Outreach physiatry clinics in remote Manitoba communities: an economic cost analysis.

BACKGROUND: One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba. METHODS: Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars. RESULTS: Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit. INTERPRETATION: An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

"Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers.

INTRODUCTION: Neonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia. METHODS: This study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services. RESULTS: Among a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths. CONCLUSION: The current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future.

Polypharmacy and Cognition Function Among Rural Adults.

BACKGROUND: Polypharmacy (using≥5 medications) is associated with poor health outcomes. Mixed results from past studies surrounding chronic medication use, control of chronic conditions, and their effects on cognitive performance warrant further attention. OBJECTIVE: Investigate a link between polypharmacy and cognition function in rural-dwelling adults in Texas, USA. METHODS: Project FRONTIER (Facing Rural Obstacles to Healthcare Now Through Intervention, Education & Research) is a cross-sectional epidemiological study using community-based participatory research in three counties of Texas. Residents age > 40 were eligible for inclusion. The primary outcome is cognitive impairment, and exposures of interest are polypharmacy; comorbidities; and diabetes, hypertension, and depression medication. Logistic regression was used to assess association. RESULTS: Six hundred eighty-nine individuals participated; the mean age was 61, and the majority were female (68.7%).The median number of medications taken by participants was 3.3 (IQR: 0-5); the rate of polypharmacy was 29.6%. Anti-hypertensive agents were the most common medications (15%) used. Polypharmacy users were 2.84 times more likely to have cognitive impairment [OR: 2.84, 95%CI (1.32-6.09)] than those using < 5 medications. Participants on hypertensive medications had 1.85 times higher odds [OR: 1.85, 95%CI (1.14-3.01)] of having cognitive impairment than those who did not have cognitive impairment. CONCLUSION: Polypharmacy increases the odds of cognitive impairment. The odds of presenting with cognitive impairment increased as the number of medications increased. Additionally, we identified a large, concerning number of participants with pharmacotherapy and poor chronic disease management. A larger study should examine medication adherence among rural elders to manage chronic disease and any healthcare barriers to adherence.

Transition from pediatric to adult aftercare for survivors of pediatric cancer in Newfoundland and Labrador: a qualitative study.

BACKGROUND: Childhood cancer survivors (CCSs) face increased risks during the period when they leave pediatric care and transition into adult-focused aftercare. We examined the experiences of CCSs entering adult-focused aftercare to gain a better understanding of current transition practices and barriers to transition, and to identify opportunities for improving care. METHODS: We conducted a qualitative study using in-person and telephone semi-structured interviews. Childhood cancer survivors who recently transitioned out of pediatric care and health care providers (HCPs) who provide care for CCSs in Newfoundland and Labrador were identified using purposive sampling. Participants were interviewed between July 2017 and March 2019. Data were analyzed using both qualitative descriptive and thematic analysis. RESULTS: We conducted interviews with 5 CCSs and 9 HCPs. All CCSs interviewed reported receiving aftercare through their pediatric oncology program; only 2 reported receiving any form of aftercare in the adult setting. The lack of a structured transition process for CCSs in the province emerged as a theme in this study. Interview participants identified several barriers to transition: the added challenges for survivors in rural areas, changes in the availability of services after the transition to adult-focused aftercare, challenges associated with navigating the adult system, and a lack of education on transitioning into adult aftercare. INTERPRETATION: We found that there was little preparation for the transition of CCSs into adult care, and their aftercare was disrupted. Programs serving CCSs have opportunities to improve care by standardizing and better supporting these transitions, for example through the development of context-appropriate educational resources.

Rural resilience: The role of birth centers in the United States.

PURPOSE: To explore the role of the birth center model of care in rural health and maternity care delivery in the United States. METHODS: All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data RegistryTM user sites between 2012 and 2020 are included in this descriptive analysis. FINDINGS: Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data RegistryTM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities. CONCLUSIONS: Rural populations cared for within the birth center model of care experienced high-quality outcomes. HEALTH POLICY IMPLICATIONS: A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.

The Benefits and Challenges of Point-of-Care Testing in Rural and Remote Primary Care Settings in Australia.

