South Dakota Dermatology: Urban vs Rural Wait Times and Dermatologist Density.

BACKGROUND: As of 2019, South Dakota had only 32 registered dermatologists, one per 27,569 people. Wait times for dermatologic care are affected by factors such as socioeconomic status, provider distribution, and patient to provider ratios. This inaccessibility to care or prolonged wait times may lead to diagnosis and treatment delays as well as disease progression. We hypothesized wait times to see a dermatologist would be longer in rural areas than urban areas in South Dakota. METHODS: Dermatology clinics throughout South Dakota were contacted to obtain wait times. An internet search was conducted to develop a list of dermatology providers. A population of 50,000 or greater defined an urban area and a ratio of four dermatologists per 100,000 people was used as an ideal patient to provider ratio. RESULTS: Overall, 75% of South Dakota's dermatology clinics participated with an equal rural to urban distribution. There was no difference in wait times for new (p=0.787) or established patients (p=0.461) comparing rural and urban clinics. All South Dakota cities with clinics met the goal patient to dermatologist ratio except for Dakota Dunes (included as part of the Sioux City, Iowa, metro population). CONCLUSIONS: The data does not support the hypothesis that wait times for dermatologists would be longer in rural locations than urban locations. Despite adequate dermatologist to patient ratios throughout most of South Dakota, wait times of over six weeks were found at both urban and rural locations, indicating the need for future studies to assess potential solutions for improving timely access to dermatologic care.

Needs of transgender children and adolescents presenting to an urban gender health program.

BACKGROUND: Youth who identify as transgender and gender diverse (TGD) are increasingly presenting to pediatric providers. Gender-affirming surgery is often delayed until after a patient reaches the age of majority; however, patients may desire surgery at a younger age. OBJECTIVE: We explore the specific clinical needs of this vulnerable population, including surgical requests. STUDY DESIGN: We present a cross-sectional study of patient intake interviews at time of presentation to our gender health program from 2017 to 2020. We summarize patient demographics, medical histories, and gender-affirming care needs by gender identity and age of presentation. RESULTS: Of 92 patients analyzed, those included were 19 trans girls, 55 trans boys, and 18 non-binary individuals. The median age of our sample was 15 (range 5-17). The median age (IQR) while first questioning gender was 10 (7-12). Sexual orientation was variable with 28 (43%) not sure/unknown. The majority of patients present for primary care services (grade schoolers 75%, early teens 78%, and late teens 77%, p = 0.97) and hormone management (grade schoolers 42%, early teens 62%, and late teens 77%, p = 0.06). Late teens were more likely to present for surgical services (49%) compared to grade schoolers (25%) and early teens (11%), p = 0.001. Prior psychiatric diagnoses were common in all age groups. Trans girls were interested in a variety of affirming procedures whereas trans boys and non-binary individuals primarily sought chest surgery (see summary figure). CONCLUSION: Pediatric gender affirming care needs are varied and multidisciplinary within our center. By age 16, about half of TGD individuals are seeking surgical services. On average, there was a 4-5 year delay from age at first questioning one's gender and presenting to our gender health program. Primary care physicians in particular may prepare to serve this complex population by familiarizing themselves with treatment needs, including developing a network of competent surgical referrals.

Assessing urban family physician program challenges in Iran: the insurance organizations' perspective(2021).

BACKGROUND: The Family Physician Programme is a key health reform in Iran that faces significant challenges in urban areas, particularly in Mazandaran and Fars provinces The study aims to critically evaluate the challenges encountered in the Urban Family Physician Program, with a particular focus on the perspectives of insurance organizations. METHODS: A qualitative approach was adopted, involving semi-structured interviews with 22 experts and managers from basic health insurance funds. Snowball sampling facilitated participant selection, and interviews proceeded until saturation. Data analysis utilized content analysis and Atlas-T software, adhering to COREQ criteria. RESULTS: Implementation problems of the urban family physician program were categorized into ten Categories and 22 Subcategories, including financing, stewardship, human resources, structure, culture, information system, payment, monitoring and control, the function of insurance organizations, and implementation. CONCLUSION: The urban family physician program's implementation challenges, as viewed by health insurance organizations, underscore the necessity for strategic decision-making in financing, payment models, electronic system integration, structural adjustments, comprehensive monitoring, evaluation, cultural considerations, and appropriate devolution to insurance entities.

