Analysis of cross-state cancer care signals need for improved telehealth

A new paper, published in JAMA Network Open, finds a surprising number of Americans traveling out-of-state for cancer care.

The study, co-authored by Center for Geographic Analysis research associate Lingbo Liu, focuses on older adults whose treatment is covered by traditional Medicare, with the most striking results concerning rural Americans. Rural cancer patients in the study’s sample were about twice as likely as city-dwellers to cross state lines for surgical treatments. Rural residents were also three times more likely to leave the state for radiation and four times more likely for chemotherapy.

These findings have important implications for healthcare fragmentation, or receiving services at more than one institution. Fragmentation, which is common with cancer care, is associated with communication gaps and decreased patient satisfaction. But telehealth has the potential to ease these concerns.

“When telehealth is used,” Liu offered, “it’s most likely to improve cancer care equity in rural areas and for the diverse populations within those areas.” 

The study was made possible by CGA’s Spatial Data Lab project, led by Liu since 2022 with support from the National Science Foundation Industry-University Cooperative Research Centers Program. The lab teamed up with the Future Data Lab and KNIME to make geospatial data science more accessible and replicable. Their no/low-code visual programming platform, developed by CGA, is called the Geospatial Analytics Extension for KNIME.

The lab also entered a partnership with Huntsman Cancer Institute on a long-term initiative titled “Access, Utilization and Outcomes of Cancer Services in the Era of Telemedicine.” The five-year research project, which kicked off in 2022, seeks to understand where telehealth can improve cancer care access and outcomes. The project is funded by the National Cancer Institute. Principal investigators are University of Utah cancer epidemiologist Tracy Onega and geographer Fahui Wang from Louisiana State University.

The team has already produced several publications covering everything from predicting cancer rates to the specifics of telehealth access in Baton Rouge. For the JAMA Network Open paper, the researchers studied more than 1 million Medicare beneficiaries diagnosed with breast, colon, lung, or pancreatic cancer between 2017 and 2020. Thanks to Liu’s geospatial analysis expertise, they quantified cross-state cancer care while uncovering patterns consistent with the draw of regional healthcare hubs.

Medical licensing is regulated by states, with several allowing clinicians from neighboring states to provide telehealth services. However, the researchers uncovered a pattern unaddressed by typical reciprocity agreements. A snowbird effect was found for patients based in the Midwest and Northwest.

“People will fly from Florida back to Massachusetts to get their cancer care,” Liu explained. 

Cross-state travel proved most frequent for surgical procedures, especially for patients with lung and pancreatic cancer in need of specialized services. Cross-state travel was least frequent for chemotherapy, which requires multiple cycles with long hours of in-person treatment. 

“We believe telehealth can decrease patients’ travel burden while also improving outcomes,” Liu summarized. “It means they can get their cancer service in time. They don’t need to wait.”