Addressing Transportation Disparities in Radiation Oncology
Cone Health implements transportation hub, resulting in decreased "no-show" or canceled appointments
By Matt Manning, MD, FASTRO, and Rachel Marquez, MPH
For decades, medical experts have focused their time and attention on our individual behaviors and the associated importance as it pertains to our health and well-being. Elements such as refraining from smoking, engaging in physical activity, taking prescriptions as prescribed, checking in regularly with your physician, and eating a balanced diet, are all important focal points to experiencing overall wellness. Even when faced with managing a chronic illness, these behaviors help to reduce or eliminate progression of the disease.
Unfortunately, engaging in these behaviors is not easy for everyone to do as doing so depends on the resource availability in your community, your ability to navigate the health system around you, economic resources you possess, and the time you have to devote to your health. For those that have diminished capacity, many are shamed by the health care system, labeled as “non-compliant” in their treatment plans and subsequently experience undue burden of disease.
Fortunately, we now understand that while our health behaviors are an important influence in our overall well-being, our health is ultimately driven by the economic, physical and environmental components of the communities in which we live, learn, work and play. And while we have identified the root cause of disparities experienced by high-risk populations, our medical practices continue to reflect a system focused on health behaviors and provide little relief for those navigating the limitations associated with their economic and physical environment or their social determinants of health (SDOH).
SDOH significantly influence a person’s health and play a very important role in health outcomes, as many who experience inequities in health outcomes are often navigating varying levels of resource availability. For patients navigating needs associated with SDOH, adding in a cancer diagnosis as well as the demanding schedule of fractionated treatment regimens in radiation oncology, often reveal hidden needs that influence a patient’s ability to adhere to treatment, fill medications or afford costs associated with treatment. As value-based health care transitions to the outpatient setting, these disparate outcomes are fueled by care that makes patients and their families responsible for the logistics of treatment. In this sense, transportation represents an increasingly important SDOH. The protracted daily treatment schedule spread over weeks may represent an insurmountable obstacle for patients with limited transportation and social support.
A radiation treatment regimen can be relatively easy for privileged populations to complete while others find it difficult or impossible to present to the clinic on a regular basis over several weeks of treatment. Historically, such interruptions in planned treatment were broadly labeled as noncompliance, connoting personal failure on the part of the patient. This behavior was ultimately accepted leaving patients vulnerable to the negative impacts on their ability to control their disease due to the delays and disruptions in their treatment. While our team and many across the country tried to address patient compliance issues with a standard mixture of support (gas cards, bus vouchers, etc.) and encouragement, it was not enough to overcome the disparity in treatment completion outcomes that we were seeing.
High capital and operational costs restrict the geographic availability of radiotherapy to a limited number of facilities. In many communities, all patients are served by a single radiation oncology clinic. Cone Health operates one of the busiest radiation treatment facilities in North Carolina, treating over 120 patients per day with four linear accelerators. Understanding the privilege of our facility to treat such a large number of patients, we dove into uncovering which of those patients were at an increased risk of delaying or missing their treatments. What we found was that our increased rates of no-shows and cancellations were largely concentrated in particular zip codes that lacked a robust transportation infrastructure and also had a large concentration of people living in poverty. This meant that despite our efforts to help with bus passes and gas cards, a more holistic approach was going to be needed. One that would not rely on a patient asking for help or one that wouldn’t kick in until after a patient had missed treatment.
To address transportation concerns and improve on our no-show and cancellation rates for those at risk, Cone Health implemented a novel virtual logistics hub platform, capable of managing rideshare, taxis, wheelchair accessible vehicles, vehicles with car seats for children and stretcher vehicles. Through this commercially available tool, it is possible to coordinate transportation services for patients. This solution was offered proactively to patients coming from the disparate zip codes at the start of their treatment and offered free of charge to the patient. Cone architected a complex playbook for implementation taking into consideration the return on investment, legal and compliance regulations, as well as baking this into the medical care delivery. A pilot study was performed applying this model in radiation oncology to establish proof of concept and measure completion rates as well as patient satisfaction.
Over a four-month period, patients consulted in radiation oncology were screened proactively to identify transportation needs and given results of the screener, were enrolled into the free transportation program. Those who received rides for radiation treatment were included in this study. Patients received surveys following each ride to rate their experience: 82% of patients responded that their ride experience was above average and 92% indicated that they would not have been able to attend their appointment without the ride.
In the four-month pilot program, overall no-show appointments for the cancer center decreased by 48%, from 6.1% to 3.2%. No-show incidence by zip code decreased for the specific, disparate zip codes. Zip codes with the greatest disparity for no-show/cancellation had a 12% and 15% no-show rate before Transportation Hub implementation. After hub implementation, no shows dropped to 1.2% and 1.3%.
As we evolve into an era of population health, the responsibility for access and treatment completion is shifting from the patient to the health care system and to the community. This requires a deeper understanding of the complex factors contributing to the access disparity phenomenon and new solutions. Understanding the economic, physical and environmental forces that contribute to health behaviors and working to address will help to reduce disparities and improve the overall health of our communities.
Matt Manning, MD, FASTRO, is a practicing radiation oncologist in Greensboro, North Carolina. He previously served as the Chief of Oncology for Cone Health when the transportation services were launched.
Rachel Marquez, MPH, was the Director of Transportation Services at Cone Health where she was responsible for creating and implementing this new service. She is now the Regional Operations Director for Galileo Health.
