RURAL CANCER

Challenges Abound in Rural Cancer Care

People who live in rural areas of the United States face many impediments when it comes to being screened and treated for cancer—economic hardships, lower access to care and fewer, if any, specialists.

Some rural areas cannot provide cancer treatment or diagnostic screenings locally. “In Appalachia where we are, some counties don’t even have a hospital,” said Electra Paskett, a professor of Cancer Research at Ohio State University. “There are a lot of long distances and geographic barriers that impede their way to services—washed out roads, bad mountain roads, dirt gravel roads.  Now gas prices add to the problem.”

“Rural people have lower incomes,” Paskett added. “Rural people are also less likely to go to the doctor until something is really wrong. And they are less likely to practice healthy lifestyle habits that are attributed to cancer prevention.”

But the overall reality of rural cancer isn’t entirely bleak. Telemedicine is bringing both cancer screenings and treatment to remote areas. Mobile screening programs are taking off across the country. And support services for rural cancer patients are growing, taking place in local groups, sometimes enriched via teleconferencing with larger hospitals and research centers.

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Getting Cancer Screenings to Rural Patients

by Candi Helseth

A doctor and a patient are each proving that one person can make a difference in the fight against cancer.

Understanding the importance of early detection in cancer treatment, Dr. Thomas Moody in Birmingham, Alabama, and Pat Sitzes in Brackettville, Texas, have worked to improve cancer detection by bringing cancer screenings to their areas. Sitzes, a breast cancer survivor, mobilized a San Antonio hospital 120 miles away to bring mammography screenings to her small town in west Texas. After learning that the National Prostate Cancer Coalition had named Alabama as one of five states with the worst prostate cancer screening and death rates, Moody involved his partners at Urology Centers of Alabama in a regional effort to offer free prostate cancer screenings.

In Kinney County, where Sitzes lives, women traveled 60 to 80 miles round-trip to the nearest mammography facilities. The county’s 3,342 residents are predominantly Hispanic and 20 percent of the county falls within the poverty level.

“A lot of the people in our area don’t even really leave this area and I knew these women weren’t having mammograms,” Sitzes said. “There was also a lack of education about what they should be doing.”

Sitzes single-handedly campaigned to bring mammography services into the community. She formed a nonprofit organization, CHEER (Center for Health Evaluation, Education & Resources), and partnered with CHRISTUS Santa Rosa Hospital-Medical Center in San Antonio to send its mobile unit and staff to Brackettville. Eighty-one women were screened the first two times and 10 required follow up. The mobile unit will return to Brackettville again this November.

Sitzes organized a CHEER board of directors and engaged community members in her cause. CHEER sponsors public education on breast cancer and mammography, organizes an annual community public health fair, and raises funds to cover individual mammogram costs and follow-up for uninsured women.

Urology Centers of Alabama, where Moody is one of 17 urologists, is Alabama’s largest urology medical practice. Moody says they’ve been blessed in their work and they have an obligation to help more men get prostate cancer diagnoses before it’s too late.

“Alabama has a lower incidence of prostate cancer than the national average, yet it has the third worst death rate in the country,” Moody said. “That indicates that men aren’t being diagnosed in the early stages, when the cancer is very curable.”

Urology Centers has provided prostate screenings so far in seven rural Alabama counties. The counties have large rural areas, high populations of African Americans and have had high prostate cancer death rates. (Black men have more than double the death rate from prostate cancer, according to American Cancer Society statistics.) Urology Centers provides free prostate screenings at the counties’ health departments and in mobile units. It absorbs screening costs not covered by insurance and also provides follow-up care for men diagnosed with prostate cancer—even if they have no insurance.

Depending on the area where they live, from 11 to 15 percent of men have had abnormalities requiring follow-up, Moody said. “Men are also less likely to participate in health care and there are a lot of cultural issues that contribute to their lack of participation, so we’ve had to do a lot of education about prostate cancer and the importance of screenings.”

This year, Urology Centers increased its screening outreach after receiving a $50,000 grant from the Alabama Department of Economic and Community Affairs. Moody has also lobbied the Alabama Legislature, which allocated $100,000 to expand screenings in 2009. Moody says their urology practice alone can't screen the entire state.

He is also working with the National Prostate Cancer Coalition (recently renamed ZERO - The Project to End Prostate Cancer) to get federal funding approved for screenings and research. Federal funding for breast cancer research is almost twice that of prostate cancer research, he said.

Rural people less likely to be screened

The advantage of cancer screenings has been very well established with certain cancers, according to Robert A. Smith, Ph.D., director of the American Cancer Society Cancer Screening Division. “Breast cancer screenings in women 40 and over, colorectal screenings for men and women 50 and over, and cervical screenings beginning around age 21 have been proven effective by research. There hasn’t been conclusive research conducted with prostate cancer screenings to prove effectiveness because it takes a number of years to complete these studies. We expect to have results on prostate screenings within two to five years.”

