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1.
J Health Care Poor Underserved ; 35(2): 439-464, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38828575

RESUMO

Between 1990 and 2020, 334 rural hospitals closed in the United States, and since 2011 hospital closures have outnumbered new hospital openings. This scoping review evaluates peer-reviewed studies published since 1990 with a focus on rural hospital closures, synthesizing studies across six themes: 1) health care policy environment, 2) precursors to rural hospital closures, 3) economic impacts, 4) effects of rural hospital closures on access to care, 5) health and community impacts, and 6) definitions of rural hospitals and communities. In the 1990s, rural hospitals that closed were smaller, while rural hospitals that closed in the 2010s tended to have more beds. Many studies of the health impacts of rural hospital closures yielded null findings. However, these studies differed in their definitions of "rural hospital closure." Given the accelerated rate of hospital closures, more attention should be paid to hospitals that serve rural communities of color and low-income communities.


Assuntos
Fechamento de Instituições de Saúde , Acessibilidade aos Serviços de Saúde , Hospitais Rurais , Humanos , Estados Unidos , Política de Saúde
2.
PLoS One ; 19(6): e0300977, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38843178

RESUMO

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.


Assuntos
Hospitais Rurais , Melhoria de Qualidade , Serviços de Saúde Rural , Humanos , Serviços de Saúde Rural/normas , Serviços de Saúde Rural/organização & administração , Hospitais Rurais/organização & administração , Feminino , Gravidez , Obstetrícia/normas , Obstetrícia/organização & administração , Inquéritos e Questionários
3.
J Rural Health ; 40(3): 485-490, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38693658

RESUMO

PURPOSE: By assessing longitudinal associations between COVID-19 census burdens and hospital characteristics, such as bed size and critical access status, we can explore whether pandemic-era hospital quality benchmarking requires risk-adjustment or stratification for hospital-level characteristics. METHODS: We used hospital-level data from the US Department of Health and Human Services including weekly total hospital and COVID-19 censuses from August 2020 to August 2023 and the 2021 American Hospital Association survey. We calculated weekly percentages of total adult hospital beds containing COVID-19 patients. We then calculated the number of weeks each hospital spent at Extreme (≥20% of beds occupied by COVID-19 patients), High (10%-19%), Moderate (5%-9%), and Low (<5%) COVID-19 stress. We assessed longitudinal hospital-level COVID-19 stress, stratified by 15 hospital characteristics including joint commission accreditation, bed size, teaching status, critical access hospital status, and core-based statistical area (CBSA) rurality. FINDINGS: Among n = 2582 US hospitals, the median(IQR) weekly percentage of hospital capacity occupied by COVID-19 patients was 6.7%(3.6%-13.0%). 80,268/213,383 (38%) hospital-weeks experienced Low COVID-19 census stress, 28% Moderate stress, 22% High stress, and 12% Extreme stress. COVID-19 census burdens were similar across most hospital characteristics, but were significantly greater for critical access hospitals. CONCLUSIONS: US hospitals experienced similar COVID-19 census burdens across multiple institutional characteristics. Evidence-based inclusion of pandemic-era outcomes in hospital quality reporting may not require significant hospital-level risk-adjustment or stratification, with the exception of rural or critical access hospitals, which experienced differentially greater COVID-19 census burdens and may merit hospital-level risk-adjustment considerations.


Assuntos
COVID-19 , Censos , Hospitais Rurais , SARS-CoV-2 , Humanos , COVID-19/epidemiologia , Estados Unidos/epidemiologia , Hospitais Rurais/estatística & dados numéricos , Hospitais Rurais/normas , Pandemias , Número de Leitos em Hospital/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/normas , Benchmarking
4.
Health Aff (Millwood) ; 43(5): 641-650, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38709968

