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Purpose

Evaluation by a gynecologic oncologist (GO) is associated with improved clinical outcomes for patients with gynecologic cancers, yet little is known about healthcare factors that influence patients' referrals to GO.

Methods

Medical records of 50 consecutive new patients seen in GO clinics at each of 6 referral centers across the United States were reviewed. Patient and disease characteristics were collected along with referral indication, evaluation and referral dates, diagnostic procedures, provider specialties, and ZIP code of up to three referring providers per patient. The primary outcome was the interval between first evaluation and referral. Univariate associations were evaluated with Chi-square and Wilcoxon rank-sum tests and multivariable associations with negative binomial regression models. Secondary outcome was prolonged time to GO referral, defined as greater than the 75th percentile. Logistic regression was used for multivariable modeling.

Results

Three hundred patient records were analyzed. The median time from first healthcare encounter to referral was 15 days (IQR 5-43). The mean distance from residence to GO was 39.8 miles (standard deviation 53.8). Seventy-one percent of GO referrals were initiated by obstetrician-gynecologists, 9% by family physicians, and 6% by internists. Presentation-to-referral interval was 76% shorter for patients evaluated by an emergency medicine clinician (exp(Beta) 0.24, 95% CI 0.11-0.53, P<0.001). Public insurance was associated with 1.47 times longer time to referral compared with private insurance (exp(Beta) 1.47, 95% CI 1.05-2.04, P=0.001). Residents of nonmetropolitan ZIP codes were less likely to have prolonged time to referral (odds ratio [OR] 0.288, P=0.017). Distance from residence to GO (per 10 miles) increased the likelihood of prolonged time to referral (OR 1.10, P=0.010).

Conclusion

Interventions are needed to improve recognition and referral of patients for gynecologic oncology evaluation. Community outreach and engagement with obstetrician-gynecologists should be prioritized to improve times to referral.

Read a Q&A about the study here.