Evidence based general practice

OBJECTIVES

To estimate the proportion of interventions in general practice that are based on evidence.

DESIGN

A one-year cross-sectional study involving all consultations by patients over age 15 years seen in 34 national primary health care centers.

SETTING

The rural Castellon provincial district within the Valencian Community in eastern Spain, with a total population of 21,155 inhabitants.

SUBJECTS

of 1990 case histories registered in the course of one year, 4800 consultations were identified; of these, 2341 (49%) distinct diagnosis-intervention pairs were identified and coded.

MAIN RESULTS

The evidence basis for the diagnosis-intervention pairs in the study was derived from a computerized search of the scientific literature published in 1992-1996. The quality of the evidence was classified according to the method of Ellis et al. Within the 2341 diagnosis-intervention pairs, there was positive evidence in support of the intervention used in 55%. The evidence basis was sound for 42%, with 38% being based on Type I (clinical trials) evidence and 4% on Type II evidence. The most frequently presenting diseases involved the circulatory (18.7%), respiratory (14.9%), nervous (14.2%), musculo-skeletal (12.5%) and nutrition and metabolism and digestive systems, with 12.1% each.

CONCLUSIONS

Clinical practice was clearly supported by positive evidence of all Types (I-III) in a total of 55% of interventions, and by good positive evidence of Type I or II in 42% of interventions. The percentage of evidence-based interventions in general practice serving a substantial population in rural Spain was lower than had been reported by some authors.

Renal Home Support Scheme quality initiative

In 1995 the practice of visiting home dialysis patients was challenged. In order to justify this practice, a benchmarking approach was adopted comprising a literature search, surveys of all relevant patients and their primary health carers, as well as all dialysis units in Australia. The results favoured the home visits and facilitated the establishment of a baseline standard of one home visit at least every 6 months. This standard was audited and reviewed annually. In 1996, Queensland Health launched the Renal Home Support Scheme which was targeted at improving the delivery of health care in the home, leading to efficiencies in the delivery of care to specific groups within the community such as the indigenous population. Successful submissions had to identify objectives, strategies and performance indicators that demonstrated the likelihood of success. The Renal Unit at Townsville General Hospital successfully tendered a submission to Queensland Health and the scheme was implemented in November 1996.

Rationality of drug prescriptions in rural health centres in Burkina Faso

The objective of this study is to investigate the quality of drug prescriptions in nine health centres of three districts in rural Burkina Faso. 313 outpatient consultations were studied by methods of guided observation. Additionally interviews were held with the health care workers involved in the study. A total of 793 drugs prescribed by 15 health care workers during the observation period and 2815 prescribed drugs copied from the patient register were analyzed. An average of 2.3 drugs were prescribed per visit. 88.0% of the prescribed drugs were on the essential drug list. 88.4% were indicated according to the national treatment guidelines. 79.4% had a correct dosage. The study revealed serious deficiencies in drug prescribing that could not be detected by assessing selected quantitative drug-use indicators as recommended by the WHO. In two-thirds of the cases the patients received no information on how long the drug had to be taken. Errors in dosage occurred significantly more often in children under 5 years. The combined analysis of choice and dosage of drugs showed that 59.3% of all the patients received a correct prescription. Seven out of 21 pregnant women received drugs contraindicated in pregnancy. We conclude that assessment of quantitative drug-use indicators alone does not suffice in identifying specific needs for improvement in treatment quality. We recommend that prescribing for children under 5 and for pregnant women should be targeted in future interventions and that the lay-out, content and distribution of treatment guidelines must be improved.

A comparison of a hospital outpatients department and general practice in remote Queensland

A survey of all ambulant patients attending the hospital outpatients' department and the private general practice in a remote town in Queensland sought information on patients' reasons for attending. Patients handed the completed questionnaires to their practitioner, who indicated the type of visit and the focus of the encounter. There was little difference between the facilities in terms of patient demographics, except that males accounted for a higher proportion of encounters at the Outpatients' Department (OPD), mainly as emergency encounters. Excluding emergency encounters, patients appeared to perceive the facilities as alternative practices. The practitioners' reports suggested some differences in practice and/or experience between the two facilities, which were in line with commonly held perceptions about OPD and private general practice. The data suggest that the similarities between the two facilities may outweigh the differences. Moreover, the differences between rural hospital practice and rural general practice should be seen as providing the opportunity for more rounded training, rather than mutually exclusive forms of practice.

