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.

A mixed-methods descriptive study on the role of continuous quality improvement in rural surgical and obstetrical stability: Considering enablers, challenges and impact.

INTRODUCTION: The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers' experiences with CQI and the implications for service stability. BACKGROUND: Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings. METHODS: Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023. FINDINGS: Qualitative findings revealed participants' perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships). CONCLUSION: Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care.

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.

The motivations and experiences of specialists who provide outreach services in rural operating rooms: A survey study from British Columbia.

INTRODUCTION: Outreach care has long been used in Canada to address the lack of access to specialist care in rural settings, but research on the experiences of specialists providing these services is lacking. This descriptive survey study aimed to understand 1) specialists' motivation for engaging in outreach work, (2) their perceptions of the quality of care at their rural outreach hospital, and (3) the supports they receive for their outreach work, in order to create a supportive framework to encourage specialist outreach contributions. METHODS: In July 2022, specialist physicians who provide outreach operating room services at rural hospitals participating in the Rural Surgical and Obstetrical Networks initiative in the province of British Columbia were invited to complete an anonymous survey. RESULTS: 21 of 45 invited outreach specialists completed the survey (47% response rate). Three-quarters of respondents had a surgical specialty. The opportunity to deliver care to underserved patients was the most common motivator for outreach work. Rural hospitals received high ratings from respondents on overall safety and various aspects of communication and teamwork. Postoperative care was a concern for a minority (one-fifth) of respondents, and about half had experienced unnecessary delays between procedures some or most of the time. Generally, respondents felt integrated into rural teams and reported receiving adequate nursing and anesthetic support. The two most common desired additional supports were better/more equipment and space and additional staffing. All 19 respondents not planning to retire soon intended to provide outreach services for at least three more years. CONCLUSION: Specialists providing outreach OR services in small volume rural hospitals in BC usually have altruistic motives for outreach work. For the most part, these specialists have positive experiences in rural hospitals, but they can be better supported through investment in infrastructure and health human resources. Specialists intend to provide outreach services long-term, indicating a stable outreach workforce. More research on the facilitators and barriers of specialist outreach work is needed.

Optimizing rural healthcare through improved team function: a case study of the Rural Surgical Obstetrical Networks programme.

We explored enablers and mechanisms of optimal team function within rural hospital teams, and the impact of these factors on health service sustainability in British Columbia. The data were drawn from interviews and focus groups with healthcare providers and administrators (n = 169) who participated in the Rural Surgical Obstetrical Networks (RSON) initiative to support low-volume rural surgical and obstetrical services in British Columbia, Canada. The 5-year programme (2018-2022) provided evidence-based system interventions across eight rural sites with the objective of providing sustainable, quality health services to meet population needs. To explore the impact of RSON interventions on local team function, we performed a scoping review, to assess the current literature surrounding enablers of effective rural hospital teamwork. Through inductive thematic analysis of interview data, we identified five enablers of good team function at RSON sites, including emphasis on local leadership, shared direction, commitment to sustainability, respect and solidarity among colleagues, and meaningful communication. The RSON project led to a shift in team culture in participating sites, improved team function, and contributed to improved clinical processes and patient outcomes. The findings have implications for rural health policy and practice in British Columbia and other jurisdictions with similar health service delivery models and geographic contexts.

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.

Rural family physician use of point-of-care ultrasonography: experiences of primary care providers in British Columbia, Canada.

