Drawing upon a comparative, qualitative study of the experiences of rural women accessing maternity care in two Canadian provinces, we demonstrate that availability of services, having economic and informational resources to access the services offered, and the appropriateness of those services in terms of gender, continuity of care, confidentiality, quality of care, and cultural fit are key to an accurate understanding of health care access. We explore the implications of living rurally on each of these dimensions, thereby revealing both gaps in and solutions to rural maternity care access that narrower, proximity-based definitions miss.
BACKGROUND: In 2002 the Norwegian Board of Health made a survey of the accessibility of general practitioners in Troms county in North Norway. MATERIAL AND METHODS: In a telephone interview one secretary in each surgery informed about telephone response time, planned time for telephone consultations, recorded numbers of urgent consultations, and waiting time to obtain a routine consultation. RESULTS: On average, the planned telephone time was two hours per week. Telephone time was in inverse proportion to the number of patients on the doctor's list. Rural doctors spent twice as much time as urban colleagues on the telephone with their patients. Doctors with lists between 500 and 1500 patients had a higher proportion of urgent consultations compared with doctors with shorter or longer lists. INTERPRETATION: Telephone response time below two minutes and waiting times for routine consultations below 20 days appear to be within acceptable norms. When patient lists are above 1500, doctors' capacity to offer telephone contact and emergency services to their patients seems reduced.
To assess the quality of care of acute myocardial infarction (AMI) in a rural health region.
Clinical audit employing multiple explicit criteria of care elements for emergency department and in-hospital AMI management. The audit was conducted using retrospective chart review.
Twelve acute care health centres and hospitals in the East Central Health Region, a rural health region in Alberta, where medical and surgical services are provided almost entirely by family physicians.
Hospital inpatients with a confirmed discharge diagnosis of AMI (ICD-9-CM codes 410.xx) during the period April 1, 2001, to March 31, 2002, were included (177 confirmed cases).
Quality of AMI care was assessed using guidelines from the American College of Cardiology and the American Heart Association and the Canadian Cardiovascular Outcomes Research Team and Canadian Cardiovascular Society. Quality of care indicators at three stages of patient care were assessed: at initial recognition and AMI management in the emergency department, during in-hospital AMI management, and at preparation for discharge from hospital.
In the emergency department, the quality of care was high for most procedural and therapeutic audit elements, with the exception of rapid electrocardiography, urinalysis, and provision of nitroglycerin and morphine. Average door-to-needle time for thrombolysis was 102.5 minutes. The quality of in-hospital care was high for most elements, but low for nitroglycerin and angiotensin-converting enzyme (ACE) inhibitors, daily electrocardiography, and counseling regarding smoking cessation and diet. Few patients received counseling for lifestyle changes at hospital discharge. Male and younger patients were treated more aggressively than female and older patients. Sites that used care protocols achieved better results in initial AMI management than sites that did not. Stress testing was not readily available in the rural region studied.
Quality of care for patients with AMI in this rural health region was high for most guideline elements. Standing orders, protocols, and checklists could improve care. Training and resource issues will need to be addressed to improve access to stress testing for rural patients. Clinical audit should be at the core of a system for local monitoring of quality of care.
Cites: Am J Med. 2000 Jun 1;108(8):642-910856412
Cites: J Am Coll Cardiol. 1999 Sep;34(3):890-91110483976
For the first time in its history, the Health Advocacy Award has been granted to a group of nurses--the Nuu-chah-nulth Community and Human Services Community Health Nurses on Vancouver Island. They have been recognized for their advocacy in providing culturally sensitive nursing care to the Nuu-chah-nulth First Nations.
The purpose of Health Technology Assessment (HTA) is to make the best possible summary of the evidence regarding specific health interventions in order to influence health care and policy decisions. The need for decision makers to find relevant HTA data when it is needed is a barrier to its usefulness. These barriers are highest in rural areas and amongst isolated practitioners.
A multidisciplinary team developed an interactive case-based instructional strategy on the topic of chronic non-cancer pain (CNCP) management using clinical evidence derived by HTA. The evidence for each of 18 CNCP interventions was distilled into single-sheet summaries. Clinicians and HTA specialists ('Ambassadors') conducted 11 two-hour interactive sessions on CNCP in eight of Alberta's nine health regions. Pre- and post-session evaluations were conducted.
