Society for Surgery of the Alimentary Tract
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Joel T. Zimmerman*1, Shawnda Schroeder1, Hilla I. Sang2,3, Sabha Ganai1,2,3
1University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND; 2Sanford Medical Center Fargo, Fargo, ND; 3Sanford Research, Sioux Falls, SD

Introduction: Mortality-to-incidence rate ratio (MIR) is a measure for evaluating cancer control programs and access to care. Little research has been done to explore the facilitators and barriers to colorectal cancer (CRC) care including travel factors, health behaviors, and preventative measures faced by rural populations. The objective of this study was to explore the differences in spatial and aspatial factors between residents of high and low MIR counties in North Dakota (ND), a rural state with high mortality from CRC.

Methods: An ecologic cohort study was conducted at a population level in ND using data from the ND Statewide Cancer Registry. After analyzing MIR by quintile, we identified 11 high ("hot-spot") and 11 low ("low-spot") MIR counties. We then created a questionnaire exploring demographics, health behaviors, travel factors, and healthcare mistrust using several validated instruments. Surveys were mailed by random sampling to residents of hot-spot and low-spot MIR counties. Rurality was defined by USDA Rural Urban Commuting Area (RUCA) code 4-10 via zip code of residence. Nonparametric statistical analyses were conducted to perform comparisons between respondents from the two populations.

Results: Respondents from hot-spot counties (n=17) were more likely to make less than $50,000 annually (64.7% vs 18.8%, p<0.05), less likely to have a bachelor's degree or higher (17.7% vs 82.4%, p<0.001), and were more likely to be a rural resident (100% vs. 70.6%, p<0.05) compared to respondents from low-spot counties (n=17). Similar self-reported health behaviors and preferences towards screening were noted between groups. While there were significant differences in travel for dental visits, there were non-significant trends between the one-way travel time to colonoscopy services between hot-spot (60 minutes; IQR, 45-90) and low-spot respondents (40 minutes; IQR, 12.5-60; p=0.07). Residents of both regions noted differences in winter versus summer travel for access to food and various healthcare services, including minor surgery and cancer care (paired t-test p<0.05). Residents of hot-spot and low-spot counties had similar levels of trust in their healthcare. Self-reported health ratings with the EQ-5D-5L instrument were not significantly different between hot-spot and low-spot residents.

Conclusion: Populations in CRC MIR hot-spot counties have less education, are more rural, and have lower incomes. This study is low powered, but found no important differences in travel time to nutrition or health services between hot-spot and low-spot counties in either the winter or the summer, although travel distances are long for both groups. While travel distance is often considered important, future research should focus on the aspatial facilitators and barriers that positively and negatively impact CRC outcomes of rural residents.

Figure 1: Travel Time to Colorectal Cancer Care in North Dakota

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