Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service

A child and adolescent telepsychiatry service in rural New South Wales was evaluated. Part of the evaluation was to assess whether rural mental health workers and patients were satisfied with the videoconferencing services provided by child psychiatrists from the Children's Hospital at Westmead. During a 12-month study, information was collected using questionnaires on a total of 136 new patients who had been interviewed via videoconferencing. Satisfaction questionnaires were completed by 100 rural mental health workers, and 82 patients and their families/carers. Questionnaires about satisfaction with the technology were completed by 136 child psychiatrists, 101 rural mental health workers and 79 patients. Patients and their families/carers, as well as rural clinicians, expressed high overall satisfaction with the telepsychiatry service. The evaluation suggested that videoconferencing is a good method of providing child and adolescent psychiatry services to remote and rural communities.

Successes and failures in videoconferencing: a community health education programme

Women's Health Queensland Wide began delivery of community education programmes for rural women via videoconferencing in the year 2000. A series of three, 90 min videoconference sessions from Brisbane were delivered to 13 sites in northern Queensland. The sessions related to health issues for women at midlife. The sessions were delivered by health experts in Brisbane, who provided a short presentation on their topic; the majority of the videoconference was dedicated to questions from the participants. Each site was supported by a technical coordinator, who ensured that the equipment functioned properly, and a local health worker, who facilitated women's participation in the videoconference as well as providing a local services perspective. Women's Health Queensland Wide was responsible for overall planning and promotion of the sessions. Feedback from these programmes demonstrated women's and health-care professionals' acceptance of videoconferencing as a mechanism for receiving health information. Sustainability of these programmes depends upon the following issues: cost, delivery model, and the availability of appropriate technology and women-friendly sites.

Teledermatology in the Waikato region of New Zealand

Teledermatology consultations over a video-link began at Health Waikato in 1995. Clinical trials involving about 500 patients have demonstrated the diagnostic accuracy and economic gains of these teleconsultations, and patient satisfaction with them. Yet, six years on, out-of-date equipment remains under-used. There has been no expansion of the network and no additional clinical teleconsultation services. Possible reasons include the excessive capital cost of videoconferencing equipment, clinician overwork, inconvenience, lack of reimbursement, administrative and governmental inertia, and little demand from patients and their doctors. To widen our referral base without the inconvenience of videoconferencing, we decided to offer a secure browser-based dermatology tele-advice service to referring general practitioners who owned digital cameras. With the increase in online health information and electronic communication, we assumed it would be popular. But, despite up to six-month waits for patients to be seen in the dermatology outpatient clinic, few patients have been referred to the service. Explanations have included time constraints, unavailability of a camera, no Internet access at the time of consultation and lack of reimbursement. Can we look forward to a future in which all doctors have high-speed access to the Internet at their desktop through their practice management systems? Who will pay? Will they continue to prefer conventional referral?

Progress in Australian teledermatology

Because of their remoteness, the majority of rural towns in Australia are disadvantaged in terms of access to dermatological services. Telemedicine offers one solution. Since the mid-1990s, Australian dermatologists have experimented with telemedicine as an adjunct to clinical practice. The technical viability of teledermatology was first demonstrated in 1997. In 1999, the accuracy and reliability of teledermatology were demonstrated in a real-life urban setting. In 2001, Broken Hill (in western New South Wales), a location remote from dermatology services, served as a trial site for the institution of teledermatology as the primary method of accessing dermatological services. High patient and general practitioner acceptability and positive medical outcomes were demonstrated, but the study also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology.

Some successes and limitations with telehealth in Canada

Canada has taken important steps towards establishing telehealth within its health-care system. However, in many areas telehealth in Canada has yet to progress beyond the stage of testing feasibility. A recent survey of eight Canadian telehealth programmes that are using videoconferencing indicated that there is little evidence of either clinical or economic benefits compared with conventional care. There are examples of sustainable, routine telehealth services in Canada. However, overall, the number of patients seen by telehealth is still very small in comparison with the number of face-to-face visits. 'People-related' factors seem dominant in determining the degree of success of telehealth applications.

