Evaluating rural health outcomes: A methodological approach using population-level data.

Background: The sustainability of rural surgical and obstetrical facilities depends on their efficacy and quality of care, which are difficult to measure in a rural context. In an evaluation of rural practice, it is often the case that the only comparators are larger referral facilities, for which facility-level comparisons are difficult due to differences in population demographics, acuity of patients, and services offered. This publication outlines these limitations and highlights a best-practice approach to making facility-level comparisons using population-level data, risk stratification, tests of noninferiority, and Firth logistic regression analysis. This includes an investigation of minimum sample-size requirements through Monte Carlo power analysis in the context of low-acuity rural surgical care. Methods: Monte Carlo power analysis was used to estimate the minimum sample size required to achieve a power of 0.8 for both logistic regression and Firth logistic regression models that compare the proportion of surgical adverse events against facility type, among other confounders. We provide guidelines for the implementation of a recommended methodology that uses risk stratification, Firth penalized logistic regression, and tests of noninferiority. Results: We illustrate limitations in facility-level comparison of surgical quality among patients undergoing one of four index procedures including hernia repair, colonoscopy, appendectomy, and cesarean delivery. We identified minimum sample sizes for comparison of each index procedure that fluctuate depending on the level of risk stratification used. Conclusion: The availability of administrative data can provide an adequate sample size to allow for facility-level comparisons in surgical quality, at the rural level and elsewhere. When they are made appropriately, these comparisons can be used to evaluate the efficacy of general practitioners and nurse practitioners in performing low-acuity procedures.

Rural patients' experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities.

Introduction: Rural patients face barriers to accessing surgical care and often need to travel long distance for pre- or post-surgical consultations. Although adaptation to the COVID-19 pandemic has demonstrated the efficacy of virtual care, there is minimal data available to evaluate patient satisfaction with this modality and consequent health service utilization if virtual services are not available. Methods: An online survey was conducted with participants living in rural British Columbia, Canada who had undergone surgery within 12 months of data collection and had either virtual or face-to-face pre- or post-surgical consultations. It was supplemented by an in-person survey administered in two rural sites to all patients who had a virtual visit prior to undergoing procedural care. A ten-point scale was used to assess satisfaction. Quantitative and qualitative data were collected and analyzed. Results: Findings from the province-wide survey (n = 163) revealed no significant differences in average satisfaction ratings between people with in-person and virtual surgical consultations (8.03 versus 8.38, p = 0.26). However, most participants indicated that virtual appointments saved them time traveling, energy, and money and made them less dependent on others, accruing significant social benefit.In the community-focused sample (n = 71), 38% said they would not have had the procedure without a virtual visit option and 21% said that they would have delayed the procedure. Virtual consultations saved patients an average of 9 h (range 1-90). Participants traveled an average of 427 kilometers round trip to have the procedures. Conclusion: Findings reveal costs and time saved in accessing care due to the introduction of pre- and post-operative virtual care visits, and further investments in virtual care are warranted. This will contribute to promoting equitable access to healthcare for rural residents.

Perinatal Outcomes at Rural Hospitals That Participated in the Rural Surgical and Obstetrical Networks (RSON) of British Columbia (2016-2021).

BACKGROUND: The goal of the Rural Surgical and Obstetrical Networks (RSON) of British Columbia was to support safe and appropriate surgery, operative birth, and perinatal care closer to home for rural communities. Family physicians with enhanced obstetrical and/or surgical skills provide cesarean delivery and family practice anesthetists manage anesthesia for labour pain and operative births at RSON-supported hospitals, with the involvement of a local specialist at one site. OBJECTIVES: The objectives of the study were to: (1) compare perinatal outcomes at hospitals participating in the RSON initiative with outcomes at referral hospitals and (2) examine temporal changes in the proportion of childbearing people who resided in RSON communities and gave birth locally. METHODS: Poisson regression analysis was used to model the effect of hospital type (RSON vs. referral) on perinatal outcomes. We restricted the analysis to singleton births and controlled for differences in maternal characteristics, obstetric history, and pregnancy complications. RESULTS: Childbearing people who gave birth at RSON-supported hospitals (n = 3498) had a 10% lower incidence of adverse maternal-newborn outcomes compared to those who gave birth at referral hospitals (n = 14 772), after controlling for referral bias. We found a small increase (3.2 %) in the proportion of local births over the study period. CONCLUSION: Findings provide evidence that childbearing people can safely give birth at smaller rural hospitals in British Columbia and that investments in rural hospitals contribute to service stability. Stabilizing local birth services in rural communities benefits the whole region because it reduces surgical overload in regional referral centres.

Surgical Task-Sharing to Non-specialist Physicians in Low-Resource Settings Globally: A Systematic Review of the Literature.

