Centralization of Cancer Care: Implications for Access, Outcomes, and Disparities

Project Summary In recent years, cancer treatment has dramatically shifted towards a centralized model of care, whereby patients receive complex treatment at regional referral centers. Centralization is associated with improved outcomes for the patients who receive care at high-volume regional referral centers, which are generally better resourced and more experienced than other centers. However, there is concern that patients who do not receive care at these centers, but instead go to non-regional referral centers, suffer worse outcomes due to decreased volumes at those hospitals, leading to lower quality. Moreover, to the degree these patients who are "left-behind" represent traditionally underserved patients (i.e., sociodemographic groups that have long experienced health disparities such as racial and ethnic minorities, low-income individuals, and rural residents), the trend towards centralized care may inadvertently widen disparities in outcomes, worsening care for those patients left behind. In our parent R37, we are using state-level discharge data linked to cancer registry data in New York and Pennsylvania to directly examine this critical issue, defining the effects of centralization at the population level and the degree to which centralization is widening health disparities. In this R37 extension, we propose to expand our current work by directly examining the added effects of the COVID-19 pandemic on the centralization of cancer care and outcomes. The COVID-19 pandemic upended cancer care delivery, forcing hospitals to make difficult decisions about how to best maintain access while also conserving resources and protecting health care workers. The pandemic also accelerated the adoption of telemedicine, a key strategy for expanding access to specialized care. More specifically, it is likely that the pandemic also affected centralization trends, given that well-resourced hospitals were likely better equipped to handle external stressors, a concept known as "organizational resiliency". By examining the effects of the COVID-19 pandemic on cancer care through the lens of organizational resiliency, this work will provide new tools for hospitals and health systems that can help preserve access to cancer care during times of disruption, whether that be another pandemic or other stressors. In Aim 1, we will identify organizational strategies employed by referral and non-referral centers to maintain high quality cancer care delivery during the pandemic. In Aim 2, we will examine cancer outcomes and organizational resiliency during the pandemic. Findings from this proposal will add to the lessons learned from the COVID-19 pandemic, which will better prepare hospitals and health systems to provide quality and timely cancer care during times of future disruptions, such as other pandemics, provider shortages, hospital closures, and natural disasters.