), and direct distances (DD). The ETTs were compared using the Brunner-Munzel test. The average cases per year for each hospital were plotted. The annual trends during 1998-2017 on ETT, ETD, and DD were investigated using Joinpoint regression models. The ETTs were 0.38-0.45 hours on median for three periods (1998-2005, 2006-2012, and 2013-2017) in three treatment groups and increased by 0.02-0.07 hours from 2006-2012 to 2013-2017, with a statistically significant difference in the radiotherapy group (0.07 hours, P = 0.037). The average cases per year increased for the top hospital in each group, and regression model analyses showed no joinpoint on the annual median trend. In conclusion, the increases in travel times were small and not considered clinically significant, and treatment centralization was observed from 2006-2012 to 2013-2017.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas.

PURPOSE: Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures. METHODS: We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care. FINDINGS: Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively. CONCLUSIONS: Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

Geographic variations in driving time to US mental health care, digital access to technology, and household crowdedness.

Rural residents face significant barriers in accessing mental health care, particularly as the demand for such services grows. Telemedicine has been proposed as an answer to rural gaps, but this service requires both access to appropriate technology and private space in the home to be useful. Our study documented longer travel time to mental health facilities in rural areas and greater barriers to digital devices for telemedicine access in those same areas. However, urban areas demonstrated greater household crowdedness than rural noncore areas when looking at private space within the home. Across ZIP Code Tabulation Areas located more than an estimated 30 minutes from the nearest outpatient care, 675 950 (13.1%) rural households vs 329 950 (6.4%) urban households had no broadband internet. The current Affordable Connectivity Program should target mental health-underserved communities, especially in rural America, where the scarcity of digital access compounds travel burdens to mental health care.