Access, Utilization and Outcomes of Cancer Services in the Era of Telemedicine

摘要 自新冠肺炎大流行开始以来，远程医疗的使用激增。在大流行之前，只有6万人 6300万按服务收费的联邦医疗保险受益人每月获得远程医疗服务，相比之下，这一数字为2450 从2020年3月到10月，这一数字为100万，地理差异很大(例如，南达科他州为8.4% 到马萨诸塞州的47.6%)。这种远程医疗扩展出现在通常情况下非常严重的接入问题 对于农村个人而言，这已成为卫生政策和公平的焦点。农村癌症的旅行时间更长 患者已被证明对治疗方案、随机对照试验的参与度和症状有负面影响 管理层。通常需要多个专家团队来进行全面的癌症护理， 农村地区的协调尤其具有挑战性。这些壁垒导致了 农村和城市患者之间的癌症死亡率。衡量癌症护理的可获得性是一个基本的 确定准入方面的差距，以及开发护理提供模式，以缓解 差距。由于远程医疗超越了地理上的接近，它在解决农村地区的问题方面前景广阔 癌症护理服务的获取不平等。远程医疗允许专家与地理位置遥远的患者联系，并 否则将有更多受限的转介选择的提供者。具有预期的持久性 在新冠肺炎大流行之后，现在是时候开发新的方法来衡量 获得癌症护理，将地理空间措施与远程保健和转诊模式相结合，以便 改善卫生保健机会和成果的公平性。在一些地区，远程医疗现在是农村癌症护理不可或缺的部分 区域，但在使用方面存在差距，获取方面的不平等如何影响利用和成果 未知。只有通过衡量癌症护理可获得性的新现实，包括远程医疗，了解 远程医疗对结果的影响，并将这一证据应用于假设情景/预测，我们是否可以开始 利用和积极引导远程保健在减少农村癌症差距方面的潜力。这项研究将 采取关键和及时的步骤，在全国范围内制定纳入远程保健的准入措施， 确定远程保健在癌症护理中使用的决定因素，测试远程保健对癌症结局的影响，以及 分析如果在癌症中使用远程医疗对癌症护理机会和结果的公平性的预测影响 扩展，同时考虑基于城乡连续体的不同影响。为此，我们将使用 国家医疗保险声称在癌症患者中使用远程医疗，联邦通信 委员会(FCC)宽带数据和2020年全美人口普查数据，以扩展我们之前的地理空间 癌症护理获取工作(R21CA212687)和基于人群的结果建模与政策相关性。

ABSTRACT Use of telehealth has skyrocketed since the start of the COVID-19 pandemic. Pre-pandemic, only 60,000 of the 63 million fee-for-service Medicare beneficiaries received a telehealth service each month compared to 24.5 million from March to October, 2020, with wide geographic variation in that uptake (e.g. 8.4% in South Dakota to 47.6% in Massachusetts). This telehealth expansion comes at a time when the often-severe access issues for rural individuals have become a focus for health policy and equity. Longer travel times for rural cancer patients have been shown to negatively impact treatment regimens, RCT participation, and symptom management. Multi-specialist teams are often required for comprehensive cancer care, making care coordination in rural areas particularly challenging. These barriers have contributed to the widening gap in cancer mortality between rural and urban patients. Measuring access to cancer care is a fundamental component of both identifying gaps in access, as well as developing care delivery models to mitigate disparities. Because telehealth transcends geographic proximity, it holds great promise for addressing rural cancer care access inequities. Telehealth allows specialists to connect with geographically distant patients and providers who otherwise would have had more restricted options for referral. With the expected persistence of expanded telehealth following the COVID-19 pandemic, the time is now to develop new ways to measure access to cancer care that integrate geospatial measures with telehealth and referral patterns in order to improve equity in health care access and outcomes. Telehealth is now integral to rural cancer care in some regions, yet where gaps are in its use and how inequities in access impact utilization and outcomes is unknown. Only by measuring the new reality of cancer care access that includes telehealth, understanding telehealth impacts on outcomes, and applying this evidence to “what if” scenarios/projections, can we begin to harness and proactively direct the potential that telehealth has to reduce rural cancer disparities. This study will take the critical and timely steps of developing measures of access nationally that incorporate telehealth, identifying determinants of telehealth use in cancer care, testing effects of telehealth on cancer outcomes, and analyzing the projected impact on equity in cancer care access and outcomes if telehealth use in cancer is expanded, while considering differential effects based on the rural-urban continuum. To do this, we will use national Medicare claims for telehealth utilization among cancer patients, Federal Communications Commission (FCC) broadband data, and 2020 Census data for the entire U.S., to extend our prior geospatial cancer care access work (R21CA212687) and population-based outcomes modeling with policy relevance.