Rural physicians' understanding of the state-of-the-art in breast, colon and rectum cancer treatment

OBJECTIVES

This study measured the impact of an educational intervention aimed at heightening rural physicians' awareness of state-of-the-art breast and colorectal cancer therapies.

METHODS

Pre- and post-intervention mailed surveys were administered to all primary-care physicians and referring physicians in the seven-county intervention region in North Carolina (NC) and a comparison region in South Carolina (SC).

RESULTS

The survey revealed few significant changes in physicians' perspectives that could be attributed to the intervention. Physicians erroneously stated that lumpectomy without follow-up radiation was acceptable for treating breast cancer (55%), failed to indicate that adjuvant therapy was an accepted practice for treating Stage I breast cancer (67%), failed to acknowledge chemotherapy as experimental for Dukes' B colon cancer patients (70%), and failed to recognize a combination of surgery, chemotherapy, and radiation as a standard treatment for rectal cancer (25%).

CONCLUSIONS

The low levels of awareness of National Cancer Institute guidelines were reflected in low breast-sparing surgery rates for women living in the intervention region. Stronger consensus on appropriate cancer treatments is needed throughout the medical community in order to reduce undesired variation in rural, community-based cancer care.

A model for multidisciplinary peer review and supervision of behavioral health clinicians

The authors describe a semi-annual program for multidisciplinary peer review and supervision that is in use at two rural adult and child mental health and drug and alcohol service agencies. The program incorporates semiannual chart reviews and face-to-face discussions held with each clinician by a multidisciplinary supervisory group. Several quality improvement issues addressed by this program are described, including improved communication, improved clinical diagnosis, the establishment of service parameters, more appropriate referrals for psychiatric and other medical care, and improved clinician skills. The program represents an inexpensive approach to peer review and supervision that can incorporate university-based consultants, improve quality of care, improve clinicians' skills, and be readily applied by clinical supervisors to most behavioral health settings.

Improving quality in general practice: qualitative case study of barriers faced by health authorities

OBJECTIVES

To identify and assess the barriers that health authorities face as they manage quality improvements in general practice in the context of the NHS reforms.

DESIGN

Qualitative case study.

SETTING

Three UK health authorities: a rural health authority in the south west, a deprived inner city health authority in the north east, and an affluent suburban health authority in the south east.

PARTICIPANTS

Senior and junior managers.

MAIN OUTCOME MEASURES

Structure of strategic and organisational management, and barriers to the leadership and management of quality improvement in general practice.

RESULTS

Seven barriers were identified: absence of an explicit strategic plan for general practice, competing priorities for attention of the health authority, sensitivity of health professionals, lack of information due to poor quality of clinical data, lack of authority to implement change, unclear roles and responsibilities of managers within the organisations, and isolation from other authorities or organisations facing similar challenges.

CONCLUSIONS

The health authorities faced significant barriers that would impede their ability to fulfil their responsibilities in the new NHS and that would reduce their capacity to contribute to quality improvements in general practice.

Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh

Two alternative service delivery strategies to improve the effectiveness and efficiency of the Bangladesh national Family Planning and Maternal and Child Health programme have been tested: (1) service delivery at cluster spots, a centrally located neighbourhood spot, rather than at the client's home, and (2) increased frequency of outreach clinics merged with immunization spots. The cost-effectiveness of these strategies was compared with baseline estimates of the cost of providing services. The data were collected in two rural sites of Bangladesh, Mirsarai Thana of Chittagong and Abhoynagar Thana of Jessore, in August 1996. The results of this analysis indicate that cluster service delivery of contraceptive services in their present form are not more cost-effective than home delivery services. The cost per birth averted was lower in only one out of three services in each of the field sites. When the cost-effectiveness of increasing the frequency of SCs combined with EPI services was examined, the service delivery was found to be more cost-effective for all services in one thana and for two out of three services in the higher performing thana, Abhoynagar. This implies that the provision of a wider range of services is improving overall cost-effectiveness.