Aboriginal and Torres Strait Islander community members' experiences of care in an urban Aboriginal Community Controlled Health Service transforming to a Patient Centred Medical Home.

Background Few studies have examined patient experiences of the Patient Centred Medical Home (PCMH). This qualitative study explores the experiences of patients of an urban Aboriginal Community Controlled Health Service during its transition to a model of a PCMH. Methods Twenty-eight community members who were registered as patients of an urban Aboriginal Community Controlled Health Service were purposively recruited to participate in yarning interviews. Yarns were conducted using a guide containing open-ended questions in the same domains as those used in patient satisfaction surveys at the participating clinic. Data from yarns were analysed by Aboriginal and non-Indigenous researchers using thematic analysis. The interpretations of Aboriginal and Torres Strait Islander researchers were privileged in the analysis. Results Key themes highlighted the importance of relationships, connectedness, and personal growth and empowerment to community members' health and wellbeing, which they described as a journey of healing and recovery. Delays in implementing a process to empanel patients in a care team meant that most community members were unaware a PCMH had been implemented. However, community members commonly reported a more welcoming environment, more contact with the same doctor and more involvement of Aboriginal Health Workers in their care. Conclusions Aboriginal and Torres Strait Islander community members' narratives of their experiences bear evidence of the acceptability of a PCMH model for delivery in Aboriginal Community Controlled Health Services to improve relational care between patients and health staff. A patient-directed empanelment process has been implemented to better connect patients to their care team in the clinic, and the role of the Aboriginal Health Worker reshaped to strengthen connections between patients and their care team in and outside the clinic.

Service quality: perspective of people with type 2 diabetes mellitus and hypertension in rural and urban public primary healthcare centers in Iran.

OBJECTIVE: This study aimed to assess the service quality (SQ) for Type 2 diabetes mellitus (T2DM) and hypertension in primary healthcare settings from the perspective of service users in Iran. METHODS: The Cross-sectional study was conducted from January to March 2020 in urban and rural public health centers in the East Azerbaijan province of Iran. A total of 561 individuals aged 18 or above with either or both conditions of T2DM and hypertension were eligible to participate in the study. The study employed a two-step stratified sampling method in East Azerbaijan province, Iran. A validated questionnaire assessed SQ. Data were analyzed using One-way ANOVA and multiple linear regression statistical models in STATA-17. RESULTS: Among the 561 individuals who participated in the study 176 (31.3%) were individuals with hypertension, 165 (29.4%) with T2DM, and 220 (39.2%) with both hypertension and T2DM mutually. The participants' anthropometric indicators and biochemical characteristics showed that the mean Fasting Blood Glucose (FBG) in individuals with T2DM was 174.4 (Standard deviation (SD) = 73.57) in patients with T2DM without hypertension and 159.4 (SD = 65.46) in patients with both T2DM and hypertension. The total SQ scores were 82.37 (SD = 12.19), 82.48 (SD = 12.45), and 81.69 (SD = 11.75) for hypertension, T2DM, and both conditions, respectively. Among people with hypertension and without diabetes, those who had specific service providers had higher SQ scores (b = 7.03; p = 0.001) compared to their peers who did not have specific service providers. Those who resided in rural areas had lower SQ scores (b = -6.07; p = 0.020) compared to their counterparts in urban areas. In the group of patients with T2DM and without hypertension, those who were living in non-metropolitan cities reported greater SQ scores compared to patients in metropolitan areas (b = 5.09; p = 0.038). Additionally, a one-point increase in self-management total score was related with a 0.13-point decrease in SQ score (P = 0.018). In the group of people with both hypertension and T2DM, those who had specific service providers had higher SQ scores (b = 8.32; p < 0.001) compared to the group without specific service providers. CONCLUSION: Study reveals gaps in T2DM and hypertension care quality despite routine check-ups. Higher SQ correlates with better self-care. Improving service quality in primary healthcare settings necessitates a comprehensive approach that prioritizes patient empowerment, continuity of care, and equitable access to services, particularly for vulnerable populations in rural areas.

