Critical Reviews in Oncology/Hematology 40 (2001) 131–138

Ethics of rural health care

Laurie J. Lyckholm , Mary Helen Hackney *, Thomas J. Smith Department of Medicine and the Di�ision of Hematology/Oncology, Massey Cancer Center,

Virginia Commonwealth Uni�ersity School of Medicine, 401 College Street, Richmond, VA 23298-0037, USA

Accepted 6 February 2001

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

2. Program description: The Rural Cancer Outreach Program (RCOP) . . . . . . . . . . . . . . . . . . . . . 132

3. Program analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 3.1. Impact of the program on the clinical care provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 3.2. Impact of the program on health care professional recruitment and retention . . . . . . . . . . . . . 133

4. Economic analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

5. Other programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

6. Applicability to other settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

7. Ethical issues in rural health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 7.1. Justice issues: access to and delivery of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 7.2. Competency of medical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 7.3. Confidentiality and privacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.4. Institutional ethics committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

8. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Abstract

One quarter of the US population live in areas designated as rural. Delivery of rural health care can be difficult with unique challenges including limited access to specialists such as oncologists. The Rural Cancer Outreach Program is an alliance between an academic medical center and five rural hospitals. Due to the presence of this program, the appropriate use of narcotics for chronic pain has increased, the number of breast conserving surgeries has more than doubled and accrual to clinical trials has gone from zero to nine over the survey period. An increase in adjuvant chemotherapy has been noted. The rural hospitals and the academic center have seen a positive financial impact. The most prominent ethical issues focus on justice, especially access to

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* Corresponding author. Tel.: +1-804-8280450; fax: +1-804-8288453. E-mail addresses: [email protected] (L.J. Lyckholm), [email protected] (M.H. Hackney).

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L.J. Lyckholm et al. / Critical Re�iews in Oncology/Hematology 40 (2001) 131–138132

health care, privacy, confidentiality, medical competency, and the blurring of personal and profession boundaries in small communities. As medical care has become more complex with an increasing number of ethical issues intertwined, the rural hospitals have begun to develop mechanisms to provide help in difficult situations. The academic center has provided expertise and continued education for staff, both individually and within groups, regarding ethical dilemmas. © 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Care of the poor; Cost analysis; Medically under-served; Rural; Strategic alliances

1. Introduction

One quarter of the US population lives in areas designated as rural, or fewer than 2500 people per town boundary, and frontier, or fewer than 6.6 people per square mile [1]. The geographical and socioeconomic features of rural America present unique challenges to delivery of health care resources, especially delivery of oncology care.

Rural patient health is often poorer than urban or suburban patient health. The long distances make some types of care difficult. There is increasing evidence that high volume produces high quality cancer care [2,3] and many rural hospitals will always have low volume.

This article will explore the ethical issues related to rural health care, particularly oncology care. It will describe the rural cancer outreach program of the Massey Cancer Center (MCC) including a clinical and financial analysis of the program; the ethics of the program; applicability to other settings; and what we have learned in 10 years of creating access to care.

2. Program description: The Rural Cancer Outreach Program (RCOP)

The rural cancer outreach started as a ‘strategic alliance’ [4] between academic centers and rural non- for-profit hospitals. The goal was to establish a model of care that would provide state of the art care in rural areas, increase the access to care, generate services and revenue for both the rural and academic center, train health care professionals [5], and serve as a laboratory for intervention. (Table 1).

The RCOP has grown from one program in 1988 to five programs operating at five rural hospitals. Briefly, the majority of cancer care is provided at the rural hospital. A team of two– three oncologists and two nurse practitioners or nurse clinical specialists travel to each site weekly. While there, they see new consulta- tions and patients under treatment. They work with primary care doctors at the rural sites who have ex- pressed an interest in care of cancer patients; this typically includes two– three surgeons and two– four primary care internists or family physicians. Nurses

from the rural site come to the academic center for specialized cancer nursing, then receive annual updates. Many of the rural nurses have become certified in oncology nursing.