Elderly citizen's perception of their health and care provided in a rural South African community

A descriptive survey of 201 senior citizens, 55 years or older was conducted June 2001, using face-to-face interviews to establish a database. Structured tools were used to measure self appraisal of family stress, perceived social support, caregiver satisfaction and psychological health of family members and of themselves. Even though the senior citizens had survived past the estimated life expectancy, the quality of life has not improved significantly in the post-apartheid period.

Developing a prioritization matrix for improving breast care--a complex project

Prioritization is an ongoing challenge for quality management professionals. A previous companion Brief Report described a tool for prioritizing improvement projects (Pelletier, Beaudin, and van Leeuwen, 1999). This tool provides a framework for prioritizing opportunities/solutions for major institutional improvement projects. By separating and categorizing opportunities and solutions and then weighing their importance and impact, the organization can graphically evaluate and then select interventions to initiate.

Space-age medicine, stone-age government: how Medicare reimbursement of telemedicine services is depriving the elderly of quality medical treatment

We have the technology. What is needed is government financial commitment, so argues Kristen Jakobsen in the following discussion of "telemedicine." The term refers to the delivery of health care services by means of modern telecommunications technology. According to Ms. Jakobsen, the telephone, the fax machine, the Internet, and interactive audio-visual transmissions hold the key to making medical care more accessible and less expensive. Potential beneficiaries include vast populations of elderly in rural areas, who tend to be remote from upscale health care facilities and in need of the wherewithal to reach them. Standing in the way, in Ms. Jakobsen's view, is a government which lacks the boldness and the vision to lay an adequate fiscal foundation for this promising possibility.

A case study in using VET qualifications to rejuvenate learning and change in a complex and disparate rural area health service

The Boggabri Health Service is typical of many rural and remote public health facilities. Twenty-four staff, only a third of whom work full-time, service the needs of a population of 1601. Change from a focus on acute care to a model of wellness through redevelopment as a Multi Purpose Service is providing staff with a unique opportunity for continuing professional development, particularly in regard to aged care standards, their core business. Use of flexible delivery and self-directed learning has transformed this facility from ignorance about the value of undertaking vocational education and training (VET) to 80% enrollment in certificate and diploma qualifications, ever a six month period from January 2001. Some twenty-five facilities comprise the New England Area Health Service, of which Boggabri is but one. The learning innovation demonstrated at Boggabri is being duplicated across other facilities. Interest in VET qualifications from staff at all levels is a remarkable renaissance.

[Emergency care in tropical areas: status report based on surgical emergencies in Senegal]

Management of surgical emergencies in Senegal is characterized by a mismatch between supply of facilities and demand for care. The situation has been complicated by runaway urban growth. Two situations can be distinguished in rural zones and in the major city of Dakar. The common features in both locations are chronic underfunding, absence of pre-hospital emergency and rescue services, and inadequacy of health care facilities to manage emergency situations. In urban and rural areas, hospital are oversollicited, poorly designed and managed in terms of infrastructure and equipment, and understaffed in terms of surgeons and qualified paramedical personnel. The main differences between urban and rural areas involve the volume and type of surgical emergencies with a constantly increasing number of trauma emergencies in cities. Solving these problems will require a specific national plan to develop emergency care services in general. This plan will require coordination of funding, re-organisation of hospital facilities, and hiring and training of qualified personnel (surgeons and paramedical staff).

An economic analysis of midwifery training programmes in South Kalimantan, Indonesia

In order to improve the knowledge and skills of midwives at health facilities and those based in villages in South Kalimantan, Indonesia, three in-service training programmes were carried out during 1995-98. A scheme used for both facility and village midwives included training at training centres, peer review and continuing education. One restricted to village midwives involved an internship programme in district hospitals. The incremental cost-effectiveness of these programmes was assessed from the standpoint of the health care provider. It was estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$ 764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$ 1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$ 898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison.

