The various health care shortages that trouble rural populations are well known, much discussed, and have hit Iowa hard. The state ranks 44th in the U.S. for physician-to-patient ratio, and that dismaying stat is not expected to get much better. Iowa is projected to be short of about 1,600 doctors by 2030.
Add to that the fact that cancer care, often difficult in urban areas, is more challenging in the small towns and rural communities where a third of all Iowans live. Those patients face hours of travel to see a specialist, which makes seeking treatment more difficult, especially for older adults, the self-employed, or those working on farms or for small businesses. Too often, that burden means delayed care or forgoing it altogether.
“Iowa has the second highest cancer rate in the country, and we’re the only state with continually rising rates,” explained Mary Charlton, PhD, professor at the University of Iowa College of Public Health and leader within the Iowa Cancer Affiliate Network (I-CAN), one example of the efforts of University of Iowa (UI) to connect researchers and clinicians within the UI Health Care Holden Comprehensive Cancer Center to support the delivery of comprehensive cancer care at community hospitals across Iowa.
“There's also a gap in terms of higher mortality rates from cancer in our rural populations compared to urban environments,” Charlton added, noting “there’s no convenient public transportation system within Iowa that gets anyone from one town to another easily on any kind of regular basis, so for a lot of people, traveling to a larger community like Iowa City is just not a viable option.”
At the beginning of last year, UI Health Care significantly expanded the reach of its cancer care services by adding an oncology practice with over 20 clinics across central and western Iowa. At the same time, the I-CAN network has grown to six community hospitals that now have access to more resources to aid in developing and enhancing their cancer care programs, with three more interested in joining I-CAN in the coming year.
University of Iowa Health Care is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
A statewide solution needed
UI Health Care and the Mission Cancer + Blood oncology group joined forces to meet urgent need to enhance cancer services across the entire state, said Mark Burkard, MD, PhD, an oncologist and director of UI Health Care Holden Comprehensive Cancer Center.
“We have always served all 99 counties in Iowa through our commitment to serve all Iowans. But people who might have to travel up to three hours to access care tended to be underdiagnosed, did not get timely treatment, and experienced poorer outcomes,” Dr. Burkard explained.
Now, UI Health Care is bringing the benefits of a National Cancer Institute-designated comprehensive cancer center closer to where patients live. The over 20 oncology clinics that are now part of UI Health Care through its agreement with Mission Cancer + Blood can now offer treatment options once only available at the academic health system’s main campus.
This expansion is more than mere ownership. It is a robust integration of clinical care, research and technology, and it delivers accessible, consistent and high-quality cancer treatment throughout the state.
To enhance coordination of care at its broad network of clinics, UI Health Care is one of the first to implement augmented intelligence (AI)—also called artificial intelligence—tools that integrate with the EHR system to help physicians and other health professionals identify patients who are candidates for clinical trials.
“These AI tools will allow us to match patients to our 200-plus clinical trials, then share that information with the provider as soon as the patient walks into a clinic,” Dr. Burkard said.
This strategy means cutting-edge therapies can be triaged more efficiently. Some patients may still need to go to Iowa City, but many more will be treated locally with support from UI Health Care.
“Cancer is an incredibly complex set of hundreds of diseases,” Dr. Burkard noted. “It takes a village to make sure that each cancer patient gets what they need. Our goal is to make sure more of Iowa’s oncologists are able to tap into highly specific, specialized knowledge.”
Sitting at the table together
The addition of more than 20 oncology clinics helped expand UI Health Care’s direct clinical presence. As one element of the UI’s cancer research initiatives, I-CAN provides a complementary, supportive role for community hospitals that includes building capacity within existing rural cancer centers.
“The driving vision behind both of these initiatives is for all Iowans to have access to high-quality cancer care close to home,” said Charlton. “One way I-CAN is achieving this is by helping community hospitals develop and expand their cancer programs through multidisciplinary care team meetings, or tumor boards, to ensure that patients receive the highest standards of care and treatment established by the American College of Surgeons Commission on Cancer.”
As a resource, I-CAN provides detailed data on cancer quality measures, facilitates educational initiatives, and helps develop critical services such as palliative care, nutritional support, genetic counseling, and survivorship planning. This support is game-changing for rural hospitals with limited staff and resources.