The program is administered by the Massey Cancer Center of the Medical College of Virginia, Virginia Commonwealth University, and each of the rural hos- pitals. Support for this program comes from the Com- monwealth of Virginia.

3. Program analysis

3.1. Impact of the program on the clinical care pro�ided

We have analyzed three important index conditions in our first two rural hospitals [6]. We chose these conditions because there was documented wide varia- tion in practice, and poor medical outcomes if optimal process was not followed (Table 2). It was difficult to

Table 1 Goals of the rural cancer outreach program

Goal Comment

Virginia is typical rural USEstablish a model of care for staterural Virginia

Deliver state of the art care in See what care could be delivered at the rural site,rural areas what should be centralized

Increase access to clinical trials Allow access to new drugs; increase accrual to clinical trials for the academic center

Train health care professionals Help recruit and retain primary care and specialist physicians and nurses for the rural area. Provide a specialty service that makes rural practice more attractive

Link academic and rural Make regional policy, not hospital against hospital, tohospitals in strategic alliance solve problems of indigent care. Help support unprofitableHelp finances of both hospital

partners small rural hospitals. Use the program for tobaccoServe as a entry point for

community based interventions and nutrition interventions if desired by rural community.in prevention

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Table 2

Level before RCOPIndex condition Level after RCOP Morphine use in chronic pain 0 +500%

60%�20%Breast conserving therapy 9Clinical trial accrual 0

Adjuvant therapy for early breast Unknown. Probably high for affluent patients Offered to all patients regardless of ability who could travel, low for the poor to paycancer

analyze the type of care because the volume of any one condition, e.g. use of adjuvant chemotherapy in Stage I–III breast cancer, was always low and usually less than ten cases per year. However, the importance of high quality care to those individuals is as impor- tant as in other settings. There is often reluctance to analyze care patterns if it is likely to show less than optimal care; for instance, a hospital that reports ex- cess mortality from routine myocardial infarction may find that patients avoid that hospital for all cardiac care, especially troublesome for a small hospital that depends on retaining a large percentage of its market for survival. Also, there is often no financing avail- able to support an in depth look at practice patterns and survival or recurrence.

The use of morphine for cancer pain was studied in one hospital. In the preceding 3 years before RCOP, there had been almost no morphine prescribed; within 2 years the amount of oral and intravenous morphine increased by over 500%. In addition, the use of mepe- ridine declined. Breast conservation, considered the desired treatment for early stage breast cancer, had been rarely used before RCOP. By the 3rd year of operation at our first hospital, over 60% of patients were routinely treated with breast conservation. In addition, before the RCOP, all breast cancer patients were not routinely offered adjuvant treatment, be- cause many could not see an oncologist due to dis- tance or cost. In other studies, the referral of patients to a medical oncologist — rather than treatment by a surgeon alone — was significantly correlated with the likelihood of receiving adjuvant chemotherapy [7]. Clinical trial accrual to Cancer and Leukemia Group B (CALGB), National Surgical Adjuvant Breast and Bowel Program (NSABP) and other trials increased from essential zero to 9% of eligible patients. This compares favorably with the 2% national average in the US.

3.2. Impact of the program on health care professional recruitment and retention

The RCOP has been successful in helping to recruit and retain good physicians to rural areas. Physicians commonly mention the increased academic linkage

and ease of referral to the academic center. These rural doctors have noted that the concentration of complex cancer care in the hands of a few local doc- tors rather than many has allowed them to increase their expertise. There has also been continued central- ization of some complex procedures such as radiation and leukemia treatment that are not feasible to per- form at a rural center.

4. Economic analysis

Pre- and post-RCOP financial data were collected on 1745 cancer patients treated at the participating centers, two rural community hospitals, and MCC. The main outcome measures were costs (estimated re- imbursement from all sources), revenues, contribution margins, and profit (or loss) of the program.