Quality assurance and continuing education needs of rural and remote general practitioners: how are they changing?

The Royal Australian College of General Practitioners' (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College's QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad 'rural set' of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is: (1) to identify problems associated with the quality of hysterectomy care accessed by members of SEWA, an Indian CBHI scheme; and (2) to discuss mechanisms that might be put in place by SEWA, and CBHI schemes more generally, to optimize quality of health care. Data on the structure and process of hysterectomy care were collected primarily through review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varies tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects of structure include: operating theatres without separate hand-washing facilities or proper lighting; and the absence of qualified nursing staff. Dangerous aspects of process include: performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology, even when symptoms and signs are suggestive of disease. Women pay substantial amounts of money even for care of poor, and potentially dangerous, quality. In order to improve the quality of hospital care accessed by its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate cases where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocation decisions; (3) select, and contract with, providers who provide a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better-quality care and contract directly with them.

Use of a clinical audit to promote the quality use of medicines to rural and remote general practitioners

Very few methods have been shown to change prescribing behaviour. Queensland Rural Medical Support Agency's Quality Use of Medicines (QUM) Program aims to engage rural general practitioners (GPs) in the development of strategies to improve health outcomes in relation to the quality use of medicines. The present paper describes the development of a tool to audit the management of heart failure in rural general practice and to encourage rural GPs to undertake such an audit as a method of continuing medical education. A self-administered retrospective clinical audit of heart failure patients was undertaken by rural and remote GPs. Fourteen doctors undertook the audit, providing data on 270 patient cases. Patient data collected include 30% not receiving adequate angiotensin-converting enzyme inhibitor doses, 45% of patients who may benefit from a beta-blocker and 14% of patients taking a drug known to aggravate heart failure. The majority of participants would review a patient following the audit and 93% confirmed that the audit assisted them in identifying patients whose heart failure management could be enhanced. The clinical audit provided results and a commentary to allow GPs reflective educational opportunities through the dissemination of results and engagement with appropriate educational organisations (e.g. Australian College of Rural and Remote Medicine) to inform the development of educational standards for personal development programs in QUM. Audits must be relevant and practical to meet the learning needs of GPs.

Emergency preparation in schools: a snapshot of a rural state

OBJECTIVE

To study emergency preparedness in public schools in a rural state.

METHOD

Questionnaires were mailed to school nurses registered with the State Department of Education. Data collected included school nurse and staff training, school location, emergency equipment available, and Emergency Medical Service (EMS) access.

RESULTS

Seventy-two percent of the surveys were returned after one or two mailings. They report little emergency training for both school nurses and school staff. Emergency equipment available varies widely: oxygen 20%, artificial airways 30%, cervical collars 22%, splints 69%. Equipment was more likely to be available in communities with populations of less than 200,000. Sixty-seven percent of schools activate EMS for a student and 37% for an adult annually. Eighty-four percent of schools have a less than 10-minute EMS response time.

CONCLUSIONS

EMS activation to schools is a common occurrence. Schools are ill prepared to care for this acuity of student or staff as assessed by equipment and emergency training. Schools in smaller communities, however, are better prepared for emergencies.

Advocates for culture, advocates for health

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.

[Telemedicine in sparsely populated areas yields satisfied patients and better competence]

A telemedical pilot-project involving two rural primary health care centers in Tärnaby/Storuman in Southern Lappland and the University Hospital of Umeå was carried out during the period Sept. 1, 1996-Dec. 31, 1998. Out of 169 consultations in all, 40 pertained to dermatology, 50 to ENT, 40 to orthopedics, and a further 27 to other specialties (surgery, medicine and gynecology). Among the 169, 47 cases were successfully managed via telemedicine. 30% of consultations were made in order to secure a second opinion. The remaining 70% were made in order to seek advice concerning a possible referral. At the telemedical visit, patients indicated a satisfaction score of 5.5 on a scale up to 6.0. The GP's rated the educational value at 4.4. After completion of the pilot-project, a survey of acceptance and ratings of the future potential of telemedicine for the health care system was carried out among 191 doctors and other health care workers in Västerbotten county. Using a similar graded scale up to 6.0, physicians rated telemedicine as regards utility for patients and quality of care at 4.6 and 4.5 respectively, somewhat higher than they rated the consequences of telemedical consulting for their working conditions and health care organizations, at 3.8 and 4.1 respectively. Despite a low volume of patients in the pilot project, we can conclude that telemedical consultations seem to reduce the number of referrals and raise the level of competency of the GP's. It's important to find further fields of application, as well as further ways of working and organizing the communication network in order to increase volume.