RESUMO

Fluctuations in patient volume during the COVID-19 pandemic may have been particularly concerning for rural hospitals. We examined hospital discharge data from the Healthcare Cost and Utilization Project State Inpatient Databases to compare data from the COVID-19 pandemic period (March 8, 2020-December 31, 2021) with data from the prepandemic period (January 1, 2017-March 7, 2020). Changes in average daily medical volume at rural hospitals showed a dose-response relationship with community COVID-19 burden, ranging from a 13.2 percent decrease in patient volume in periods of low transmission to a 16.5 percent increase in volume in periods of high transmission. Overall, about 35 percent of rural hospitals experienced fluctuations exceeding 20 percent (in either direction) in average daily total volume, in contrast to only 13 percent of urban hospitals experiencing similar magnitudes of changes. Rural hospitals with a large change in average daily volume were more likely to be smaller, government-owned, and critical access hospitals and to have significantly lower operating margins. Our findings suggest that rural hospitals may have been more vulnerable operationally and financially to volume shifts during the pandemic, which warrants attention because of the potential impact on these hospitals' long-term sustainability.


Assuntos
COVID-19 , Hospitais Rurais , Hospitais Urbanos , Pandemias , COVID-19/epidemiologia , Humanos , Hospitais Rurais/estatística & dados numéricos , Estados Unidos , SARS-CoV-2
5.
Health Care Manage Rev ; 49(3): 220-228, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38775732

RESUMO

BACKGROUND: Rural hospitals are increasingly at risk of closure. Closure reduces the availability of hospital care in rural areas, resulting in a disparity in health between rural and urban citizens, and it has broader economic impacts on rural communities as rural hospitals are often large employers and are vital to recruiting new businesses to a community. To combat the risk of closure, rural hospitals have sought partnerships to bolster financial performance, which often results in a closure of services valuable to the community, such as obstetrics and certain diagnostic services, which are viewed as unprofitable. This can lead to poor health outcomes as community members are unable to access care in these areas. PURPOSE: In this article, we explore rural hospital service offerings and financial performance, with an aim to illuminate if specific service offerings are associated with positive financial performance in a rural setting. METHODS: Our study used hospital organization data, as well as county-level demographics with periods of analysis from 2015 and 2019. We employed a pooled cross-sectional regression analysis with robust standard errors examining the association between total margin and service lines among rural hospitals in the United States. RESULTS: The findings suggest that some services deemed unprofitable in urban and suburban hospital settings-such as obstetrics and drug/alcohol rehabilitation-are associated with higher margins in rural hospitals. Other unprofitable service lines-such as psychiatry and long-term care-are associated with lower margins in rural hospitals. CONCLUSION: Our results suggest the need of rural hospitals to choose services that align with environmental circumstances to maximize financial performance. PRACTICE IMPLICATION: Hospital administrators in rural settings need to take a nuanced look at their environmental and organizational specifics when deciding upon the service mix. Generalizations regarding profitability should be avoided to maximize financial performance.


Assuntos
Hospitais Rurais , Hospitais Rurais/economia , Humanos , Estudos Transversais , Fechamento de Instituições de Saúde , Estados Unidos
6.
BMJ Open ; 14(5): e075559, 2024 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-38719287

RESUMO

OBJECTIVES: The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi. DESIGN: We conducted semistructured qualitative interviews among PLWT1D and healthcare providers participating in the study. Standardised interview guides elicited perspectives on the appropriateness and acceptability of CGM use for PLWT1D and their providers, and provider perspectives on the effectiveness of CGM use in Malawi. Data were coded using Dedoose software and analysed using a thematic approach. SETTING: First-level hospitals in Neno district, Malawi. PARTICIPANTS: Participants were part of a randomised controlled trial focused on CGM at first-level hospitals in Neno district, Malawi. Pretrial and post-trial interviews were conducted for participants in the CGM and usual care arms, and one set of interviews was conducted with providers. RESULTS: Eleven PLWT1D recruited for the CGM randomised controlled trial and five healthcare providers who provided care to participants with T1D were included. Nine PLWT1D were interviewed twice, two were interviewed once. Of the 11 participants with T1D, six were from the CGM arm and five were in usual care arm. Key themes emerged regarding the appropriateness and effectiveness of CGM use in lower resource setting. The four main themes were (a) patient provider relationship, (b) stigma and psychosocial support, (c) device usage and (d) clinical management. CONCLUSIONS: Participants and healthcare providers reported that CGM use was appropriate and acceptable in the study setting, although the need to support it with health education sessions was highlighted. This research supports the use of CGM as a component of personalised diabetes treatment for PLWT1D in resource constraint settings. TRIAL REGISTRATION NUMBER: PACTR202102832069874; Post-results.