Rural breast cancer treatment: evidence from the Reaching Communities for Cancer Care (REACH) project

BACKGROUND

Research shows that rural populations are more likely than their urban counterparts to be diagnosed with late-stage cancer, but less is known about appropriateness of cancer treatment in rural locations after diagnosis. The objective of this analysis was to assess the degree to which rural breast cancer treatment was received in concordance with national recommendations.

METHODS

Data came from 251 stage I and II breast cancer patients residing in rural North Carolina. State-of-the-art care was defined using the National Cancer Institute's (NCI) physician data query (PDQ) database, and cases were categorized into appropriate primary and/or adjuvant treatment. Chi-square and Fishers' exact tests were used to assess changes in appropriate treatment over time (1991-1996) and between stage. Multiple logistic regression was used to determine whether any patient or disease characteristics were associated with receipt of appropriate treatment.

RESULTS

Most (81-90%) of the breast cancer cases received the appropriate primary therapy (mastectomy or lumpectomy followed by radiation therapy); of these, the majority received a mastectomy (66-72%). Fewer women received adjuvant therapy as recommended (27-61%), although significantly more stage II than stage I cases did so (p < or = 0.05). Regression showed that stage and estrogen-receptor (ER) status were associated with appropriate therapy.

CONCLUSIONS

The findings suggest that there exist deviations from NCI established treatment recommendations among rural breast cancer patients. More research is needed to develop better methods for dissemination of state-of-the-art cancer information to rural physicians and patients, and to understand how treatment decisions are made.

Culturally sensitive research methods of surveying rural/frontier residents

This article describes adaptations to conventional survey research methods based on knowledge of and respect for characteristics and qualities of rural communities and rural culture. These culturally sensitive methods may have contributed to a high response rate in a population-based study of frontier residents conducted in one western state in the United States. Through these methods, residents' interests in the study was heightened and the study's visibility was increased. Adaptations were also necessary to compensate for shortcomings in the available sample frame for the rural population of interest. References on survey research by mail provide standards for generally accepted procedures but offer few guidelines for tailoring these approaches for varying cultures. Approaches based on the local culture of the persons to be surveyed can increase response rates as well as demonstrate respect for the culture of intended study participants.

Improving client outcomes through differentiated practice: a rural nursing center model

The TriCounty Community Health Center (the Center) was created in 1994 with federal grant monies to increase access and to provide outreach and primary health care services for rural residents. The Center employs a differentiated practice model of nursing care in which all nurses use the nursing process targeted to client systems that match the nurse's level of educational preparation and competence. The model allows nurses to intervene with various client systems, including the individual, family, aggregate, and community. Program outcomes for the Center suggest that using a differentiated nursing practice model for outreach and primary care services appears to have a positive impact on the health of individuals, families, and aggregates in rural settings, using the Omaha Classification System as a framework for evaluation.

Distance education and caregiver support groups: comparison of traditional and telephone groups

OBJECTIVE

To implement and evaluate the impact of telephone caregiver groups, compared with traditional face-to-face, on-site caregiver groups.

DESIGN

Quasi-experimental design comparing the two group types across time.

SETTING

An urban tertiary rehabilitation hospital with a brain injury program servicing a vast geographical area.

PARTICIPANTS

Caregivers of an adult person with a brain injury participated in either one of the 10 telephone groups (TGs) (N = 52 caregivers who completed a full set of research forms) or one of the 10 on-site groups (OGs) (N = 39 caregivers who completed a full set of research forms). The combined total from both groups was 91.

INTERVENTION

Caregivers who lived within 40 km of the facility were placed in one of the OGs, and all others were placed in one of the TGs. Both types of groups met weekly for 9 to 10 weeks and were led by either social work or psychology professionals. The TGs met using teleconference technology.

MAIN OUTCOME MEASURES

Profile of Moods States (POMS), Caregiver Burden Inventory (CBI), and the McMaster Model Family Assessment Devise (FAD), were administered 2 months before the first day of group, on the first day of group, on the last day of group, and 6 months after group. On the last day of group, a participant satisfaction survey was administered.