Providing screenings requires a certain infrastructure, such as mammography equipment for breast cancer screenings, and specialists who can interpret the exams. “Once again, greater distances, especially in frontier areas, lower volumes, and shortages of physicians and staff can make access difficult,” Smith said.

Rural residents are also less likely to engage in preventive screenings, according to Electra Paskett, Marion N. Rowley Professor of Cancer Research at Ohio State University. In studies done of breast and cervical screenings, which are the most common screenings, rural women—particularly those in minority groups— were less likely than urban counterparts to have these screenings, Paskett said.

“Rural America has more low-income residents and higher numbers of residents without medical insurance so from an economic standpoint they are less likely to participate,” Paskett said. “There are also other factors—cultural issues, lack of accessibility, geographic barriers and other influences that are more predominant in rural areas.”

Sitzes said it took dogged persistence and networking to bring mobile mammography to Brackettville. “I was relentless. I couldn’t find funding for our county and the big city hospitals thought we were too far away. But as I learned the ropes and met the right people in health-related circles, the doors finally started opening. In my eyes, really rural areas like us are the ones that need help more but it’s hard to get it.”

Reaching out across rural barriers

Cancer organizations are actively working to better understand how to reach rural, at-risk populations, improve accessibility and educate Americans about the importance of screenings. Team Up, a partnership between the ACS, National Cancer Institute (NCI), Centers for Disease Control and Prevention, and the U.S. Department of Agriculture, targeted specific underserved populations in six states. More than 300 women who had rarely or never been screened have participated in breast and cervical screenings through the combined effort of these organizations.

NCI has funded the Appalachian Community Cancer Network to work on cancer-related health disparities with community cancer coalitions in seven Appalachian states. The Ohio region is working specifically with rural Ohio Appalachian populations, Paskett said, to address high rates of cervical, lung and colorectal cancers in that region. The effort also includes testing interventions designed to improve Pap smear screenings that detect cervical cancer.

Earlier this year, ACS announced a major three-year campaign to increase awareness of the importance of lifestyle factors in cancer risk, as well as the importance of early detection screening tests. ACS publishes a variety of early detection, screening and cancer check-up guidelines on its web site, http://cancer.org.

“From every perspective, even economically, it makes sense to diagnose early and cure early so the individual continues to be a productive citizen as opposed to treating that person for end-of-life care,” Moody said. “In terms of human suffering, what cancer does to the individual and family is truly immeasurable.”

RURAL CANCER

Telemedicine Revolutionizing Rural Cancer Care

by Candi Helseth

Telemedicine is helping more and more rural hospitals support and treat patients with cancer.

“Telemedicine is probably the most important development we’re seeing in rural areas, and I believe it’s going to revolutionize our access and delivery,” says Dale White, CEO at Horton Community Hospital in Horton, Kansas. “I think in the next five years, services like teleoncology will become as common as the computer.”

Working with the Kansas University Center for Telemedicine and Telehealth (KUCTT) at Kansas City, Horton Community Hospital has provided chemotherapy treatments in-house for the last 10 years. The 15-bed Critical Access Hospital and clinic serves a multi-county area of about 15,000 people.

Arizona’s telemedicine program is delivering medical services with real-time technologies to thousands of patients in 20 communities, according to Dr. Ana Maria Lopez, an oncologist and medical director of the Arizona Telemedicine Program at the University of Arizona in Tucson. Several of those services—among them telemammography, telecolposcopy and telepathology—contribute to improved cancer detection and treatment.

“Transportation, childcare and elder care with consequent lost wages are significant barriers for rural people to access care,” Lopez said. “These barriers are magnified with the increasing cost of gas. Teleoncology is cost effective for these patients and improves their likelihood of getting treatment. We estimate that just over half of patients in these very rural communities simply wouldn't obtain specialty treatment otherwise.”

Teleoncology benefits patients and providers

About one-third of the 3,000 rural Kansas patients receiving live interactive physician consultation services each year are being treated for cancer, according to Ryan J. Spaulding, director of KUCTT. Kansas began its program in 1991, and was one of the first states to initiate teleoncology services. Spaulding said patients have consistently rated the service highly.

Teleoncology allows rural hospitals to improve patient services and is cost-effective because patient charges for chemotherapy, pharmacy and diagnostic imaging are then billed locally, Spaulding explained.

“We can handle the diagnostic, lab and pharmacy work for cancer here,” White said. “Our nurse is certified to administer chemo. She’s the eyes, ears and hands here. Teleoncology brings Dr. Doolittle (Gary Doolittle, M.D., Kansas University oncologist) physically into our facility.”