Maternal mortality in Kenya: the state of health facilities in a rural district

BACKGROUND

This study was formulated from the premise that the known causes of maternal mortality, namely haemorrhage, sepsis, obstructed labour and abortion belie the more fundamental development problems that influence it, such as the state of local medical services, quality of care and the facilities' ability to respond to reproductive health emergencies.

OBJECTIVE

To document some of the underlying problems and how they were found to influence maternal mortality in Kenya, with specific reference to a rural district.

DESIGN

The researchers used the Prevention of Maternal Mortality Network (PMMN) methodology/study design to assess the current state of health facilities, their level of function, and factors influencing their utilisation. Both qualitative and quantitative methods of data collection tools were used.

SETTING

Siaya District in the western region of Kenya. Data were collected from thirty facilities, which provide obstetric care in the district.

PARTICIPANTS

Data were collected by nurse/midwives, nursing school tutors and social scientists with experience in qualitative research methods. Respondents included health service providers and managers at the 30 health facilities. Qualitative data were obtained through focus group discussions with health facility staff as well as community members.

RESULTS

All the thirty facilities studied, were grossly wanting in terms of staffing, equipment, essential drugs and supplies. Both quality of care and record keeping were well below acceptable standards.

CONCLUSIONS

The study findings are a sad but a fair reflection of our situation not only in Kenya but also in sub-Saharan Africa ten years after the declaration of the Safe Motherhood Initiative (SMI). The results indicate a predictable, widening gap in basic service provision that must be urgently bridged as a prerequisite to any serious and meaningful approaches to reducing maternal mortality in Africa.

[Responses to a questionnaire on laboratory examinations performed by graduates of Jichi Medical School in rural practice]

Graduates from Jichi Medical School are obligated to work at rural clinics or hospitals, where most of them are the only medical doctor in the house. Our need to continuously improve medical education, including the learning that takes place in the clinical setting, requires us to understand how these graduates actually use laboratory examinations and what examinations they find most important in their practice. We designed a questionnaire to address these questions. Three hundred sixty-eight graduate physicians working at clinics or hospitals in both rural or urban areas were asked to complete the questionnaire, providing information on the size of their institution, the laboratory equipment and examinations that they have direct access to, and what examinations they find most important. Two hundred seventy-eight (75.5%) of the 368 recipients responded. More than seventy percent of the respondents reported that their institutions had electrocardiographs, abdominal and cardiac ultrasonographs, urinalysis test paper, and portable blood glucose meters; and more than half of them reported having used these instruments without assistance in emergency situations and outside of ordinary office hours. Moreover, a majority of the respondents said that they considered it important that a physician is able to use these instruments without the help of other staff members. These responses clearly show the importance and usefulness of covering examination techniques and the principles of laboratory medicine in medical education.

Abortion admissions in rural Matebeleland north province

OBJECTIVES

To describe the characteristics, clinical features and management of women admitted with an abortion in rural Zimbabwe.

DESIGN

Cross sectional descriptive study.

SETTING

Four government and two mission hospitals in rural Matebeleland North province.

SUBJECTS

Hospital records of 355 consecutive women admitted with the diagnosis abortion from May to October 2000, and delivery registers covering the same six month period.

MAIN OUTCOME MEASURES

Age, marital status, reproductive history, referral status, distance home to hospital, presenting symptoms, findings on examination, complications, management in hospital, final diagnosis, length of hospital stay.

