Introduction

In many developing countries, care is regionalized at a few high volume centers. However, unlike Western nations where high percentages live in urban areas, developing countries have a higher percent living in rural areas or small towns. It is unknown if the benefits of regionalization outweigh the barriers this creates for access. We tested the link between distance from screening site to biopsy (bx) referral center and risk of non-compliance with showing up to have a bx in a population-based PC screening cohort in Brazil. _x000D_

Methods

We reviewed records from 1,561 men recommended to undergo a bx after an initial PC screen by a medical mobile unit at their local clinic between 2004 and 2007. Bxs were performed at a regional referral center, Barretos Cancer Hospital (BCH). Clinical data between men who complied with the bx vs. not were compared with rank-sum & chi-square. Multivariable logistic regression analysis of distance from screening site to BCH (km) and risk of non-compliance was performed adjusting for age and year of screening.

Results

Median distance was 257km (IQR 135-718). Non-compliant men were older (68 vs 66 yrs), had a higher PSA (4.9 vs 4.2), were less likely to have an abnormal DRE (20% vs 33%) and lived further from BCH (921 vs 225 km) (all p<0.001). On crude and multivariable analyses, further distance was significantly linked with bx non-compliance (OR/100km 0.83, p<0.001, see figure). Among men who lived within 150km of BCH, distance was unrelated to compliance (OR/100km 1.09, p=0.87). _x000D_

Conclusions

In Brazil, where distances from PC screening to bx clinic can be hundreds of kms, greater distance to referral center was related to reduced compliance to bx. However, among men who lived within 150km, distance was unrelated to compliance. While regionalization of care may in theory improve quality, it comes at the cost of reduced compliance and thus reduced access and represents a significant barrier to optimal care if distances are large. In regards to PC screening and bx, our data suggest distances up to 150km do not create barriers for care. Alternative thresholds, however, may apply for other services and in other cultures.

Funding

none