RESULTS

There were similar amounts of improvements for the outcomes from OGs and TGs. Rural caregivers had fewer difficulties on all measures at all measurement intervals. In both types of group, participants showed a statistically significant improvement in POMS scores and a trend toward improvement in FAD and CBI results. Participants of both group types rated their experience highly, although rural caregivers were somewhat more satisfied.

CONCLUSIONS

Telephone groups offer a method of providing support and education to rural caregivers that is as effective as traditional in-person OGs.

Universal precautions compliance and exposure frequency to patient body fluids in nurses employed by urban and rural health care agencies

Previous studies have suggested that health care workers may differ with respect to universal precautions knowledge, compliance, practice setting barriers, or exposure to patient body fluids in rural and urban areas. The purpose of this study was to determine whether or not there are rural/urban differences in the degree of precaution taken by health care workers to prevent the spread of blood borne pathogens, specifically human immunodeficiency virus (HIV) and hepatitis B virus (HBV). A random sample of rural and urban registered and licensed practical nurses in Tennessee was surveyed. The respondents completed two instruments that assessed self-reported universal precautions knowledge, precautions, and practice barriers. No measurable differences in universal precautions knowledge, compliance, or barrier scores between the two groups were found; yet rural nurses were 2.7 times as likely to be exposed to patient body fluids than urban nurses (P < 0.005). The conclusion was that rural nurses were as experienced and as knowledgeable about universal precaution techniques as their urban peers, but their knowledge was not translated into practice to the same degree. Two possible explanations offered are (1) rural nurses are more likely to be acquainted with, and thus trusting of, their patients, and (2) the lower seroprevalence of human immunodefiency virus and hepatitis B virus in rural areas may lead to complacency.

Rural emergency medical services: patients, destinations, times, and services

This study sought to describe the volume of use, mix of patients, origin and destination of runs, times and distances to care, and the volume of clinical services provided in a rural emergency medical services region. This study summarizes all 6,080 rural emergency ambulance trip reports filed from April through September 1991 from the 12 rural counties surrounding Augusta, GA. Rural ambulances are regularly used and are used extensively by elderly populations. The pattern of services provided suggests that while advanced care may or may not have been indicated, it was rarely provided and that rural emergency medical service programs should consider a greater reliance on basic life support teams.

The role of the College of Medicine of South Africa Diploma in Anaesthesia in southern Africa

OBJECTIVE

To determine the role that the College of Medicine Diploma in Anaesthesia (DA) plays in health services in southern Africa.

DESIGN

A postal questionnaire. MAIN INFORMATION SOUGHT: Reasons for doing the DA, percentage of diplomates still actively involved in anaesthesia, career pathways of diplomates, perceived value of the DA, geography and type of anaesthetic practice of diplomates, and participation in continuing medical education.

SUBJECTS

The 1,096 candidates who passed the DA between 1974 and 1993.

METHODS

Questionnaires were sent to all 861 diplomates with known addresses.

RESULTS

The response rate was 62.1% (535/861). Over 70% of diplomates are still actively involved in anaesthesia. Approximately one-third of all diplomates specialize in anaesthesia. The majority of GP anaesthetists with the DA have trained in anaesthesia for more than 1 year. Thirty-three per cent of GP anaesthetists work in small towns or rural areas. Nearly 20% of GP anaesthetists spend more than 75% of their time in anaesthetic practice. Twenty-eight diplomates are working in southern African countries outside South Africa. The DA is perceived to have been of value by the majority of specialist and non-specialist diplomates.

CONCLUSIONS

Diplomates are playing a valuable role in anaesthesia throughout the southern African region.

Frontier ethics: mental health care needs and ethical dilemmas in rural communities

Roughly 15 million of the 62 million rural U.S. residents struggle with mental illness and substance abuse. These rural dwellers have significant health care needs but commonly experience obstacles to obtaining adequate psychiatric services. Important but little-recognized ethical dilemmas also affect rural mental health care delivery. Six attributes of isolated settings with limited resources appear to intensify these ethical dilemmas: overlapping relationships, conflicting roles, and altered therapeutic boundaries between caregivers, patients, and families; challenges in preserving patient confidentiality; heightened cultural dimensions of mental health care; "generalist" care and multidisciplinary team issues; limited resources for consultation about clinical ethics; and greater stresses experienced by rural caregivers. The authors describe these features of rural mental health care and provide vignettes illustrating dilemmas encountered in the predominantly rural and frontier states of Alaska and New Mexico. They also outline constructive approaches to rural ethical dilemmas in mental health care.