RESULTS

Abortion patients tended to be older and of higher parity than women who delivered in the same period. Fifteen percent were teenagers, 81.2% were married and 2% nullipara. Mean period of gestation was 11.3 weeks. About half of the women had been referred and 74.4% lived within a 50 km radius from the hospital. Forty two percent had never used contraception. Of the users, 38.6% had discontinued in order to conceive and 19.3% had fallen pregnant on the method. Thirty one percent of the women wanted no more children. One third of the abortion patients had a temperature above 37.6 degrees C; 25.9% offensive vaginal discharge and 7% a haemoglobin of less than 6 g/dl. Eighty percent were given antibiotics and 4.2% received a blood transfusion; 73.2% had an evacuation of the uterus for incomplete abortion, with a mean delay between admission and evacuation of 32.5 hours. Only 17.5% of the women had on record that they were given a contraceptive method on discharge. Mean length of hospital stay was 3.1 days. The case fatality rate was more than 1%. An estimated 43.4% of the women had a possibly unsafe induced abortion prior to admission.

CONCLUSION

As evidenced by the high morbidity and mortality, abortions are a serious public health problem in rural Matebeleland North. Taking into account that only a minority of the women with both unsafe and spontaneous abortions present to a hospital, it is imperative that the reproductive needs of the women who do come are addressed. No opportunity should be missed to offer contraceptives to a group of women whose use of contraception is lower than average. Clinical management of abortion patients could improve by earlier evacuation of the uterus in cases of incomplete abortion, use of local or no anaesthesia and by increased availability of suction cannulas in district level hospitals, which would also reduce length of hospital stay.

Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities

OBJECTIVE

Our goal was to compare the quality of diabetic care received by patients in rural and urban communities.

STUDY DESIGN

We performed a retrospective analysis of claims data captured by the Medicare program.

POPULATION

We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994.

OUTCOME MEASURES

The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination.

RESULTS

A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests.

CONCLUSIONS

Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

Women's strategic responses to violence in Nicaragua

STUDY OBJECTIVE

To describe the responses of women in León, Nicaragua to partner abuse and identify contextual factors associated with the use of certain coping mechanisms and the likelihood of permanent separation.

DESIGN

Cross sectional population-based survey.

SETTING

León, Nicaragua.

PARTICIPANTS

188 women 15-49 years of age who had experienced physical partner abuse, out of 488 women interviewed.

MAIN RESULTS

66% of women defended themselves effectively from abuse either physically or verbally. Forty one per cent of women had left home temporarily because of violence and 20% had sought help outside the home. Women experiencing severe abuse were more likely to leave or seek help, whereas women with less severe abuse were more able to defend themselves effectively. Seventy per cent of women eventually left abusive relationships. Help seeking and temporary separations increased the likelihood of a permanent separation, whereas women who defended themselves and were able to stop the violence, at least temporarily, were more likely to remain in abusive relationships.

CONCLUSIONS

Women in Nicaragua use a variety of methods in order to overcome physical partner abuse. Temporary leaving and help seeking are critical steps in the process of leaving a violent relationship. However, many women indicated that they did not receive support for their situation. More interventions are needed to help women recognise and deal with violence, as well as strengthening the community support networks available to abused women.

Rural training and the state of rural health services: effect of rural background on the perception and attitude of first-year medical students at the university of melbourne

