Journal Search

Journal Search - issue 3, 2012


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


26 September 2012 Volume 12 Issue 3


RECEIVED: 26 September 2012

ACCEPTED: 26 September 2012


Richmond J.  Journal Search - issue 3, 2012. Rural and Remote Health 2012; 12: 2363.


© Jennifer Richmond 2012 A licence to publish this material has been given to James Cook University,

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Journal Search brings Rural and Remote Health readers information about relevant recent publications. This issue includes recent rural health publications in North American and Australian rural health journals.

This issue contains abstracts from:


Journal of Rural Health

Contents: 2012; 28:(3)
Issue includes:

What Is the Impact of Health Reforms on Uncompensated Care in Critical Access Hospitals? A 5-Year Forecast in Washington State
Joseph Coyne, Benjamin Fry, Sean Murphy, Gary Smith and Robert Short

Context: The 2008 financial crisis had a far-reaching impact on nearly every sector of the economy. As unemployment increased so did the uninsured. Already operating on a slim margin and poor payer mix, many critical access hospitals are facing a tough road ahead.
Purpose: We seek to examine the increasing impact of uncompensated care on the revenues earned by Washington's critical access hospitals; to forecast uncompensated care to the year 2014; and to forecast the financial impact on rural hospital uncompensated care of HR 3590, the Affordable Care Act (ACA).
Findings: For critical access hospitals in the state of Washington, total uncompensated care increased by almost $16 million, a 22% increase from 2008 to 2009. By 2014, total uncompensated care is forecast to more than double from 2009, totaling $174 million annually without health reforms. Using the Urban Institute's Health Insurance Policy Simulation Model, uncompensated care is forecast to fall by $106 million in 2014, thereby reducing the uncompensated care percentage from 5.31% to 2.07%.
Conclusions: Policy makers and health care managers should note that a substantial portion of the newly insured from the ACA will most likely be Medicaid participants. Given this source of lower revenue per case, critical access hospital administrators should seek additional public and private sources of revenue. Most importantly, rural hospital managers must maintain or improve their cost efficiency, while serving the needs of their rural population as we move closer toward the implementation of health reforms.

Lower Rehospitalization Rates Among Rural Medicare Beneficiaries With Diabetes
Kevin J. Bennett, Janice C. Probst, Medha Vyavaharkar and Saundra H. Glover

Purpose: We estimated the 30-day readmission rate of Medicare beneficiaries with diabetes, across levels of rurality.
Methods: We merged the 2005 Medicare Chronic Conditions 5% sample data with the 2007 Area Resource File. The study population was delimited to those with diabetes and at least 1 hospitalization in the year. Unadjusted readmission rates were estimated across levels of rurality. Multivariate logistic regression estimated the factors associated with readmissions.
Findings: Overall, 14.4% had a readmission; this was higher among urban (14.9%) than rural (12.9%) residents. The adjusted odds indicated that remote rural residents were less likely to have a readmission (OR 0.74, 0.57-0.95) than urban residents. Also, those with a 30-day physician follow-up visit were more likely to have a readmission (OR 2.25, 1.96-2.58) than those without a visit.
Conclusion: The factors that contribute to hospital readmissions are complex; our findings indicate that access to follow-up care is highly associated with having a readmission. It is possible that residents of remote rural counties may not receive necessary readmissions due to lower availability of such follow-up care. Policy makers should continue to monitor this apparent disparity to determine the impact of these lower rates on both patients and hospitals alike.

Variables Associated With Utilization of a Centralized Medical Post in the Andean Community of Pampas Grande, Peru
Stephen P. Merry, James E. Rohrer, Thomas D. Thacher, Matthew R. Summers, Jonathan D. Alpern and Robert W. Contino

Context: Integral to the location of health resources is the distance decay of utilization observed in a population. In rural Peru, a nongovernmental organization planning to increase the availability of health services needed this information.
Purpose: To determine variables associated with utilization of a central medical clinic and determine whether, because of the mountainous topography, travel time (TT) would be a better predictor of utilization than distance.
Methods: A door-to-door survey of all available households (81% of total), using a Spanish translation of questions excerpted from the Behavioral Risk Factor Surveillance System Survey, was conducted in the summer of 2008 to determine variables associated with self-reported history of clinic utilization.
Results: Utilization was inversely related to TT and distance. Of those living within 5 minutes of the clinic, 61% had been to the clinic whereas only 25% of those living 30 or more minutes away had sought care. Female gender and fever predicted increased odds of clinic utilization. Having a disability reduced one's odds (OR 0.55) of visiting the clinic, after adjusting for gender, TT, and fever. The inverse correlation of utilization with travel distance and TT was not significantly different, thus failing to demonstrate that TT is a better predictor of utilization than distance.
Conclusion: In health service planning, care for common conditions should be available within 5 minutes' TT or a few kilometers' distance from each person's home in order to improve health care access and reduce health care disparities worsened by disability.