Management of reproductive tract infections in rural Bangladesh

This study was undertaken to identify existing reproductive tract infection (RTI) treatment practices of the government family planning (FP) paramedics in rural Bangladesh. It also assessed the knowledge and perceptions of the clients about RTIs as well as the service-seeking behaviour of the clients and their husbands. Data on paramedic treatment practices were collected by observing paramedic-client interactions at the family welfare centres (FWCs) and satellite clinics (SCs). One hundred clients seeking RTI treatment were observed. The same clients were interviewed at departure from the health-care facility to assess their knowledge and perceptions about RTIs as well as service-seeking behaviour of the clients and their husbands. Twenty-four village practitioners were also interviewed to assess their knowledge on the subject. Results of the study showed that in the treatment of RTI, paramedics of government FP services commonly: (i) did not do a physical examination, (ii) used a substandard dosage of drugs, and (iii) made no attempt to notify or treat male partners. Thirty-one of the 97 clients reported that their husbands had some kind of genital problem. It was revealed from the study that as an alternative to the government FP services, the clients and their husbands often seek RTI treatment from the village practitioners though the village practitioners' knowledge concerning RTI is poor. Based on the findings of this study, it is recommended that the knowledge and skills of the paramedics and village practitioners for RTI treatment be strengthened. Prevention of RTI through awareness campaigns is essential for the control of RTIs, and especially of STDs.

Rural women's satisfaction and stress as family health care gatekeepers

Women shoulder much of the responsibility for their families' health care, making women's satisfaction with available services an important issue for their families and for women's personal stress levels. Lack of services and resulting stress may be acute for rural women, the focus of this study. In a state-wide survey, fewer than one-half of rural women were satisfied with the health services available; dissatisfaction was a strong determinant of women's stress over health care issues. Rural women are at risk for a pile-up of stressors that could impede their ability to care for themselves and their families.

Behavior changes among crack-using rural and urban women

This study compared rural and urban crack-using women and examined their responses to two interventions. A prospective cohort study design was employed to assess the effectiveness of standard and innovative HIV prevention interventions on 541 urban and 268 rural women in Florida. Generalized estimating equation analysis, accounting for repeated measures, found that for combined urban and rural samples, the innovative intervention was more effective than the standard for a number of drug and sexual risk behaviors. However, the analysis indicated no significant differences in intervention efficacy between rural and urban women. The results imply that there is a need for similar HIV prevention services in both areas.

[Community emergency medical service. Epidemiology and quality of treatment in a rural district]

OBJECTIVES

Rapid aid provided by lay witnesses and emergency services can improve the outcome in medical emergencies arising in the community. We attempted to study the quality of first aid rendered by lay persons, paramedical personnel, and community medical practitioners attending out-of-hospital emergencies. We also evaluated the frequency of first aid provided before the arrival of specialised emergency physicians.

METHODS

Over a period of six months all emergencies in a rural district of Germany leading to the pre-hospital medical service being dispatched were studied. Specialised community emergency physicians arriving at the site of the event recorded demographic, clinical, and process data using a standardised instrument. They also assessed the performance of lay persons, paramedical personnel, and community physicians providing immediate care. Implicit and explicit criteria were used.

RESULTS

In 97% of cases analysed (n = 1150) members of the above mentioned groups were present before the arrival of the dedicated medical service. Lay persons were judged to provide inadequate care especially with regard to airway management and immobilisation of suspected fractures. For paramedical personnel, the administration of medication, venous lines and immobilisation turned out to be problematic areas. Medical practitioners fell below the defined standards especially in airway management, immobilisation and venous lines.

CONCLUSION

Our project has shown how important the evaluated groups are for community emergency care. Despite methodological problems in this area of study, the shortcomings demonstrated may be targeted by future training at different levels.

