(UroToday.com) The 2024 American Urological Association (AUA) annual meeting held in San Antonio, TX was host to the Society of Urologic Oncology (SUO) session Dr. Samuel Washington in his presentation talked about barriers and strategies to improve dissemination and availability of minimally invasive treatments to underserved populations with prostate cancer (PCa).
Dr. Washington began his talk by presenting a case involving a 67-year-old man diagnosed with Gleason 4+5 disease, PSA 13, and 5 out of 16 positive cores, with N0M0 status. This patient, uninsured but Medicare-eligible, was initially offered open radical prostatectomy at a safety net hospital. However, upon referral to an academic center, he underwent PSMA-PET, which returned negative results, leading to a robotic prostatectomy two weeks later. Dr. Washington emphasized the substantial variation in care between two hospitals located just 1.6 miles apart, underscoring how differences in resource availability significantly impact access to minimally invasive surgery (MIS).
He proceeded to discuss the well-known disparities in treatment influenced by factors such as socioeconomic status, race and ethnicity, English proficiency, and insurance coverage, all of which impact patients' access to MIS. In addition to patient characteristics, various other variables influence access to higher-quality care, as depicted in the graphic below.
Dr. Washington presented data from a systematic review by Mao et al., which assessed racial and ethnic disparities in the use of robot-assisted surgery in prostate, endometrial, bladder, and rectal cancer between 2001 and 2022.1 This study included 13 studies related to robotic-assisted surgery (RAS) and 23 studies related to minimally invasive surgery (MIS). They found that black patients were 33% less likely to receive MIS compared to white patients. Additionally, both black and Hispanic patients were 19% less likely to be treated at facilities with RAS.
He said there are two areas of improvement to improve access to MIS or RAS for underserved communities:
- Underserved communities defined by individuals and outcomes.
- Findings of previous studies focus on non-modifiable characteristics.
He mentions one strategy to improve care is by changing focus to systems change. In the real-world patients can not rapidly change insurance, residence, and education, also hospitals cannot buy new equipment or provide more resources, so we have to identify what processes/policies dictate where people receive care.
Dr. Washington discussed a paper published in JAMA that examined segregated patterns of hospital care delivery and healthcare outcomes. This cross-sectional study assessed US hospital referral regions (HRRs), focusing on hospitalization patterns for all non-Hispanic Black or non-Hispanic white Medicare fee-for-service beneficiaries with at least one inpatient hospitalization. They evaluated hospital segregation and its association with health outcomes at the HRR level. The study found that hospital segregation was highly correlated with residential segregation. An increase in hospital segregation was associated with a nearly 28% increase in acute hospitalizations, 15% more chronic hospitalizations, and a 6% increase in additional deaths in Black patients compared to White patients.2
The presenter discussed a strategy that improves and increases access to robotic and MIS. This clinical case should undergo revision with urology providers and the support of the department chair, the safety net hospital cases are now referred to academic hospitals. However, to be able to do this, there needs to be a systems policy change.
Patient-level factors, such as tumor characteristics, socioeconomic status, health-related behaviors, mistrust, and social barriers, can significantly influence access to and outcomes of healthcare. Similarly, policy-level influences can impact healthcare referral patterns, and compliance with state and national mandates can directly affect patients' treatment options. Both patient and policy-level factors contribute to disparities in access to minimally invasive surgery (MIS) and healthcare outcomes.
Dr. Washington concluded his presentations by leaving the following takeaways:
- Clinical outcomes are influenced by patient and regional factors.
- Patterns and policies in healthcare systems influence where and how patients are managed.
- To improve the availability of minimally invasive surgery we must work on:
- Removing barriers requires change in policy.
- Advocate for local vs national systems policy change
Presented by: Samuel Washington, MD, MAS, Urologist at University of California, San Francisco
Written by: Julian Chavarriaga, MD – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @chavarriagaj on Twitter during the 2024 American Urological Association (AUA) Annual Meeting, San Antonio, TX, Fri, May 3 – Mon, May 6, 2024.
References
- Mao J, Genkinger JM, Rundle AG, Wright JD, Aryal S, Liebeskind AY, Tehranifar P. Racial and Ethnic Disparities in the Use of Robot-Assisted Surgery and Minimally Invasive Surgery in Pelvic Cancer Treatment: A Systematic Review. Cancer Epidemiol Biomarkers Prev. 2024 Jan 9;33(1):20-32. doi: 10.1158/1055-9965.EPI-23-0405. PMID: 37870412.
- Lin SC, Hammond G, Esposito M, Majewski C, Foraker RE, Joynt Maddox KE. Segregated Patterns of Hospital Care Delivery and Health Outcomes. JAMA Health Forum. 2023 Nov 3;4(11):e234172. doi: 10.1001/jamahealthforum.2023.4172. PMID: 37991783; PMCID: PMC10665978.