Ethics of rural health care
Introduction
One quarter of the US population lives in areas designated as rural, or fewer than 2500 people per town boundary, and frontier, or fewer than 6.6 people per square mile [1]. The geographical and socioeconomic features of rural America present unique challenges to delivery of health care resources, especially delivery of oncology care.
Rural patient health is often poorer than urban or suburban patient health. The long distances make some types of care difficult. There is increasing evidence that high volume produces high quality cancer care [2], [3] and many rural hospitals will always have low volume.
This article will explore the ethical issues related to rural health care, particularly oncology care. It will describe the rural cancer outreach program of the Massey Cancer Center (MCC) including a clinical and financial analysis of the program; the ethics of the program; applicability to other settings; and what we have learned in 10 years of creating access to care.
Section snippets
Program description: The Rural Cancer Outreach Program (RCOP)
The rural cancer outreach started as a ‘strategic alliance’ [4] between academic centers and rural non-for-profit hospitals. The goal was to establish a model of care that would provide state of the art care in rural areas, increase the access to care, generate services and revenue for both the rural and academic center, train health care professionals [5], and serve as a laboratory for intervention. (Table 1).
The RCOP has grown from one program in 1988 to five programs operating at five rural
Impact of the program on the clinical care provided
We have analyzed three important index conditions in our first two rural hospitals [6]. We chose these conditions because there was documented wide variation in practice, and poor medical outcomes if optimal process was not followed (Table 2). It was difficult to analyze the type of care because the volume of any one condition, e.g. use of adjuvant chemotherapy in Stage I–III breast cancer, was always low and usually less than ten cases per year. However, the importance of high quality care to
Economic analysis
Pre- and post-RCOP financial data were collected on 1745 cancer patients treated at the participating centers, two rural community hospitals, and MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins, and profit (or loss) of the program.
Key results are shown in Table 3, modified from the full report in the Journal of Rural Health [8].
The RCOP had a positive financial impact on the rural and academic medical center hospitals. The
Other programs
Similar results of improved clinical care process, equal or better patient outcomes and cost savings have been reported from the Manitoba Cancer Outreach Program, but final results have not yet been published. The Manitoba Cancer Research and Treatment Program was started in 1984 with similar goals [10]. It works on a similar model of consultation with the academic center, then all the care is delivered in one of six regional centers. Insurance is not an issue in Manitoba since there is a
Applicability to other settings
We have not identified other similar programs that have published their clinical and economic results. The closest is the Centre Bernard Lyon that has shown good adoption of clinical practice guidelines and better clinical practice [12], [13]. This program should be applicable to other centers that serve rural, dispersed populations. The main problems have been sustaining the medical innovation part of the program, and not ‘burning out’ the doctors and nurses who must travel the distance. The
Ethical issues in rural health care
The challenge is to provide high quality, affordable, accessible care for all. In the US, the absence of a single payer system allows exclusion of whole segments of the population. Combined with the dispersed poor population in rural areas, these issues represent significant obstacles to delivery of care. In Virginia, one third of the population is rural and most of these people are medically underserved for both primary and specialty care. The rural population has more federal Medicare and
Conclusions
There are distinct and novel ethical issues in providing rural health care. Two groups have shown that rural cancer outreach (a structured alliance of a cancer center and rural hospitals and providers) works well clinically and economically. In addition, rural cancer outreach is ethical because it is distributive and just.
Reviewers
Dr Dieter K. Hossfeld, Universitäts-Krankenhaus Eppendorf, Medizinische Klinik, Abteilung Onkologie und Hämatologie, Martinistrasse 52, D-20246 Hamburg, Germany.
Dr Leslie R. Laufman, Hematology/Oncology Consultants, Inc., 8100 Ravines Edge Ct., Columbus, OH, 43235-5436, USA.
Acknowledgements
We gratefully acknowledge grant support from the Jessie Ball duPont Fund, 225 Water Street, Jacksonville, Florida, USA
Laurie Lycholm, M.D., is director of the ethics program for the medical school. She also has active roles as a traveling physician with the Cancer Outreach programand as a member of the Brain Tumor Multidisciplinary Clinic.
References (19)
- et al.
The rural cancer outreach program: clinical and financial analysis of palliative and curative care for an underserved population
Cancer Treat Rev.
(1996) - Ricketts T, Savitz L, Gesler S, Osborne D. Geographic methods for health services research: a focus on the rural-urban...
- Hewitt, M and Simons, P. Ensuring quality cancer care....
- et al.
Hospital volume and patient outcomes in major cancer surgery: a catalyst for quality assessment and concentration of cancer services
J. Am. Med. Assoc.
(1998) - et al.
Evaluating organizational design to assure technology transfer: the case of the Community Clinical Oncology Program
JNCI
(1989) - et al.
Variation in patient utilities for outcomes of the management of chronic stable angina
J. Am. Med. Assoc.
(1995) - et al.
Compliance with practice guidelines for node-negative breast cancer
J. Clin. Oncol.
(1997) - et al.
A rural cancer outreach program lowers patient care costs and benefits both the rural hospitals and sponsoring academic medical center
J. Rural Health
(1999) - et al.
A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients
Palliat. Med.
(1996)
Cited by (15)
Guided Internet-based Psycho-educational Intervention Using Cognitive Behavioral Therapy and Self-management for Individuals with Chronic Pain: A Feasibility Study
2017, Pain Management NursingCitation Excerpt :Potential participants e-mailed the researcher to indicate interest. A search of peer-reviewed literature and Internet sites was completed in order to identify a computer-based intervention that was evidence-based, cost-effective, of reasonable length and complexity, and with no in-person attendance commitment to address barriers to participation faced by those with chronic pain (Baer et al., 2007; Bromberg et al., 2012; Lyckholm, Hackney, & Smith, 2001; Lynch et al., 2008; Peng et al., 2007; Vogel et al., 2006). When no intervention incorporating all these criteria was found, one was constructed using psycho-educational and cognitive-behavioral therapy components and self-management techniques found effective in face-to-face interventions, and using structure and sequence similar to existing group programs (Andersson et al., 2005, 2006; Ghahari et al., 2009; Hoffman et al., 2007; LeFort et al., 1998; Lorig et al., 2006; McCracken et al., 2007; Stinson et al., 2010; Sveinsdottir et al., 2012).
Improving access to urologic care for rural populations through outreach clinics
2013, UrologyCitation Excerpt :The average provider traveled over 100 miles roundtrip per visiting clinic day. Travel time, especially in relationship to outreach clinics, has been shown to increase the risk of physician burnout.21 Additional potential problems with the VCU model include worries about costs and substandard patient outcomes.
Coordination of care in colon cancer
2015, CancerTrends in medical oncology outreach clinics in rural areas
2014, Journal of Oncology Practice
Laurie Lycholm, M.D., is director of the ethics program for the medical school. She also has active roles as a traveling physician with the Cancer Outreach programand as a member of the Brain Tumor Multidisciplinary Clinic.
Mary Helen Hackney, M.D., is the director of Rural Cancer Outreach Program and travels regularly to rural clinics. She is also part of the Breast Health Center and is involved in patient and physician education about breast cancer.
Tom Smith, M.D., is recognized nationally and internationally for his papers on health services research. He is currently the director of the ASCO curriculum on palliative care and has focused his research on palliative care topics. He is a Project on Death in America Scholar.