“A lot of the community hospitals we work with have cancer services arranged by service line instead of functioning as an overall program,” Charlton noted. “Now, with cancer committees in place, we’ve seen nutritionists, social workers, oncologists and surgeons all sitting at the table together, talking about how to move the program forward.”
Creating a culture of collaboration
I-CAN helps foster a culture of trust and transparency through regular meetings with each facility’s physicians and care teams. The I-CAN team uses the standards of cancer care established by the American College of Surgeons Commission on Cancer as a framework to assist community cancer programs in achieving their goals. The I-CAN team and community cancer program leadership and staff work together, to create implementation plans that prioritize the standards most relevant to that location and community.
“They’re driving it, but we are in it with them,” Charlton said. “Our data collection supports them and helps build capacity in those cancer centers.”
Respecting these relationships includes peer-to-peer learning, which many rural health professionals find more useful than academic lectures.
“What works at a large academic medical center doesn’t necessarily translate to a rural environment,” she added. “It’s really helpful for them to hear it from their peers at similar sized hospitals.”
I-CAN has also reshaped thinking around obtaining second opinions. Local physicians and other health professionals now participate in collaborative care consults with academic specialists at the University of Iowa. Treatment plans are reviewed in partnership, with respect for the local team’s expertise and the crucial role they play in their home communities.
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Improving access to clinical trials
UI Health Care is also working to make access to clinical trials available to patients statewide.
“There are now 300 approved drugs and hundreds more in development,” Dr. Burkard noted.
Not every trial or therapy can be delivered in a local clinic, but many can be with the help of telemedicine, remote monitoring and flexible trial protocols introduced during the COVID-19 public health emergency. Now, more patients can participate in trials without ever setting foot on the Iowa City campus.
Learn more about monitoring chronic conditions outside of the traditional health care environment with the “AMA Remote Patient Monitoring Implementation Playbook.”
Continuing to expand services
UI Health Care’s recent efforts to expand access to cancer care are just the latest examples in which the health system continues to explore innovative solutions to reach more Iowans.
“We’re gathering data on which communities need access to care the most,” Dr. Burkard said. “Public health is about prevention and early detection, so it's equally important to make sure we're delivering interventions, prevention and screening to those communities.”
Planning includes leveraging nonphysician providers, telemedicine, pharmacists and local infusion nurses to deliver even more highly specialized care through a model that can be designed to scale and replicated by other academic centers serving rural populations.
“Those who provide care in rural areas are proud of what they’re doing and are doing it the best that they can,” Charlton said. “For the most part, they seem very appreciative of having more data, more support around them and helping them offer the best care possible, as well as having objective measures of quality they can use to demonstrate how well they are doing.”
Patients are also benefiting from access to palliative care, psychosocial support and nutritional counseling—services that were once only available in large urban centers.
“Those services are critically important,” Charlton said. “They might not be the forefront of treatment such as chemotherapy or surgery, but they’re still incredibly crucial to treatment and helping people cope.”
A model for rural cancer care
The success of UI Health Care’s approach, purchasing the assets of a large, multi-clinic oncology group along with providing network-based support to community hospitals, offers a potential solution to a state struggling with rising cancer rates.
I-CAN has laid the groundwork for developing trust-based relationships with community cancer providers in rural areas of Iowa, and processes and resources that support them in a manner they find most helpful.
In addition, the data collection and monitoring infrastructure that I-CAN has established in rural hospitals is key to ensuring that providers and staff know how they are doing and can easily identify opportunities for improvement. Expanding I-CAN to include additional rural cancer centers where Mission Cancer + Blood oncologists practice will help demonstrate the high-quality cancer care delivered across UI Health Care sites.
As Iowa continues to grapple with a high cancer burden and physician shortages, UI Health Care is proving that geography doesn’t have to be a roadblock to care.
“We're not there yet, but every patient in Iowa who touches our health system should have access to the same care,” Dr. Burkard said.
By building systems of trust, nurturing real connection, embracing technology and combining knowledge gained on the ground and academically, UI Health Care is creating a future in which every Iowan, no matter where they live, has access to the best cancer care possible.