Postacute Stroke Rehabilitation Utilization: Are There Differences Between Rural-Urban Patients and Taxonomies?
Huanguang Jia, Diane C. Cowper, Yuhong Tang, Eric Litt and Lauren Wilson

Purpose: To assess the association between Veterans Affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies.
Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received 12-months poststroke hospitalization. Patients' urban, rural, or isolated/highly rural status was determined using the Rural-Urban Commuting Areas (RUCA) and VA Rural Urban (VARU) definitions based on patient residential ZIP code. Logistic regression models were fit for the rehabilitation outcome, adjusting for potential risk factors.
Findings: Among the 8,296 stroke patients, 69.6%/61.1% were categorized as urban, 21.3%/37.5% as rural, and 9.1%/1.4% as isolated/highly rural by the RUCA/VARU definitions, respectively. Compared with their urban counterparts, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home, and not intubated. Compared with the rural patients, odds of receiving rehabilitation therapy were 1.2 times (RUCA) and 1.1 times (VARU) by the urban patients, and 0.53 times (VARU only) by the highly rural patients, after risk adjustment. The above comparisons were significant at P < .05.
Conclusions: With both taxonomies, the rural patients were less likely to receive postacute stroke rehabilitant therapy than their urban counterparts. With the VARU, the highly rural patients were less likely to receive rehabilitation care than their rural counterparts. Different taxonomy may lead to different rural-urban classification yields and different yields may lead to different outcomes and conclusion.

Are the CMS Hospital Outpatient Quality Measures Relevant for Rural Hospitals?
Michelle M. Casey, Shailendra Prasad, Jill Klingner and Ira Moscovice

Context: Quality measures focused on outpatient settings are of increasing interest to policy makers, but little research has been conducted on hospital outpatient quality measures, especially in rural settings.
Purpose: To evaluate the relevance of Centers for Medicare and Medicaid Services' (CMS) outpatient quality measures for rural hospitals, including Critical Access Hospitals.
Methods: Researchers analyzed Medicare hospital outpatient claims and Hospital Compare outpatient quality measure data for rural hospitals to assess the volume of conditions addressed by the measures in rural hospitals. A literature review and information from national quality organizations were used to assess the external and internal usefulness of the measures for rural hospitals. A panel of rural hospital quality experts reviewed the measures and provided additional input about their usefulness and data collection issues in rural hospitals.
Results: The rural relevant CMS outpatient measures include most of the Emergency Department (ED) measures. The outpatient surgical measures are relevant for the majority of rural hospitals providing outpatient surgery. Several measures were not selected as relevant for rural hospitals, including the outpatient imaging and condition-specific measures.
Conclusions: To increase sample sizes for smaller rural hospitals, CMS could combine data for similar inpatient and outpatient measures, use composite measures by condition, or use a longer time period to calculate measures. A menu of outpatient measures would allow smaller rural hospitals to choose relevant measures depending on the outpatient services they provide. Global measures and care coordination measures would be useful for quality improvement and have sufficient sample size to allow reliable measurement in smaller rural hospitals.

Gender as a Moderator Between Having an Anxiety Disorder Diagnosis and Coronary Artery Bypass Grafting Surgery (CABG) Outcomes in Rural Patients
Tam K. Dao, Emily Voelkel, Sherine Presley, Brendel Doss, Cashuna Huddleston and Raja Gopaldas

