Should low-molecular-weight heparin be used in the treatment of acute coronary syndromes in rural hospitals?
Doug G Manuel, Caroline A Knight, Muhammad Mamdani
Objective: To evaluate the use of low-molecular-weight heparin (LMWH) for acute coronary syndromes (ACS) in a rural setting.
Methods: A review of LMWH effectiveness and a simplified costing exercise that focused on potential differences between rural and urban settings for delivering LMWH versus unfractionated heparin (UFH).
Results: LMWH is as clinically effective as UFH for the treatment of ACS in a rural setting. The estimated drug delivery cost of the dalteparin ($65 per admission) was less than that for UFH ($110). The high cost of after-hours activated partial thromboplastin time monitoring in a rural setting ($86 per admission) more than offset the increased cost of LMWH compared to UFH.
Conclusions: LMWH is the heparin of choice for the treatment of ACS in a rural setting. The method of using an abbreviated effectiveness and costing exercise may be a practical approach for evaluating other health interventions in a rural setting.
Vitamin B12 deficiency and megaloblastic anemia in elderly female patients in a rural community
Lynn Ann Bussey, Peter Rothfels
Vitamin B12 deficiency is a common problem in elderly females. The purpose of this study is to determine if macrocytic anemia is a useful indicator of vitamin B12 deficiency. This study was conducted in the rural town of Noel, Nova Scotia, where one of the authors was the sole family practitioner. A retrospective chart review was completed on the 102 females over the age of 65 who were part of his family practice. Of the 50 women with documented B12 levels, 10 were deficient in vitamin B12. Of those 10, only 2 had red blood cell changes that suggested vitamin B12 deficiency. Thus, in elderly women with B12 deficiency, 90% were not anemic and 90% had normal mean corpuscular volumes. These results emphasize that vitamin B12 deficiency is often present without macrocytic anemia. This is important to consider because other studies have shown that irreversible neurological damage can occur without changes on the complete blood count, especially in the elderly population, and that early treatment can reverse the damage before it becomes permanent.
Rural emergency department antibiotic prescription patterns for the treatment of childhood upper respiratory tract infections
Scott Hamilton, Duncan Graham
Objective: To examine the antibiotic prescribing habits for childhood upper respiratory tract infections in a rural emergency department (ED). Design: A detailed chart review was conducted of 852 ED records spanning over a total of 8 months between August 2000 and July 2001. Setting: The South Bruce Grey Health Centre in Walkerton, Ont. Participants: Children 18 years of age or younger, who had an ED diagnosis of bronchitis, pharyngitis, acute otitis media or viral upper respiratory tract infection. Main outcome measures: Antibiotic prescription rates for upper respiratory diagnoses. Rates were compared for variations based on patient age and gender, as well as the time of day and the season of year the patient was diagnosed. Results: Antibiotics were prescribed to 59% of the patients diagnosed, with over half of the prescriptions going to those with acute otitis media (AOM). For the diagnoses of pharyngitis, bronchitis and AOM, antibiotics were given to 64%, 74% and 90% of patients, respectively. Patients were less likely to receive a prescription during the afternoon than during any other time in the emergency room (p = 0.04), possibly due to a decreased patient load and stress on the physician's time during this period. The season of year and patient age and gender did not have an impact on the likelihood of receiving antibiotics. Conclusion: Prescription rates from this rural ED parallel those seen in other Canadian studies. AOM is the most common cause for antibiotic prescription, and should therefore be a focus in educating physicians about appropriate pediatric management.