BACKGROUND: As the global community increasingly recognizes the large and unmet burden of surgical disease, a new emphasis is being placed on strengthening the health system at the first-level hospital. The shortage of surgical care providers at this district and rural level can be met by surgical task-shifting/sharing to non-physician clinicians (NPCs) and non-specialist physicians (NSPs). While the role of NPCs in low-middle-income countries (LMICs), in particular in sub-Saharan Africa (SSA), has been well documented in the literature, there has been little focus on NSPs. In addition to providing essential surgical services, this physician cadre also practices generalist medicine, an advantage at the first-level hospital. The present study seeks to explore where, across all country income groups, NSPs are providing surgical services and what additional surgical training, if any, is available in each identified country. METHODS: A systematic review of the literature was performed, following PRISMA guidelines. Medline, EMBASE, EBM Reviews, and CINAHL were searched. Including hand-searching for further references, 53 publications met inclusion/exclusion criteria and were identified for data extraction purposes. Gray literature was also explored within the time limits for this study. RESULTS: Surgical task-shifting/sharing to NSPs occurs across all country income groups; some provide surgical obstetrics, while others also provide a broader scope of surgical services. Within LMIC countries, the majority are in SSA. In SSA, 16 of 54 countries were included in the reviewed articles, only 4 of which (Ethiopia, Niger, Nigeria, and Sierra Leone) have a formal surgical program beyond the regular medical officer/general practitioner training. Canada and Australia have established programs for both surgical obstetrics and the broader scope, while the USA has several programs for surgical obstetrics and is developing a new, broad-scope program. CONCLUSION: This study has demonstrated that NSPs are providing surgical services across all income groups, with varying degrees of additional training specific to the surgical needs of their district/rural location. To "close the gap" in needed surgical services at the first-level hospital, more task-sharing needs to occur to both NSPs (the focus of this study) and NPCs. Collaboration between practitioners and training programs, given the shared challenges and practice environments, would help support task-sharing at the first-level hospital and improve access to the 5 billion underserved people.

An evidence-based program for rural surgical and obstetrical networks.

CONTEXT: Over the past 25 years, the attrition of small volume rural surgery programs across Western Canada has been significant and sustained. The 'Joint position paper on rural surgery and operative delivery' (JPP) offers a consensus policy framework for the sustainability of rural surgical programs by nesting them within larger regional programs. The many recommendations in the JPP coalesce around the recognition that surgical care should be provided as close to home as possible. To achieve this, surgical care should be delivered within rural and regional surgical programs integrated into well-functioning networks staffed by generalist specialist surgeons trained across surgical disciplines and family physicians with enhanced surgical skills (FPESS). ISSUES: There are important issues to be addressed in the creation of these networks, not the least of which is the sometimes challenging relationships between the stakeholders in these networks and skepticism about the training of FPESS and the safety and quality of low volume surgical programs. Relationships extend from the patient-provider nexus to include interprofessional relationships and those between the pentagram partners (patients/communities, care providers, administrators, researchers and policymakers). Equally important to resolve is the issue of the minimum threshold volume of local surgical activity required for a sustainable professional workforce in a small rural program. LESSONS LEARNED: A collaborative effort by key stakeholders in British Columbia has produced a program designed to overcome these challenges and build effective networks of rural surgical care, based on the synergistic interplay of five key pillars to support small surgical sites. These five pillars include clinical coaching, continuing quality improvement (CQI), remote presence technology to mitigate geographic challenges, sustainable local surgical capacity, and evaluation of dimensions of network function and clinical outcomes. This is the first time that the integration of these five pillars, each derived from best available evidence, have been positioned together as deliberate strategic policy to improve rural surgical care.

Satisfaction and sustainability: a realist review of decentralized models of perinatal surgery for rural women.

INTRODUCTION: This article was developed as part of a larger realist review investigating the viability and efficacy of decentralized models of perinatal surgical services for rural women in the context of recent and ongoing service centralization witnessed in many developed nations. The larger realist review was commissioned by the British Columbia Ministry of Health and Perinatal Services of British Columbia, Canada. Findings from that review are addressed in this article specific to the sustainability of rural perinatal surgical sites and the satisfaction of providers that underpins their recruitment to and retention at such sites. METHODS: A realist method was used in the selection and analysis of literature with the intention to iteratively develop a sophisticated understanding of how perinatal surgical services can best meet the needs of women who live in rural and remote environments. The goal of a realist review is to examine what works for whom under what circumstances and why. The high sensitivity search used language (English) and year (since 1990) limiters in keeping with both a realist and rapid review tradition of using reasoned contextual boundaries. No exclusions were made based on methodology or methodological approach in keeping with a realist review. Databases searched included MEDLINE, PubMed, EBSCO, CINAHL, EBM Reviews, NHS Economic Evaluation Database and PAIS International for literature in December 2013. RESULTS: Database searching produced 103 included academic articles. A further 59 resources were added through pearling and 13 grey literature reports were added on recommendation from the commissioner. A total of 42 of these 175 articles were included in this article as specific to provider satisfaction and service sustainability. Operative perinatal practice was found to be a lynchpin of sustainable primary and surgical services in rural communities. Rural shortages of providers, including challenges with recruitment and retention, were found to be a complex issue, with scope of practice and contextual support as the key factors. Targeted educational programs, exposure to rural practice and living environments, accessible and appropriate continuing medical education, and strong clinical support (including locum coverage and sustainable on-call schedules) were all found to be areas of important consideration in rural service sustainability. CONCLUSIONS: Rural practice was found to be a site to actualize personal goals and values for providers. A broad and challenging scope of practice and the opportunity to participate in community level health improvements were seen as critical to the retention of providers. Without proper support, however, providers reported a feeling of being 'in too deep'. Common themes were a lack of health human resource redundancies, compromised access to specialist support and technology, and a lack of work-life balance. Burnout and attrition in perinatal surgical services threaten to destabilize other aspects of rural community health services, making the need to address sustainability of rural providers urgent.

