Improving rural cancer patients' outcomes: a group-randomized trial.

CONTEXT: Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable. PURPOSE: To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care, satisfaction, economic barriers, and health-related quality of life. METHODS: A group-randomized trial was conducted with 18 rural communities in the north-central United States. Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study. The intervention targeted rural providers and their practice environment. The subjects were patients with breast, colorectal, lung, and prostate cancers from the rural communities. The main outcomes were patients' travel to obtain health care, satisfaction with care, perceptions of economic barriers to care, and health-related quality of life. In total, 881 patients were included. RESULTS: Group randomization was balanced. Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis. The mean miles traveled per patient were 1,326 (SE = 306) for the experimental group and 2,186 (SE = 347) for the control group (P = 0.03). No significant differences in satisfaction with care, economic barriers to care, or health-related quality of life were found. CONCLUSIONS: The intervention significantly reduced cancer patient travel for health care, which suggests that access to care improved in the experimental group. The results of this study do not allow conclusion that there was no effect on other patient outcomes. The results supported the study's conceptual framework and many of its hypotheses.

Lake Superior Rural Cancer Care Project, Part III: provider practice.

PURPOSE: Effective methods that encourage rural primary-care physicians to adopt state-of-the-art cancer-management practices are needed. The purpose of this study was to evaluate educational and systems strategies to improve rural primary-care physicians' cancer practice behaviors. DESCRIPTION OF STUDY: The Lake Superior Rural Cancer Care Project was a group-randomized, controlled trial conducted with 18 rural communities in the North Central United States over 4 years. Although the unit of analysis was the community, the subjects were 104 primary-care physicians and 2089 rural patients with cancer. The intervention was educational and comprised systems strategies that targeted rural primary-care physicians and their healthcare delivery systems. The outcome measures reported here were physician practice behaviors regarding cancer diagnosis, staging, treatment, clinical trial participation, and post-treatment surveillance. RESULTS: The intervention significantly improved 5 of the 37 cancer practice end points. The overall result of the study did not support the majority of the study hypotheses. Because 16 practice end points were found to be at acceptable performance levels, the possibility of a measurable intervention effect was limited. CLINICAL IMPLICATIONS: Earlier, the authors reported the results of the intervention on providers' cancer management knowledge, which showed significant improvement. The present study findings demonstrated that improving provider knowledge does not necessarily improve practice performance. Changing practice behaviors requires much more effort. Furthermore, interventions found to be effective in other diseases, types of providers, or settings may not work on rural providers for cancer management.