Ultrasound-guided fine needle aspiration cytology of impalpable breast lesions in a rural setting. Comparison of cytology with imaging and final outcome

OBJECTIVE

To analyze the effectiveness of fine needle aspiration (FNA) cytology in a multidisciplinary setting in rural Australia and to compare the imaging (mammographic and ultrasound) appearances and cytomorphologic findings with the final outcome.

STUDY DESIGN

Prospective analysis of ultrasound-guided FNA cytology results from 426 women, aged 40-86 years, with screening-detected mammographic abnormalities. Cases of microcalcification, assessed mainly by stereotactatic core biopsy, were not included in the study. The FNAs were performed at a rural breast screening and assessment program in New South Wales, Australia, over a three-year period between May 1993 and May 1996.

RESULTS

Imaging, FNA and combined imaging and FNA results from 426 women were as follows. The imaging diagnoses included 176 (41%) benign, 34 (8%) probably benign, 17 (4%) equivocal, 104 (24%) suspicious and 95 (23%) malignant cases. The FNA findings showed 59 (14%) no epithelial cells seen (nondiagnostic), 175 (41%) benign, 36 (8%) atypical, 41 (10%) suspicious and 115 (27%) malignant. Combined imaging and cytologic results comprised 224 (52.6%) benign, 10 (2.3%) atypical/equivocal, 59 (13.9%) suspicious and 133 (31.2%) malignant cases. All the malignant cases, by combined assessment, had malignant histology, and all the benign cases behaved in a benign fashion. In 80% of the suspicious lesions, the histologic diagnosis was malignant, but only 10% of the atypical/equivocal lesions had malignant histology. The positive predictive value of diagnosis of malignancy by combined imaging and FNA was 100%, and the false negative rate was 0%.

CONCLUSION

Despite the recent surge in the popularity of core biopsy, FNA cytology of impalpable, mammographically detected lesions, when practiced in a multidisciplinary setting, is an extremely accurate test with high sensitivity, specificity, predictive values and efficacy. FNA cytology of the breast is a well-tolerated, relatively noninvasive test with a very low risk of complications. The sensitivity and positive predictive values for malignant and suspicious mammographic categories are also very high.

The rural health care workforce implications of practice guideline implementation

BACKGROUND

Rural health care workforce forecasting has not included adjustments for predictable changes in practice patterns, such as the introduction of practice guidelines.

PURPOSE

To estimate the impact of a practice guideline for a single health condition on the needs of a rural health professional workforce.

METHODS

The current care of a cohort of rural Medicare recipients with diabetes mellitus was compared with the care recommended by a diabetes practice guideline. The additional tests and visits that were needed to comply with the guideline were translated into additional hours of physician services and total physician full-time equivalents.

RESULTS

The implementation of a practice guideline for Medicare recipients with diabetes in rural Minnesota would require over 30,000 additional hours of primary care physician services and over 5,000 additional hours of eye care professionals' time per year. This additional need represents a 1.3% to 2.4% increase in the number of primary care physicians and a 1.0% to 6.6% increase in the number of eye-care clinicians in a state in which the rural medical provider to population ratios already meet some recommended workforce projections.

CONCLUSIONS

The implementation of practice guidelines could result in an increased need for rural health care physicians or other providers. That increase, caused by guideline implementation, should be accounted for in future rural health care workforce predictions.

Determinants of attendance and patient satisfaction at eye clinics in south-western Uganda

PURPOSE

To identify the reasons for subjects deciding to attend or not attend local and referral ophthalmology clinics in south-west Uganda, and to establish the levels of satisfaction of clinic attenders with the services they received.

METHODS

A population survey identified subjects with ocular conditions who were referred to the local clinic or the district hospital. All non-attenders and a group of attenders were interviewed at home.

RESULTS

31% of those referred did not attend the local clinic. The most common reasons were 'too busy' (29%) or 'unwilling to buy spectacles' (17%). Less than half of attenders were satisfied, mainly because of no perceived clinical improvement or having to buy spectacles. Only 13% of those referred to the district hospital clinic attended. The main reasons for non-attendance were high transport cost and fear of the clinic.

CONCLUSION

Attendance and satisfaction with the community ophthalmology service could be improved by more intensive motivation and explanation for patients, and assistance with spectacle and transport costs. The use of aphakic motivators should be tested in this context.

