Closure of Labor & Delivery units in rural counties is associated with reduced adequacy of prenatal care, even when prenatal care remains available.

PURPOSE: Closure of rural Labor & Delivery (L&D) units can impact timely access to hospital-based obstetrical care. Iowa has lost over a quarter of its L&D units in the previous decade. Assessing the effect of these closures on prenatal care in those rural communities is important to understanding the full effect of unit closures on maternal health care. METHODS: Using birth certificate data in Iowa from 2017 to 2019, the initiation of prenatal care and adequacy of prenatal visits were assessed for 47 rural counties in Iowa. Of these, 7 experienced a closure of the only L&D unit between 1/1/2018 and 1/1/2019. The impact of these closures is modeled for all birthing parents and compared for Medicaid versus non-Medicaid recipients. FINDINGS: All 7 counties that experienced the loss of their only L&D unit continued to have prenatal care services available. Experiencing a closure of an L&D unit was associated with a lower likelihood of overall adequate prenatal care but not significantly associated with a lower rate of first-trimester prenatal care utilization. Among Medicaid recipients of the communities where an L&D unit closed, there was an association of closure with both a lower likelihood of adequate prenatal care and entry to prenatal care after the first trimester. CONCLUSIONS: Utilization of prenatal care is lower in rural communities following L&D unit closure, especially among Medicaid recipients. This suggests that the overall maternal health systems were disrupted by the closure of the L&D unit, impacting the utilization of services that remained available to the community.

Trends in Rural Outreach by Orthopedic Surgeons.

BACKGROUND: Sixty million rural residents have limited access to orthopedic care due to a small rural orthopedic surgery workforce. Increases in specialized training add to the challenge of attracting orthopedic surgeons to rural communities. Answering the call for research on models to meet the needs of rural orthopedic patients, we examine long-term trends in visiting consultant clinics (VCCs) in Iowa, a state with a large rural population. METHODS: The Office of Statewide Clinical Education Programs (Carver College of Medicine) compiles an annual report of outreach clinic locations, frequencies and participating physicians. Trends in the total number of VCCs, days and locations (1989-2018) were analysed using joinpoint analysis. RESULTS: Total clinic days grew rapidly from 1992-1997 (Average Percent Change: 19.7%) before a decline ending in 2009 (APC: -4.1%). A new growth period (2009-2013, APC: 7.5%) preceded another decline (APC: -3.6%) ending in 2018. The number of cities hosting a VCC grew from 56 (1989) to a peak of 90 (1999) and fell an average of 0.9% a year thereafter. More than 80% of all VCCs in the last ten years were offered 2 or more times per month. The average participation rate for Iowa-based orthopedic surgeons was 44%. The mean number of VCCs staffed by a single physician was 1.32 (std. dev. = 0.53) with a median of 1. The average number of VCC days per month for a participating physician was 3.22 (std. dev. = 2.41) with a median of 2.66. CONCLUSION: The VCC model of rural outreach is sustainable (30+ year history) and self-funded. Most clinics occur with sufficient frequency to allow timely follow-up care. This model of rural outreach is supported by the participation of a large segment (44%) of Iowa's orthopedic surgeons. Visiting orthopedic surgeons provide access to care in 65 of the 76 Critical Access Hospitals in Iowa offering orthopedic services compared to 8 staffed by a local orthopedic surgeon.Level of Evidence: V.

Treatment Setting Influences Treatment Modality for Urinary Stone Disease.

OBJECTIVE: To determine whether selection of treatment modality for urinary stone disease differs between primary and outreach healthcare centers, and if patient rurality predicts treatment modality. METHODS: We retrospectively evaluated Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) procedural data from the Iowa Office of Statewide Clinical Education Programs (OSCEP) and Iowa Hospital Association (IHA) databases from 2007 to 2014. Geographical data was used to analyze travel metrics and patient proximity to sites of stone treatment. Rural-urban commuting area (RUCA) codes were used to characterize patient rurality. Chi-square tests and t tests were used to compare ESWL and URS patients, and multilevel logistic regression model was used to assess influence of treatment setting on surgical modality. RESULTS: A total of 18,831 stone procedures were performed by urologists in Iowa on patients from Iowa (10,495 URS; 8336 ESWL). Around 2630 procedures occurred at outreach centers. Ureteroscopy comprised 59.7% of procedures at primary centers, but only 31.2% at outreach centers. On multilevel analysis, outreach location was associated with 2.236 OR toward ESWL (P <.001). Individual physician treatment patterns accounted for 32% of treatment variation. Patient rurality was not significantly associated with treatment modality as an independent factor (P = .879). CONCLUSIONS: Wide variation exists in urolithiasis treatment modality selection between outreach and primary centers. Outreach locations perform a significantly higher frequency of ESWL compared to URS, and much of the variation in treatment selection (32%) arises from individual physician practice patterns.