Assuntos
Automonitorização da Glicemia , Diabetes Mellitus Tipo 1 , Pesquisa Qualitativa , Humanos , Malaui , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 1/psicologia , Masculino , Feminino , Adulto , Aceitação pelo Paciente de Cuidados de Saúde , Pessoa de Meia-Idade , Glicemia/análise , Entrevistas como Assunto , Hospitais Rurais , Hospitais de Distrito , Monitoramento Contínuo da Glicose
7.
BMJ Open Qual ; 13(Suppl 1)2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38719495

RESUMO

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India.


Assuntos
Melhoria de Qualidade , Triagem , Humanos , Triagem/métodos , Triagem/normas , Triagem/estatística & dados numéricos , Feminino , Índia , Gravidez , Hospitais Rurais/estatística & dados numéricos , Hospitais Rurais/normas , Hospitais Rurais/organização & administração , Adulto , Obstetrícia/normas , Obstetrícia/métodos
8.
World J Surg ; 48(2): 290-315, 2024 02.
Artigo em Inglês | MEDLINE | ID: mdl-38618642

RESUMO

Introduction/Background: Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. Methods: We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. Results: None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). Conclusions: This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.


Assuntos
Hospitais de Distrito , Cirurgiões , Humanos , Criança , Ruanda , Anestesiologistas , Hospitais Rurais
9.
BMC Pediatr ; 24(1): 258, 2024 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-38641785

RESUMO

BACKGROUND: The incidence of neonatal opiate withdrawal syndrome (NOWS) in the US has grown dramatically over the past two decades. Many rural hospitals not equipped to manage these patients transfer them to hospitals in bigger cities. METHODS: We created a curriculum, the NOWS-NM Program, a web-based curriculum training in best practices. To evaluate the curriculum, we conducted pre- and post-surveys of NOWS knowledge, attitudes, and care practices, plus post-curriculum interviews and focus groups. RESULTS: Fourteen participants completed both pre- and post-curriculum surveys. They indicated an increase in knowledge and care practices. A small number of respondents expressed negative attitudes about parents of infants with NOWS at pre-test, the training curriculum appeared to have no impact on such attitudes at post-test. Sixteen participants participated in focus groups or interviews. Qualitative data reinforced the positive quantitative results and contradicted the negative survey results, respondents reported that the program did reduce stigma and improve provider/staff interactions with patients. CONCLUSIONS: This curriculum demonstrated positive impacts on NOWS knowledge and care practices. Incorporating focus on core concepts of trauma-informed care and self-regulation in future iterations of the curriculum may strengthen the opportunity to change attitudes and address the needs expressed by participants and improve care of families and babies with NOWS.


Assuntos
Analgésicos Opioides , Síndrome de Abstinência Neonatal , Lactente , Humanos , Recém-Nascido , Hospitais Rurais , Síndrome de Abstinência Neonatal/tratamento farmacológico , Currículo , Internet
10.
JAMA Netw Open ; 7(3): e241845, 2024 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-38470424
11.
Aust Health Rev ; 48(3): 248-253, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38522435

RESUMO

Objectives This study aimed to evaluate patient outcomes from a 12-month pilot program establishing specialist surgical services in a small rural (Modified Monash Model, MM4) hospital on the south coast of NSW. Methods Suitable patients for ambulatory surgery were selected based on strict anaesthetic, surgical and social criteria. Skills shortfalls among nursing staff, usually with emergency or inpatient experience, were addressed by appropriate re-training and in-service training in scrub, scout and anaesthetic duties. An anonymous post-operative patient survey was administered during the pilot program, which assessed patient experiences and outcomes. Of 162 patients undergoing surgery during the pilot, 50 consecutive participants completed the survey. Results Of the 161 procedures during the pilot program, 100 were performed under sedation and locoregional anaesthesia and 62 under general anaesthesia. Half (n = 86, 53.4%) were complex excisions of malignant skin lesions, and of these 63% also required either a skin graft or local flap repair. Survey respondents reported adequate information and pain relief upon discharge (n = 45, 96%) and 100% were satisfied with the care received. No respondents needed to see a doctor following discharge. There were no mortality events or major issues of morbidity during the study period or subsequently, no further overnight admissions or return to theatre and no re-presentations within 48 h of operating. Two superficial surgical site infections were reported. Conclusions There is merit in drawing on underutilised resources in small rural hospitals in support of initiatives to reduce surgical waitlists. Appropriate outpatient surgeries can be safely performed with high levels of patient satisfaction.