Patients benefit from their local physician’s capability to interact directly with specialists during teleconsultations, Lopez said. For instance, Mariposa Community Health Center in the small border town of Nogales serves a primarily poor, Hispanic population. The Center offers cervical (Pap smears) and breast cancer-screening exams as part of its women’s wellness services. When Pap smears are abnormal, Mariposa physicians perform a colposcopy exam and the digital images are transmitted instantaneously to the Tucson office. Lopez then works directly with the local physician and the telemedicine team to address the patient's specific needs.

“After the tissue is reviewed (telepathology) or the digital images are reviewed (telemammography or telecolposcopy), a report is returned to the referring clinician,” Lopez explained. “In addition to these store-forward teleconsultations, real-time teleconsultation in cancer care can take place. These teleconsultations can include evaluating the patient's entry into cancer clinical trials, second-opinion telemedical oncology treatment guidance, telesurgical oncology pre- and post-operative evaluations, urgent side-effect management teleconsultations and follow-up cancer teleconsultations.”

With real-time teleconsultations, patients are scheduled to meet directly with a specialist for a telemedicine clinical exam. The technology facilitates the performance of an actual physical exam from a distance, Lopez said.

Patients at Horton Community Hospital appreciate having chemotherapy treatments close to home, White asserted. “We’re not going to be able to get an oncologist on staff in an area this rural and people here know that. But patients come to our hospital and get a face-to-face visit and treatment with an oncologist. They establish an ongoing relationship with that doctor.

“That screen melts away pretty quickly for those patients,” White said.

RURAL CANCER

Support Services Enhance Rural Cancer Care

by Candi Helseth

Using grant money from national foundations as well as money from their own pockets, volunteers and researchers are helping rural cancer patients get the support they need.

With grant monies from the Susan G. Komen Breast Cancer Foundation, Dr. Ana Maria Lopez directs ¡VIDA! Breast Cancer Education for Survivors & Providers via Telemedicine, an effort to educate and involve rural Arizona women diagnosed with breast cancer. The program was established as a partnership with seven rural communities; educational topics are developed for both the public and professionals.

"We’ve involved the communities by having partnership groups identify educational topics of interest for their communities," Lopez said. “We took this breast cancer education throughout the state and in areas where we have high minority groups and delivered it in a bilingual format. Participants loved it because they got to ask questions directly and have direct access to faculty doing state of the art work in breast cancer. In some of these communities, we only had 10-15 people but they still get the benefit of the distance education program. If they missed a session, they could review the session via the Internet or request a DVD."

Local American Cancer Society (ACS) affiliates also provide support services. Jean Siemers, who lives in Calhoun County, West Virginia, was diagnosed with breast cancer 15 years ago and had a recurrence in the other breast three years ago. She is active in Reach to Recovery, an ACS program that puts breast cancer survivors in touch with recently diagnosed women.

Siemer’s husband, Burl, drove her 80 miles each way to Charleston for six months of chemotherapy after each of her diagnoses. Burl is among “a handful” of drivers volunteering for the local ACS Road to Recovery program. Volunteers donate their time and use their personal vehicles to transport patients; ACS reimburses them for mileage, but Burl doesn’t turn in his mileage.

“It’s just something I can do for people,” Siemers said. “I made eight trips with one boy. He had no family to take him. Another lady didn’t even own a car. There’s a guy in the next county over who does driving too. But I had to take him when he went to get a melanoma off his shoulder because he was afraid he wouldn’t be able to drive home. He and his wife both have cancer. She was too sick to take him.

“Mostly our people are low-income and mostly retired,” he said. “It’s good, clean country living here, but long driving when you need more than the local hospital.”

Pat Sitzes’ personal experience with cancer awakened her to the lack of support services in her community. So the speech pathologist quit her job to take on a new role as cancer champion in Brackettville, Texas, where the Sitzes live. Sitzes formed a nonprofit organization, CHEER, and organized a cancer support group, which just marked its sixth year.

“We people in rural areas are already at a disadvantage because most of our treatment is going to be somewhere away from where we live,” Sitzes said. “If you’re the patient, you better learn everything you can and be part of the process of helping yourself.”

Some Facts About Rural Cancer There appears to be little difference in the cancer incidence and mortality rates of rural and urban populations, with the exception of cancer staging. There is evidence to suggest rural populations are diagnosed at a more advanced stage of cancer.1 Only limited data are available to assess cancer incidence, cancer prevention behaviors and cancer-related mortality within rural populations. Cancer registry data, both at state and national levels, are not represented by metropolitan areas versus nonmetropolitan areas.1 Data for specific cancers and for specific rural areas show that: the death rate in rural Appalachia for all cancers is higher than all of Appalachia, and it is significantly higher than the national cancer death rate1 skin and lip cancer mortality rates are higher in rural areas and may be attributed to increased sun exposure of rural residents, particularly among farmers1 the rate of colorectal cancer among men tended to be lower among those who resided in rural areas2 Sources: “Cancer in Rural Areas: A Literature Review,” Annie Gosschalk and Susan Carozza in Rural Healthy People 2010. “Rural/nonrural differences in colorectal cancer incidence in the United States, 1998-2001,” Steven S. Coughlin et al., Cancer, 107, S5, 2006.

