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

摘要 自2019冠状病毒病大流行开始以来，远程医疗的使用激增。在大流行前， 6300万按服务收费的医疗保险受益人每月获得远程医疗服务，而2450万受益人每月获得远程医疗服务。 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% 至马萨诸塞州的47.6%）。这种远程医疗的扩展正值通常严重的接入问题 为农村个人提供保健服务已成为保健政策和公平的重点。农村癌症的旅行时间更长 患者已被证明对治疗方案、RCT参与和症状产生负面影响， 管理综合癌症护理通常需要多专家团队， 农村地区的协调尤其具有挑战性。这些障碍导致了在以下方面差距的扩大： 农村和城市患者的癌症死亡率。衡量癌症护理的可及性是一项基本的 确定获取方面的差距以及制定护理提供模式， 差距。由于远程保健超越了地理上的邻近性，它为解决农村地区的问题带来了巨大的希望。 癌症治疗的不平等。远程医疗允许专家与地理上遥远的患者联系， 提供者，否则他们在转诊方面的选择将更加有限。随着预期的持久性， 在COVID-19大流行之后扩大了远程医疗，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， 改善获得保健和保健结果的公平性。在一些国家，远程保健现在是农村癌症护理的组成部分。 区域，但在其使用方面存在差距，以及获取方面的不平等如何影响利用和成果， 未知只有通过衡量包括远程医疗在内的癌症护理可及性的新现实， 远程医疗对结果的影响，并将此证据应用于“如果”情景/预测，我们是否可以开始 利用并积极引导远程保健减少农村癌症差距的潜力。本研究将 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普及措施， 确定在癌症护理中使用远程保健的决定因素，测试远程保健对癌症结果的影响， 分析如果远程医疗在癌症中的使用是 扩大，同时考虑基于农村-城市连续体的差异效应。为此，我们将使用 联邦通信公司：癌症患者远程医疗利用的国家医疗保险索赔 委员会（FCC）的宽带数据和2020年美国人口普查数据，扩展我们之前的地理空间 癌症护理访问工作（R21 CA 212687）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.