BACKGROUND: In British Columbia (BC), rural and remote areas lack proximal access to radiographic services. Poor access to radiographic services in rural settings presents a challenge to timely diagnosis and screening across many disease states and healthy pregnancies. As a solution to the lack of access to radiographic services in rural settings, the Rural Coordination Centre of BC (RCCbc) supported rural Family Physicians (FPs) wishing to use PoCUS through the Intelligent Network for PoCUS (IN PoCUS) program. This study evaluates FPs' experience and use of PoCUS in their clinical practice. METHODS: This qualitative study conducted in-depth virtual interviews with 21 FPs across rural BC. The interview asked participants' motivation to participate in the RCCbc program, the type of training they received, their current use of PoCUS, their experience with the technology, and their experience interacting with specialists in regional centres. Thematic analysis of findings was undertaken. RESULTS: This study used Rogers' framework on the five elements of diffusion of innovation to understand the factors that impede and enable the adoption of PoCUS in rural practice. Rural FPs in this study differentiated PoCUS from formal imaging done by specialists. The adoption of PoCUS was viewed as an extension of physical exams and was compatible with their values of providing generalist care. This study found that the use of PoCUS provided additional information that led to better clinical decision-making for triage and allowed FPs to determine the urgency for patient referral and transport to tertiary hospitals. FPs also reported an increase in job satisfaction with PoCUS use. Some barriers to using PoCUS included the time needed to be acquainted with the technology and learning how to integrate it into their clinical flow in a seamless manner. CONCLUSION: This study has demonstrated the importance of PoCUS in improving patient care and facilitating timely diagnosis and treatment. As the use of PoCUS among FPs is relatively new in Canada, larger infrastructure support such as improving billing structures, long-term subsidies, educational opportunities, and a quality improvement framework is needed to support the use of PoCUS among rural FPs.

System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program.

BACKGROUND: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. METHODS: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. FINDINGS: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. CONCLUSION: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Feasibility issues impacting optimal levels of maternity care in rural communities: implementing the Rural Birth Index in British Columbia.

INTRODUCTION: The continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation. BACKGROUND: Predictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators. METHODS: We conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC). RESULTS: Participants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport. CONCLUSIONS: Current models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.

Actualizing community-academic partnerships in research: a case study on rural perinatal peer support.

BACKGROUND:  Within the field of patient and public involvement in health service research, there is a growing movement towards not only involving patients in research but engaging them as co-producers of knowledge. We explore such a co-productive research relationship in a case study on rural perinatal mental health, with the aim of collaboratively developing knowledge based on both the relevant lived experience of a community partner, and the systemic knowledge of academic researchers. METHODS:  Data was gathered through a community forum and subsequent interviews with social service program administrators from rural British Columbia, Canada. Interviews were analyzed separately by the community partner and academic researchers using principles of thematic analysis. Both the community partner and academic researchers were involved from project genesis to data collection, analysis, interpretation, and manuscript writing. RESULTS: Common themes identified by the academic and community researchers included needs for peer support, barriers to peer support, and gaps in mental health care. Divergently, the academic researcher focused on systems-level challenges while the community partner emphasized the impact of power dynamics within health systems. Researchers generated five methodological values propositions from the process of co-production, including (a) mutual respect for all viewpoints, (b) a rejection of assumed hierarchy, (c) commitments to truth speaking, (d) attention to process, and (e) equivalence of contribution. CONCLUSIONS: Co-production highlights the value of lived experience in health research, sets it in conversation with scientific inquiry, and moves away from hierarchies of assumed knowledge often embedded in traditional health care research. Incorporating both academic researcher and community partner writing into our paper reflects a commitment to maintaining the integrity and authenticity of lived experience, an affirmation of its equal validity as a source of knowledge, and a rejection of qualifying patient voices. The exploration of this co-production research relationship lays groundwork for future research teams considering collaborative methodology. We suggest co-productive research as a means of addressing the epistemic injustice that arises in health care research from the privileging of certain forms of knowledge, and the exclusion of others, namely that derived from patient experience.

