Jacqueline Fannin: Thank you for having me, Dr. Joyce. Growing up in West Virginia, I knew a mile on the mountain was different than a mile in the interstate. So it goes back to the country roads song, right?
Daniel Joyce: Yeah.
Jacqueline Fannin: And I knew through my lived experience that travel distance was probably not represented correctly in our population based on those metrics.
Daniel Joyce: And so you looked at two different ways to calculate that geographic distance. Can you explain them as simply as possible to ... They're complex. So I want people who have no idea what we're talking about. Give me a breakdown of what those different methods are and how they differ.
Jacqueline Fannin: Absolutely. So those metrics we used was a centroid-based unit of measure of travel distance. It was not as the crow flies, which is just a straight-line distance from point A to the facility. It was a geo distance measure, which takes in consideration the curvature of the earth.
And I wanted to have that because as you all know, well, maybe not everybody, that West Virginia is very mountainous. And so I wanted to make sure it was closer to that than the actual as the crow flies. So the centroid-based measurement was based on that geo style of measurement.
Daniel Joyce: So not as the crow flies, but as the curvature.
Jacqueline Fannin: Right.
Daniel Joyce: Okay.
Jacqueline Fannin: So it's actually not as extreme as the crow flies.
Daniel Joyce: And then the second method was?
Jacqueline Fannin: Was just the actual travel distance from our patients.
Daniel Joyce: Typing into Google Maps or how did you get-
Jacqueline Fannin: Yes, absolutely. And so we did that and we compared the two and what we found was there was a 40% difference between those two measurements.
Daniel Joyce: And the Google Maps version closer distance than the other way of calculating the earth's hills?
Jacqueline Fannin: The centroid based?
Daniel Joyce: Yes.
Jacqueline Fannin: No, actually it was the opposite. The centroid based measurement underestimated the travel distance.
Daniel Joyce: Interesting. So how do we apply that then moving forward? What does that signify for future research looking at geographic distance in this patient population? Which should we use? I guess that's my question.
Jacqueline Fannin: What should we use? I think we should actually use the network-based because it's more representative of the actual distance. But with that measurement, we need to take in account the commuting activity between the facility and where the residents live. And so when we selected the RUCA codes, which are the Rural-Urban Commuting and Area Codes, those codes took that in consideration. And so with that network-based travel measurement and those RUCA codes, it was able to pick out those patients who are actually delayed with care.
Daniel Joyce: Gotcha. And is there a reason you focused on bladder cancer patients in particular?
Jacqueline Fannin: Yes, there was a reason because their care has frequent visits. They have to come in for surveillance and so that's why we selected these populations.
Daniel Joyce: Yeah. I do think it's a really interesting population to look at because as we look at, especially in the non-muscle-invasive bladder cancer space, the BCG-unresponsive space, we have a lot of different treatments now that all have different ways of giving that treatment and different time demands on the patient as well.
One thing that's been of interest to me is looking at the healthcare contact days of those patients. So how often are they interacting with the healthcare system? And we treat that as one day as burnt in their life if they have to interact with a doctor, but it is probably totally different if you're talking about somebody who's traveling from the hills of West Virginia versus somebody who's traveling five minutes to get to their care. Is there a better way to understand how much that travel distance is really impacting patients?
So for instance, traveling 30 minutes for one patient may be very different than traveling 30 minutes for another patient. Is there a way to assess that? Does it matter, do you think, or is it the geographic understanding their geographic distribution? How do you really interpret that data for the individual patient as you're seeing them?
Jacqueline Fannin: I'm glad you asked that question. So with this travel distance analysis, we also did a bladder cancer survey. And what we found was those who were more concerned about the transportation needs for their care, they were more anxious and more engaged in their healthcare and were actually more present during that healthcare management. They didn't have that delay in care that we saw just looking at that travel distance.
Daniel Joyce: Fascinating.
Jacqueline Fannin: So those two didn't match up, but when we looked at the Area Deprivation Index, I think it was more of an understanding of their care, which was also reflected into that bladder cancer.
Daniel Joyce: So explain that a little more. Why would the Area Deprivation Index impact their understanding of care?
Jacqueline Fannin: Well, the Area Deprivation Index takes into account the education within that geographic region, which matched with our areas that we were looking into for travel.
Daniel Joyce: So geographic location being a portion of the bigger puzzle of how we can deliver care better for those patients.
Jacqueline Fannin: Yes.
Daniel Joyce: So geography alone is not the whole picture. Certainly a piece we need to account for, but not everything.
Jacqueline Fannin: Yes.
Daniel Joyce: Really what we're getting down to is some of the indirect costs of these treatments. So we have the financial toxicity of a lot of these treatments. They're expensive, they pay a lot of cash for them. However, there is all the intangibles that impact their financial health also. Travel time being one of those.
It seems like using this geographic measure, is there a way we could implement it and understand it and use it in the clinic setting to understand how our patients can make decisions? So should their geographic location based on either one of these measures, should that influence their treatment decision-making in your opinion? Or is it something clinicians can use to inform their guidance of that treatment?
Jacqueline Fannin: Based on my understanding of how the clinic works, I think they've already tried to make sure that those patients who lived farther away had... They were scheduling them sooner based on my understanding. So they were being involved at that level in their treatment decision.
Daniel Joyce: Interesting. I think it really is a great area to focus on as we start thinking about how do we weigh the pros and cons of these seemingly equivalent treatments in bladder cancer. Is there a way we can present to patients the trade-offs of having a cystoscopy every three months versus every six months? Or getting a six-week treatment of BCG versus six weeks plus maintenance for three years? All these things that we need to bring into play for the patient.
And for some patients, as you mentioned, it may not matter as much as others. So understanding who those patients are where the indirect costs are going to matter, how do we screen for that with a measure that's easy to do and then incorporate that into our decision making, I think really is a huge area of need that I think your work is really helping to solve. So thank you and congratulations on the work.
Jacqueline Fannin: Oh, I forgot. There is an assessment, the prepare assessment that has a transportation question and it links it to an ICD-10 code and so you can see if they have transportation issues.
Daniel Joyce: So the ICD-10 code being a diagnostic code for their location?
Jacqueline Fannin: For their transportation burden.
Daniel Joyce: Wow. I did not know that. That's fantastic.
Jacqueline Fannin: So that's a tool, we haven't implemented it yet, but it's available, but it incorporates the workflow. It has to be incorporated in your workflow and you have to have social workers there to-
Daniel Joyce: Bill for it.
Jacqueline Fannin: ... bill for it and to provide something for that since you're recording it.
Daniel Joyce: And even more of an impetus to do that as we try to study it because claims-based research, we could use those codings to really understand the burden to patients better, but we're not going to be able to do that if clinicians aren't using it and recognizing that it's there. So that's hugely important.
Jacqueline Fannin: And we don't have the resources to implement even if we wanted to, because it would dedicate more social workers, I would imagine. I don't work on that side, but just on my side of things, just to look at the data, collect the data, I wouldn't have enough time to-
Daniel Joyce: Absolutely.
Jacqueline Fannin: ... focus on my other things.
Daniel Joyce: And maybe we have the technology now to be a little bit better at integrating that into the workflow.
Jacqueline Fannin: Yeah.
Daniel Joyce: So that's exciting. Well, really, really great work. Congratulations again and I look forward to seeing what you do next.
Jacqueline Fannin: Thanks.