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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. As always, I'm Ruchika Talwar and I'm thrilled to have you join us today. Today we'll be speaking with Dr. Randie White, who is a resident at Maine Medical Center. She'll be going over the results of her new study, Distance to Treatment with Radical Cystectomy in a Rural State - Long Car Rides, Equivalent Outcomes. This was recently published in Urology Practice. Thank you so much, Dr. White, for being here with us today.

Randie White: Thank you for having me. I'm excited to talk about it.

Ruchika Talwar: Awesome. So why don't we dive right in and you can show us your study and give us an overview of your results.

Randie White: So a little bit about our study. As mentioned, we looked into the distance of travel at our center. So for a little bit of background on our study, as most people watching this probably know, radical cystectomy is the most common treatment for non-metastatic muscle invasive bladder cancer. It's a procedure that has high morbidity and mortality and high 90-day readmission rates. As such, it's a procedure that tends to be performed at high volume centers, which is a concept known as regionalization of care, and as such, patients may travel far distances for care.

They have a figure over here on the right that shows our state, the state of Maine and our location of our medical center down in the southern part of the state. This is an important concept for our study because you can see Maine is a very large and rural state. We have patients traveling upwards of five hours for care, from the northern part of the state up in Canada, all the way down to the southern part of the state. But 80% of cystectomies in the state of Maine are performed at a single institution at our academic medical center. We also have a very high incidence of bladder cancer in the state of Maine, and it's the highest incidence of bladder cancer by state compared to all other states in the nation.


So we wanted to look at how well do systemic processes prevent the fragmentation of care, what is the impact of travel distance on 90 day outcomes, readmissions, and time to treatment? So I'll get a little bit into our results. So these are just the background results of our patients that we looked at. We had 220 patients in the study. We separated them out by short distance travel, distances less than 12.5 miles, 12.5 to 49 miles and greater than 50 miles. Overall, we didn't find a major difference between the patients and their demographics. They're pretty evenly spread out. Most of the patients in our study were males. They were white and non-Hispanic. That tends to be the population up here in Maine. They had similar BMIs, ASAs and there was no difference between whether they received neoadjuvant chemotherapy amongst the groups.


When we performed a multi-variable logistic regression analysis, we controlled for BMI, ASA, age, blood loss, node positive status. You can see that listed down here. We again didn't see a difference amongst complications, high grade complications, readmissions, 90 day mortalities or length of stay based on the distance traveled. So again, you can see it didn't seem to matter where patients were coming from or how far they traveled.


I think what was most interesting in the study and a big take home point for us is that when it comes to readmissions for these patients, there did seem to be a difference as to whether they had high grade or low grade complications and where they got readmitted. So looking at this figure here, this heat map of patients on the right is just where they're all from in figure A. In figure B, it shows all patients readmitted in general. So you can see patients are readmitted across the state.


We found that patients, for the most part, were readmitted back to us or back to the treatment center. However, if patients had high-grade complications, you can see that down here in figure C, the majority of them ended up getting readmitted back to us regardless of where they were traveling from. Versus if they had low-grade complications, the majority of them ended up getting readmitted back to a critical access hospital or a hospital closer to where they were from. So this indicated to us that our systemic processes in terms of how we interact with outside hospitals, how we interact with referring urologists did seem to work quite well in terms of our readmission rates.


And then finally, one of the last things that we looked at was time to treatment for our patients. In this figure here, you can see that we looked at time to neoadjuvant chemotherapy, time to surgery after neoadjuvant chemotherapy, and then time to surgery alone. We didn't see any difference based on distance traveled between time to neoadjuvant chemotherapy and then time to surgery after neoadjuvant chemotherapy based on distance traveled.


However, we did notice that for patients traveling farther distances, there was this increase in delay of care for patients going to surgery alone, which I think makes sense overall. These patients have only one place where they can get a radical cystectomy, but there are many more institutions where they can receive neoadjuvant chemotherapy. So our conclusions from the study were that we found that we have multidisciplinary processes of care such as nurse navigators, support services, and coordination with referring urologists throughout the state.


We do have this statewide health information exchange where we've been able to share information with other urologists in the state to keep information about our patients, which has been quite helpful. We did find that with increased travel distance there was this increased likelihood of a readmission to an outside hospital, however, but overall high-grade readmissions ended up coming back to the treatment center. And then finally, there was this increase in time to surgery based on distance traveled that was not seen with an increase in travel distance to neoadjuvant chemotherapy alone.


Ruchika Talwar: Thank you for that great overview. You brought up a lot of really interesting points. There are a couple of things that I want to highlight for our discussion here. First of all, you mentioned a statewide EMR information exchange. Tell me more about that.

