The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach

Abstract

Background: Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies.

Methods: We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay.

Results: We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25).

Conclusions: Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.

Keywords: Breast cancer; Fee-for-service; Medicare; Oncology outreach; Treatment initiation.

Fig 1.. Visual illustration of patient exposure to oncology outreach across the phases of care

a For patients in the surgery cohort, we defined the primary exposure, 1a (preoperative outreach), as a Boolean variable representing whether a patient received any cancer care at a physician outreach visit during the preoperative period. Similarly, we defined the secondary exposure, 2a (surgical outreach), as a Boolean variable representing whether a patient received their first surgery at a physician outreach visit. b For the subset of surgery-receiving patients in the adjuvant therapy cohort, we defined the primary exposure, 1b (postoperative outreach), as a Boolean variable representing whether a patient received any cancer care at a physician outreach visit during the postoperative period. Similarly, we defined the secondary exposure, 2b (adjuvant outreach), as a Boolean variable representing whether a patient received their first adjuvant therapy at a physician outreach visit. Detailed definitions of all terminology pertinent to the phases of care, types of care, and exposure variables are outlined in Table 1.

Fig 2.. Treatment cohort patient flow diagram

Using a 100% fee-for-service sample of Medicare claims from 2015 to 2020, we identified ≈ 1.2 M female patients with a cancer-directed biopsy for breast cancer. To enrich for incident cases, we excluded ≈ 893 K patients without 2 cancer diagnosis codes in the 12 months following biopsy and/or with a cancer diagnosis code in the 12 months preceding biopsy. We excluded another ≈ 81 K patients who were younger than 66 years or older than 99 years at biopsy, were not continuously enrolled in Medicare Parts A and B in the 12 months prior and following biopsy, received multiple cancer diagnoses, or had a missing or non-US ZIP code. We also excluded an additional ≈ 17 K patients who were diagnosed with metastatic cancer, received neoadjuvant chemotherapy or radiotherapy, or who had breast surgery with immediate reconstruction. Of the ≈ 186K patients who met the basic inclusion criteria, ≈ 159 K patients received surgery, and ≈ 84K of surgery-receiving patients received adjuvant therapy (chemotherapy or radiotherapy). We further restricted these samples to patients living in rural areas, those who traveled ≤ 4 h to their treatment, and those who received treatment before the onset of the COVID-19 pandemic. This resulted in 30,337 and 14,501 patients who were enrolled into the final surgery and adjuvant therapy cohorts, respectively.

Fig 3.. Distribution of the types of oncology outreach provided to patients, stratified by physician specialty

Overall, physicians provided oncology outreach during 5209 unique patient encounters. Approximately 34.9% of this care was provided to patients during the preoperative period (preoperative outreach), 14.0% at the time of surgery (surgical outreach), 31.4% during the postoperative period (postoperative outreach), and 19.7% at the time of first adjuvant therapy (adjuvant outreach). The distribution of the types of oncology outreach provided to patients varied significantly by physician specialty. Surgeons provided oncology outreach during 1639 unique patient encounters, of which 48.9% was considered preoperative outreach, 44.5% surgical outreach, and 6.6% postoperative outreach; medical oncologists provided oncology outreach during 1700 unique patient encounters, of which 45.8% was considered preoperative outreach, 51.1% postoperative outreach, and 3.1% adjuvant outreach; radiation oncologists provided oncology outreach during 1870 unique patient encounters, of which 12.9% was considered preoperative outreach, 35.1% postoperative outreach, and 52.0% adjuvant outreach.