full article:Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in rural health journals worldwide.
Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine [in French and English]
Contents, 2006; 11: (3) Summer 2006 / Ete 2006
Research methodology for the investigation of rural surgical services
Erik Ellehoj, Joshua Tepper, Brendan Barrett, Stuart Iglesias
This paper describes a functional approach to the definition of rural populations for purposes of rural health care research. Rather than define "rural" directly, we created a definition of urban populations and our research target became the non-urban component. Using Geographic Information Systems technology, isochrones (drivetime zones) were created that attached suburban populations to urban centres and mapped non-urban populations into rural hospital catchment areas. For population-based analyses, we have proposed a methodology for constructing catchment areas attached to Rural, Regional and Metropolitan services. We have developed a model for calculation of travel time for patients required to travel for care. We successfully applied these methodologies to the disparate regions of rural Alberta and Northern Ontario in 2 papers that investigated the delivery of rural surgical services. This methodology represents a durable and portable designation of "rural" with potential for research applications in other areas of health research. By defining "urban" rather than "rural," we avoided many of the methodological conundrums in this research field.
Utilization rates for surgical procedures in rural and urban Canada
Joshua Tepper, William Pollett, Yan Jin, Erik Ellehoj, Don Schopflocher, Brendan Barrett, Stuart Iglesias
Objective: To investigate whether utilization rates of common surgical procedures are different between urban and rural Canadians in 2 provinces and to examine whether these rates are influenced by the presence and scope of local surgical programs and by the availability of different physician providers.
Methods: Utilization rates for 8 common surgical procedures (appendectomy, carpal tunnel release, closed hip fracture repair, rectal cancer surgery, joint replacement, thyroidectomy, unilateral or bilateral inguinal herniorrhaphy, and cholecystectomy) were identified in rural Alberta and rural Northern Ontario from hospital discharge records. Rural populations were characterized by 3 types of communities, based on availability of local physician and diagnostic resources. Travel time for consultations and surgery were estimated. Age-sex-adjusted rates, their standard errors, and 95% confidence intervals (CIs) were calculated for the purpose of comparisons among residents' locations using the method of direct standardization. To test a possible association between travel times and utilization rates, hierarchical linear and nonlinear modelling was used to analyze a 2-level model, with patients nested within rural hospital catchment areas in the province of Alberta.
Results: Utilization rates for appendectomy, cholecystectomy and carpal tunnel release are significantly greater for rural populations compared with urban in both Alberta and Northern Ontario. Rural Northern Ontario had higher rates of utilization than rural Alberta for carpal tunnel release and cholecystectomy (p < 0.01) and closed hip fracture repair (p < 0.05). No statistical differences between the provinces were noted for the remaining procedures. No difference in utilization rates was found between the 3 types of rural centres. The modelling found a significant association between travel time and use for only one procedure - carpal tunnel release. Patients who had to travel ≤1 hour had a 13% higher surgery rate.
Conclusion: Rates of utilization were higher in rural areas for procedures where greater surgical variability is known to exist. These higher rural rates were not influenced by either the presence or scope of local surgical programs nor by the differences in providers. There was no difference in rates for procedures where previous research has shown little variability.
Rural surgical services in two Canadian provinces
Stuart Iglesias, Joshua Tepper, Erik Ellehoj, Brendan Barrett, Peter Hutten-Czapski, Kir Luong, William Pollett
Objective: Contrast alternative health delivery systems and the use of differently trained physician providers in the supply of surgical services to rural residents in 2 Canadian provinces.
Methods: Four surgical procedures (carpal tunnel release, inguinal herniorrhaphy, appendectomy and cholecystectomy) provided to rural residents of Alberta and Northern Ontario were identified between 1997/98 and 2001/02. Surgical staff were identified as specialists or non-specialists. Rural populations were mapped into the catchment areas of rural acute care facilities. Rural surgical programs were characterized by the level of surgical service available locally.
Results: Alberta and Northern Ontario have a similar number of rural surgical programs staffed by Canadian-certified general surgeons (10 and 12, respectively). However, Alberta has 27 smaller rural surgical programs staffed by non-specialist surgeons and Northern Ontario has only 4. These non-specialist surgeons play a significant role in Alberta, often in collaboration with specialist surgeons. In Northern Ontario the non-specialist surgeons play a minor role. The small rural surgical programs in Northern Ontario that are staffed by specialist surgeons are significantly more successful in retaining the local surgical caseload compared with similar programs in Alberta.