Assuntos
Hospitais Rurais , Listas de Espera , Humanos , Projetos Piloto , New South Wales , Procedimentos Cirúrgicos Ambulatórios , Feminino , Masculino , Satisfação do Paciente , Adulto , Pessoa de Meia-Idade
12.
Am Surg ; 90(7): 1899-1903, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38551609

RESUMO

OBJECTIVE: The aim was to determine the impact of consolidation of two rural level 1 trauma centers on adult trauma patients presenting to the remaining level 1 trauma center. To our knowledge, a study assessing the impact of trauma center consolidation on adult trauma patients had yet to be performed. METHODS: A single institution, retrospective study was conducted at a rural level 1 trauma center. Adult trauma patients who presented to our center from January 2017 to January 2022 were included. The cohorts spanned 33 months pre- and post-consolidation. Multiple demographic and outcome measures were gathered. Data were analyzed using the student's t-test and Chi-squared testing. RESULTS: There was a 33% increase in overall trauma activations and 9% increase in transfers from outside facilities post-consolidation. The post-consolidation group was significantly older, had higher mean injury severity score, and decreased hospital-free days. The post-consolidation group also saw an increase in ICU admission and surgical intervention. While there were no significant differences in ICU-free days or ventilator days, patients in the post-consolidation group with the highest level of activation who required both surgical intervention and ICU admission experienced decreased mortality. CONCLUSION: The consolidation of trauma services to a single level 1 trauma center in a rural Appalachian health system led to higher trauma volume and acuity, but most importantly decreased mortality for the most severely injured trauma patients.


Assuntos
Escala de Gravidade do Ferimento , Centros de Traumatologia , Ferimentos e Lesões , Humanos , Estudos Retrospectivos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Ferimentos e Lesões/terapia , Ferimentos e Lesões/mortalidade , Hospitais Rurais/estatística & dados numéricos , Serviços de Saúde Rural/organização & administração , Serviços de Saúde Rural/estatística & dados numéricos
13.
JAMA Netw Open ; 7(3): e241838, 2024 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-38470419

RESUMO

Importance: COVID-19 pandemic-related disruptions to the health care system may have resulted in increased mortality for patients with time-sensitive conditions. Objective: To examine whether in-hospital mortality in hospitalizations not related to COVID-19 (non-COVID-19 stays) for time-sensitive conditions changed during the pandemic and how it varied by hospital urban vs rural location. Design, Setting, and Participants: This cohort study was an interrupted time-series analysis to assess in-hospital mortality during the COVID-19 pandemic (March 8, 2020, to December 31, 2021) compared with the prepandemic period (January 1, 2017, to March 7, 2020) overall, by month, and by community COVID-19 transmission level for adult discharges from 3813 US hospitals in the State Inpatient Databases for the Healthcare Cost and Utilization Project. Exposure: The COVID-19 pandemic. Main Outcomes and Measures: The main outcome measure was in-hospital mortality among non-COVID-19 stays for 6 time-sensitive medical conditions: acute myocardial infarction, hip fracture, gastrointestinal hemorrhage, pneumonia, sepsis, and stroke. Entropy weights were used to align patient characteristics in the 2 time periods by age, sex, and comorbidities. Results: There were 18 601 925 hospitalizations; 50.3% of patients were male, 38.5% were aged 18 to 64 years, 45.0% were aged 65 to 84 years, and 16.4% were 85 years or older for the selected time-sensitive medical conditions from 2017 through 2021. The odds of in-hospital mortality for sepsis increased 27% from the prepandemic to the pandemic periods at urban hospitals (odds ratio [OR], 1.27; 95% CI, 1.25-1.29) and 35% at rural hospitals (OR, 1.35; 95% CI, 1.30-1.40). In-hospital mortality for pneumonia had similar increases at urban (OR, 1.48; 95% CI, 1.42-1.54) and rural (OR, 1.46; 95% CI, 1.36-1.57) hospitals. Increases in mortality for these 2 conditions showed a dose-response association with the community COVID-19 level (low vs high COVID-19 burden) for both rural (sepsis: 22% vs 54%; pneumonia: 30% vs 66%) and urban (sepsis: 16% vs 28%; pneumonia: 34% vs 61%) hospitals. The odds of mortality for acute myocardial infarction increased 9% (OR, 1.09; 95% CI, 1.06-1.12) at urban hospitals and was responsive to the community COVID-19 level. There were significant increases in mortality for hip fracture at rural hospitals (OR, 1.32; 95% CI, 1.14-1.53) and for gastrointestinal hemorrhage at urban hospitals (OR, 1.15; 95% CI, 1.09-1.21). No significant change was found in mortality for stroke overall. Conclusions and Relevance: In this cohort study, in-hospital mortality for time-sensitive conditions increased during the COVID-19 pandemic. Mobilizing strategies tailored to the different needs of urban and rural hospitals may help reduce the likelihood of excess deaths during future public health crises.