The aim of this project is to investigate the relationship between medical students' background and their perception of the state of rural health services; willingness to undertake internship training or work as a doctor in a rural hospital; expected benefits and disadvantages of training or working as a doctor in a rural hospital; and factors interfering with acceptance of a job as a doctor in rural areas. A questionnaire-based survey was distributed to 100 first-year medical students attending the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne at the end of semester 1. The response rate was 97%, including 44 males and 53 females. A strong relationship was found between rural background and an intention to undertake internship training in a rural hospital (86% of students from a rural background expressed this desire vs 30% of students from an urban background). Furthermore, all students from a rural background expressed a desire to work as a doctor in a rural hospital after completing postgraduate training. Compared to urban students, students from a rural background showed a more positive attitude towards health services in rural areas including public hospitals ( P = 0.02), private general practice ( P = 0.004), ambulance service ( P = 0.0002) and baby health centres ( P = 0.005). Citizenship or gender was not significantly related to the perception of any of these services. The ranking of factors interfering with acceptance of a job as a doctor in rural areas were different for rural and urban students. Students from rural backgrounds reported spouse/partner needs (76% vs 49%, P = 0.038) and school availability for children (59% vs 30%, P = 0.023) as barriers more frequently than urban students, respectively). On the other hand, urban students rated the following factors higher: personal factors (76% vs 53%, respectively), education opportunities (56% vs 24%), social/cultural facilities (50% vs 41%) and the need for frequent travel (29% vs 12%). None of these interfering factors were significantly different. Urban students were more likely than rural students to report that their views were a result of adverse media reports. In conclusion, students from a rural background were more willing to be trained or to work as doctors in rural areas. This was associated with a greater adverse influence by the media upon students.

Rural Alabama Health Professional Training Consortium: six-year evaluation results

The Rural Alabama Health Professional Training Consortium is a rural community health center-based program that began in 1990 to provide interdisciplinary training for medical, nursing, pharmacy, dentistry, and nutrition students. After 6 years, 166 students had participated. This article discusses an evaluation of the impact of this program on these students by means of comparing pre-tests and posttests. Dentists demonstrated attitudes less favorable to locating in rural practices compared to other students. There was a significant increase in clinical competencies relevant to rural practice. Professional perceptions about working in an interdisciplinary environment were significantly lower for medical students compared to pharmacists, but their attitudes improved over time. The team concept was highly rated. Over 90% of the students thought that the program met or exceeded their expectations and would recommend it to other students, except for nurses. Over 80% of the students will consider working in a rural area on graduation, except for dentists.

A comparison of rural and urban Emergency Medical System (EMS) personnel: a Texas study

INTRODUCTION

In treating accident victims, actions by the Emergency Medical Personnel (EMP) at the scene may be the difference between life or death, full recovery or permanent disability. Development of selected profiles based on locale of services, tenure, and paramedic certification will provide valuable insight into the diversity within the Emergency Medical Services (EMS) profession. Not only will these profiles enable administrators to improve their recruitment, training, and retention of the emergency medical workforce, it potentially could enhance the quality of health care in the community.

POPULATION

Emergency medical personnel attending a statewide conference in Texas in late 1996 (n = 425).

HYPOTHESES

1) There is no difference between the profiles of urban and rural EMP; 2) There is no difference between the profiles of urban EMP with < 9 years of experience and those with > or = 9 years of experience; 3) There is no differences between the profiles of rural EMP with < 9 years of experience and those with > or = 9 years of experience. 4) There is no difference between the profiles of urban EMP with paramedic certification and those without certification; and 5) There is no difference between the profiles of rural EMP with paramedic certification and those without certification.

METHODS

EMP attending the conference completed 425 survey instruments measuring five demographic features, five work-related features, and two psychological features. Survey instruments were included in each registrant's conference package. Completed surveys were deposited anonymously in labeled receptacles throughout the statewide conference site. Data collection ceased at the end of the conference. Discriminant analysis identified distinct profiles for the urban and rural EMP.

RESULTS

The urban EMP, more than rural subjects, was younger (mean = 36 years), more likely to be compensated 100% for their services, had a higher level of education (mean = 13.8 years), and reported a lower level of burnout. Urban EMP with < 9 years of experience tended to be younger, male, married, and reported less burnout. Urban paramedics were more likely to be compensated 100% for their services, and had achieved a higher level of education. The rural EMP with < 9 years of experience were less likely to be paramedic, reported lower burnout scores, and was younger. The rural EMP without paramedic certification was more likely to be a volunteer, and have had fewer years of service.

CONCLUSIONS

In Texas, locale of service (urban or rural), length of tenure as an EMP (> or = 9 years), and paramedic certification appear to be significant factors that define the EMP population in Texas.