Key results are shown in Table 3, modified from the full report in the Journal of Rural Health [8].

The RCOP had a positive financial impact on the rural and academic medical center hospitals. The RCOP was associated with an increased number of referrals of 330% more cancer patients and 9% more other medical/surgical patients. The MCC had in- creased receipts of 6.2%. The rural hospitals each had over a million dollars in new charges and over $500 000 US new profit each year. In total, the re- ceipts for both centers increased by 137%. Most of this additional income was from ‘ancillary’ services such as increased use of the computerized axial to- mography (CAT) or magnetic resonance imaging (MRI) scan, laboratory, and pharmacy. All patients were treated regardless of ability to pay, and the pro- gram generated sufficient profit to allow increased in- digent care.

The net annual cost per patient fell from $10 233 to $3862 (−62%) associated with more use of outpa- tient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to MCV fell by 40%, compared to only an 2% decrease for all other cancer patients consistent with other programs that have in- creased coordination among providers [9].

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5. Other programs

Similar results of improved clinical care process, equal or better patient outcomes and cost savings have been reported from the Manitoba Cancer Out- reach Program, but final results have not yet been published. The Manitoba Cancer Research and Treat- ment Program was started in 1984 with similar goals [10]. It works on a similar model of consultation with the academic center, then all the care is delivered in one of six regional centers. Insurance is not an issue in Manitoba since there is a single universal payer. However, there are limited funds for cancer and dol- lars that can be saved by off loading to a regional center preserve dollars for research. Distance is even more problematic, with some centers 8 h by train, impassible by cars, and air transport too costly. Key rural primary care doctors and surgeons are iden- tified, and given an initial training program followed by yearly updates. All protocols are specified in a central care plan, and the central hub audits dicta- tions from the rural centers. Similar clinical results have been obtained, with excellent clinical care and less overall cost to the province [11]. (personal com- munication, Harvey Schipper 1999)

6. Applicability to other settings

We have not identified other similar programs that have published their clinical and economic results. The closest is the Centre Bernard Lyon that has shown good adoption of clinical practice guidelines and better clinical practice [12,13]. This program should be applicable to other centers that serve rural, dispersed populations. The main problems have been sustaining the medical innovation part of the pro- gram, and not ‘burning out’ the doctors and nurses who must travel the distance. The continued travel can be a major problem for health professionals.

7. Ethical issues in rural health care

The challenge is to provide high quality, affordable, accessible care for all. In the US, the absence of a single payer system allows exclusion of whole seg- ments of the population. Combined with the dis- persed poor population in rural areas, these issues represent significant obstacles to delivery of care. In Virginia, one third of the population is rural and most of these people are medically underserved for both primary and specialty care. The rural population has more federal Medicare and state Medicaid health insurance coverage with a low rate of reimbursement compared to most insurance, so rural hospitals and providers have less income than urban centers. ‘Nega- tive marketing’ or locating services in affluent areas so that the poor do not have access is widespread.

The ethical issues most prominent in rural health care include justice issues, especially those involving access to and delivery of health care, related issues of medical competency, confidentiality and privacy is- sues, and conflicts of interest related to blurring of personal and professional boundaries. Finally, institu- tional ethics committees at rural hospitals are evolv- ing, but may not have the necessary elements of expertise that are more accessible in urban centers.