Assuntos
COVID-19 , Fraturas do Quadril , Infarto do Miocárdio , Sepse , Acidente Vascular Cerebral , Adulto , Humanos , Masculino , Feminino , Hospitais Rurais , Pandemias , Estudos de Coortes , Hemorragia Gastrointestinal
14.
J Stroke Cerebrovasc Dis ; 33(6): 107702, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38556068

RESUMO

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.


Assuntos
Prestação Integrada de Cuidados de Saúde , Fibrinolíticos , AVC Isquêmico , Indicadores de Qualidade em Assistência à Saúde , Sistema de Registros , Telemedicina , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual , Humanos , South Carolina , Masculino , Feminino , Fatores de Tempo , Idoso , Resultado do Tratamento , Prestação Integrada de Cuidados de Saúde/organização & administração , Pessoa de Meia-Idade , Indicadores de Qualidade em Assistência à Saúde/normas , Ativador de Plasminogênio Tecidual/administração & dosagem , Fibrinolíticos/administração & dosagem , AVC Isquêmico/terapia , AVC Isquêmico/diagnóstico , Idoso de 80 Anos ou mais , Modelos Organizacionais , Serviços de Saúde Rural/organização & administração , Serviços de Saúde Rural/normas , Número de Leitos em Hospital , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Hospitais Rurais/normas , Serviços Urbanos de Saúde/normas , Serviços Urbanos de Saúde/organização & administração , Acidente Vascular Cerebral/terapia , Acidente Vascular Cerebral/diagnóstico
15.
PLoS One ; 19(3): e0299289, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38427646

RESUMO

INTRODUCTION: There is a pressing need for transitional care that prepares rural dwelling medical patients to identify and respond to the signs of worsening health conditions. An evidence-based warning signs intervention has the potential to address this need. While the intervention is predominantly delivered by nurses, other healthcare providers may be required to deliver it in rural communities where human health resources are typically limited. Understanding the perspectives of other healthcare providers likely to be involved in delivering the intervention is a necessary first step to avert consequences of low acceptability, such as poor intervention implementation, uptake, and effectiveness. This study examined and compared nurses' and other healthcare providers' perceived acceptability of an evidence-based warning signs intervention proposed for rural transitional care. METHODS: A cross-sectional design was used. The convenience sample included 45 nurses and 32 other healthcare providers (e.g., physical and occupational therapists, physicians) who self-identified as delivering transitional care to patients in rural Ontario, Canada. In an online survey, participants were presented with a description of the warning signs intervention and completed established measures of intervention acceptability. The measures captured 10 intervention acceptability attributes (effectiveness, appropriateness, risk, convenience, relevance, applicability, usefulness, frequency of current use, likelihood of future use, and confidence in ability to deliver the intervention). Ratings ≥ 2 indicated acceptability. Data analysis included descriptive statistics, independent samples t-tests, as well as effect sizes to quantify the magnitude of any differences in acceptability ratings between nurses and other healthcare providers. RESULTS: Nurses and other healthcare providers rated all intervention attributes > 2, except the attributes of convenience and frequency of current use. Differences between the two groups were found for only three attributes: nurses' ratings were significantly higher than other healthcare providers on perceived applicability, frequency of current use, and the likelihood of future use of the intervention (all p's < .007; effect sizes .58 - .68, respectively). DISCUSSION: The results indicate that both participant groups had positive perspectives of the intervention on most of the attributes and suggest that initiatives to enhance the convenience of the intervention's implementation are warranted to support its widespread adoption in rural transitional care. However, the results also suggest that other healthcare providers may be less receptive to the intervention in practice. Future research is needed to explore and mitigate the possible reasons for low ratings on perceived convenience and frequency of current use of the intervention, as well as the between group differences on perceived applicability, frequency of current use, and the likelihood of future use of the intervention. CONCLUSIONS: The intervention represents a tenable option for rural transitional care in Ontario, Canada, and possibly other jurisdictions emphasizing transitional care.