The views of Otago urban and rural general practitioners on mental health services

AIM

To examine the views of Otago general practitioners (GPs) about local mental health services and their role in providing such health care.

METHODS

A questionnaire was distributed to all GPs working in Otago.

RESULTS

100 replies (59%) were received. There were large differences between GPs in the estimated numbers of patients with psychiatric conditions they were seeing. 85% were keen on sharing management of patients with mental health services. Average confidence levels for diagnosis and management of depression and anxiety were good. GPs felt less confident about psychosis, somatisation, eating and personality disorders. Obstacles to GPs doing more mental health work included time, cost, access to specialist services and training. On balance, GPs viewed the present mental health services as adequate.

CONCLUSIONS

GPs appeared prepared to do more mental health work if the barriers of cost and time could be overcome and they were provided with adequate education and backup from specialised services.

State HMO accreditation and external quality review requirements: implications for HMOs serving rural areas

The purpose of this article is to analyze state regulations regarding health maintenance organization (HMO) accreditation and external quality review; to briefly describe states' experiences implementing these regulations; and to discuss the implications of these regulations for HMOs serving rural areas. The incorporation of HMO accreditation and external quality review requirements into state HMO licensure processes and state employee contracting raises many policy issues, including several that are especially relevant to HMOs serving rural populations. A key issue is whether the linkage of accreditation and external quality review requirements to HMO licensure will be an additional deterrent to the development of new HMOs or the expansion of existing HMOs into rural areas. Other issues relate to the costs and benefits of accreditation for HMOs serving rural populations, and the potential impact of HMO accreditation requirements on efforts to expand managed care enrollment of rural Medicaid and Medicare beneficiaries and rural state employees. Nine states were identified that have regulations requiring HMOs to seek accreditation or to undergo an external quality review as a condition of licensure. Four states were identified as implementing requirements that an HMO be accredited in order to serve state employees. Many of these requirements are still in the early stages of implementation. Several states with the requirements have significant rural populations and will provide opportunities to evaluate their impact on HMOs serving rural areas, rural providers and rural consumers.

A consumer's perspective of a suicide intervention programme

The objective of this study was to assess the impact of a suicide intervention program from a consumer perspective. Self-administered questionnaires were distributed to consumers who had been referred to a suicide intervention counsellor in the 2-year period of the programme in rural southwest Western Australia. Three-quarters of respondents were positive about their experience with the service, with half of the respondents no longer having thoughts of suicide and only 20% of all respondents reporting having attempted deliberate self-harm postcounselling. Reported suicidal ideation and attempted self-harm were much higher in the dissatisfied group. Dissatisfaction of respondents stemmed from the history of their treatment and 'the hassle created by the many systems for them to access care'. However, the overall outcome of this study is that, from the consumer's perspective, a high intensity approach to suicide intervention resolved or improved the presenting problem and their ability to deal with it.

Military, civilian, and rural application of the damage control philosophy

Damage control surgery is a useful salvage strategy for the most critically injured patients. Conceptually, this approach to individual patients can be extrapolated to situations such as military field surgery, civilian mass casualty events, and long-range transfers from rural areas. The logistic realities of Army forward surgery teams are addressed with regard to typical damage control maneuvers and evacuation. Specific areas requiring improvement through directed research are identified. Initial civilian mass casualty strategies are discussed, and a plan to prevent transfer delays of rural trauma patients is presented. By transferring the lessons learned from individual damage control patients to military, civilian mass casualty, and rural casualty events, resource utilization is optimized. The concept of minimal acceptable care rather than optimal trauma care can be applied to these three seemingly different situations.