Impact of nonphysician providers on spatial accessibility to primary care in Iowa.

OBJECTIVE: To assess the impact of nonphysician providers on measures of spatial access to primary care in Iowa, a state where physician assistants and advanced practice registered nurses are considered primary care providers. DATA SOURCES: 2017 Iowa Health Professions Inventory (Carver College of Medicine), and minor civil division (MCD) level population data for Iowa from the American Community Survey. STUDY DESIGN: We used a constrained optimization model to probabilistically allocate patient populations to nearby (within a 30-minute drive) primary care providers. We compared the results (across 10 000 scenarios) using only primary care physicians with those including nonphysician providers (NPPs). We analyze results by rurality and compare findings with current health professional shortage areas. DATA COLLECTION/EXTRACTION METHODS: Physicians and NPPs practicing in primary care in 2017 were extracted from the Iowa Health Professions Inventory. PRINCIPAL FINDINGS: Considering only primary care physicians, the average unallocated population for primary care was 222 109 (7 percent of Iowa's population). Most of the unallocated population (86 percent) was in rural areas with low population density (< 50/square mile). The addition of NPPs to the primary care workforce reduced unallocated population by 65 percent to 78 252 (2.5 percent of Iowa's population). Despite the majority of NPPs being located in urban areas, most of the improvement in spatial accessibility (78 percent) is associated with sparsely populated rural areas. CONCLUSIONS: The inclusion of nonphysician providers greatly reduces but does not eliminate all areas of inadequate spatial access to primary care.

Compliance With American Urological Association Guidelines for Nonmuscle Invasive Bladder Cancer Remains Poor: Assessing Factors Associated With Noncompliance and Survival in a Rural State.

OBJECTIVE: To identify factors associated with nonmuscle invasive bladder cancer (NMIBC) American Urological Association (AUA) guideline compliance in a rural state, to evaluate compliance rates over time, and to assess the impact of patient and provider rurality on delivery of NMIBC care. METHODS: We identified 847 Iowans in Surveillance, Epidemiology, and End Results-Medicare from 1992 to 2009 with high-grade NMIBC who survived 2 years and were not treated with cystectomy or radiation during this period. Compliance with AUA guidelines was assessed over time and compared to patient demographic, tumor, and treatment institution variables. Impact of rurality was analyzed using Surveillance, Epidemiology, and End Results ZIP code data travel distance of patient to nearest urologist practice location. RESULTS: Overall compliance with AUA guidelines was low (<1%), and did not markedly improve over the study period. In the multivariable model, only care at an academic medical center (OR 11.68, 95% CI 7.07-19.29) and tumor stage (Tis; OR 3.24, 95% CI 1.86-5.63) increased the odds of compliance. Patients living closer (<10 miles) to their urologists underwent more cystoscopies than patients living further (>30 miles) but distance did not affect compliance with other measures. Compliance was not associated with cancer-specific survival. CONCLUSION: Compliance with post-Transurethral Resection of Bladder Tumor (TURBT) NMIBC treatment guidelines has improved but remains suboptimal in our rural state, and is highly associated with treatment at an academic cancer center for reasons that could not be fully explained with these data.

The workforce trends of physician assistants in Iowa (1995-2015).