Joint position paper on rural surgery and operative delivery.

Our professional organizations have prepared this paper as part of an integrated, multidisciplinary plan to ensure the availability of well-trained practitioner teams to sustain safe, effective and high-quality rural surgical and operative delivery services. Without these robust local (or nearby) surgical services, sustaining rural maternity care is much more difficult. This paper describes the "network model" as a health human resources solution to meet the surgical needs, including operative delivery, of rural residents; outlines necessary policy directions for achieving this solution; and poses a series of enabling recommendations.

Nos organisations professionnelles ont préparé cet article dans le cadre d'un plan multidisciplinaire intégré visant à assurer la disponibilité d'équipes soignantes bien formées pour offrir des services obstétricaux interventionnels et chirurgicaux sécuritaires, efficaces et de grande qualité en milieu rural. Sans de tels solides services chirurgicaux locaux (ou de proximité), il est beaucoup plus difficile d'assurer les soins obstétricaux en milieu rural. Cet article décrit le « modèle en réseau ¼ comme une solution au chapitre des ressources humaines en santé pour répondre aux besoins chirurgicaux des populations rurales, y compris pour les services obstétricaux interventionnels. On y décrit aussi les orientations politiques nécessaires à l'application de cette solution et on formule une série de recommandations préparatoires.

The outcomes of perinatal surgical services in rural British Columbia: a population-based study.

INTRODUCTION: A substantial number of small surgical services in rural Canada have been discontinued in the past 15 years because of difficulties recruiting and retaining practitioners, health care restructuring and a lack of a coherent evidence base regarding the safety of small services. The objective of this study was to examine the safety of small perinatal surgical services. METHODS: We accessed perinatal data for singleton births that occurred in British Columbia between Apr. 1, 2000, and Mar. 31, 2007. We defined hospital service levels, population catchment areas surrounding each hospital and the postal codes linked to those catchment areas. Births were linked with specific catchment areas and amalgamated by service level. We made comparisons among service strata populations and adjusted for potentially confounding characteristics. RESULTS: A total of 87 294 births occurred during the study period. The births were distributed across 6 strata of services, which ranged from no local maternity services to services supported by obstetricians. Fifteen catchment areas were served by general practitioners with enhanced surgical skills (GPESSs), and 9174 births were included from this obstetric service level. Outcomes for surgical services provided by GPs compared favourably to those provided by obstetricians. CONCLUSION: Our results suggest that small surgical services supported by GPESSs are a safe health services model to meet the needs of rural women and families.

INTRODUCTION: Plusieurs raisons expliquent la fermeture d'un nombre substantiel de petits services chirurgicaux en milieu rural ces 15 dernières années au Canada : difficulté à recruter et à fidéliser les médecins, restructuration des soins de santé et manque de preuves cohérentes à l'appui de la sécurité de ces services de petite taille. L'objectif de cette étude était de vérifier la sécurité des services chirurgicaux périnataux de petite taille. MÉTHODES: Nous avons accédé aux données périnatales concernant les naissances simples survenues en Colombie-Britannique entre le 1er avril 2000 et le 31 mars 2007. Nous avons défini les niveaux de services hospitaliers, délimité les bassins de populations entourant chaque hôpital et identifié les codes postaux correspondants. Les naissances ont été assorties aux différents bassins de population, puis amalgamées par niveau de services. Nous avons procédé à des comparaisons entre les populations par niveau de services, puis effectué les ajustements nécessaires pour tenir compte de variables de confusion potentielles. RÉSULTATS: En tout, 87 294 naissances ont eu lieu au cours de la période de l'étude. Les naissances ont été distribuées entre 6 niveaux de services allant de « absence de services locaux de maternité ¼ à « services assurés par des obstétriciens ¼. Quinze des bassins de populations étaient desservis par des omnipraticiens ayant des compétences chirurgicales avancées et 9174 naissances ont été assorties à ce niveau de services obstétricaux. Au plan des résultats, les services chirurgicaux fournis par les omnipraticiens se sont comparés favorablement aux services offerts par les obstétriciens. CONCLUSION: Nos résultats donnent à penser que les petits services chirurgicaux assurés par des omnipraticiens ayant des compétences chirurgicales avancées constituent un modèle de services de santé sécuritaire pour répondre aux besoins des femmes et des familles des milieux ruraux.