Quality, accessibility, and contraceptive use in rural Tanzania

We examine how informants' reports on community perceptions of the quality and accessibility of family planning facilities relate to the use of modern contraceptives by individuals in rural Tanzania. Using information on individual-level contraceptive use in conjunction with community-level information on the accessibility and quality of family planning facilities, we employ two distinct statistical procedures to illustrate the impacts of accessibility and quality on contraceptive use. Both procedures treat the community-level variables as imperfect indicators of characteristics of the facilities, and they yield nearly identical implications. We find that a community-level, subjective perception of a family planning facility's quality has a significant impact on community members' contraceptive use whereas other community measures such as time, distance, and subjective perception of accessibility have trivial and insignificant direct impacts, net of the control variables. Future research that uncovers the determinants of perceptions of both community-level and individual-level quality could provide key insights for developing effective and efficient family planning programs.

Obstetric outcomes in an aboriginal community: a comparison with the surrounding rural area

Antenatal, intranatal and postnatal features of all Aboriginal women who lived at Cherbourg Aboriginal Community and delivered during 1990, 1991 and 1992 were compared with all non-Aboriginal women in the same rural area who delivered at Kingaroy Base Hospital during 1991. Almost all the Aboriginal women also delivered at Kingaroy. The data for 146 Aboriginal and 139 non-Aboriginal women were taken from the hospital records. The Aboriginal women were generally younger at delivery (Aboriginal 35% younger than 20 years vs non-Aboriginal 12%), made their first antenatal visit later (Aboriginal 49% after 20 weeks vs non-Aboriginal 10%) and made fewer antenatal visits (Aboriginal 43% < 4 visits vs non-Aboriginal 2% < 4 visits). They were more likely to be anaemic (Aboriginal 65% < 110 g/L vs non-Aboriginal 13% < 110 g/L), have a sexually transmitted disease (STD; Aboriginal 13% vs non-Aboriginal 2%) and drink alcohol (Aboriginal 54% vs non-Aboriginal 32%). After making an allowance for repeat Caesarean sections, there was no significant difference in the proportion of abnormal deliveries, but birthweights of Aboriginal infants were lower. Postnatally, the only significant difference between the two groups was a lower incidence of jaundice in Aboriginal infants. Multifactorial analysis showed that birthweights were significantly decreased by primagravidy, alcohol intake and STD. It is likely that the effects of STD and alcohol on birthweight were due to associated lifestyle factors. When these factors were allowed for, ethnic background had no significant effect on birthweight.

Rural versus urban home health: does locale influence OASIS outcomes?

As home health administrators select performance evaluation systems to meet the benchmark requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a frequently asked question is: Does rural versus urban locale influence patient outcomes? To answer the question, patient outcome data were collected from rural and urban home health agencies. Data analysis showed better outcomes for rural than for urban patients. Locale predicted less than 1% percent of the variance in each of the five outcomes studied. Factors that could account for rural-urban outcome differences were suggested.

Quality assessment of the primary health care services provided for ARI control in Alexandria

The aim of the present study was to assess the quality of services provided for acute respiratory infections (ARI) control in Alexandria after about five years of its integration into primary health care (PHC). The ARI training coverage of actively practicing physicians was only 35% and of nurses 37.5%, due to inappropriate allocation of trained human resources. The knowledge of trained PHC physicians was slightly better than that of untrained staff and both were unsatisfactory. The main deficiency was in detecting the dangerous signs and in classifying "cough or difficult breathing", which resulted in missing all cases of "severe pneumonia" and "very severe disease" needing referral to higher levels, in order to reduce the ARI specific mortality rates. The rate of oral antibiotic abuse reached about 55%, which was much higher than that found in the ARI annual report 1997 and is more likely to be the true figure. On the other hand, long acting penicillin was underutilized, due to fear of its allergic reaction and oral antibiotics were used instead of it. Therefore, the later were unavailable at the PHC facilities for about 7 months, mainly during winter and spring time.