Considering the “D” word

Last spring, I talked about the prospects of a national, or even, global recession. At that point, the smart money was that a formal recession, two consecutive quarters of declining GDP, was possible but not necessarily probable.

Today, the specter of an actual depression, the dreaded “D” word, is fast becoming a haunting reality. “This is terrifying,” economist Paul Krugman asserted during a recent news conference, after he received the Nobel Prize. “I had never thought that, in my lifetime, I would see anything that resembled the Great Depression, but this in fact does.” A Wall Street insider looked at the recent carnage and observed that our current economic situation is the “… financial equivalent of the Reign of Terror during the French Revolution.”

Are these calls of alarm unwarranted hyperbole? Are we likely to revisit the bleakest days of the last Great Depression? Might we see once again vast armies of dispossessed farmers migrating in search of new opportunities, much as the Okies from the Great Plains wandered toward unfulfilled promises in California in the 1930s? Could we possibly see rural banks fail by the hundreds, or even thousands, with small towns literally evaporating as if they had never existed? Such images are apocalyptic, but are they at all possible?

If there are any parallels with the Great Depression, we might expect to see rural devastation. Banks in rural areas are often semi-independent, with no one to bail them out. As credit dries up, farmers cannot get loans and small, vulnerable businesses will struggle and go under. There is a smaller margin for error.

Recent headlines are not comforting. In a few short days, the world’s biggest insurer, two of the world’s biggest investment banks and two behemoths of the mortgage industry either failed or were rescued from imminent collapse. Together, these firms had theoretical assets totaling some $4.3 trillion.

The stock market has been on a nerve-shattering ride. In one October week, investors lost $2.5 trillion in wealth. During that week, the Dow dropped over 18 percent, very close to the textbook definition of a market collapse—a 20 percent decline in a matter of days. In the year since the Dow hit its all-time high, well over $8 trillion in wealth has disappeared. Moreover, there is a feel of emotions run amok in the markets, leading to wild gyrations. In one day, the trading range on the Dow was over 1,000 points.

If Wall Street and Main Street were not connected, the fate of traders might not concern rural America all that much. We live, however, in an interconnected world. The smart money is that the economic crisis will worsen and affect us all. The Wall Street Journal now reports that 52 economists surveyed generally agree that the U.S. economy will contract over the next three quarters, something that has not happened in many decades. The probability of a recession over the next year is put at 90 percent, about as certain as you can get in an uncertain world.

All this uncertainty means fewer jobs. Payrolls contracted by 169,000 in September alone, and by some 760,000 since the beginning of the year. The unemployment rolls have grown to 9.5 million, the highest total since 1992. In addition, over six million workers were involuntary part timers in September, the highest number since 1993. These numbers are expected to get worse, much worse.

An interconnected economy means that the effects of problems in the United States find their way around the world. Take Ireland, for example. Last year, economic growth was in the 6 percent range. For 2008, the prediction is that the Irish economy will contract by 1 percent, at a minimum.

What happened? Greed, enflamed by a relaxed regulatory environment, led to unwarranted risk taking. America went on a borrowing binge. We assumed ever rising housing prices and borrowed and spent based on that clearly false premise. A whole financial system abetted and enabled this fairy tale through easy credit and subprime loans. Quickly, two critical dimensions of any sound financial system failed—transparency and trust.

At the same time, the risk to those making easy credit available was not fully appreciated. Through a set of inscrutable instruments, financial institutions thought they could protect themselves against potential downside risk. But no one really understood how these risk protection instruments really worked. That is, there existed a lack of transparency where people could understand what was going on. Eventually, as it had to, it all unraveled. Housing prices have fallen by a quarter and will likely fall another 15 percent, at least.

As things unraveled, the issue of trust became paramount—this is the key connection between Wall Street and Main Street. Financial systems did not know how much each other’s assets were really worth. As a consequence, trust across institutions congealed along with credit flows. Big loans and small loans slowed, even stopped. Businesses and individuals had more trouble getting what they needed to keep going. If this continues, the economy will slow, then stop, and the apocalyptic images of the Great Depression will become a reality.

But will this come to pass? In the last Great Depression, government was hobbled by ideology and impoverished economic theory. The dominant laissez-faire attitude inhibited public response. And when governments acted, they did the wrong things, restricting the money supply when it should have been expanded. Moreover, each government acted alone, raising tariffs to protect their own, which further constricted trade and economic activity.

Today, we easily look to governments for a response, and action is coordinated and worldwide. Even in the United States, we are nationalizing financial institutions, if only partially and temporarily, with little outcry. In Europe, they are pumping $2.3 trillion of liquidity into their banking systems (about ten times our investment).