BACKGROUND: Physician assistants are expected to have an important role in providing both primary and specialty care. Iowa has a large rural (and aging) population and faces challenges to provide equitable access to care. This study examined changes in the Iowa physician assistant workforce (1995-2015) focusing on practice setting (primary v. subspecialty care) and geographic location (rural/urban, Health Professional Shortage Area). Documenting their current locations and service in HPSAs for primary care will help health planners track future changes. METHODS: Data from 1995-2015 from the Iowa Health Professions Inventory (Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa) were combined with US census data on rural location and HPSA status. SPSS was used to compare Iowa and national data. Growth trends were analyzed using joinpoint regression. RESULTS: The overall Iowa physician assistant workforce increased 161% between 1995 and 2015. In 2015, more than two-thirds (71%) were female and more than 30% practiced in rural counties. The average annual growth rate of primary care PAs (per 100,000 population) was significantly higher in the periods from 1995-1997 and 1997-2001 (22.4% and 7.4% respectively) than in period from 2001-2015 (3.8%). By 2015, 56% of Iowa's physician assistants practiced in primary care (versus 29.6% nationally). Of these, 44% of primary care physician assistants in Iowa practiced in counties, geographic locations or worksites designated as Health Professional Shortage Areas for primary care. CONCLUSIONS: A high proportion of Iowa's physician assistant workforce practiced in primary care and many served patients in Health Professional Shortage Areas. The number of physician assistants in Iowa will continue to grow and serve an important role in providing access to health care, particularly to rural Iowans.

Sex and cardiovascular disease status differences in attitudes and willingness to participate in clinical research studies/clinical trials.

BACKGROUND: While women are under-represented in research on cardiovascular disease (CVD), little is known about the attitudes of men and women with CVD regarding participation in clinical research studies/clinical trials. METHODS: Patients with CVD (and/or risk factors) and patients with other chronic conditions from Iowa were recruited from a commercial panel. An on-line survey assessed willingness to participate (WTP) and other attitudes towards aspects of clinical research studies. RESULTS: Based on 504 respondents, there were no differences in WTP in patients with CVD compared to patients with other chronic diseases. Across all respondents, men had 14% lower WTP (relative risk (RR) for men, 0.86, 95% CI, 0.72-1.02). Among patients with CVD, there was no significant difference in WTP between women (RR for women = 1) and men (RR for men, 0.96, 95% CI, 0.82-1.14). There were no significant differences based on sex or CVD status for attitudes on randomization, blinding, side effects, conflict of interest, experimental treatments or willingness to talk to one's physician. Women had more favorable attitudes about participants being treated like "guinea pigs" (RR for men, 0.84, 95% CI, 0.73-0.98) and clinical trials being associated with terminally ill patients (RR for men, 0.93, 95% CI, 0.86-1.00). CONCLUSIONS: The findings reported here suggest that the observed lower levels of participation by women are due to factors other than a lower WTP or to women having more negative attitudes towards aspects of study participation. Patients with CVD have similar attitudes and WTP as patients with other chronic conditions.

Determinants of the 5-Year Retention and Rural Location of Family Physicians: Results from the Iowa Family Medicine Training Network.

BACKGROUND AND OBJECTIVES: States are seeking ways to retain primary care physicians trained within their borders. We analyzed the 5-year retention and rural Iowa location decisions for 1,645 graduates of the Iowa Family Medicine Training Network (IFMTN)-eight residency programs (in seven different cities) that are affiliated with the Carver College of Medicine (University of Iowa). METHODS: Data from 1977-2014 includes 98.5% of active graduates. Location in Iowa 5 years after graduation was the dependent variable in a binary logistic regression. A second model used rural location in Iowa as the dependent variable. Independent variables included graduation year cohort, IMG status, sex, undergraduate medical training in Iowa, medical degree, and residency location. RESULTS: Undergraduate medical training in Iowa was strongly related to retention. Compared to graduates of the AMC residency, graduates of six of the seven community-based programs were significantly more likely to be practicing in Iowa. While the overall proportion of graduates practicing in rural Iowa was high (47.3%), women and IMGs were significantly less likely to practice in rural areas. Graduates of the Mason City program were significantly more likely to practice in a rural area after graduation. CONCLUSIONS: The experience of the IFMTN suggests that educating family physicians in community-based programs contributes significantly to in-state retention even 5 years after graduation. While all programs contribute to the rural FM workforce in Iowa, the residency program located in a rural community (Mason City) has a disproportionately positive impact.

Taking the Procedure to the Patient: Increasing Access to Urological Procedural Care through Outreach.