2003; 19(3): Summer
Education for and Retention in Rural Practice [Commentary]
Jack M Colwill
Predictive Accuracy of Rural Physicians' Stated Retention Plans
Donald E Pathman, Thomas R Konrad, Christopher R Agnew
Context: The retention of rural physicians is a difficult phenomenon to study because job changes-the outcome of interest-take years to unfold. One common way to study retention is to ask rural practitioners through surveys how much longer they expect to remain in their current positions and use these statements of "anticipated retention" as an expedient proxy measure of actual retention. Purpose: To test the predictive accuracy of rural physicians' stated retention plans and test the hypotheses that predictions are more accurate for certain physicians, such as those with more experience, more control of their work situations, and at less risk for job burnout. Methods: A 1991 mail survey (national stratified random sample) prospectively queried rural physicians' retention plans, and a follow-up survey 5 to 6 years later determined if and when respondents (N = 405, 67.5% combined response rate) had moved. Findings: Retention predictions for the entire cohort corresponded remarkably well to the group's actual retention, with the proportion remaining each year deviating by only a few percentage points from what the group collectively expected. Predictions for individuals were also moderately accurate: 4 of 5 physicians who predicted remaining at least 5 years did so; 2 of 3 who predicted remaining less than 5 years indeed left before 5 years. Predictions of job changes in less than 2 years tended to be more accurate than predictions of 2 to 5 years. Physicians' predictions were more accurate when they worked in practices they owned (greater control) and were on-call 2 or fewer times each week (lower burnout risk). Accuracy was not greater with any of 5 measures of experience. Conclusions: Rural generalist physicians are moderately accurate when reporting how much longer they will remain in their jobs, validating the use of anticipated retention in rural health workforce studies.
Using the Theory of Reasoned Action to Model Retention in Rural Primary Care Physicians
Thomas Hugh Feeley
Context: Much research attention has focused on medical students', residents', and physicians' decisions to join a rural practice, but far fewer studies have examined retention of rural primary care physicians. Purpose: The current review uses Fishbein and Ajzen's Theory of Reasoned Action (TRA) to organize the literature on the predictors and correlates of retention of rural practicing physicians. TRA suggests turnover behavior is directly predicted by one's turnover intentions, which are, in turn, predicted by one's attitudes about rural practice and perceptions of salient others' (eg, spouse's) attitudes about rural practice and rural living. Methods: Narrative literature review of scholarship in predicting and understanding predictors and correlates of rural physician retention. Findings: The TRA model provides a useful conceptual model to organize the literature on rural physician retention. Physicians' subjective norms regarding rural practice are an important source of influence in the decision to remain or leave one's position, and this relation should be more fully examined in future research.
Oral Health Status of Children and Adolescents by Rural Residence, United States
Clemencia M Vargas, Cynthia R Ronzio, Kathy L Hayes
Context: The limited information available on the oral health status of rural children in the United States makes it difficult to devise policy strategies to address perceived problems. Purpose: To document the oral health status and dental care utilization of US children by place of residence. Methods: Data from National Health Interview Surveys for 1995, 1997, and 1998, and from the third National Health and Nutrition Examination Survey (1988-1994) were analyzed. Findings: Children residing in rural areas were more likely to be uninsured for dental care than were children from urban areas (41.1% versus 34.7%). A greater percentage of rural than urban children reported unmet dental needs (7.5% versus 5.6%); there was no difference in selfreported poor dental status. Urban children were more likely than rural children to have visited the dentist in the past year (73.6% versus 69.9%) and were also more likely to be regular users of dental care (61.7% versus 51.4%). Differences in percentage of rural and urban children with caries lesions and caries experience were not significant. Conclusions: Children residing in rural areas have less access to and utilization of dental care compared to children residing in urban areas. Moreover, poor rural children display less utilization of dental services than poor urban children. Differences in the sum of decayed and filled primary teeth and the sum of decayed, missing, and filled permanent teeth were not significant.