Will all this work? I don’t think we will see the Great Depression revisited. But we will experience great pain for our past excesses. Hopefully, the financial and economic system that emerges from this crisis will be based on the two Ts. It will have transparency and be based on realistic trust. After all, we are all in this together.

Tom Corbett has emeritus status at the University of Wisconsin-Madison and is an active affiliate with the Institute for Research on Poverty where he served as Associate Director. He has worked on welfare reform issues at all levels of government and continues to work with a number of states on issues of program and systems integration.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Professor Corbett welcomes your feedback. Comments and reactions can be sent to: Corbett@ssc.wisc.edu.

Recession, Health and Health Care

This is being written a week after the $700 billion financial rescue was adopted in Washington. It is unclear whether we are headed for economic bad times, or really bad times. Prognostications range from a recession of the sort we have every decade or so, to a worldwide depression resembling that of the 1930s. Knowledgeable guessers seem to foresee an episode between these two limiting cases. What will the coming months mean for health and health care?

At the moment, from the point of view of most hospitals, clinics and families, we are in the “ordinary recession” mode. Rising unemployment has made more people eligible for Medicaid at a time when state tax revenues are falling. Most states are already struggling to meet their Medicaid bills, shaving and delaying payments. Clinicians across the country tell me their facilities are seeing increasing numbers of people who have lost their jobs and their insurance, i.e., “self pay/no pay” patients. Caring for these folk who can’t pay will increase the costs that facilities try to recover from private insurers. This, paired with Medicaid payment problems, will increase cost shifting, raise medical bills and push up premiums at a time when employers who help buy insurance for their employees are facing hard times. Some employers will cancel their employees’ insurance plans, putting additional pressure on health care facilities, not to mention patients. Some hospitals and clinics will close. Unfortunately, essential low-margin primary care facilities are the most vulnerable, while high-end referral facilities such as clinician-owned imaging facilities have ample margins and reserves. General medical and primary care facilities that must treat all comers will move to join and combine, while high-profit single service providers such as surgical specialty facilities will move out on their own. Medical bankruptcies will surge.

Some other adaptations, constructive and destructive, are likely, even in this “ordinary recession” scenario. More people will be trying to care for themselves and their families without seeing clinicians. Sales of dietary supplements and over-the-counter remedies will surge. We’ll see increased experimentation with lower cost ways to get health care advice, searching the Internet or e-mailing the clinic. Gardening is expanding in our community. All sorts of stress-related problems from heart disease to spouse abuse will become more common. Home extraction of decayed, painful teeth, always in the background in some poor communities, will increase as will human consumption of commercial pet food. All this is likely in the “normal recession” scenario. We’ve experienced it all before.

It is much harder to know what to expect if the recession approaches, even remotely, the severity of the Depression of the 1930s. All of the consequences of ordinary recession, discussed above, are likely, but will be more widespread and intense. It may be worth considering the consequences of the Depression in trying to guess what the “super-recession of 2009-10” might produce, though we can’t learn much about health policy. Health care was moving from “likely to be damaging” to “likely to be helpful” in the late 1920s. Health care counted for little, either in health or the economy. During the Depression years, though, the idea of pooling risk and payments in health plans spread from isolated experiments to established programs.

It seems that Americans value self-reliance when things are going well, and welcome protection when times are scary. In the United States these protections in the 1930s took the form of social safety net programs such as Social Security, publicly funded jobs in construction and the arts, and heavy regulation of banking and finance. It seems that political resistance to rapid change and expanding government weakens at such times.

In contrast to the 1930s, health care now makes up about one-sixth of the economy, is widely perceived as failing to meet public needs, operates outside the market rules that generally guide other sectors of our economy and is growing at an unsustainable rate. Health care seems likely to be a focus of attention if we start doing serious reconstruction of our economy.

Other modern countries have devised many models for managing and paying for health care. I’ll not presume to choose among them in this brief, publicly funded space. But I would point out that no aspect of health reform is more important or politically difficult than building constraints on cost expansion. Because health spending grows more rapidly than the rest of the economy even in good times, health cost escalation has overwhelmed attempts by several states to make health care more equitably accessible.

A deep, prolonged recession could be a time of frightening misery and opportunity.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Dr. Myers welcomes your feedback. Comments and questions can be sent to him at myers@raconline.org.

IT Project Connects Rural Louisiana Hospitals

by Candi Helseth

As Hurricane Katrina ravaged Louisiana, its fallen residents landed in clinics and hospitals long distances away from their homes. Many rural health facilities were destroyed and harried hospital staff in the overwhelmed, still-functioning facilities lacked access to patients’ medical records. The catastrophe underscored the need for electronic medical records, said Linda Welch, executive director of the Louisiana Rural Hospital Coalition (LRHC).

“There were unresponsive patients that came in with a sticky note attached to them that just had their name on it,” Welch elaborated. “There were patients with chronic diseases who weren’t able to communicate or who didn’t even know what medications they were on. Most of our hospitals had safeguarded their records but when a patient was transported to another facility, that facility often had nothing. It was a real nightmare, but it should never happen again.”