Conclusions: The principal differences between Alberta and Northern Ontario in the delivery of rural surgical services are the greater number of small rural surgical programs in Alberta, and the substantial role of non-specialist surgical staff in these programs.
Journal of Rural Health
Contents: 2006; 22 3
Rural-Urban Disparities in Health-Related Quality of Life Within Disease Categories of Veterans
William B. Weeks, Amy E. Wallace, Stanley Wang, Austin Lee, Lewis E. Kazis
Context: Compared to their urban counterparts, rural veterans have been found to have lower health-related quality of life.
Purpose: To determine whether these disparities persist when examining disease categories of rural and urban veterans.
Methods: We obtained survey data on 748,216 veterans who were current or anticipated Veterans Health Administration patients. Using International Classification of Diseases (ICD)-9CM codes, we determined whether these veterans had diagnoses that fell into any of 30 physical health disease categories, and we used ZIP codes to determine whether veterans lived in rural or urban settings. We compared rural to urban prevalence of disease categories as well as urban to rural health-related quality-of-life physical health component summary scores (PCS) and mental health component summary scores (MCS) for each disease category.
Findings: Physical diagnoses were significantly more prevalent in the rural veteran population for most disease categories examined. For every disease category examined, PCS were significantly lower for veterans who lived in rural, compared to urban, settings (P< .001 for all); rural veterans also experienced lower MCS for all disease categories although differences were modest. Differences persisted after controlling for sociodemographic factors.
Conclusions: Compared to the urban veteran population, within disease categories, the rural veteran population experiences higher disease prevalence and lower physical and mental quality-of-life scores. Policymakers should anticipate greater health care demands from the rural veteran population and work to meet that demand.
The Role of Rural Health Clinics in Hospitalization due to Ambulatory Care Sensitive Conditions: A Study in Nebraska
Wanqing Zhang, Keith J. Mueller, Li-Wu Chen, Kevin Conway
Context: Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear.
Purpose: The purpose of this study was to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an acute or chronic ACSC as the reason for hospitalization
Methods: Nebraska hospital discharge data (1999-2001) and the 2003 Area Resource File were used in this analysis. A multilevel logistic regression analysis was used to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an ACSC as the reason for hospitalization, after controlling for individual characteristics and county-level contextual factors stratified by 3 age groups. The eligibility for logistic regression was limited to patients from 28 rural Nebraska counties designated as HPSAs in 2001. Patients with commercial payers were excluded from the study.
Findings: Elderly patients residing in rural Nebraska HPSAs with at least one RHC were significantly less likely to have a hospitalization due to chronic ACSCs.
Conclusions: The presence of RHC is a significant factor associated with fewer hospitalizations for chronic ACSCs among the rural elderly residing in HPSAs.
Physicians Who Treat the Elderly in Rural Florida: Trends Indicating Concerns Regarding Access to Care
Anne Gunderson, Nir Menachemi, Ken Brummel-Smith, Robert Brooks
Context: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population.
Purpose: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients.
Methods: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined.
Results: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P = .001). Mental health services (47% vs 18%, P = .001), vaccine administration (39% vs 16%, P = .008), and Pap smears (41% vs 13%, P = .008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P = .012) with their practice.
Conclusions: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.
Barriers to Quality Care for Dying Patients in Rural Communities
Rebecca F. Van Vorst, Lori A. Crane, Phoebe Lindsey Barton, Jean S. Kutner, K. James Kallail, John M. Westfall
Context: Barriers to providing optimal palliative care in rural communities are not well understood. Purpose: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care.
Methods: An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes.
Findings: Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities.
Conclusions: Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.
An Instrument for Assessing Public Health System Performance: Validity in Rural Settings
David Driscoll, Lucia Rojas-Smith, Sergey Sotnikov, Kim Gadsden-Knowles, Natalie Brevard Perry, Dennis D. Lenaway, Paul K. Halverson
Purpose: This study evaluated the validity and utility of the Local Public Health System Assessment Instrument (Local Instrument) of the National Public Health Performance Standards Program in rural settings.