Assuntos
Hospitais Rurais , Cuidado Transicional , Humanos , Estudos Transversais , População Rural , Pessoal de Saúde , Ontário
16.
Int J Stroke ; 19(5): 577-586, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38346936

RESUMO

BACKGROUND: Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS: This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS: In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS: In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS: 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT: The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.


Assuntos
Acidente Vascular Cerebral , Telemedicina , Terapia Trombolítica , Humanos , Feminino , Masculino , Alemanha/epidemiologia , Estudos Retrospectivos , Idoso , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Resultado do Tratamento , Trombectomia/métodos , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Tempo para o Tratamento , Hospitais Rurais , População Rural
18.
J Stroke Cerebrovasc Dis ; 33(4): 107580, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38325033

RESUMO

OBJECTIVES: Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon. MATERIALS AND METHODS: We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0. RESULTS: Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital. CONCLUSIONS: Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.


Assuntos
Acidente Vascular Cerebral , Humanos , Estudos Retrospectivos , Camarões/epidemiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Hospitalização , Hospitais Urbanos , Hospitais Rurais , População Rural
19.
J Surg Oncol ; 129(6): 1159-1164, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38414222

RESUMO

BACKGROUND AND OBJECTIVES: In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital. METHODS: Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed. RESULTS: A total of 56 patients were included. The most common free flap undertaken was free anterolateral thigh flap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods. CONCLUSION: Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.


Assuntos
Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Centros de Atenção Terciária , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/métodos , Idoso , Adulto , Neoplasias/cirurgia , Hospitais Rurais
20.
BMC Health Serv Res ; 24(1): 236, 2024 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-38395849

RESUMO

BACKGROUND: Medical internship is a key transition point in medical training from student to independent (junior) doctor. The national Regional Training Hubs (RTH) policy began across Australia in late 2017, which aims to build medical training pathways for junior doctors within a rural region and guide students, interns and trainees towards these. This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools. METHODS: Data from all applicants to Queensland Health intern positions between 2014-2021 were available, notably their preference order and location of accepted internship position, classified as rural or metropolitan. Matched data from Queensland's medical schools were added for rural training time and other key demographics. Analyses explored the statistical associations between these factors and preferencing or accepting rural internships, comparing pre-RTH and post-RTH cohorts. RESULTS: Domestic Queensland-trained graduates first preferencing rural intern positions increased significantly (pre-RTH 21.1% vs post-RTH 24.0%, p = 0.017), reinforced by a non-significant increase in rural acceptances (27.3% vs 29.7%, p = 0.070). Rural interns were more likely to have previously spent ≥ 11-weeks training in rural locations within medical school, be rurally based in the year applying for internship, or enrolled in the rural generalist pathway. CONCLUSIONS: The introduction of the RTH was associated with a moderate increase of graduates both preferencing and accepting a rural internship, though a richer understanding of the dominant reasons for and against this remain less clear. An expansion of graduates who undertook longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for these opportunities. Overall, domestic graduates are identified as a reliable source of intern recruitment and retention to rural hospitals across Queensland, with entry to the rural generalist pathway and extended rural placement experiences enhancing uptake of rural practice.


Assuntos
Internato e Residência , Serviços de Saúde Rural , Estudantes de Medicina , Humanos , Queensland , Hospitais Rurais , Escolha da Profissão , Faculdades de Medicina , Área de Atuação Profissional
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