Gaps like that are being rectified through the formation of the Louisiana Rural Health Information Exchange (LARHIX), an information technology project bringing together 24 rural hospitals and the Louisiana State University Health Sciences Center at Shreveport (LSUHSC-S), which serves as a tertiary-care site for the rural network.

LARHIX’s system provides access to patient records electronically so they are easily available from any site in the event of another disaster, Welch said. Rural primary care physicians are able to consult and share patient records with LSUHSC-S specialists. LSUHSC-S physicians can also examine and treat patients from their Shreveport offices, using telemedicine technology. The LARHIX five-year plan includes adding pharmaceutical records, laboratory histories and other patient information to the exchange.

“We have made phenomenal strides in connectivity, doing in a year what’s taken others at least four to five years,” Welch said. “I think this is going to be one of the most exciting and best things Louisiana’s rural health care has ever done. Governor (Bobby) Jindal and our legislature funded the project all with state money. He is a godsend to rural Louisiana. Without his help, we would still be looking for grants and funding sources.”

During the 2007 Louisiana Legislative session, an initial $13 million was approved for LARHIX. Last year the Legislature appropriated an additional $18 million. The project will connect all 24 rural hospitals from central Louisiana to the Shreveport medical center.

The integrated system will allow health care professionals to access patient data from multiple hospitals at any time and from anywhere within the system. Welch says the completed system will have several benefits: rural patients will receive specialized health care in their own communities, travel time for both patients and physicians will be reduced, chronic disease will be better managed through streamlined information sharing, the state will realize savings due to reduced duplication of services and future catastrophic situations will be better managed because of the common information accessibility.

“LSU is a major teaching hospital with cutting edge technology that follows disease management protocols and utilizes quality indicators that far exceed current quality standards,” Welch said. “Their partnership with our rural hospitals will bring specialized medical care and quality standards to our rural patients. Dr. McDonald (John McDonald, LSUHSC-S chancellor) plans to do general internist and student rotations in these rural areas. This project is revolutionizing health care for our rural patients.”

To date, all 24 hospitals have been equipped with the telemedicine equipment and a web site has been created for initial document and information sharing. The rural hospitals’ systems will have some unique characteristics meeting their specific needs, yet all systems will share commonalities that ensure seamless interaction throughout the state. Integrated software will be identical for all users.

The new technology is phenomenal,” Welch noted. “I’ve talked to some of our rural physicians and they say the electronic X-rays have better magnification than the equipment they’ve been using in their hospitals.”

Staff at DeSoto Regional Hospital at Mansfield, a 57-bed facility, understands firsthand the difference that kind of information can make. De Soto, which was outside of Hurricane Katrina’s path, took all the patients from a hospital shut down by the hurricane’s forces.

“There was no LARHIX at that time and I can’t stress enough how valuable LARHIX will prove in the event of another hurricane or disaster,” Assistant Administrator Crystal Burns said. “We are continuing to improve our disaster preparedness team and plan in the event we are needed to help in another disaster. However, with LARHIX, we would have been able to more easily access patient information. We would also have been able to discuss patient care issues with the patients’ doctors through telemedicine.”

Welch said the coalition also plans to add infrastructure to expand treatment for chronic diseases such as cancer, improve stroke treatment in rural areas, implement preventive care strategies, and expand the teaching or referral sites to include other major tertiary sites in addition to LSU. LARHIX “is like a dream come true,” Welch concluded.

For more information, contact Jamie Welch, LRHC Chief Information Officer, by phone: (225) 389-9429, or by email: jwelch@larhc.org.

AROUND THE COUNTRY

Mobile Unit Brings Cancer Screenings to Native American Women

by Candi Helseth

While mortality rates among Caucasian and African American women were declining in the last decade, mortality rates were increasing among American Indian women living on reservations in the Midwest. The Indian Health Service (IHS) at Aberdeen, S.D., is working to reverse this trend by providing a Mobile Women’s Health Unit, which travels to remote areas on American Indian reservations in South Dakota, North Dakota, Nebraska and Iowa.

“Breast cancer was being caught late in the disease process and had metastasized to other organs so women (there) were dying at a higher rate,” said Willeen Druley, Women's Health Consultant at IHS. “We knew we needed to get them earlier detection.”

Since beginning the mobile service in March 2006, about 2,200 women have been screened. The mobile unit regularly travels to 19 reservation locations in the four-state area, providing mammography services at no charge; the unit also provides Pap smears and bone density tests. Druley said mammography services aren’t available in these areas and lack of transportation or other socioeconomic factors prevent these women from traveling to cities where mammography is offered. Reservation health centers’ limited funding rules out installation of mammography technology.

“The clinics and service units in these areas do work very closely with us,” Druley commented. “They advertise the mammography on radio and through posters. And the women’s appointments are scheduled through the service unit.”