CONTEXT.­: Point-of-care (POC) testing has significant potential application in rural and remote Australian communities where access to laboratory-based pathology testing is often poor and the burden of chronic, acute, and infectious disease is high. OBJECTIVE.­: To explore the clinical, operational, cultural, and cost benefits of POC testing in the Australian rural and remote health sector and describe some of the current challenges and limitations of this technology. DATA SOURCES.­: Evidence-based research from established POC testing networks for chronic, acute, and infectious disease currently managed by the International Centre for Point-of-Care Testing at Flinders University are used to highlight the experience gained and the lessons learned from these networks and, where possible, describe innovative solutions to address the current barriers to the uptake of POC testing, which include governance, staff turnover, maintaining training and competency, connectivity, quality testing, sustainable funding mechanisms, and accreditation. CONCLUSIONS.­: Point-of-care testing can provide practical and inventive opportunities to revolutionize the delivery of pathology services in rural and remote sectors where clinical need for this technology is greatest. However, many barriers to POC testing still exist in these settings, and the full potential of POC testing cannot be realized until these limitations are addressed and resolved.

Survey of Neonates in Pomerania (SNiP): Study design and cohort update.

BACKGROUND: The health status of newborns is a major concern for parents and medical personnel. Recent studies have provided increasing evidence that factors from the foetal and perinatal periods of life influence health later in life. The "Follow-up of the Survey of Neonates in Pomerania" (SNiP-I-Follow-up) is the first follow-up of the population-based birth cohort study, SNiP-I, established in north-east Germany. OBJECTIVES: The primary aim of SNiP-I-Follow-up study was the collection of longitudinal data on children and adolescents. The associations will be analysed between risk factors in pregnancy and the perinatal period and health status in infancy and later childhood. POPULATION: The population-based cohort study SNiP-I was conducted in Pomerania in north-east Germany between February 2002 and November 2008. All mothers from the SNiP-I birth cohort were recontacted when their children were from 9 to 15 years of age. DESIGN: The SNiP-I-Follow-up study was carried out between December 2016 and August 2017 and is a questionnaire-based survey. METHODS: Physical development, health status, and social behaviour (school and leisure behaviour) of children were analysed using a questionnaire comprising medical, epidemiological, and socio-economic data, associated health care risk factors, and life circumstances of newborns, children, and their parents. PRELIMINARY RESULTS: Out of 5725 children invited to participate in the SNiP-I-Follow-up study between December 2016 and August 2017, 29% (n = 1665) children participated in the SNiP-I-Follow-up study, providing data on 1665 mothers-child dyads. Responders had higher socio-economic status, especially in relation to maternal education status. CONCLUSION: As a longitudinal birth cohort from rural Germany, the SNiP cohort will be a resource to address urgent research needs and contribute to overall population health.

What Is Rural? Challenges And Implications Of Definitions That Inadequately Encompass Rural People And Places.

Monitoring and improving rural health is challenging because of varied and conflicting concepts of just what rural means. Federal, state, and local agencies and data resources use different definitions, which may lead to confusion and inequity in the distribution of resources depending on the definition used. This article highlights how inconsistent definitions of rural may lead to measurement bias in research, the interpretation of research outcomes, and differential eligibility for rural-focused grants and other funding. We conclude by making specific recommendations on how policy makers and researchers could use these definitions more appropriately, along with definitions we propose, to better serve rural residents. We also describe concepts that may improve the definition of and frame the concept of rurality.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis.

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009. Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland. Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient). Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004-2008 to 1.5% (n = 126) in 2010-2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all). Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Equitable Health Care and Low-Density Living in the United States.

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.

Point-of-care troponin use in New Zealand rural hospitals: a national survey.

AIMS: Accelerated diagnostic chest pain pathways (ADP) have become standard of care in urban emergency departments. It is, however, unknown how widely they are used in New Zealand's rural hospitals because ADP require immediate access to contemporary or high-sensitivity troponin (hs-Tn). We aimed to determine for rural hospitals the troponin assay being used, if they were using an ADP and if they had access to on-site exercise tolerance testing (ETT). METHODS: An online survey was sent to 27 rural hospitals providing acute care in New Zealand. RESULTS: Most rural hospitals (23/27, 85%) responded to the survey. Most (17/23, 74%) used point-of-care cardiac troponin (POC-cTn) and the majority of these hospitals (15/17, 88%) were reliant on this assay 24-hours per day. All hospitals that had timely access to hs-Tn (8/23, 35%) used an ADP but only a minority (4/17, 24%) of hospitals using POC-cTn used an ADP. Only a minority of the larger rural hospitals (7/23, 30%) had access to on-site ETT. CONCLUSIONS: Most New Zealand rural hospitals rely on POC-cTn to assess chest pain and are not using an ADP. There are limited data available to support this approach in rural settings especially with patients who are not low-risk.

Subscribers' perception of quality of services provided by Ghana's National Health Insurance Scheme - what are the correlates?