Purpose: This paper examines gender as a moderating variable between having an anxiety disorder diagnosis and coronary artery bypass grafting surgery (CABG) outcomes in rural patients.
Methods: Using the 2008 Nationwide Inpatient Sample (NIS) database, 17,885 discharge records of patients who underwent a primary CABG surgery were identified. Independent variables included age, gender, race, median household income based on patient's ZIP code, primary expected payer, the Deyo, Cherkin, and Ciol Comorbidity Index, and an anxiety comorbidity diagnosis. Outcome variables included in-hospital length of stay and patient disposition (routine and nonroutine discharge). A 2 × 2 analysis of variance and logistic regression analyses were used to assess the interaction between gender and an anxiety disorder diagnosis on in-hospital length of stay and patient disposition.
Findings: Twenty-seven percent of rural patients undergoing a CABG operation had a comorbid anxiety diagnosis. Rural patients who had nonroutine discharge were more likely to have comorbid anxiety diagnosis compared to rural patients who had a routine discharge. There was a significant interaction effect between having an anxiety diagnosis and gender on length of hospital stay but not for patient disposition.
Conclusions: Three findings were noteworthy. First, anxiety disorder is prevalent in rural patients who are undergoing a CABG operation. Second, anxiety was a significant independent predictor of both length of hospital stay and nonroutine discharge for patients receiving CABG surgery. Last, having an anxiety disorder diagnosis increased hospital stay for both males and females; however, females seemed to be impacted more than males.

The Association of Sleep Duration and Depressive Symptoms in Rural Communities of Missouri, Tennessee, and Arkansas
Jen Jen Chang, Joanne Salas, Katherine Habicht, Grace W. Pien, Katherine A Stamatakis and Ross C. Brownson

Purpose: To determine the association between sleep duration and depressive symptoms in a rural setting.
Methods: We conducted a cross-sectional study using data from Wave 3 of the Walk the Ozarks to Wellness Project including 12 rural communities in Missouri, Arkansas, and Tennessee (N = 1,204). Sleep duration was defined based on average weeknight and weekend hours per day: short (<7), optimal (7-8), and long (>8). The primary outcome was self-reported elevated depressive symptoms. Multivariable logistic regression was used to estimate adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (95% CI).
Findings: Elevated depressive symptoms were common in this rural population (17%). Depressive symptoms were more prevalent among subjects with short (26.1%) and long (24%) sleep duration compared to those with optimal (11.8%) sleep duration. After adjusting for age, gender, race, education, employment status, income, and BMI, short sleep duration was associated with increased odds of elevated depressive symptoms (aPOR = 2.12, 95% CI: 1.49, 3.01), compared to optimal sleep duration. Conversely, the association between long sleep duration and depressive symptoms was not statistically significant after covariate adjustment. Similar findings were observed when we excluded individuals with insomnia symptoms for analysis.
Conclusions: This study suggests that short sleep duration (<7 hours per night) and depressive symptoms are common among rural populations. Short sleep duration is positively associated with elevated depressive symptoms. The economic and health care burden of depression may be more overwhelming among rural populations, necessitating the need to target modifiable behaviors such as sleep habits to improve mental health.

Correlates of Mental Health Among Latino Farmworkers in North Carolina
Rebecca Crain, Joseph G. Grzywacz, Melody Schwantes, Scott Isom, Sara A. Quandt and Thomas A. Arcury

Purpose: Latino farmworkers are a vulnerable population who confront multiple threats to their mental health. Informed by the stress-process model of psychiatric disorder, the goal of this paper is to determine primary and context-specific stressors of poor mental health among Latino farmworkers.
Methods: Structured interview data were obtained from farmworkers (N = 69) in 6 counties in eastern and western North Carolina.
Findings: Results indicated that a substantial number of farmworkers have poor mental health, as indicated by elevated depressive symptoms (52.2%) and anxiety (16.4%). Results also indicated that each mental health outcome had different predictors.
Conclusion: Addressing the mental health issues of farmworkers requires a comprehensive, multifaceted approach.

An Investigation of Bioecological Influences Associated With First Use of Methamphetamine in a Rural State
Anne Bowen, John Moring, Mark Williams, Glenna Hopper and Candice Daniel