7.1. Justice issues: access to and deli�ery of health care

The principle of justice calls for equitable distribu- tion of health care resources, meaning that health care is distributed according to need rather than to the ability of a person to obtain it. Challenges to this principle in the rural health care setting include geo- graphical and financial barriers. In some rural com- munities health care may be hours away. Nonmetro and frontier areas possess far less physician coverage than more urbanized areas even after controlling for population size. For example, in 1988, the ratio of primary care physicians per 100 000 persons for re-

Table 3 Impact of RCOP on rural and academic programs

Change (%)Post-RCOPbPre-RCOPa

330%Cancer patients from RCOP areas seen at MCC 173 743 9%75726958All patients from RCOP areas seen at MCC

Estimated receipts, MCC 6.2%$1 770 256 1 879 542 NAEstimated receipts, RCOP $2 314 516 –

137%Total estimated receipts $1 770 256 $4 194 058 −62%$3862$10 233Net annual cost per patient in the system

Inpatient admission, MCC −40%$7370$12 268

a Represents average values of 1988 and 1989 financial data. b Represents average values of 1992 and 1993 financial data.

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mote rural areas was 38.2; for the more inclusive nonmetro areas it was 51.3. In comparison, metro areas had a ratio of 95.9 [14,15].

This problem will be compounded as more inde- pendent community hospitals close their doors due to the lack of funding. The poor and elderly without access to transportation may receive little to no health care. The traffic and complexity of urban cen- ters may intimidate those who have always lived in rural areas.

Financial barriers are similar to those experienced by the poor urban population. The community, how- ever, may actually be a positive factor in overcoming these barriers. In a review of these issues, Purtilo and Sorrell remarked that in times of hardship, rural com- munity members often help those of their community who are most financially strapped [16]. Among those community members are the physicians, who are also ‘expected’ to contribute their services and advocacy for the patient. Physicians are part of the community, and ‘‘the high probability that the physician will see a rejected patient at the drug store, Lions Club dinner, or next PTA meeting makes saying ‘no’ practically impossible’’ [17]. This situation may create a tremen- dous conflict of interest between the physicians’ alle- giance to their community and their hospital, which may not have the financial resources to provide care for indigent members of the community.

Improved access to oncology care is at the heart of our rural cancer outreach program. Oncology care in the rural setting is equivalent, or sometimes better, in terms of convenience, than that in the academic medi- cal center. The most important aspect of the program is improving financial and geographic access to sub- specialty care and consultation. Transportation is pro- vided for patients who have daily radiation treatments. Although we cannot impact direct costs of the patients’ oncology care, reducing out-of-pocket spending, which is significant, appears to be of great assistance to many of the patients. Finally, by provid- ing care close to home, we hope to offer comfort and a greater sense of security to patients who are fright- ened or feel threatened by the diagnosis of cancer and the therapy they must endure.

7.2. Competency of medical care

Several issues surrounding competency of medical care exist in the rural setting, and some are particular to our rural outreach oncology setting. The first con- cerns competency to provide specialty care. Many rural areas have few primary care providers, and no specialists. There is increasing evidence that high vol- ume produces high quality and many rural hospitals will always have low volume [3]. Physicians may feel forced to provide care, including procedures which

they perform infrequently or are beyond their level of expertise, especially if the closest large medical center is 3–4 h away. Physician assistants, nurse practi- tioners and other nursing personnel may also provide care beyond their level of expertise, with minimal su- pervision, to meet the health care needs of the rural population.

One of our primary goals was to surmount this problem by traveling 1–2 h to several rural areas to provide oncology expertise in the form of clinics in which we see new and returning patients on a bi- weekly basis. During the clinic appointment, the med- ical and radiation oncologists and nurse practitioners perform ongoing management of established patients, plan diagnostic and therapeutic interventions for new patients, and counsel patients regarding palliative care and end of life issues. We also educate the hospital oncology nursing staff, many of whom have become certified in oncology nursing. These specialized nurses see patients every day and administer chemotherapy and other treatments such as transfusions and intra- venous fluids, and perform limited patent assessments thus trouble shooting problems experienced by the oncology patients.

Problems that can occur in this setting include are lack of direct supervision on a daily basis, lack of continuity of care, and problems related to handling and communicating medical information between the outreach sites and the cancer center.