BACKGROUND: Ghana's National Health Insurance Scheme (NHIS) has witnessed an upsurge in enrollment since its inception in 2003, with over 40% of the Ghanaian population actively enrolled in the scheme. While the scheme strives to achieve universal health coverage, this quest is derailed by negative perceptions of the quality of services rendered to NHIS subscribers. This paper presents an analysis on perceptions of service quality provided to subscribers of Ghana's NHIS with emphasis on rural and urban scheme policy holders, using a nationally representative data. METHODS: The study used data from the 2014 Ghana Demographic and Health Survey. Ordered logistic regressions were estimated to identify the correlates of perceived quality of care of services rendered by the NHIS. Also, chi-square statistics were performed to test for significant differences in the proportions of subscribers in the two subsamples (rural and urban). RESULTS: Rural subscribers of the NHIS were found to identify more with better perception of quality of services provided by the NHIS than urban subscribers. Results from the chi-square statistics further indicated that rural subscribers are significantly different from urban subscribers in terms of the selected socioeconomic and demographic characteristics. In the full sample; age, out-of-pocket payment for healthcare and region of residence proved significant in explaining perceived quality of services rendered by the NHIS. Age, out-of-pocket payment for healthcare, region of residence, wealth status, and access to media were found to be significant predictors of perceived quality of services provided to both rural and urban subscribers of the NHIS. The significance of these variables varied among men and women in rural and urban areas. CONCLUSION: Different factors affect the perception of quality of services provided to rural and urban subscribers of Ghana's NHIS. Health financing policies geared toward improving the NHIS-related services in rural and urban areas should be varied.

Increases in statin eligibility to reduce cardiovascular risk according to the 2013 ACC/AHA cholesterol guidelines in the Africa Middle East region: a sub-analysis of the Africa Middle East Cardiovascular Epidemiological (ACE) study.

BACKGROUND: With development of cholesterol management guidelines by the American College of Cardiology/American Heart Association (ACC/AHA), more individuals at risk of cardiovascular disease may be eligible for statin therapy. It is not known how this affects statin eligibility in the Africa and Middle East Region. METHODS: Data were used from the Africa Middle East Cardiovascular Epidemiological (ACE) study. The percentage of subjects eligible for statins per the ACC/AHA 2013 cholesterol guidelines and the 2002 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III) recommendations were compared. Analyses were carried out according to age, gender, community (urban/rural), and country income categories based on World Bank definitions. RESULTS: According to the ACC/AHA recommendations, 1695 out of 4378 subjects (39%; 95% confidence interval [CI], 37-40%) satisfied statin eligibility criteria vs. 1043/4378 (24%; 95% CI, 23-25%) per NCEP-ATP recommendations, representing a 63% increase in statin eligibility. Consistent increases in eligibility for statin therapy were seen according to the ACC/AHA vs. NCEP-ATP guidelines across sub-groups of age, gender, community, and country income. Notable increases for statin eligibility according to ACC/AHA vs. NCEP-ATP were seen, respectively, in subjects aged ≥65 years (86% vs. 39%), in males (46% vs. 25%), in low-income countries (28% vs. 14%), and rural communities (37% vs. 19%). CONCLUSION: An increase in statin eligibility was seen applying ACC/AHA cholesterol guidelines compared with previous NCEP-ATP recommendations in the Africa Middle East region. The economic consequences of these guideline recommendations will need further research. TRIAL REGISTRATION: The ACE trial is registered under NCT01243138 .

The Jamkhed Comprehensive Rural Health Project and the Alma-Ata Vision of Primary Health Care.

The Jamkhed Comprehensive Rural Health Project (Jamkhed CRHP) was established in central India in 1970. The Jamkhed CRHP approach, developed by Rajanikant and Mabelle Arole, was instrumental in influencing the concepts and principles embedded in the 1978 Declaration of Alma-Ata. The Jamkhed CRHP pioneered provision of services close to people's homes, use of health teams (including community workers), community engagement, integration of services, and promotion of equity, all key elements of the declaration. The extraordinary contributions that the Jamkhed CRHP has made as it approaches its 50th anniversary need to be recognized as the world celebrates the 40th anniversary of the International Conference on Primary Health Care and the writing of the declaration. We describe the early influence of the Jamkhed CRHP on the declaration as well as the work at Jamkhed, its notable influence in improving the health of the people it has served and continues to serve, the remarkable contributions it has made to training people from around India and the world, and its remarkable influences on programs and policies in India and beyond.

Emergency Medical Services Utilization by Children.

OBJECTIVE: The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California. METHODS: We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS. RESULTS: Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (ß = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum. CONCLUSIONS: Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.