Purpose: Methamphetamine (MA) addiction is a significant problem in rural areas of the United States. Yet, little theoretically driven formative research has been conducted on the interactions of factors influencing initiation. The study was guided by Bronfenbrenner's bioecological model.
Methods: Eighty-three MA users participated in an interview. Quantitative data included sociodemographic characteristics, drug use history, and psychosocial functioning. Semistructured interviews examined MA use histories with a focus on initiation. Transcripts of the interviews were coded for 5 themes related to Bronfenbrenner's influences including individual motivation, family, peers, work or school, or community as factors influencing initiation of MA use. Five dummy variables representing the presence or absence of a mention of Bronfenbrenner's 5 influences were created from the qualitative codes and entered into a hierarchical cluster analysis.
Findings: The analyses revealed 4 distinct clusters: (1) predominantly female, influenced by peers and individual curiosity, (2) predominantly female, youngest age of first use, influenced by a family culture of drug use, (3) predominantly male, older age at first use, influenced by work settings and family co-workers, and (4) predominantly male, older age at first use, in the school context with a desire to increase intimacy.
Conclusions: Bronfenbrenner's bioecological model was useful for classifying initiating influences and grouping individuals based on different combinations of influences. Identifying combinations of initiating factors such as work and community may facilitate tailoring of prevention programs, which may maximize efficacy and cost-effectiveness.

Differences in Late-Stage Diagnosis, Treatment, and Colorectal Cancer-Related Death Between Rural and Urban African Americans and Whites in Georgia
Robert B. Hines and Talar W. Markossian

Purpose: Disparities in health outcomes due to a diagnosis of colorectal cancer (CRC) have been reported for a number of demographic groups. This study was conducted to examine the outcomes of late-stage diagnosis, treatment, and cancer-related death according to race and geographic residency status (rural vs urban).
Methods: This study utilized cross-sectional and follow-up data from the Surveillance, Epidemiology, and End Results (SEER) Program for all incident colon and rectal tumors diagnosed for the Atlanta and Rural Georgia Cancer Registries for the years 1992-2007.
Findings: Compared to whites, African Americans had a 40% increased odds (OR, 1.40; 95% CI, 1.30-1.51) of late-stage diagnosis, a 50% decreased odds (OR, 0.50; 95% CI, 0.37-0.68) of having surgery for colon cancer, and a 67% decreased odds (OR, 0.33; 95% CI, 0.25-0.44) of receiving surgery for rectal cancer. Rural residence was not associated with late stage at diagnosis or receipt of treatment. African Americans had a slightly increased risk of death from colon cancer (HR, 1.11; 95% CI, 1.00-1.24) and a larger increased risk of death due to rectal cancer (HR, 1.24; 95% CI, 1.14-1.35). Rural residents experienced a 15% increased risk of death (HR, 1.15; 95% CI, 1.01-1.32) due to colon cancer.
Conclusions: Further investigations should target African Americans and rural residents to gain insight into the etiologic mechanisms responsible for the poorer CRC outcomes experienced by these 2 segments of the population.

FOBT Completion in FQHCs: Impact of Physician Recommendation, FOBT Information, or Receipt of the FOBT Kit
Terry C. Davis, Connie L. Arnold, Alfred W. Rademaker, Daci J. Platt, Julia Esparza, Dachao Liu and Michael S. Wolf

Purpose: To determine the effect of common components of primary care-based colorectal cancer (CRC) screening interventions on fecal occult blood test (FOBT) completion within rural and urban community clinics, including: (1) physician's spoken recommendation, (2) providing information or education about FOBTs, and (3) physician providing the FOBT kit; to determine the relative effect of these interventions; and to compare the effect of each intervention between rural and urban clinics.
Methods: We conducted structured interviews with patients aged 50 years and over receiving care at community clinics that were noncompliant with CRC screening. Self-report of ever receiving a physician's recommendation for screening, FOBT information or education, physician providing an FOBT kit, and FOBT completion were collected.
Findings: Participants included 849 screening-eligible adults; 77% were female and 68% were African American. The median age was 57; 33% lacked a high school diploma and 51% had low literacy. In multivariable analysis, all services were predictive of rural participants completing screening (physician recommendation: P= .002; FOBT education: P= .001; physician giving FOBT kit: P < .0001). In urban clinics, only physician giving the kit predicted FOBT completion (P < .0001). Compared to urban patients, rural patients showed a stronger relationship between FOBT completion and receiving a physician recommendation (risk ratio [RR]: 5.3 vs 2.1; P= .0001), receiving information or education on FOBTs (RR: 3.8 vs 1.9; P= .0002), or receiving an FOBT kit from their physician (RR: 22.3 vs 10.1; P= .035).
Conclusions: Participants who receive an FOBT kit from their physician are more likely to complete screening.