Rate of caesarean section as a process indicator of safe-motherhood programmes: the case of Kenya

The study assessed the value of currently-available data on the rates of caesarean section as an indicator of safe-motherhood programmes. Data, collected through the routine health information system of the Ministry of Health, Kenya, were used for analyzing the available process indicators. The methodology of this study illustrates both usefulness and limitations of readily-available healthcare information. The rate of hospital-based caesarean section was 6.3% of all births (range 0.3-37%), whereas the rate of population-based caesarean section was 0.95% (range 0.1%-4%). The rate of population-based caesarean section indicates a significant unmet need for obstetric care in the rural areas and may be a useful tool for monitoring progress on safe-motherhood initiatives in poor settings. Rates of population-based caesarean section are low in Kenya, especially in the rural areas. The rate of caesarean section may be a valuable process indicator for identifying the gaps in obstetric care and may be used for advocating improvements for healthcare to the relevant authorities.

Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote Indigenous communities

OBJECTIVE

To evaluate a system for improving diabetes care in remote Indigenous communities.

DESIGN

Randomised, unblinded cluster trial over one year (1 March to 29 February 2000).

PARTICIPANTS AND SETTING

Primary healthcare staff in 21 primary healthcare centres in the Torres Strait and Northern Peninsula Area (NPA) Health Service District, north Queensland, and 678 people with diabetes, mostly Torres Strait Islanders.

INTERVENTION

Diabetes recall system established at eight of the 21 sites, as well as staff training in basic diabetes care, regular phone calls from the project officer, a two-monthly newsletter and a mid-project workshop.

MAIN OUTCOME MEASURES

Regular checks of weight, blood pressure, eye and foot care, serum lipid levels and glucose monitoring and control, urinary albumin to creatinine ratio and serum creatinine levels, and administration of recommended vaccines; hospitalisation in the previous 12 months.

RESULTS

There was improvement in most measures at most sites, except for blood pressure monitoring and control, and vaccination status. Intervention sites showed greater improvement in most indicators than control sites (combined relative risk [RR], 1.21; 95% CI, 1.03-1.43). The intervention group showed a 32% reduction in hospital admissions for diabetes-related conditions over the study period (P=0.012). At follow-up, patients in intervention sites were 40% less likely to be hospitalised for a diabetes-related condition than those in control sites (RR, 0.60; 95% CI, 0.41-0.86; P=0.007).

CONCLUSION

A simple recall system, managed by local healthcare workers and supported by a diabetes outreach service, achieved significant improvements in diabetes care and reduced hospitalisations in a high-risk population.

Follow-up of patients with haematological malignancies and their families in regional, rural and remote Queensland: the GPs' perspective

In rural areas of Australia the range of health services is limited and major inequities exist in health care provision. Consequently, general practitioners (GPs) are forced to play a pivotal role as key providers of health and medical services. Patients with a haematological malignancy returning home from the lengthy ordeal of high-tech specialist treatment in the metropolitan area will have a strong need for competent holistic support. For these patients and their families, establishing a positive relationship with the local GP will be an important factor in their post-treatment rehabilitation. The findings presented in this article are from recent Queensland research that looks at the support provided by GPs in regional, rural, and remote areas for patients with a haematological malignancy after they return home from specialist treatment in the metropolitan area. The findings indicate the need for support and education for GPs coping with such patients. Newsletters and telephone contact are recorded as the most popular means of support by the GPs surveyed.

Educational opportunities in palliative care: what do general practitioners want?

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.

Post-treatment support for patients with haematological malignancies: findings from regional, rural and remote Queensland

Social support is a significant factor in the cancer patient's psychosocial wellbeing. This paper presents the findings of recent Queensland-based research that explored the experience of families returning home to the regional, rural and remote sector after a family member completed specialist treatment for a haematological malignancy and related blood disorder in a major metropolitan centre. Family and friends are the key resource persons providing support. To a large degree, this is because of the absence of alternative sources. Even support from health professionals can be problematic and for many the only source of support is the specialist centre many hundreds of kilometres away. The primary response to developing supportive services needs to be through person to person contact either via telephone or newsletter. If targeted appropriately, there is also evidence that educational programs, support groups and volunteers would be an effective medium for providing support. Educating the local health professionals (GPs and nurses) about haematological conditions is a logical extension of providing support to families.