Transportation as a barrier to colorectal cancer care

Abstract

Background: Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits.

Methods: Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos.

Results: Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman's ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman's ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant.

Conclusions: Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).

Keywords: Access to care; Colorectal cancer; Life chaos; Transportation; Travel distance; Veterans Affairs.

Fig. 1

Study Participant Identification. Abbreviations: HIPAA, Health Insurance Portability and Accountability Act. ^a Two surveys were not mailed to Veterans because at the time of mailing these individuals were deemed ineligible since they did not meet inclusion criteria, had a dementia or psychosis diagnosis, or were deceased. ^b Patients were deemed ineligible because they did not meet inclusion criteria, had a dementia or psychosis diagnosis, or were deceased. ^c Study participants were required to complete and sign a HIPAA authorization form. Participants whose forms were not returned, incomplete, and/or lacked a signature were excluded from analysis

Fig. 2

Relationship Between Transportation-related Factors and Chaotic Lifestyle. Abbreviations: CRC, colorectal cancer care; VA, Veterans Affairs. ^a SAS was used to calculate Spearman’s correlation coefficients and to create the correlation heatmap. Variables were continuous (chaotic lifestyle) or categorical (transportation barriers: “Always”, “Often”, “Sometimes”, “Never”; distance to the VA: “0 to 20 miles”, “21 to 40 miles”, “41 to 60 miles”, “61 to 80 miles”, “81 to 100 miles”, “101 miles or more”; use of the VA for colorectal cancer care: “All of your cancer care”, “More than half of your cancer care”, “About half of your cancer care”, “Less than half of your cancer care”; convenience of VA: “Very convenient”, “Somewhat convenient”, “Somewhat inconvenient”, “Very convenient”; mode of travel to the VA: “Drive myself’, “Friend or family drives me”, “Health aide”, “Disabled American Veterans (DAV) or other shuttle service”, “Public transportation”, “Another source”). ^b Participants who did not respond or responded “Don’t know” were excluded from analysis (n = 2). ^c Participants who did not respond or responded “Don’t know” were excluded from analysis (n = 2). ^d Mode of travel to the VA is ordered based on decreasing travel independence. Veterans who selected (1) “Drive myself” have access to a vehicle and are in control of traveling to or from the VA as needed; (2) “Friend or family drives me” face some limitations due to others’ availability but are able to tailor transportation to or from the VA according to their needs; (3) “Public transportation” are further limited by fixed travel schedules and routes to or from the VA; or (4) “Another source” are assumed to be the most restricted in terms of travel independence (respondents did not select “Health aide” or “DAV or other shuttle service”). ^e Participants who did not respond or had missing values were excluded from analysis (n = 3)