Co-production is an approach to research where community partners and academic researchers work together to carry out a study. Our co-production team was made up of a community partner with lived experience of accessing mental health supports in rural areas, and academic researchers experienced in health systems design. Co-production emphasizes both the wisdom of lived experience and the importance of scientific approaches. What emerges is research that is both rigorous and authentic. While this form of patient partner research involvement is growing, few studies describe the process of collaboration. To address this gap, we present a case study of how university researchers worked with a patient partner on a project about mental health services for childbearing people in rural communities. The team worked together at every step, from initial study design, to reaching out to participants, reviewing the data, and writing the paper. We agreed our approach would be guided by principles such as respect for all viewpoints, speaking truth, attention to the process, and ensuring that everyone's contributions were given equal weight. The academic researchers and the community partner identified many common themes in the data. The community partner also emphasized patient experiences of unequal treatment by health care providers. The academic researchers focused on the lack of access to perinatal mental health supports. Exploring differences in perspectives like this allowed for richer interpretation of the findings. This case study offers useful insight into the value of co-production and the important role of lived experience in improving health systems.

Optimizing Community Participation in Healthcare Planning, Decision Making and Delivery through Rural Health Councils.

Background: The aim of this scoping study was to understand the opatimal structure and function of rural health councils (RHCs). Methods: The study used the scoping review methodology, informed by both Arksey and O'Malley's (2005) framework and the Joanna Briggs Institute Reviewers' Manual (The Joanna Briggs Institute 2015). Findings: Evidence demonstrates that the functions of RHCs range from identifying healthcare issues and priorities to local resource management. Enabling structures included the use of skills-based merit matrices to determine membership. Conclusion: We found evidence on how to build effective models to support patient involvement in healthcare planning and service delivery to lead to care that reflects the needs of rural communities.

Care providers' experiences with and attitudes towards virtual antenatal care: Findings from a qualitative study in British Columbia.

Background: Virtual care has emerged as an adjunctive response to challenges in rural health care, including maternity care, and use has accelerated during the coronavirus disease 2019 (COVID-19) pandemic. This gives rise to the need for a strategic plan for post-COVID-19 virtual maternity care in rural communities. To date, no provincial initiative has focused on understanding and documenting the needs of maternity care practitioners to provide virtual care. Methods: Qualitative study, including virtual interviews and focus groups with rural primary maternity care providers and urban and rural specialists on perceptions of the utility of virtual maternity care pre- and post-COVID-19, and benefits and barriers of virtual care. Data were thematically analysed. Results: In total, 82 health care providers participated in the study. Health care provider responses fell into three categories: Attributes of virtual care, barriers to virtual care and system interventions needed to optimize the provision of virtual perinatal care. Participants expressed a desire for use of virtual communication tools post-COVID-19, continued ability to use fee codes for virtual care and a need for more secure texting options. The benefits of tripartite consultations were noted by many participants; impacts of the transition to virtual care included additional workload and interrupted workflow. Concerns over the lack of physical examinations and challenges in building relationships with patients when providing virtual care were frequently noted. Conclusion: Adapting the current implementation of virtual maternity care in British Columbia may be enhanced through several provider- and evidence-derived strategies, many of which are currently underway in BC. The results from this provincial survey will be used to focus further discussion on the characteristics of an optimal system to meet patient and provider needs within a rural context.

Building Blocks to Sustainable Rural Maternity Care: Toward a Systems Approach to Service Planning.

This qualitative study aimed to understand, document and analyze system supports needed to sustain rural maternity care in communities without local access to Caesarean section. In-depth interviews and focus groups with 58 healthcare providers and administrators from rural British Columbia were conducted in 2017/2018. Themes from the data led to the development of five systems interventions necessary to stabilize local maternity care: (1) building nursing confidence; (2) supporting interprofessional teams; (3) efficient transport to referral sites; (4) clear inclusion criteria for local deliveries; and (5) enhanced relationships with referral centres.

Documenting surgical triage in rural surgical networks: Formalising existing structures.

OBJECTIVE: It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection. DESIGN: Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis. SETTING: Six community hospitals in British Columbia, Canada. PARTICIPANTS: General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists. RESULTS: Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources. CONCLUSION: Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.

Rural Residents' Perinatal Experiences During the Initial Months of the COVID-19 Pandemic: A Qualitative Study in British Columbia.