INTRODUCTION: We previously showed that urological outreach clinics significantly increase access to urological clinical care in rural populations. How such clinics affect access to urological procedural care is unknown. In this study we analyzed the use of outreach facilities for outpatient hospital based urological procedural care in a rural state. METHODS: Using information from the Office of Statewide Clinical Education Programs and the Iowa Hospital Association database, we analyzed provider level data in Iowa from 2010 to 2013. Based on CPT codes all outpatient urological procedural care was categorized by procedure type and intent. Cities containing an Iowa Hospital Association hospital were characterized as primary vs outreach. Geographic data were used for analysis of travel metrics and proximity to urological procedural care sites. Outreach urological procedures were then compared to urological procedural care at primary centers. RESULTS: During the study period 11,464 outreach urological procedures were performed, accounting for 15.0% of all outpatient urological procedures in the state. The yearly number of outreach procedures remained relatively stable during the study period. The majority (51.7%) of outreach urological procedures were therapeutic and endoscopic (62.9%) in nature. Extracorporeal shock wave lithotripsy was significantly more common for treating stone disease in the outreach setting compared to ureteroscopy (p <0.0001). CONCLUSIONS: A large percentage of the total urological procedural care in our state was done at outreach clinics and, while the majority was of low acuity, it was therapeutic. Changes in health care are projected to affect rural hospitals, which rely heavily on procedural care, and this study is the first to our knowledge to demonstrate the role that urological procedural care can have in such locations.

Providing Cardiology Care in Rural Areas Through Visiting Consultant Clinics.

BACKGROUND: Workforce experts predict a future shortage of cardiologists that is expected to impact rural areas more severely than urban areas. However, there is little research on how rural patients are currently served through clinical outreach. This study examines the impact of cardiology outreach in Iowa, a state with a large rural population, on participating cardiologists and on patient access. METHODS AND RESULTS: Outreach clinics are tracked annually in the Office of Statewide Clinical Education Programs Visiting Medical Consultant Database (University of Iowa Carver College of Medicine). Data from 2014 were analyzed. In 2014, an estimated 5460 visiting consultant clinic days were provided in 96 predominantly rural cities by 167 cardiologists from Iowa and adjoining states. Forty-five percent of Iowa cardiologists participated in rural outreach. Visiting cardiologists from Iowa and adjoining states drive an estimated 45 000 miles per month. Because of monthly outreach clinics, the average driving time to the nearest cardiologist falls from 42.2±20.0 to 14.7±11.0 minutes for rural Iowans. Cardiology outreach improves geographic access to office-based cardiology care for more than 1 million Iowans out of a total population of 3 million. Direct travel costs and opportunity costs associated with physician travel are estimated to be more than $2.1 million per year. CONCLUSIONS: Cardiologists in Iowa and adjoining states have expanded access to office-based cardiology care from 18 to 89 of the 99 counties in Iowa. In these 71 counties without a full-time cardiologist, visiting consultant clinics can accommodate more than 50% of office visits in the patients' home county.

Improving Rural Access to Orthopaedic Care Through Visiting Consultant Clinics.

BACKGROUND: Patients from rural areas tend to be older and less physically active and are more likely to be obese, increasing their need for orthopaedic services. However, few orthopaedic surgeons practice in rural areas. One approach to meeting the needs of rural patients is visiting consultant clinics (VCCs). In this study, we examined orthopaedic surgery outreach in Iowa, a state with a large rural population. We assessed the involvement of the 2014 Iowa orthopaedic surgery workforce in outreach activities for the geographically disadvantaged rural population and its effect on patient travel distances. METHODS: The University of Iowa Carver College of Medicine annually tracks VCC locations and frequencies. Data from 2014 were used to estimate average trip length for participating orthopaedic surgeons and patients in all Iowa census tracts. Primary practice locations, visiting consultant clinic locations, and census tracts were classified according to the 2010 Rural-Urban Commuting Areas (RUCA) classifications. RESULTS: In 2014, 4,596 VCC days were provided in 80 predominantly rural sites. Overall, as a result of VCCs staffed by orthopaedic surgeons in Iowa and adjoining states, the number of Iowan counties with an orthopaedic surgeon increased from 35 (at his/her primary practice location) to 88 (at a VCC or primary practice location) of 99. Forty-five percent of all Iowa-based orthopaedic surgeons participated in a VCC. Visiting orthopaedic surgeons drove a total of 32,496 mi (52,297 km) per month to conduct these clinics. The average driving distance to the nearest orthopaedic surgeon was reduced from 19.2 mi (30.9 km) to 8.4 mi (13.5 km) for rural Iowans as a result of monthly VCCs. Monthly VCCs improved access to orthopaedic surgeons for between 450,000 and 670,000 Iowans from a total population of approximately 3 million. CONCLUSIONS: VCCs staffed by orthopaedic surgeons from Iowa and surrounding states improve access to orthopaedic care by reducing driving distances for rural patients.