Randie White: Yeah, so I think most people are pretty familiar with Epic. I don't know if all institutions across the state have Epic, but we do have this EMR, this statewide information exchange called HealthInfoNet. And it's a way that for all the institutions that don't have Epic but have a different EMR, all the different EMRs are essentially able to talk to each other and connect with each other so that for any patient you're able to log onto this almost separate EMR and you can access their medical records, whether they've been admitted to an outside emergency department, you can see their clinic notes.


So it's a very good way for us to keep tabs on the radical cystectomy patients. If we haven't seen them in the office in a few weeks, it's a good way to figure out whether they've been readmitted for something. So it's been useful information for us just to figure out how we're doing in terms of our admission rates and in terms of our post-op complications.


Ruchika Talwar: Yeah, that's great. And I wonder if that explains some of the findings that you see in your study, and I'll explain what I mean. I thought it was really interesting that you were able to keep a lot of those low-grade complications seen at local ERs but still be involved in the decision-making process. That's a big barrier I see for radical cystectomy patients who have gotten their surgeries at several institutions that I've been at. And then you get a phone call from an outside ER doc or an outside provider. At any institution I have been at thus far, we don't have that kind of statewide information exchange. We do have something called Care Everywhere in Epic, but it's really cumbersome. You don't always get the information you need. The patient has to authorize it. So there are multiple barriers.


And so often what happens is we are more likely to say, "Just transfer the patient, just bring the patient here." And we've had situations where patients get transferred, costing tens of thousands of dollars, to bring patients from six, seven hours away even. And then it turns out they don't have a major issue that needed to be seen here. But because these patients are so complicated, we want to err on the side of caution, so it's tough. And I really love that you all have that up in Maine because clearly it's working to keep patients closer to home and only bring them to your major center if they need that higher level of care.


Randie White: Right. I totally agree. I think it's done a good job, especially now that I'm an attending physician who takes the transfer calls, but speaking as a resident who works closely with them, I think it's done a good job of being able to read in real time what's going on with the patients and seeing what's happening in those emergency departments.


And as you said, if it's a low-grade complication, a patient is admitted elsewhere for a UTI and pyelonephritis, talking with a physician at a small hospital who may not be as familiar with a radical cystectomy and reassuring them that this is just an admission for IV antibiotics, that's all they need, and they can stay up there versus no, this patient is obstructed and needs to come down for interventional radiology. I think that's sort of the transfer point that we've seen. So when patients need to come down to us for an intervention versus whether they need to stay at another hospital just for something minor. So I think that has been a useful tool.


Ruchika Talwar: Yeah, there's a lot of this push and pull because, as you mentioned in your introduction, we know that outcomes are better, especially for these major index oncologic procedures when they're done at high volume centers. At the same time, when you regionalize care, there are barriers that come up such as travel time, distance, etc. And I think you're right, that is highlighted by the fact that patients who are not getting neoadjuvant chemotherapy don't quite have that window for preparation for all the things that go into surgery.

So I think navigation services really are the future on that front to help with care coordination, but there are still a lot of challenges to even navigate those patients who may have worse health literacy, may not have optimal coverage, may not have transportation that's quite as easy to coordinate. But navigation services really do seem to be the way forward. I just think your data is really promising. So it tells us that despite clustering our care and regionalizing our care, we're still able to make sure that outcomes are the same. That's always been my question.


Randie White: I agree. I think we've shown with this, again, some of our outcomes are the same, and as you said, there's not a huge difference in a lot of our outcomes between patients. But I think a lot of that, as you mentioned, is because we have such a great relationship with a nurse navigator here and because they've been able to help coordinate care with a lot of the referring urologists in such a big state, I think that's been a huge part. And again, as you mentioned, a lot of these patients are coming from rural areas, they don't have the health literacy. It's a huge surgery and once the surgery is over, they require a huge amount of care afterward.

And understanding how to manage an ostomy if that's the type of diversion they received and how to manage a lot of that, nurse navigation can help with that quite a bit. But I think also the communication between the referring urologist, who has to work closely with us in our office, and a lot of the providers, APPs in the office, triage nurses in the office, I think that's gone a long way with having the back-and-forth communication between several different providers in the state has also been a huge part.


Ruchika Talwar: Yeah, I think that flow of information back and forth is essential and it's really helpful to have a good relationship with the referring urologist in the community because they can help triage some of those issues. And it's a lot easier for them to initiate a conversation via phone call or an email about an issue and have that worked up locally, and the patient only needs to come to the big city when it's time for intervention.


So I totally agree. I think that's super important. And those clinical pathways, I think we can all do a better job at formalizing them, but they really are going to be the way forward as we continue to encourage patients to get care from these major centers. I think your data is super exciting and it's going to inform these sort of health policy questions in regards to is there differential coverage in certain services based on volumes and outcomes and whatnot. So congratulations on publishing this data. I think it's really forward-thinking and I appreciate you spending time with us today.


Randie White: Thank you. Thank you for having me on.

Ruchika Talwar: And to our UroToday audience, thanks again for joining us and we'll see you next time.