Direct supervision by a specialist is obviously im- possible 2 h away. We work closely with the primary care physicians in the community and the patients continue to see them regularly after diagnosis. The community physicians are most often the first to see and evaluate patients having problems, and will then often call one of the oncology physicians to discuss the case. If a patient is having a specific problem that must be handled by a specialist, such as a compli- cated neutropenic fever, or spinal cord compression, the patient usually must be transported to our medi- cal center. However, the patient may often be stabi- lized and kept at the rural hospital if the primary care physician has the support of the oncologists and other members of the medical center faculty.

Continuity of care is an important concept in the patient–clinician relationship. Unfortunately, we are not always able to provide direct continuity of care to our oncology patients because of time and sched- ule constraints. We do the best we can by maintain- ing a constant pool of physicians and nurses designated for each site, detailed patient summaries and clinic visits, so that the next physician will know what the treatment plan and previous problems are, and frequent use of phone calls to patients we know are having problems.

Handling and communication of patient informa- tion involves confidentiality issues described below,

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and also involves management of large volumes of information from multiple sites, which is extremely challenging. Some information is critical, and elabo- rate systems are in place to assure that the informa- tion is noted and recorded by the site nurses and the cancer center nurse practitioners, and that the oncol- ogy physicians are made aware of any critical values, such as abnormal CT scans or blood tests. Ongoing quality assessment is in place to assure impeccable data management, to avoid missing critical informa- tion.

7.3. Confidentiality and pri�acy

The proximity in which patients and health care workers live and work in rural communities makes it much more likely that physicians and other health care workers will know their patients personally and socially, which creates significant challenges to main- taining respect for confidentiality and patient privacy. A 1993 survey of 510 general and family physicians in Kansas revealed that 46% of respondents practic- ing in a community of less than 5000 were likely to have more than 5% of patients who were family members or friends of the physician or staff, signifi- cantly more than the 13% of respondents from com- munities of more than 20 000. fourteen percent of the physicians in the communities of less than 5000 also reported that in more than 5% of cases medical infor- mation is passed through the physician or staff to an outside party who knows the patient in question [18].

Purtillo and Sorrell describe a patient who is found to have genital herpes during a routine prenatal visit. The patient pleads with the physician not to enter the information in her chart: her sister-in-law is the physician’s receptionist, the county public health clerk to which this transmissible disease should be reported is her cousin; other relatives work at the hospital where she will deliver; ‘‘virtually everybody in the sit- uation is either a relative, friend or foe’’ [16].

In an instance reported by Roberts et al., a patient drove 6 h to an urban center for help with his sub- stance abuse problems. He told the attending physi- cian that he couldn’t go to his community clinic because his sister worked there, and he was afraid she would tell the whole family. The patient’s subsequent non-compliance with the program was at least par- tially blamed on the burdensome long distance drive to the urban facility [17].

We have had several patients in our rural oncology clinics that have expressed unwillingness to be treated at the facility, because their privacy might be jeopar- dized. The waiting rooms of these clinics are often crowded with people who are friends, neighbors and relatives. Because it is a specialty clinic only for pa- tients with hematologic or oncologic problems, it is

not difficult for one to know another’s general diag- nosis. Diagnostic tests are performed, interpreted and transcribed by patients’ relatives and acquaintances. The patients are given chemotherapy in one large room and on any given day, they may find them- selves sitting next to a neighbor, the local florist, or a distant cousin. Several of the nurses have found themselves treating old friends, teachers, neighbors and relatives. This may sometimes be a comfort to the patient. but may also be embarrassing or uncom- fortable for both the patient and nurse.

In our rural outreach practice, we must exchange information about patients frequently by phone and often by fax and by email over the Internet. None of these communication devices are entirely secure, espe- cially the email system, but they are necessary in communicating important patient information in a timely and efficient manner.