Reaching rural patients through otolaryngology visiting consultant clinics.

Providing otolaryngology care to rural populations is a major challenge. In this study, we focus on rural outreach by the otolaryngology workforce in Iowa, a state with a high proportion of rural residents. Using data from 2013, we find that almost half (46%) of Iowa-based otolaryngologists participate in outreach. Along with colleagues from adjoining states, Iowa otolaryngologists staffed more than 2100 in-person clinic days in 76 mainly rural sites. This system of rural outreach has expanded access from 20 to 85 of the 99 counties in Iowa. These efforts improve access for more than 1 million residents out of a total population of 3 million. However, this improved level of access comes at a cost as visiting otolaryngologists drove an estimated 17,000 miles per month. This established approach to serving rural patients may be negatively impacted by changes under the Affordable Care Act.

Trends in medical oncology outreach clinics in rural areas.

PURPOSE: To examine the long-term trends in medical oncology outreach in Iowa, a state with a high proportion of rural residents, and to assess the involvement of the 2011 Iowa oncology workforce in visiting consultant clinics using a unique data source. METHODS: Outreach locations and clinic frequencies are tracked annually in the Visiting Medical Consultant Database (Carver College of Medicine) along with the physicians' primary practice locations. Growth in the number of cities served and number of clinic days from 1989 to 2011 was analyzed using joinpoint analysis. Data from 2011 were used to estimate the trip length for participating oncologists. RESULTS: The number of rural cities served by medical oncology outreach increased significantly between 1989 and 1996. Clinic days grew significantly in two periods: 1989 to 1998 and 2003 to 2005. In 2011, more than 2,100 clinic days were provided in 66 sites (95% of clinic days in rural areas). Almost half of all Iowa-based oncologists regularly participate in outreach. Oncologists staffing visiting consultant clinics in Iowa drive an estimated 21,000 miles per month. CONCLUSIONS: For more than 20 years, visiting medical oncologists have brought cancer care to rural patients in Iowa. Access to cancer care in rural Iowa (ie, clinic days) increased significantly in the post-Medicare Modernization Act period (after 2005). High participation rates and travel burdens may influence oncologist training and retention strategies. Because the Affordable Care Act seeks to expand access for vulnerable populations (eg, rural elderly), it is critical to better understand the existing system of rural cancer care delivery.

Improving access to urologic care for rural populations through outreach clinics.

OBJECTIVE: To determine the effect of outreach clinics on access to urologic care in a state with a large rural population. This is especially pertinent given the predicted shortage of urologists over the next decade and the trend toward practice in urban area. METHODS: We analyzed provider level data from urologic practices within the state of Iowa using information from 2 publicly available sources: (1) the Office of Statewide (Iowa) Clinical Education Programs, which collects detailed information on visiting consultant urologists (VCU), and (2) the Iowa Physician Information System, which tracks demographic and professional data on all active physicians in Iowa. Factors analyzed included percent of counties and Iowans served by urologists and travel distances/times for patients and physicians. RESULTS: Currently, 57% of Iowans are within 30 minutes of a urologist's primary office, increasing to 84% with VCU outreach clinics. Fifty-five urologists, including 40 of 69 (58%) of Iowa-based urologists, perform outreach within Iowa, accounting for 198 clinic days and 20,400 miles of travel per month. CONCLUSION: Within Iowa, the lack of rural urologists has been mitigated, in part, by an extensive VCU network. However, improved access has required significant effort from urologists in both time and miles traveled. This study is the first to show how a rural state can effectively use physician outreach clinics to provide specialized urologic care to underserved, rural communities.

The influence of visiting consultant clinics on measures of access to cancer care: evidence from the state of Iowa.

OBJECTIVE: To determine the effect of visiting consultant clinics on measures of access to cancer care for rural patients. DATA SOURCES: 2010 Visiting Medical Consultant Database for the state of Iowa (Carver College of Medicine) and the Iowa Physicians Information System (Carver College of Medicine). STUDY DESIGN: We compared shortest driving times to the nearest medical oncologist for all Iowa census tracts under two scenarios: including only primary practice locations and adding monthly visiting consultant clinic locations. PRINCIPAL FINDINGS: For rural Iowans, the median driving time to the closest site for medical oncology care falls from 51.6 to 19.2 minutes when monthly visiting consultant clinics are considered. CONCLUSIONS: Including visiting consultant clinics has a significant impact on measures of geographic access to cancer care.