Beyond the no-show: A case study highlighting the hidden scope of barriers to radiotherapy adherence in cancer care.
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BACKGROUND: Despite prevalent systemic barriers to accessing healthcare services, Virginia Mason Medical Center's Floyd & Delores Jones Cancer Institute has historically taken a piecemeal approach in responding to barriers. To uphold the organization's mission, they participated in the Commission on Cancer's "Breaking Barriers" national quality improvement collaborative in 2023 to investigate the predictable and modifiable reasons for radiotherapy nonadherence among their patients with cancer. METHODS: From March 1 to December 15, 2023, a multidisciplinary quality improvement team prospectively collected data on patients aged 18-99 years scheduled to receive 14-15 fractions of radiotherapy, excluding palliative care and ultrafractionation regimens. The team employed REDCap for bimonthly reporting and used multiple investigative methods including community assessments, patient chart reviews, patient narratives, and stakeholder input sessions. Environmental and community factors affecting transportation access were systematically evaluated using established quality improvement frameworks. Social work activity data were also collected to quantify institutional resource allocation. RESULTS: Among 104 eligible patients during the initial study period, 85.6% completed all scheduled appointments, 14.4% missed at least 1 appointment, and 3.8% met the no-show threshold of missing at least 3 appointments. By the end of 2023, the total institutional no-show rate was 5.2%, with transportation accounting for only 5.3% of all missed radiotherapy appointments. However, oncology social workers spent 14.8% of their time addressing transportation needs. Transportation-related missed appointments decreased to 3.7% by December 2023, while social work interventions prevented numerous potential no-shows from being recorded. CONCLUSION: This project reveals an "iceberg problem" where transportation insecurity's true magnitude remains hidden beneath outcome-oriented no-show metrics. The substantial discrepancy between low rates of transportation-related missed appointments (5.3%) and high social work time allocation (14.8%) demonstrates that no-show rates mask significant institutional workload required to maintain treatment adherence. Social work time emerges as a more sensitive, novel indicator of barrier vulnerability that reframes the problem from patient-centric failure to system-level resource demands. Health care organizations should implement proactive, data-driven barrier management systems that account for hidden workloads while developing sustainable, multilevel interventions to ensure equitable cancer care access.