INTRODUCTION: Many studies have explored the impact of the coronavirus disease 2019 (COVID-19) pandemic on perinatal health, but few have examined the effects of the pandemic on birthing families through a rural lens. Given that the COVID-19 pandemic has reinforced long-standing disparities between urban and rural communities, it is important that the significance of place on the health and wellness of rural populations is made visible. METHODS: In-depth interviews and focus groups with 16 participants from rural communities in British Columbia, Canada, were performed. Participants included those who had been pregnant or given birth after March 11, 2020. Data from the interviews and focus groups were analyzed using the principles of thematic analysis to understand the perinatal experiences of rural families during the initial months of the COVID-19 pandemic. RESULTS: Analysis of the data revealed 4 major themes: perceived risk of infection, navigating uncertainty, experience of care received, and resilience and silver linings. In general, participants conceptualized rural communities as safer bubbles. Exceptions included specific vectors of risk such as tourism travel and border communities. Challenges experienced by rural families including anxiety around changing health guidelines, reduced social support, and potential loss of their partners' support at births. Additional concerns specific to rural experiences added to this burden, including fear of traveling to referral centers for care and increased difficulties accessing resources. DISCUSSION: Participants reported positive, compassionate care experiences that helped to mitigate some of the added stressors of the pandemic. These findings highlight the importance of perinatal care provision that integrates physiologic and mental health supports. This study provides a foundation for a comprehensive inquiry into the experiences of rural perinatal services during COVID-19.

Rural citizen-patient priorities for healthcare in British Columbia, Canada: findings from a mixed methods study.

BACKGROUND: The challenge of including citizen-patient voices in healthcare planning is exacerbated in rural communities by regional variation in priorities and a historical lack of attention to rural healthcare needs. This paper aims to address this deficit by presenting findings from a mixed methods study to understand rural patient and community priorities for healthcare. METHODS: We conducted a provincial survey of rural citizens-patients across British Columbia, Canada to understand their most pressing healthcare needs, supplemented by semi-structured interviews. Survey and interview participants were asked to articulate, in their own words, their communities' most pressing healthcare needs, to explain the importance of these priorities to their communities, and to offer possible solutions to address these challenges. Open-text survey responses and interview data were analyzed thematically to elicit priorities of the data and their significance to answer the research questions. RESULTS: We received 1,287 survey responses from rural citizens-patients across BC, 1,158 of which were considered complete. We conducted nine telephone interviews with rural citizens-patients. Participants stressed the importance of local access to care, including emergency services, maternity care, seniors care, specialist services and mental health and substance use care. A lack of access to primary care services was the most pronounced gap. Inadequate local health services presented geographic, financial and social barriers to accessing care, led to feelings of vulnerability among rural patients, resulted in treatment avoidance, and deterred community growth. CONCLUSIONS: Two essential prongs of an integration framework for the inclusion of citizen-patient voices in healthcare planning include merging patient priorities with population needs and system-embedded accountability for the inclusion of patient and community priorities.

The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia.

BACKGROUND: A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income. METHODS: We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA. RESULTS: On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient's stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking. CONCLUSIONS: These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient's overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

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.

Medical Abortion in Midwifery Scope of Practice: A Qualitative Exploration of the Attitudes of Registered Midwives in British Columbia.

INTRODUCTION: Across Canada and internationally, access to abortion remains challenging, particularly for those living in rural and remote communities. International research and policy call for the training of advanced practice clinicians, including midwives, to provide abortion services to fill the ever-increasing access gap. Research in other jurisdictions has examined the attitudes of midwives toward this potential expansion of scope of practice, but such studies have not been undertaken in British Columbia. This qualitative research study explored the attitudes of registered midwives toward expanding their scope of practice to include the provision of medication abortion in British Columbia. METHODS: In-depth qualitative interviews with British Columbia registered midwives were conducted and analyzed using thematic analysis. RESULTS: Fifteen interviews were conducted. Analysis of the interviews identified 5 primary themes: the incorporation of medication abortion into the midwifery scope of practice to increase access, the congruence of the midwifery model of care and provision of medication abortion, the role of registered midwives as guardians of reproductive rights, the need for a paradigm shift in how the profession is viewed, and the practicalities of potential scope expansion. DISCUSSION: This study shows some British Columbia registered midwives are interested in including medication abortion in their scope of practice. Midwives have the potential to bridge some of the health care delivery gaps in areas underserved by abortion providers and communities where medication abortion is not available. Further research is needed to more fully understand the perspectives of registered midwives in British Columbia as a whole.