Self-Reported Cancer Screening Among Elderly Medicare Beneficiaries: A Rural-Urban Comparison
Lin Fan, Supriya Mohile, Ning Zhang, Kevin Fiscella and Katia Noyes

Purpose: We examined the rural-urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening.
Methods: Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural-urban disparity and rurality's independent impact on cancer screening, controlling for patient, and area factors.
Results: From urban, large rural, small rural, and isolated rural areas, the rates for mammogram last year were 53%, 52%, 45%, and 44%, respectively. They were 56%, 50%, 48%, and 43% for CRC screening, respectively. After controlling for patient and area level characteristics, rurality is significantly associated with CRC screening, but not mammogram.
Conclusions: We found rural-urban disparities for both mammogram and CRC screenings. Patient and area factors totally eliminated the rural-urban disparity for mammogram but not CRC screening. Health promotions to improve cancer screening should focus more on small and isolated rural areas.

Physical Activity and Cervical Cancer Testing Among American Indian Women
Kyle J. Muus, Twyla B. Baker-Demaray, T. Andy Bogart, Glen E. Duncan, Clemma Jacobsen, Dedra S. Buchwald and Jeffrey A. Henderson

Purpose: Studies have shown that women who engage in high levels of physical activity have higher rates of cancer screening, including Papanicalaou (Pap) tests. Because American Indian (AI) women are at high risk for cervical cancer morbidity and mortality, we examined Pap screening prevalence and assessed whether physical activity was associated with screening adherence among AI women from 2 culturally distinct regions in the Northern Plains and the Southwest.
Methods: A total of 1,979 AI women at least 18 years of age participating in a cross-sectional cohort study reported whether they received a Pap test within the previous 3 years. Physical activity level was expressed as total metabolic equivalent (MET) scores and grouped into quartiles. We used binary logistic regression to model the association of Pap testing and MET quartile, adjusting for demographic and health factors.
Findings: Overall, 60% of women received a Pap test within the previous 3 years. After controlling for covariates, increased physical activity was associated with higher odds of Pap screening (OR = 1.1 per increase in MET quartile; 95% CI = 1.1, 1.2).
Conclusions: This is the first study to examine physical activity patterns and receipt of cancer screening in AIs. While recent Pap testing was more common among physically active AI women, prevalence was still quite low in all subgroups. Efforts are needed to increase awareness of the importance of cervical cancer screening among AI women.


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]

Contents: 2012; 17:(3)
Issue includes:

Barriers to patient care in southwestern Ontario rural emergency departments: physician perceptions
Kyle William Carter, Kelsey Cassidy, Munsif Bhimani

Introduction: We sought to determine the perceptions of physicians staffing rural emergency departments (EDs) in southwestern Ontario with respect to factors affecting patient care in the domains of physical resources, available support and education.
Methods: A confidential 30-item survey was distributed through ED chiefs to physicians working in rural EDs in southwestern Ontario. Using a 5-point Likert scale, physicians were asked to rate their perception of factors that affect patient care in their ED. Demographic and practice characteristics were collected to accurately represent the participating centres and physicians.
Results: Twenty-seven of the 164 surveys distributed were completed (16% response rate). Responses were received from 13 (81.3%) of the 16 surveyed EDs. Most of the respondents (78%) held CCFP (Certificant of the College of Family Physicians) credentials, with no additional emergency medicine training. Crowding from inpatient boarding, and inadequate physician staffing or coverage in EDs were identified as having a negative impact on patient care. Information sharing within the hospital, access to emergent laboratory studies and physician access to medications in the ED were identified as having the greatest positive impact on patient care. Respondents viewed all questions in the domain of education as either positive or neutral.
Conclusion: Our survey results reveal that physicians practising emergency medicine in southwestern Ontario perceive crowding as the greatest barrier to providing patient care. Conversely, the survey identified that rural ED physicians perceive information sharing within the hospital, the availability of emergent laboratory studies and access to medications within the ED as having a strongly positive impact on patient care. Interestingly, our findings suggest that physicians in rural EDs view their access to education as adequate, as responses were either positive or neutral in regard to access to training and ability to maintain relevant skills.

