Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety.

BACKGROUND: The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review. METHODS: This paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014. RESULTS: Two hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians. CONCLUSION: Findings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.

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.

Medical students' self-reported preparedness and attitudes in providing care to ethnic minorities.

BACKGROUND: To assess medical students' self-reported preparedness to provide care to ethnic minorities, factors that influence preparedness, and attitudes toward cultural competency training. METHODS: A cross-sectional study, which invited University of British Columbia medical students to participate in a survey on student demographics, knowledge and awareness, preparedness and willingness, and personal attitudes. Of 1024, eligible, 301 students consented to study. RESULTS: Students across all year levels felt significantly less ready to provide care for non-English speaking Chinese patients compared to "any" patients. Proficiency in working with interpreters was correlated with readiness, OR 4.447 (1.606-12.315) along with 3rd and 4th year level in medical school, OR 3.550 (1.378-9.141) and 4.424 (1.577-12.415), respectively. Over 80% of respondents reported interest in learning more about the barriers and possible ways of overcoming them. CONCLUSIONS: More opportunities for cultural competency training in the medical curriculum are warranted and would be welcomed by the students.

The sub-fossil diatom distribution in the Beibu Gulf (northwest South China Sea) and related environmental interpretation.

Located in northwestern South China Sea (SCS), the Beibu Gulf constitutes an environmentally sensitive region shaped by land-ocean-atmosphere interactions in Asia between the western Pacific and eastern Indian Oceans. This study aims to provide a comprehensive view of the sub-fossil diatom biogeography, distribution pattern and oceanographic environmental controls with support of multivariate methods based on Beibu Gulf core-top samples. Cluster analysis of diatom assemblages divides the distribution pattern into four subclusters. Sea surface salinity (SSS), temperature (SST), trophic state (chlorophyll a concentration in this study) and water depth constrain the diatom distribution pattern through canonical redundancy analysis although only partly support an interpretation of the relationship between these various variables. Chlorophyll a has a strong correlation to diatom distribution, and responds to Paralia sulcata occurrence, while SSS and SST also have significant influence and indicate warm water invasion from the open SCS. Water depth is a subordinate factor in terms of Beibu Gulf diatom distribution. The ca. 25 m water-depth marks the upper extent of Paralia sulcata dominance in the northern Beibu Gulf. A strong mixing area with a complex diatom distribution exists below this water depth in the middle of Beibu Gulf. Coastal currents from north of SCS invade Beibu Gulf through Qiongzhou Strait and south of Hainan Island, as recorded by higher percentages of Paralia sulcata and Cyclotella striata at these sites. Our results provide a selection of evaluation method for a marine ecological red-line definition for sustainable development. This study highlights the perspective relationships between the spatial distribution of sub-fossil diatom assemblages in surface sediments and oceanographic variables, which could serve as a model for paleoenvironmental and paleoclimatic reconstruction in future marginal sea geoscience research for the Beibu Gulf, northwestern SCS.

The Corporate Elite and the Architecture of Climate Change Denial: A Network Analysis of Carbon Capital's Reach into Civil Society.

This study employs social network analysis to map the Canadian network of carbon-capital corporations whose boards interlock with key knowledge-producing civil society organizations, including think tanks, industry associations, business advocacy organizations, universities, and research institutes. We find a pervasive pattern of carbon-sector reach into these domains of civil society, forming a single, connected network that is centered in Alberta yet linked to the central-Canadian corporate elite through hegemonic capitalist organizations, including major financial companies. This structure provides the architecture for a "soft" denial regime that acknowledges climate change while protecting the continued flow of profit to fossil fuel and related companies.

Cette étude emploie une analyse de réseaux sociaux faisant la carte du réseau Canadien des corporations de 'carbon-capital' dont les comités sont liés à des organisations civiles de production de savoir, incluant des groupes de réflexion ('think thanks'), des associations d'entreprises, des groupes de défense des milieux d'affaire, des universités et des instituts de recherche. Nous avons découvert un modèle se fondant sur une tendance omni-présente ('pattern') dans le secteur du carbone, formant un réseau singulier centré en Alberta mais lié néanmoins à l'élite corporative à travers les organisations capitalistes hégémoniques, incluant des compagnies financières majeures. Cette structure révèle l'architecture d'un régime de déni 'mou' qui reconnaît le changement climatique tout en protégeant le flot continu de profit de compagnies liées au combustible fossile.