Methods: The study compared the Local Instrument scores of 6 rural local public health systems to external assessments of those public health systems. The 6 public health systems represented 3 states in which 1 of the 2 local jurisdictions had scored well below and the other well above the state median in a pilot test of the Local Instrument. The study design featured a case study approach consisting of an iterative and integrated combination of semistructured individual and focus group interviews along with the collection of archival materials provided by the 6 public health systems.
Findings: Despite differences in Local Instrument scores, the representative public health systems in each state provided roughly the same levels of public health services. Sites varied tremendously in the percentage of survey items rated highly or less relevant.
Conclusions: The National Public Health Performance Standards Program Local Instrument can provide a useful structure and process for assessing public health system performance at the local level. Key informants provided several recommendations to improve the Local Instrument, including clarification of difficult terminology and acronyms, and development of multiple instruments structured around subsets of survey items.
Connecting Allied Health Students to Rural Communities
W. Kent Guion, Shelley C. Mishoe, Arthur A. Taft, Carol A. Campbell
Context: Statewide studies indicate a continuing shortfall of personnel in several allied health disciplines in rural Georgia. National trends indicate lagging enrollment in allied health education programs, suggesting that the workforce shortages will worsen.
Purpose: This article describes the efforts of the School of Allied Health Sciences at the Medical College of Georgia to increase allied health student participation in interdisciplinary health care services in rural areas of the state during fiscal years 2001-2003.
Methods: Brief program description and results from survey data provided by the student participants, program administrators, and clinical site supervisors.
Results: Three-year totals indicate that 98 students (70 female, 28 male) participated and 42% reported low-income status. In line with the goals of the grant, the proportion of minority student participants steadily increased from 5% to 12% over the 3-year period. Rotation locations included 62 designated Health Professional Shortage Area counties, 71 federally designated Rural Health Clinics, and 6 Community Health Clinics. At the conclusion of the students' rural health care experience, 76% (55/72) responded positively when asked: If you had the opportunity, would you accept employment at the rotation health care site?
Conclusions: The project appears to be positively affecting allied health students' perceptions and opinions of rural health practices and willingness to work in rural areas. Although long-term goals have yet to be accomplished, early indicators show benefits to the students and the community at-large, suggesting that the current program strategies are appropriate connectors between allied health students and rural communities.
Characteristics of Rural and Urban Cadaveric Organ Transplant Donors and Recipients
William B. Weeks, Gili Lushkov, William A. Nelson, Amy E. Wallace
Context: Health disparities have been found when comparing rural and urban populations.
Purpose: To compare characteristics of rural and urban cadaveric transplant donors and recipients.
Methods: We used deidentified individual-level data on 55,929 cadaveric transplant donor-recipient exchanges between 2000 and 2003 and examined the relative rates of donating and receiving cadaveric transplants for rural compared to urban residents, as defined by ZIP Codes.
Findings: When compared to their urban counterparts, rural organ donors were more likely to have died from head trauma, drowning, motor vehicle accidents, or suicide and less likely to have died from cerebrovascular events, cardiac events, or homicide (P< .001 for all). Rural transplant recipients had lower levels of educational attainment and were less likely to have had the transplant financed by private insurance (P< .001 for all). While we found no statistical difference in days wait to organ transplantation, rural residents were more likely to donate than to receive cadaveric organs (P< .001).
Conclusions: The differences in organ donation that we found warrant further exploration.
Dental Services for Migrant and Seasonal Farmworkers in US Community/Migrant Health Centers
Sherri M. Lukes, Bret Simon
Context: Migrant and seasonal farmworkers are recognized as a medically underserved population, yet little information on need, access, and services is available-particularly with regard to oral health care. Purpose: This study describes the facilities, services, staffing, and patient characteristics of US dental clinics serving migrant and seasonal farmworkers, and identifies trends and issues that may impede or improve dental care access and service.
Methods: National databases were used to identify community and migrant health centers providing oral health care to migrant and seasonal farmworkers. Mailed surveys collected information on clinic history, operational details, services provided, patient demographics, employment and resource needs, and perceived barriers to care.