The mobile units are equipped to transmit digital mammography images through a commercial satellite service. IHS works with the University of Michigan Health System's Division of Breast Imaging, which was awarded the bid for providing radiologic assessment of the digital images. With digital technology, an electronic X-ray detector converts the breast image into a digital picture that can be more quickly transmitted via satellite. The University’s radiologists interpret and report their findings within 30 to 50 minutes of the mammogram results being delivered to them, allowing patients who require follow-up to be scheduled for a second mammogram or related follow-up while the mobile unit is still in their area.

Druley participated in a research study of the project that confirmed digital mammograms could be transmitted rapidly by satellite without loss of image quality, even though the images are very large. The study also indicated that patients were very satisfied with the care they received, Druley said.

While statistics are not yet available on whether or not the incidence of breast cancer mortality is declining in these areas, mammography results in 2007 were comparable to the general population, with about .4 percent of the women having abnormal mammograms.

“We are doing screenings only,” Druley stressed. “We’re not doing diagnostic work with the mobile units. The screenings are for women (over 40) who haven’t presented with any problems or who are 40 and need baseline screenings. If a woman has an obvious breast lump, she is sent out.”

Women with abnormal mammography results are referred back to their local service units or tribal health facilities for follow-up. Women diagnosed with breast cancer receive necessary surgery and oncology treatments, regardless of their ability to pay. The continuum of care ensures that women who are diagnosed earlier by mobile mammography receive appropriate treatment while the cancer is still in the early stages.

For more information, contact Willeen Druley at Indian Health Service, (605) 226-7387.

Theresa Chan, M.D., creator of Rural Doctoring

Theresa Chan, a family practice physician in rural northern California, began her Rural Doctoring blog in May of this year to record the “small triumphs and everyday drama of making a living in medicine.”

In her first post on May 15, Chan stated, “Perhaps I can't hold onto their every exact detail, but I can prevent their essence from escaping by the simple act of writing them down.”

Since that first post, thousands have read her musings on premedical education, doctor fatigue, physician compensation and rural life. Chan, who has helped deliver almost 500 babies, has recorded some of her more memorable birthing experiences in her ongoing Birth Stories series. She has also written a series of postings on Becoming a Rural Doctor, which examines training options for prospective rural physicians.

Chan concedes that there are already many good, existing medical blogs, but “What is missing is the voice from small-town doctors such as myself, who are struggling with policy failures in rural settings in which clinical services and political advocacy are severely limited.”

Chan was trained at Stanford and UC-San Francisco, did her residency in the rural Central Coast and moved to the far northern part of California in 2004 because she wanted to practice medicine in an underserved area. She worked as a primary care physician in a clinic there until early 2008, when she became a hospitalist.

In her spare time, other than writing for her blog 12-15 hours a week, Chan enjoys fiber arts, going to the theatre and reading Shakespeare. She and her partner live with four cats and a dog.

Why did you want to work in a rural area?
I lived in San Francisco between 1992 and 2001, during the tech boom and watched the area transform from a quirky small metropolis to a really fast-paced, competitive, crowded network of city and suburbs. I didn’t like the change and I didn’t want a lifestyle of traffic, looking for parking, road rage, etc. So I decided to move to a smaller community.

What do you like most about living in northern California?
I like the cool, coastal climate and beauty of the unspoiled landscape. I love the easy commute I have to my job and general absence of the plagues of urban life (parking problems, dense housing, edgy fast-paced lifestyle).

Sometimes the distance to any major metropolitan area feels a bit oppressive. Every so often I have to get back to San Francisco or take a big trip to widen my perspectives again.

What prompted you to create your blog?
I used to write a blog when I was a resident but let it lapse when I started my first job. There were too many competing demands upon my time and energy to keep the blog going.

After I’d been here for a while, I missed writing and I also felt a bit isolated. I have really great colleagues up here, but none who are terribly interested in writing, as I am. So I started Rural Doctoring as a way to share experiences and plug into an online community of like-minded health professionals.

Was there any discussion of blogging in medical school, among students or even in classes?
Not really. I graduated from medical school in 2001, and the blogging community has really evolved/expanded since then. During residency none of the other residents kept a blog, and not many read blogs.

I think blogging could be much more of a resource for young doctors, just as it has been for me, working in a rural community. Blogging has helped me feel less isolated and is helping me bring a lot of useful information and perspective to my day-to-day work.

Do other doctors write to you in response to your blog, and have you met any doctors who read your blog?
Yes, there’s a whole community of blogging doctors/nurses. We chat on Twitter, a social media site, and in the chat room at the weekly Doctor Anonymous Show (hosted at BlogTalkRadio, an internet radio site). We also find each other through Grand Rounds, a blog carnival roundup of recent posts by medical bloggers.