Safeguarding confidentiality in such circumstances is important; the Kansas physicians reported several measures they took to do so, some of which could potentially compromise patient care, the physician’s integrity or even legally endanger the physician, such as in the case of misrepresenting or omitting certain details on insurance forms, and omitting required not- ification of local public health officials. Other mea- sures taken included speaking with office personnel regarding the importance of confidentiality of a spe- cific patient, omitting or misrepresenting certain de- tails for the official medical record and recording the importance of confidentiality in the chart [15].

Our outreach site staff are aware of the sensitive nature of our patients’ conditions and maintain a high level of awareness regarding privacy and confi- dentiality. Simple measures such as keeping telephone conversations and reports out of hearing distance from the waiting room and patient rooms as well as ongoing discussions regarding confidentiality between nursing staff and outreach staff are highly effective. The nursing and secretarial staff maintains a high level of professionalism and respect for patients, and in particular, confidentiality, which sets the tone for the rest of the staff.

7.4. Institutional ethics committees

In response to the mounting complexity and num- ber of clinical ethical issues encountered in healthcare, institutional ethics committees are developing in rural and urban hospitals. Some have the specific goals of developing and overseeing hospital policies, to re- spond to the requirements of the JCAHO and similar organizations, and others have multiple goals, includ- ing the former as well as addressing day-to-day dilemmas that arise in the course of patient care. They are as heterogeneous in their compositions as in

L.J. Lyckholm et al. / Critical Re�iews in Oncology/Hematology 40 (2001) 131–138 137

their goals and missions, some composed of physi- cians and administrators, others representatives from multiple divisions of the hospital, such as nursing, pastoral care, and even from the community. Their members have various levels of ethics knowledge and expertise. Some have support from local institutions that have established ethics committees and consider- able expertise. Others have members who have taken additional training in bioethics at community or uni- versity programs.

The hospital ethics committee can be a tremendous source of knowledge and support for physicians and other health care providers confronted by the dilem- mas listed above. It is critical that these committees have the expertise and influence to support and up- hold behavior and policy based on ethical principles.

The development of such committees has been de- scribed as occurring in three stages: emergence of a local expert, educating the ethics committee and de- veloping a body of knowledge, and expansion of the ethics activity into policy development and consulta- tion [19].

In our rural cancer outreach programs, we have offered the expertise of our established and experi- enced hospital ethics committee and its members, as well as persuaded them to identify interested individu- als for further training by the Richmond Community Bioethics Consortium. We have also given several lec- tures and held discussions related to ethical issues in the care of oncology patients to the nursing and med- ical staff. We will continue to support them in any way possible to guarantee ethical treatment of their patients and employees.

8. Conclusions

There are distinct and novel ethical issues in providing rural health care. Two groups have shown that rural cancer outreach (a structured alliance of a cancer center and rural hospitals and providers) works well clinically and economically. In addition, rural cancer outreach is ethical because it is distribu- tive and just.

Reviewers

Dr Dieter K. Hossfeld, Universitäts-Krankenhaus Eppendorf, Medizinische Klinik, Abteilung Onkologie und Hämatologie, Martinistrasse 52, D-20246 Ham- burg, Germany.

Dr Leslie R. Laufman, Hematology/Oncology Consul- tants, Inc., 8100 Ravines Edge Ct., Columbus, OH, 43235-5436, USA.

Acknowledgements

We gratefully acknowledge grant support from the Jessie Ball duPont Fund, 225 Water Street, Jack- sonville, Florida, USA

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Biographies

Laurie Lycholm, M.D., is director of the ethics pro- gram for the medical school. She also has active roles as a traveling physician with the Cancer Out- reach programand as a member of the Brain Tumor Multi- disciplinary Clinic.

Mary Helen Hackney, M.D., is the director of Rural Cancer Outreach Program and travels regularly to

rural clinics. She is also part of the Breast Health Center and is involved in patient and physician edu- cation about breast cancer.

Tom Smith, M.D., is recognized nationally and inter- nationally for his papers on health services research. He is currently the director of the ASCO curriculum on palliative care and has focused his research on palliative care topics. He is a Project on Death in America Scholar.

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