Findings: Among the 81 respondents (response rate 41%), hours of operation varied from 1 evening a week to more than 40 hours a week; 52% had no evening hours. Almost all the clinics offered preventive, diagnostic, and basic restorative dental services, and roughly two thirds also offered complex restorative services. Patients most frequently sought emergency dental care (44%) followed by basic restorative services (32%) and preventive services (26%). The dentist position was the most difficult to fill, and new funding sources were cited as the most important resource need. Respondents perceived cost of services, lack of transportation, and limited clinic hours as primary barriers to care.
Conclusions: While some barriers to care have been almost universally addressed (eg, language), there is evidence that some impediments remain and may present significant obstacles to a broad improvement in oral health care for migrant and seasonal farmworkers.
Trends in Controlled-Release Oxycodone (OxyContin®) Prescribing Among Medicaid Recipients in Kentucky, 1998-2002
Jennifer R. Havens, Jeffrey C. Talbert, Walker Robert, Leedham Cynthia, Carl G. Leukefeld
Context: Prescription opioid abuse has emerged as a public health problem, particularly in rural America.
Purpose: To examine temporal and geographic trends in rates of controlled-release oxycodone (OxyContin) prescribing for Kentucky Medicaid recipients.
Methods: A cross-sectional analysis was completed in which the state was divided into 3 regions (distressed Appalachia, Appalachia, and other Kentucky), and data from Medicaid pharmacy claims from 1998 to 2002 were analyzed. Claims were further stratified by disability status.
Findings: Temporary Assistance for Needy Families Medicaid recipients in distressed Appalachia were more likely than those in other Kentucky regions to file controlled-release oxycodone claims in 1999, 2001, and 2002. Even after adjusting for the proportion of Temporary Assistance for Needy Families recipients in each region, the distressed region still had significantly higher rates (P< .05) than the non-Appalachian region of controlled-release oxycodone prescription claims among Temporary Assistance for Needy Families recipients. Similar findings were observed for disabled Medicaid recipients in 2002.
Conclusions: Higher rates of claims for controlled-release oxycodone in the distressed Appalachian region of Kentucky suggest that economic and health factors unique to this area may be contributing to increased use of this product. The increased availability of controlled-release oxycodone in distressed Appalachian regions may facilitate abuse.
Rural Women and Osteoporosis: Awareness and Educational Needs
Hollie L. Matthews, Mary Laya, Dawn E. DeWitt
Context: Little is known about rural women's knowledge about osteoporosis.
Purpose: To explore what women from high-prevalence rural communities know about osteoporosis and to assess their learning preferences.
Methods: We surveyed 437 women in rural Washington and Oregon.
Findings: The response rate was 93% (N = 406). The mean age of respondents was 63 years (range 16-95) and 74% (n = 301) of women were postmenopausal. While 27% over age 40 (n = 111) reported having a fracture as an adult, less than half of this group (42%, n = 47) considered themselves at risk for osteoporosis. Of the 42% (n = 171) who rated their knowledge of osteoporosis good or excellent, only 18% (n = 30) answered calcium and vitamin D questions correctly. About half (53%; n = 214) exercised 3 or more times per week. Reported sources of osteoporosis information included television, magazines, health care providers, and personal contacts. Over half of the women in this study wanted more information about osteoporosis, most wanted it before age 50, and health care providers were a preferred source. Less than half of participants reported having Internet access.
Conclusions: While many participants underestimated their osteoporosis risk, most women wanted to learn more about osteoporosis and health care providers remain a preferred source of information.
Australian Journal of Rural Health
2006; 14 (4)
Treating acute mental illness in rural general hospitals: Necessity or choice?
Objective: To identify reasons why rural general practitioners (GPs) treat a large proportion of patients with a primary psychiatric diagnosis in general beds of their local hospitals, and the barriers encountered when providing this treatment.
Design: A postal questionnaire was developed and distributed to a sample of rural GPs, asking about the treatment of patients with an acute mental illness in their local hospital.
Results: The majority of GPs agreed that they treat the acutely mentally ill in general beds of their local hospital due to lack of availability of, and inability to gain access to, mental health beds in the larger centres; and also to enable ongoing family involvement and continuity of care. Distance factors were identified as least significant. Barriers to providing care to this group of patients included a perceived lack of support by consultant psychiatrists, confidentiality issues, lack of community mental health workers to provide assistance, aggression levels of patients, inappropriate local hospital setting, and lack of confidence of GPs and general hospital nursing staff.