I haven’t met anyone in person, but I do have a number of rural doctors who read my blog and we chat in comments. It would be nice to have a rural medicine online forum but there would be a lot of work involved running it. An in-person meet-up would be nice but my experience with scheduling doctors has taught me it is almost impossible to get everyone free on the same days. An online forum might be nice for people to query/rant about small-time life. If you need a housekeeper, do you hire a patient or a friend of a patient? How is telemedicine working out in various communities? What are the politics like in the medical community where you live? Questions like that.

Running a forum is a BIG commitment, so I have no plans to start one although it might be a nice idea for the future.

How do you think most people have discovered your blog?
Links from other blogs. Doctor Anonymous linked to me within a few weeks of my blog launch, then KevinMD linked to me regularly after a while. I’m getting more hits from Google searches now, but not many.

How do your patients react to your blog?
Believe it or not, I'm not aware of any patients who have read my blog. I've made a policy of neither promoting my blog locally, nor trying to hide behind anonymity. My co-workers at the hospital, especially those involved in childbirth services, are beginning to be aware of the writing I'm doing on the blog, but that's about it.

Why did you decide to become a doctor?
It wasn’t until I was 23 that I started thinking about being a doctor. My childhood goal was to be an author, then I majored in psychology and considered being a clinical psychologist. (I wrote about this in my October 7 posting, Premedical Education, the Long Way, Part 1.) Then I discovered an interest in biopsychosocial models of human illness/wellness, which made me think, “Hmm, maybe a science background would be useful after all.”

What’s a typical workday like for you?
I don’t have many typical days, unfortunately! I spend every other week at the hospital, making rounds on inpatients and doing H&Ps [patient histories and physical examinations]. Half of these hospitalist days are daytime (7 am to 7 pm) shifts, and half are nights (7 pm to 7 am). I often overlap hospitalist responsibilities with OB call, so some days I’m there for both laboring women and inpatients. When I’m on night shifts, I try to squeeze in an afternoon prenatal clinic just to make efficient use of my day. Sometimes I wish I had a more reliable schedule but then again, I also like variety, so it is a tradeoff.

What is your favorite part of being a doctor?
It is NEVER boring! There is always something interesting going on, either an interesting patient (some people have amazing stories to tell) or an interesting clinical case.

— Interviewed by Beth Blevins

RAC Maps: Interactive Research

by Aubrey Madler, RAC Information Specialist

Are you looking for a quick visual for your presentation? Do you need to find out where a Critical Access Hospital is located in relation to where you are? Then RAC Maps—national maps on rural health and human services topics—are the perfect tools for you.

What can RAC Maps do for you?

• Strengthen your grant application with customized visual data
• Enhance a proposal, report, or presentation on a health and/or human service issue
• Augment your portfolio

Each map is available in a printable format and can also be customized for use in grant proposals and other publications.

You can customize any map by zooming in to show just your state or region. You can also choose to display county borders, locations of cities and towns, bodies of water, highways and Indian reservation boundaries, plus make other changes specific to your needs.

To learn how to use the customization feature, please see Custom Map Tips.

The Rural Assistance Center (RAC) provides these maps in partnership with RUPRI’s Center for Applied Research and Environmental Systems (CARES)—previously the Community Information Resource Center (CIRC).

Examples of entities providing map data include the Health Resources and Services Administration, the U.S. Department of Health & Human Services Child Care and Development Fund, Centers for Medicare and Medicaid Services, and the U.S. Census Bureau.

RAC Maps provide geographically represented data including:

Locations of

• Child Care Providers
• Critical Access Hospitals
• Frontier Counties
• Federally Qualified Health Centers
• Long Term Care Facilities
• Rural Health Clinics

Percentage of

• Population with Disabilities
• Population with a High School Education or Higher Educational Achievement
• Population 65 Years or Older
• Population Under 18 Years of Age
• Population without Health Insurance
• Deaths Among Medicare Enrollees
• Workers Using Public Transportation
• Minority Populations
• Hispanic/Latino Populations

Data on Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Populations

• Types of Dental HPSAs, Population Group, Single County and Geographical Area
• Type of Population that is within a Mental Health HPSA
• Location and Type of Population that is within a Dental HPSA
• Clinician Priority Scores of Dental HPSAs

More RAC Map Sources:

Maps Information Guide
As is customary for our guides, this page includes sections for Frequently Asked Questions, Tools, Maps, Documents, Organizations, Terms and Acronyms, Contacts and News Items. You will find sources of data and statistics, other web sites featuring maps and information about displaying data via maps.

Resources for All States Page
You will find links to state-level static and interactive maps for all states on topics such as food service programs and pharmacies on this page.

State Resources
The RAC web site also offers pages for each of the 50 states. Each state page includes a section on maps where you will find geographically-represented data specific to that state.

Customized Assistance
If you would like assistance in locating a map or building a custom map, please contact an information specialist at the Rural Assistance Center by e-mail, info@raconline.org, or by toll-free phone, (800) 270-1898.