District nurses experiences in providing terminal care in rural and more urban districts. A qualitative study from the Faroe Islands.

OBJECTIVE: To explore district nurses' experiences in providing terminal care to patients and their families until death in a private home setting. DESIGN, SETTING AND SUBJECTS: Qualitative study. Data derived from focus group discussions with primary nurses in The Faroe Islands. RESULTS: Four themes were identified: 'Challenges in providing terminal care', 'The importance of supporting families', 'Collaborative challenges in terminal care' and 'Differences between rural districts and urban districts'. The nurses felt that terminal care could be exhausting, but they also felt the task rewarding. Involving the family was experienced as a prerequisite for making home death possible. Good collaboration with the local GPs was crucial, and support from a palliative care team was experienced as helpful. They pointed out that changes of GP and the limited services from the palliative care team were challenging. Structural and economic conditions differed between urban and rural districts, which meant that the rural districts needed to make private arrangements regarding care during night hours, while the urban districts had care services around the clock. CONCLUSION: Our findings underline the complexity of terminal care. The nurses felt exhausted yet rewarded from being able to fulfil a patient's wish to die at home. Experience and intuition guided their practice. They emphasised that good collaboration with the GPs, the palliative care team and the families was important. Establishing an outgoing function for the palliative care team to support the nurses and the families would increase the scope for home deaths. Working conditions differed between rural and urban districts.

District nurses are key providers of care for people dying in a home care setting.Collaboration with family is essential for making home death possible.Taking care of dying patients is experienced as exhausting but also meaningful.There is a need for an outgoing palliative care team to include all patients regardless of disease.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

INTRODUCTION: Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. METHODS: Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. RESULTS: Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. CONCLUSIONS: Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.

The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina.

OBJECTIVE: To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. MATERIALS AND METHODS: Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality. RESULTS: Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. CONCLUSIONS: Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

Rural-urban variation in the utilisation of publicly funded healthcare services: an age-stratified population-level observational study.

AIM: To compare age-stratified public health service utilisation in Aotearoa New Zealand across the rural-urban spectrum. METHODS: Routinely collected hospitalisation, allied health, emergency department and specialist outpatient data (2014-2018), along with Census denominators, were used to calculate utilisation rates for residents in the two urban and three rural categories in the Geographic Classification for Health. RESULTS: Relative to their urban peers, rural Maori and rural non-Maori had lower all-cause, cardiovascular, mental health and ambulatory sensitive (ASH) hospitalisation rates. The age-standardised ASH rate ratios (major cities as the reference, 95% CIs) across the three rural categories were for Maori 0.79 (0.78, 0.80), 0.83 (0.82, 0.85) and 0.80 (0.77, 0.83), and for non-Maori 0.87 (0.86, 0.88), 0.80 (0.78, 0.81) and 0.50 (0.47, 0.53). Residents of the most remote communities had the lowest rates of specialist outpatient and emergency department attendance, an effect that was accentuated for Maori. Allied health service utilisation by those in rural areas was higher than that seen in the major cities. CONCLUSIONS: The large rural-urban variation in health service utilisation demonstrated here is previously unrecognised and in contrast to comparable international data. New Zealand's most remote communities have the lowest rates of health service utilisation despite high amenable mortality rates. This raises questions about geographic equity in health service design and delivery and warrants further in-depth research.

Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle.

INTRODUCTION: Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS: This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS: A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION: Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh.