Impact of physician distribution policies on primary care practices in rural Quebec
Roxane Borgès Da Silva, Raynald Pineault

Introduction: Accessibility and continuity of primary health care in rural Canada are inadequate, mainly because of a relative shortage of family physicians. To alleviate the uneven distribution of physicians in rural and urban regions, Quebec has implemented measures associated with 3 types of physician practices in rural areas. The objectives of our study were to describe the practices of these types of physicians in a rural area and to analyze the impact of physician distribution policies aimed at offsetting the lack of resources.
Methods: Data were drawn from a medical administrative database and included information related to physicians' practices in the rural area of Beauce, Que., in 2007.
Results: The practices of permanently settled physicians in rural areas differ from those of physicians who substitute for short periods. Permanently settled physicians offer mostly primary care services, whereas physicians who temporarily substitute devote much of their time to hospital-based practice.
Conclusion: Physician distribution policies implemented in Quebec to compensate for the lack of medical resources in rural areas have reduced the deficit in hospital care but not in primary care.

Emergency medicine ultrasonography in rural communities
Candi J. Flynn, Alison Weppler, Daniel Theodoro, Elizabeth Haney, W. Ken Milne

Introduction: The Canadian Association of Emergency Physicians (CAEP) published a position statement in 2006 encouraging immediate access to emergency medicine ultrasonography (EMUS) 24 hours a day, 7 days a week. However, barriers to advanced imaging care still exist in many rural hospitals. Our study investigated the current availability of EMUS in rural communities and physicians' ability to use this technology.
Methods: A literature review and interviews with rural physicians were conducted in the summer of 2010 to design a questionnaire focusing on EMUS. The survey was then sent electronically or via regular mail in November 2010 to all Ontario physicians self-identified as 'rural.' Descriptive statistics and the Fisher exact test were used to analyze the data.
Results: A total of 207 rural physicians responded to the survey (response rate 28.6%). Of the respondents, 70.9% were male, median age was 49 years and median year of graduation was 1988. The respondents had been in practice for a median of 20 years and had been in their present community for a median of 15 years. More than two-thirds of physicians (69.5%) practised in communities with populations of less than 10 000. Nearly three-quarters (72.6%) worked in a rural emergency department (ED). Almost all (96.9%) reported having access to ultrasonography in the hospital. However, only 60.6% had access to ultrasonography in the ED. Less than half (44.4%) knew how to perform ultrasonography, with 77.3% citing lack of training. Of those using EMUS, 32.5% were using it at least once per shift. The most common reason to use EMUS was to rule out abdominal aortic aneurysm (58.3%). Most respondents (71.5%) agreed or strongly agreed that EMUS is a skill that all rural ED physicians should have.
Conclusion: Patients in many rural EDs do not have immediate access to EMUS, as advocated by CAEP. This gap in care needs to be addressed to ensure that all patients, no matter where they live, have access to this proven imaging modality.


Australian Journal of Rural Health

2012; 20:(2)
Issue includes:

'Making evidence count': A framework to monitor the impact of health services research
Penny Buykx, John Humphreys, John Wakerman, David Perkins, David Lyle, Matthew McGrail and Leigh Kinsman

Objectives: The objective of this study is to develop a framework to measure the impact of primary health care research, describe how it could be used and propose a method for its validation.
Design: Literature review and critical appraisal of existing models of research impact, and integration of three into a comprehensive impact framework.
Setting: Centre of Research Excellence focusing on access to primary health care services in Australia.
Participants: Not applicable.
Interventions: Not applicable.
Main outcome measure: The Health Services Research Impact Framework, integrating the strengths of three existing models of research impact.
Conclusion: In order to ensure relevance to policy and practice and to provide accountability for funding, it is essential that the impact of health services research is measured and monitored over time. Our framework draws upon previously published literature regarding specific measures of research impact. We organise this information according to the main area of impact (i.e. research related, policy, service and societal) and whether the impact originated with the researcher (i.e. producer push) or the end-user (i.e. user pull). We propose to test the utility of the framework by recording and monitoring the impact of our own research and that of other groups of primary health care researchers.

Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?
Leigh D. Kinsman, Thomas Rotter, Jon Willis, Pamela C. Snow, Penny Buykx and John S. Humphreys

Objective: The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments.
Design: Cluster randomised controlled trial.
Setting: Six rural Victorian emergency departments participated.
Intervention: The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback.
Main outcome measures: The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram.
Results: Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies.
Conclusions: The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk
Kevin P. Mc Namara, James A. Dunbar, Benjamin Philpot, Jennifer L. Marriott, Prasuna Reddy and Edward D. Janus

Introduction: Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD).
Objective: This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors.
Design, setting and participants: Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self-administered health questionnaire. Overall, 1500 were invited to participate.
Results: The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone.
Conclusion: Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.