Children's Agricultural Health: Traumatic Injuries and Hazardous Inorganic Exposures
Melissa J Perry
Context: Farming is one of the most hazardous occupational ndustries in the USA, and farms pose numerous health risks for youth visiting, living in, or working in the farm environment. Purpose: This review discusses both potential traumatic injuries and hazardous inorganic exposures that are common in agricultural settings. Findings: An estimated 2 million youth under the age of 20 currently live or work on US farms. Approximately 103 farm fatalities occur in this age group each year; over 32 000 nonfatal youth injuries occurred on farms in 1998. Children working in US agriculture make up only 8% of the population of working minors overall, yet they account for 40% of work-related fatalities among minors. Farm children and youth are also exposed to potentially harmful chemicals, such as pesticides and solvents, and many of these exposures go undetected. The long-term health effects of exposure to pesticides or solvents are not known, but the developmental vulnerabilities of children and youth are of particular concern. Conclusions: Clinical and epidemiologic research in pediatric populations is needed to expand the empirical data, particularly for inorganic and organic exposures, musculoskeletal trauma, skin disorders, occupation-induced hearing loss, and psychosocial stress. Rural health professionals can work to reduce these risks to farm youth by becoming more aware of the problem, by conducting clinical and epidemiologic research, and by engaging in advocacy at state and local levels.
2003; 3(1): Fall
Depression in rural hospice family caregivers
Ladner, Christie and Cuellar Norma G
Informal, family caregivers assume an overwhelming responsibility to care for the dying in the home. Although not a long term situation, the outcomes for family hospice caregivers often have negative consequences with minimal mental health resources available in rural settings. Diagnosis and treatment of depression in caregiving has been underdiagnosed. Few studies have identified depression and treatment specifically in hospice family caregivers. The purpose of this study was to determine if informal, hospice, family caregivers in rural settings were depressed and if so, were the caregivers receiving treatment for depression, either by conventional or non-conventional interventions. The descriptive study included 30 hospice family caregivers who reported on symptoms of depression. Forty percent of the hospice caregivers were depressed with only 17% receiving treatment for depression. Future studies should include exploring interventions and outcomes of depression to improve rural health care in caregivers.
Abnormal PAP test results and the rurality factor
Elaine Dietsch, Heather Gibb and Karen Francis
Objective: To review the published socio-cultural determinants that put women in rural areas at greater risk of having an abnormal Pap test result. Design: Literature review. Conclusion: An Australian woman is at increased risk of developing cervical dysplasia if she lives in a rural area, identifies as an Indigenous Australian or is from a non-English speaking country. Being aged over 50 years, increases the risk of cervical cancer but not cervical intra-epithelial neoplasia (CIN) 1, which peaks in the 20-24 year age group. Other connections with cervical dysplasia relate to a woman or her partner's sexual history, her nutritional status and possibly even her personality type. Smoking, social isolation, high negative life change events and having lived a 'troubled' life are all identified in the literature as increasing a woman's risk of having an abnormal Pap test result. Receiving an abnormal Pap test result often leads to feelings of fear, anxiety, guilt, shock, vulnerability, powerlessness, depression, shame and feeling dirty for the woman concerned. Compounding these negative feelings are social, practical and financial difficulties that have to be addressed. It is argued that social and medical models of health must complement each other to improve the well being of rural women experiencing an abnormal Pap result.
Patterns of injury in Indigenous Australians admitted to Cairns Base Hospital
David J Macintosh, J Belinda Pearson
Aim: To study and compare the type and frequency of injury to indigenous and non-indigenous patients admitted to the Orthopaedic Unit at Cairns Base Hospital.
Method and analysis: Relevant statistics for all patients were entered or calculated: demographics, length of stay, comorbidity and complications were available. After Variance Analysis, age-standardised rates of trauma were tested using confidence intervals.
Results: Of 2254 admissions for trauma in 32 months, 23% were indigenous (12% of the catchment population). Upper limb injuries were significantly higher for all indigenes, these males being admitted three times as frequently as non-indigenous males. Specific lesions showed greater differences and punch injuries were prominent in both indigenous sexes. Indigenous women were much more likely to be the victims of assault or fights than other groups.
Conclusions: Personal injury costs are high in the indigenous community, in human and material terms. More resources should be directed towards injury prevention.