The sessions were attended by 130 individuals representing 14 health and administrative disciplines. The ambassador model was well received. The use of content experts as ambassadors was highly rated. The educational strategy was judged to be effective. Awareness of the best evidence in CNCP management was increased. Although some participants reported practice changes as a result of the workshops, the program was not designed to measure changes in patient outcome.
The ambassador program was successful in increasing awareness of the best evidence in CNCP management, and positively influenced treatment decisions. Its teaching methods were felt to be unique and innovative by participants. Its methods could be applied to other clinical content areas in order to increase the uptake of the results of HTA.
Cites: J Contin Educ Health Prof. 2002 Fall;22(4):214-2112613056
Cites: J Health Soc Policy. 2002;15(3-4):23-3712705462
The aim of the study is to examine and articulate the nature of working relationships of public health nurses and high-priority families in small communities in northern Canada. Public health nurses working in northern, rural, and remote communities face unique and varied challenges. Reportedly, the hardest part of their job is working with families who have been deemed high priority or high risk. Working with these families in these contexts relies on relationships of reciprocity, trust, and communication. This qualitative research was guided by an interpretive hermeneutic inquiry; 32 families, 25 public health nurses, and three lay home visitors were interviewed from July 2005 through July 2006. Analysis was completed individually and through teamwork of the researchers. Findings suggest that the working relationship of public health nurses and high-priority families in northern communities is complex and multifaceted. Nurses carefully negotiate the process of engaging and entering relationships, maintaining the relationships, and negotiating boundaries. The analysis offers insight into the everyday practices and problems that public health nurses and families encounter in providing care to a vulnerable, isolated, and often marginalized population while navigating the complexity of living and working in the same small communities.
OBJECTIVES: Our purpose was to explore the influences of an obstetric and gynecologic medical student clerkship on a remote medical community. Return of physicians to Alaska and faculty perceptions of their experience were central foci. STUDY DESIGN: Data were obtained on former clerks to determine choice of specialty and location of practice. Data regarding all physicians new to Alaska was correlated with the University of Washington Medical School graduate data. Additionally, a questionnaire with a Likert-type scale evaluated the 10 clinical faculty members participating in the clerkship. RESULTS: Between 1978 and 1991 we trained 266 clerks. A total of 77 of 374 (21%) new physicians in Alaska (1978 to 1991) were graduates of the University of Washington; 26 of those 77 (34%) were our former Anchorage obstetrics and gynecology clerks. The clinical faculty reported both positive and negative effects of their participation in the clerkship. CONCLUSION: The desired benefit, the return of new physicians to Alaska, seemed supported. Questionnaire results hinted at additional benefits for the supervising faculty physicians in this isolated community. The formal affiliation effected by the clerkship seemed to have a positive impact on patient care, communication, consultation, and shared action among the participating physicians.
A strategy for implementing telemedicine throughout Alberta was developed. The model was based on a comprehensive evaluation of the four clinical specialties chosen as representative telemedicine services--radiology, psychiatry, emergency services and continuing education. The goals of the telemedicine network were to improve access to health services, provide support for rural health-care providers and increase the efficiency of specialized services. The findings showed that the success factors in a national telemedicine programme depend on a clear organizational structure, with appropriate technical standards and support.
To examine the current practice of rural family physicians in managing children with attention-deficit hyperactivity disorder (ADHD).
Chart review of children and adolescents with a recorded diagnosis of ADHD. The data collected include the patient's age at diagnosis, the diagnosing physician, the number and type of presenting symptoms, whether the Diagnostic Statistical Manual, 4th ed (DSM-IV) criteria were met, pertinent treatment regimens, family history and comorbid conditions. Participating physicians were asked to complete a questionnaire.
Elgin County, Ontario.
Thirty-six family physicians were contacted and 11 agreed to participate. Thirty-nine charts were reviewed. The average number of presenting symptoms was 2.9 for ADHD-inattentive subtype and 2.1 for ADHD-hyperactivity subtype. A diagnostic protocol was included in 20.5% of the charts. Of the 39 charts reviewed, 25.6% had sufficient information for the patients to meet the ADHD criteria. Family physicians diagnosed 5.1% of the cases, and the duration of time between referral to specialist and appointment was 47.2 weeks.
Together the lack of symptom recording, the long duration between referrals, and the low percentage of family physicians diagnosing ADHD all suggest the need for developing diagnostic protocols for family physicians and increasing their knowledge of diagnosing and managing ADHD.