Is personality the missing link in understanding recruitment and retention of rural general practitioners?
Michael P. Jones, John S. Humphreys and Tahnee Nicholson

Context: Little is known about the role of personality and related constructs in general practitioners' (GPs) choices of geographic location of medical practice. There is however some theory suggesting a role for personality in career decision making and some limited empirical evidence that this applies in medical career decisions.
Purpose: The aim of this study is to gain insight into whether personality plays a role in GPs' decisions to work in rural areas and the length of time that they intend to remain as a rural practitioner.
Method: Samples of rural (n = 372) and urban (n = 100) GPs from New South Wales (Australia) completed the Neuroticism, Extraversion, Openness - Five Factor Inventory (NEO-FFI) and Adjective Checklist personality instruments and answered questions about demographics and rural upbringing.
Findings: Rural GPs scored, on average, more highly than urban GPs with respect to conscientiousness and agreeableness but lower on openness, which can also be taken to mean a more 'down-to-earth' personality. Personality together with age, gender, experience as a GP, time in current location and rural childhood yield an area under the receiver operating characteristic curve of 0.81 in discriminating rural from urban GPs. Among rural GPs openness (P = 0.007) was positively correlated with intended longevity as a rural doctor as was nurturing (P = 0.06).
Conclusions: Personality appears to play some role both in discriminating rural from urban GPs and in how long existing rural GPs intend to remain as rural GPs. Consideration of personality might assist in selection of individuals who will better fit the professional and social environment of rural life.

Nature or nurture: The effect of undergraduate rural clinical rotations on pre-existent rural career choice likelihood as measured by the SOMERS Index
George T. Somers and Ryan J. Spencer

Objective: Do undergraduate rural clinical rotations increase the likelihood of medical students to choose a rural career once pre-existent likelihood is accounted for?
Design: A prospective, controlled quasi-experiment using self-paired scores on the SOMERS Index of rural career choice likelihood, before and after 3 years of clinical rotations in either mainly rural or mainly urban locations.
Setting: Monash University medical school, Australia.
Participants: Fifty-eight undergraduate-entry medical students (35% of the 2002 entry class).
Main outcome measures: The SOMERS Index of rural career choice likelihood and its component indicators.
Results: There was an overall decline in SOMERS Index score (22%) and in each of its components (12-41%). Graduating students who attended rural rotations were more likely to choose a rural career on graduation (difference in SOMERS score: 24.1 (95% CI, 15.0-33.3) P < 0.0001); however, at entry, students choosing rural rotations had an even greater SOMERS score (difference: 27.1 (95% CI, 18.2-36.1) P < 0.0001). Self-paired pre-post reductions in likelihood were not affected by attending mainly rural or urban rotations, nor were there differences based on rural background alone or sex.
Conclusions: While rural rotations are an important component of undergraduate medical training, it is the nature of the students choosing to study in rural locations rather than experiences during the course that is the greater influence on rural career choice. In order to improve the rural medical workforce crisis, medical schools should attract more students with pre-existent likelihood to choose a rural career. The SOMERS Index was found to be a useful tool for this quantitative analysis.

Treatment via videoconferencing: A pilot study of delivery by clinical psychology trainees
Debra A. Dunstan and Susan M. Tooth

Objective: This pilot study explored the outcomes of clinical psychology trainees delivering treatments via videoconferencing.
Design: A noncurrent, multiple baseline across subjects and settings.
Setting: University outpatient psychology clinic.
Participants: Six clients (two men and four women) with an anxiety or depressive disorder were randomly assigned to received six sessions of individual therapy (either via videoconferencing or face to face) from a male or female clinical psychology trainee.
Main outcome measures: Participants provided daily ratings (0-10) of subjective distress/well-being via text messaging, and at pre-, post-, and 1 month follow-up of treatment, completed the Depression Anxiety Stress Scales and the Outcome Questionnaire-45. Along with the trainees, participants also provided feedback on the therapy experience.
Results: The subjective well-being of all participants improved, and all videoconferencing participants showed a statistically and clinically significant reduction in symptomology and gains in general life functioning. Feedback comments were positive.
Conclusions: This study suggests that there is value in clinical psychology trainees gaining experience in the delivery of treatments via videoconferencing. Further study is needed to demonstrate the potential for university clinics to deliver mental health services, via this modality, to rural and remote areas.

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