Effectiveness and implementation of a health system intervention to improve quality of cancer care for rural, underserved patients

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PROJECT SUMMARY There is growing evidence that limited access to high-quality cancer treatment is one of the main drivers of higher cancer mortality rates among rural cancer patients. Our analyses of Iowa Cancer Registry data indicate that 40% of rural patients with breast and colorectal cancers receive most or all definitive treatment in rural hospitals that do not collect or monitor data on their quality of cancer care, and are not accredited by the American College of Surgeons Commission on Cancer (CoC). Our data also shows these patients are less likely to receive guideline-concordant care. Given patients' needs and preferences to receive cancer care locally, a promising strategy to improve quality of cancer care and outcomes in rural populations is to intervene directly with the community hospitals in these areas. New evidence has demonstrated effectiveness of this approach: the Markey Cancer Center Affiliate Network (MCCAN) was formed by the University of Kentucky (UK) Markey Cancer Center to improve quality of cancer care in their own rural, low-resourced state, one that leads the nation in cancer incidence and mortality. Over the last decade MCCAN has facilitated the sharing and diffusion of resources and best practices throughout their network. As a result, affiliates markedly improved performance on established, cancer care quality measures and expanded their services (e.g., psychosocial and survivorship support). They were also almost 3 times more likely to obtain CoC accreditation than their matched controls. However, the MCCAN model has not been rigorously defined, evaluated or tested in any other setting. We propose to adapt this successful health system-level intervention for Iowa, establishing the Iowa Cancer Affiliate Network (I-CAN). Although there are similarities between Iowa and Kentucky's populations that suggest the MCCAN model may be a good fit, there are also significant differences in healthcare infrastructure and resources that require careful adaptation of the intervention prior to its implementation in order to retain its effectiveness. We will use novel, rigorously developed, theory-based implementation science methods to identify MCCAN's core functions (i.e., what makes it effective), study the implementation process and evaluate how I-CAN performs in a new context. We have identified 4 rural, Iowa hospitals to participate in this intervention trial and developed expert support teams to assist key stakeholder groups within each hospital. Through interviews and qualitative analyses, we will assess determinants and outcomes of the implementation process, and perceived value of the CoC accreditation standards and the intervention itself as a way to improve the quality of cancer care for their patients. We will compare compliance with treatment-related quality measures and the proportion of CoC standards of cancer care implemented in target and control hospitals, pre- and post-intervention using a difference-in-difference estimator. This work could lead to dissemination of similar models across rural settings thereby improving quality of care, reducing rural disparities in cancer outcomes and giving rural hospitals an avenue to demonstrate their quality of care.