Background:
Urban-rural disparities in cancer outcome exist in many countries. Investigating patient pathways can illuminate areas of inequity amenable to intervention. In the state of Victoria, Australia, rural colorectal patients have poorer survival than urban patients. Receipt of timely, quality treatment contributes to better outcomes. Little is known about how decisions are made regarding which clinician or health service is attended, yet this choice can have important implications.
Aim:
To explore rural and urban colorectal cancer patients’ decision-making experiences regarding referral to healthcare providers.
Methods:
A purposive sample of 19 Victorian patients (rural n=11; urban n=9) 6 – 12 months post-diagnosis completed a semi-structured telephone interview (40–90mins). Interviews were transcribed verbatim and realist thematic analysis conducted.
Results:
Quality of care and timeliness of treatment emerged as important themes but patients relied heavily on clinicians choosing treatment providers. The endoscopist was a key clinician facilitating referral to cancer-specific treatment provider, rather than GP. Patients with health insurance recognised having options, while uninsured patients, “don’t get a hell of a big choice”. However, both patient groups wanted the referring clinician’s opinion. A theme, ‘informal quality checks’, was evident; patients asked friends, family or GP about the reputation of surgeon referred to, and assessed professionalism by the surgeon’s communication style. Rural patients distinguished local hospitals as having shorter waiting times and providing personalised care, while city hospitals had access to more specialist clinicians or equipment/techniques. Rural patients were more active in choosing chemotherapy locally.
Conclusions:
Colorectal patients require expert advice about referral to hospital and surgeon but informally assess quality of provider. Endoscopists are key in facilitating referrals for initial cancer treatment. Uninsured patients perceived little or no choice for surgery treatment provider, but rural patients negotiated access to local chemotherapy. This work will provide directions for policy initiatives targeting rural patient pathways.