Conclusion: Addressing these barriers is necessary if rural Australians are to receive a quality of care that is equal to that received by those located in metropolitan Australia. Continuing research in this area is crucial.
Community participation in organising rural general practice: Is it sustainable?
Judy Taylor, David Wilkinson, Brian Cheers
Objective: We analysed community participation in organising rural general medical practice in order to suggest ways to extend and sustain it.
Design: A multisite, embedded case-study design collecting data through semistructured interviews, non-participation observation and a document analysis.
Setting: One remote and two rural communities in Australia.
Participants: Community members, GPs, health professionals, government officers and rural medical workforce consultants.
Results: High levels of community participation in recruiting and retaining GPs, organising the business model, and contributing to practice infrastructure were evident. Community participation in designing health care was uncommon. Participation was primarily to ensure viable general practice services necessary to strengthen the social and economic fabric of the community. There were factors about the decision-making and partnership processes in each of the communities that threatened the viability of community participation.
Conclusions: We recommend that a concept of community development and explicit facilitation of the processes involved is necessary to strengthen participation, create effective partnerships and ensure inclusive decision-making.
Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service
Bryan Hoolahan, Brian Kelly, Helen J. Stain, Didi Killen
Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co-morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co-morbid D&A and mental health disorders.
Design: Current literature on co-morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision.
Setting: A rural Area Health Service in NSW.
Participants: Rural health and welfare service providers, consumers with co-morbid D&A and mental health disorders.
Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug-taking. Information gathered from the focus groups indicated a reasonable level of awareness of co-morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources.
Discussion: Significant gaps in the provision of appropriate care for people with co-morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co-morbid care can be provided.
Statistical methods for analysis of repeated measures on maternal morbidity
M. Ataharul Islam, Rafiqul I. Chowdhury, Karan P. Singh
Objectives: This paper applies statistical methods to identify factors associated with pregnancy-related complications in rural Bangladesh. The results are examined in order to identify the factors that can help formulate policy for reducing pregnancy-related morbidity.
Methods: Two statistical methods are used in this study to analyse the repeated-measures data on pregnancy-related complications in rural Bangladesh. One method is based on the application of linear logistic regression at each follow up, and the results are compared to identify the potential risk factors. Then the generalised estimating equation (GEE) approach is used, and the results based on each follow up are compared with those obtained from the application of the GEE approach. The maternal morbidity data collected by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies are used in this paper.
Results: Economic status, visit for antenatal care, and histories of sexually transmitted disease, hypertension, heart disease and breathing problem are positively associated with the complications during pregnancy, while wanted pregnancy, household type, primary and secondary schooling, and five or more pregnancies are associated negatively with the response variable. Involvement with gainful employment shows a negative association by the first technique. The GEE approach failed to identify some important factors such as history of anaemia, previous pregnancy and gainful employment. However, duration of pregnancy appears to have an association with pregnancy complications, which was not found from the conditional model based on each follow up.
Conclusion: It appears that unwanted pregnancies need to be reduced through a well-organised and targeted family planning campaign for potential mothers of all ages in rural Bangladesh. Nutritional anaemia may cause various complications, and suggestions are given for reducing anaemia among pregnant women. In the rural areas of Bangladesh, first births usually occur at teenage. The first-birth pregnancy among teenagers can be a source of severe complications. There can be special programs to address the need for delay in the first pregnancy of those who marry at an early age.
An outbreak of acute post-streptococcal glomerulonephritis in remote Far North Queensland
Melania Scrace, Karen Koko
Background: To observe and record an outbreak of acute post-streptococcal glomerulonephritis (APSGN) in the Lockhart River community in 2005 and the steps taken by health workers to contain the epidemic.
Methods: A descriptive study of cases of APSGN and children aged from 2 to 12 years involved in the screening program.
Setting: A remote indigenous community in Far North Queensland.
Participants: All children aged from 2 to 12 years in the Lockhart River community.
Results: Eighty-seven children were screened. And 46% were found to have infected scabies.
Conclusions: There were 11 confirmed cases of APSGN over four months from February to May. Infected scabies was the main preceding finding in these children.