INTRODUCTION: Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake. METHODS: This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA. RESULTS: Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process. CONCLUSION: While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

Urban sports service structure from the public health context / Estrutura de serviços esportivos urbanos no contexto da saúde pública / Estructura de servicios deportivos urbanos en el contexto de la salud pública

ABSTRACT With the improvement of the quality of life, the residents' requirements for the construction of urban public sports services have gradually improved. In order to improve the current urban public sports service system, this study analyzes the existing public sports service through the construction of public sports service model. The results show that the current construction of public sports service has some defects, such as single construction subject, unbalanced regional development of sports service, lack of perfect performance evaluation mechanism of sports public service, and so on. Therefore, in the process of public sports service construction, we need to pay attention to the diversification of construction subjects, the cultivation of residents' awareness of physical exercise, the improvement of performance evaluation mechanisms of sports public services, and the broadening of investment channels. These measures can improve the urban public sports service system from the perspective of public health, and create better quality public sports services. This study analyzes the problems existing in the construction of public sports service by building a model, and puts forward some suggestions for improvement, hoping to provide ideas for scholars who study related experiments.

RESUMO Com a melhoria da qualidade de vida, os requisitos da população para a construção de serviços desportivos públicos urbanos melhoraram gradualmente. A fim de melhorar o atual sistema de serviço público de esportes urbanos, este estudo analisa o serviço público de esportes existente através da construção do modelo de serviço público de esportes. Os resultados mostram que a atual construção do serviço público de esportes tem alguns defeitos, como a questão da construção única, o desenvolvimento regional desequilibrado dos serviços de esportes, a falta de um mecanismo perfeito de avaliação do desempenho do serviço público de esportes e assim por diante. Por conseguinte, no processo de construção desses serviços, temos de prestar atenção à diversificação das disciplinas de construção, à cultura da conscientização da população para o exercício físico, à melhoria do mecanismo de avaliação do desempenho do serviço público de esportes e à expansão dos canais de investimento. Essas medidas podem melhorar o sistema de serviços públicos urbanos de esportes do ponto de vista da saúde pública e criar serviços desportivos públicos de maior qualidade. Este estudo analisa os problemas existentes na construção desses serviços através da construção de um modelo, e apresenta algumas sugestões para melhorias, esperando fornecer ideias para pesquisadores que estudam experimentos relacionados.

RESUMEN Con la mejora de la calidad de vida, se han ido mejorando paulatinamente las exigencias de la población para la construcción de servicios deportivos públicos urbanos. Con el fin de mejorar el actual sistema de servicios públicos deportivos urbanos, este estudio analiza el servicio público deportivo existente mediante la construcción de un modelo de servicio público deportivo. Los resultados muestran que la construcción actual del servicio público deportivo tiene algunos defectos, como el tema de construcción única, el desarrollo regional desequilibrado del servicio deportivo, la falta de un perfecto mecanismo de evaluación del desempeño del servicio público deportivo, etc. Por ello, en el proceso de construcción de los servicios públicos deportivos, es necesario prestar atención a la diversificación de los temas de construcción, el cultivo de la conciencia de la población sobre el ejercicio físico, la mejora de los mecanismos de evaluación del desempeño de los servicios públicos deportivos y la ampliación de los canales de inversión. Estas medidas pueden mejorar el sistema de servicios deportivos públicos urbanos desde la perspectiva de la salud pública y crear servicios deportivos públicos de mayor calidad. Este estudio analiza la problemática existente en la construcción del servicio público deportivo mediante la construcción de un modelo, y presenta algunas sugerencias de mejora, esperando brindar ideas para los académicos que estudian experimentos relacionados.

Guía Técnica: Procedimiento de convalidación del servicio COVID Especial-SERVICER para su contabilización como parte del Servicio Rural y Urbano Marginal de Salud / Procedure for the validation of the COVID Especial-SERVICER service for its accounting as part of the Rural and Urban Marginal Health Service. Technical guide

El documento contiene los criterios y actividades para la convalidación del tiempo de prestación del Servicio COVID Especial-SERVICER para su contabilización como parte del Servicio Rural y Urbano Marginal de Salud-SERUMS. Contiene modificatoria con RM Nro 603-2022/MINSA.