LAUSR

BACKGROUND To eliminate them, non-small cell lung cancer (NSCLC) care and outcome disparities need to be better understood. RESEARCH QUESTION How does rurality interact with NSCLC care and outcome disparities? STUDY DESIGN and Methods: We examined guideline-concordant use of active treatment for NSCLC across 5 institutions in one community-based healthcare system spanning 44% of the Delta Regional Authority catchment area from 2011-2017. Institution- and patient-level rurality were based on Rural-Urban Commuting Area codes. Chi-squared, F-tests, and logistic regressions were used to analyze differences across institutions and rurality; survival was examined using log-rank tests and Cox regression. RESULTS Of 6,259 patients, 47% resided in rural areas; 2 of 5 institutions were rurally located and provided care for 20% of patients. Compared to rural residents at rural institutions, urban and rural residents attending urban institutions were more likely to receive stage-preferred treatment: odds ratio (OR) 1.68, [95% confidence interval (CI),1.44-1.96] and 1.33 [1.11-1.61] respectively, after adjusting for insurance, age, and clinical stage. Urban and rural residents attending urban institutions had a lower hazard of death compared to rural residents attending rural institutions: hazard ratio (HR) 0.69 [0.64-0.75] and 0.61 [0.55-0.67], respectively. Among recipients of stage-preferred treatment, care at urban institutions remained less hazardous: HR 0.7 [0.63-0.79]. When further stratified by stage, care for late-stage patients at urban institutions remained less hazardous: HR 0.8 [0.71-0.91]. INTERPRETATION Rurality-associated treatment and survival disparities were present at the patient- and institution-level, but the institution-level disparity was greater. Rural residents receiving care at urban institutions had similar outcomes as urban residents receiving care at urban hospitals. To overcome rurality-associated NSCLC survival disparity, interventions should preferentially target the institution level, including expanding access to higher-quality guideline-concordant care.