Standardised early warning scores in rural interfacility transfers: A pilot study into their potential as a decision-making aid.

INTRODUCTION: While 12.4% of British Columbians live rurally, only 2.0% of specialists practise rurally, making interfacility transport of high-acuity patients vital. Decision-making aids have been identified as a way to improve the interfacility transfer process. We conducted a pilot study to explore the potential of the Standardised Early Warning Score (SEWS) as a decision-making aid for staff at sending facilities. METHODS: SEWSs were calculated from a database of 418 transfers from sending facilities in rural, small and medium population centres to larger receiving facilities. The SEWSs were compared against one another over time using McNemar's and the Wilcoxon signed-ranks tests. The SEWSs were then tested for their association with six outcomes using Pearson's or Fisher's Chi-squared test and the Mann-Whitney U-test. RESULTS: While at the sending facility, both the number of SEWSs that was four or greater and the average SEWS decreased over time (P < 0.001 for both). A first SEWS of four or greater was predictive of more intervention categories during transport (P = 0.047), an adverse event during transport (P = 0.004), an adverse event within 30 min of arrival at the receiving facility (P = 0.004) and death before discharge from the receiving facility (P = 0.043) but not deterioration during transport, or the length of stay at the receiving facility. CONCLUSION: Overall, the performance of the SEWS in the context of rural interfacility transport suggests that the tool will have utility in supporting decision-making.

Introduction: Alors que 12,4 % des résidents de la Colombie-Britannique vivent en milieu rural, seuls 2,0 % des spécialistes y pratiquent, ce qui rend essentiel le transport entre établissements des patients en état grave. Des outils de prise de décision ont été désignés comme méthode pour améliorer le processus de transfert entre établissements. Dans le cadre d'une étude pilote, nous nous sommes penchés sur le potentiel du score SEWS (Standardised Early Warning Score) comme outil de prise de décision à l'intention du personnel des établissements d'origine. Méthodes: Les scores SEWS ont été calculés dans une banque de données de 418 transferts d'établissements d'origine situés dans des agglomérations rurales de petite et moyenne taille vers des établissements de réception plus importants. Les scores SEWS ont été comparés entre eux dans le temps à l'aide des tests de McNemar et Wilcoxon Signed Ranks. L'association des scores SEWS à six paramètres d'évaluation a ensuite été testée à l'aide des tests de chi carré de Pearson ou de Fisher et du test de Mann-Whitney. Résultats: À l'établissement d'origine, le nombre de scores SEWS de quatre et plus et le score SEWS moyen se sont abaissés dans le temps (p < 0,001 dans les deux cas). Un score SEWS initial de quatre et plus prédisait un plus grand nombre de catégories d'interventions durant le transport (p = 0,047), la survenue d'un événement indésirable durant le transport (p = 0,004), la survenue d'un événement indésirable dans les 30 minutes après l'arrivée à l'établissement de réception (p = 0,004), et le décès avant le congé de l'établissement de réception (p = 0,043), mais il ne prédisait pas la détérioration durant le transport ni la durée du séjour à l'établissement de réception. Conclusion: Dans l'ensemble, le rendement du score SEWS dans le contexte du transport rural entre établissements laisse croire que l'outil serait utile à la prise de décision. Mots-clés: Early Warning Scores, Standardised Early Warning Score, Standardised Early Warning Score rural, transfert entre établissements, transport entre établissements.