The cost of home-based care for HIV/AIDS patients in Zimbabwe

From a study on the cost and quality of community home-based care (CHBC) for HIV/AIDS patients in Zimbabwe, programme and household costs were estimated. Interviews, using a structured questionnaire, were held with 60 patients and caregivers sampled from six types of established CHBC schemes. Detailed cost information was collected from four home care programmes, two urban and two rural. The cost of a home visit in the two urban programmes studied was estimated to be Z$129 (US$16) in one, and Z$183 (US$23) in the other. In one of the two rural schemes, the cost of a home visit was Z$313 (US$38), in the other this was Z$343 (US$42). A large proportion of these costs were not of direct benefit to the patients, as approximately 56-75% of the total cost per home visit was spent getting to the patient. The costs of a home visit in a rural home-based care programme corresponded to the costs of 2.7 inpatient days in a district hospital. The family cost of caring for a bedridden AIDS patient over a three-month period was estimated to be between Z$556-841. Caregivers spent as much as 2.5-3.5 hours a day on routine patient care. The programme costs are high, and schemes do not generally assess effectiveness, nor cost-effectiveness. The high cost of home visits leads to less frequent visits, leaving a larger part of both the burden and the cost of care to the families and the patients.

Lead, follow, then step aside. Partners for health in rural northern Michigan

In communities all across America, there is a new appreciation for the powerful influence of society on the health and well-being of individuals and populations. Concurrent to this growing belief that good health is made up of more than more absence of illness is the certainty that more and more, the traditional health care model has less and less to do with real health in a community.

Population-based study of the adequacy of well-child care services: a rural county's report card

OBJECTIVE

To determine the adequacy of well-child care services using a population-based study.

DESIGN

The medical records of all county providers and the immunization records at the local health department were reviewed. A county birth cohort, identified using electronic birth certificates, was compared with those who migrated into the area (hereafter, in-migrants).

SETTING

All primary care sites (private, network, etc) in a rural county.

PATIENTS

Two-year-old children born between May 31, 1993, and May 30, 1994.

MAIN OUTCOME MEASURES

Immunization rates and preventive screenings.

RESULTS

A total of 674 medical records were reviewed. Of these, 377 (56%) belonged to a county birth cohort and 297 (44%) were in-migrants. Medical records of 64% of the birth cohort were reviewed. Among all 2-year-olds, 80% received 4 doses of diphtheria and tetanus toxoids and pertussis vaccine; 89%, 3 doses of Haemophilus influenzae type b (Hib); 75%, 4 doses of Hib; 77%, 3 doses of hepatitis B vaccine; 85%, measles-mumps-rubella vaccine; 85%, 3 doses of oral poliovirus vaccine; 17%, varicella live virus vaccine (Varivax). The 4:3:1 rate was 75% at age 2 years. Sixty-eight percent had had 1 hematocrit, 74% had 1 lead screening test, and 43% had 2 lead screening tests. A total of 64% had had 6 well-child visits and 30% had had 9. The mean number of weights and heights measured was 4.8 and 4.5, respectively, at age 1 year and 7.3 and 6.8, respectively, at age 2 years. The birth cohort had notably higher rates of documented immunization and preventive screening than in-migrants.

CONCLUSIONS

This study demonstrated immunization coverage at or below the national average, and well-child care service provisions below American Academy of Pediatrics standards at a county level. This study enabled individual primary care sites to assess their well-child care provision and provided a useful baseline for targeting the improvement of well-child care services in the county.

Educational outreach to mammography facility staff to assist with compliance with the Mammography Quality Standards Act in rural North Carolina

RATIONALE AND OBJECTIVES

The purpose of this project was to develop and evaluate an educational program targeted at mammography facilities in rural areas of North Carolina that were having difficulty complying with the 1992 Mammography Quality Standards Act (MQSA).

MATERIALS AND METHODS

Fourteen facilities deemed at risk for closure under MQSA were identified by state inspection personnel. Problems at the facilities were evaluated by a radiologist, a physicist-educator, and a radiation physicist through a written survey, review of phantom and clinical images, and a site visit. Individual advice and instruction were provided on-site by the physicist-educator, with written materials provided in follow-up. A repeat site visit was made 4-6 months after the initial visit.

RESULTS

Of 51 problems identified at the 12 institutions that completed the program, 35 (69%) were corrected. All facilities that had failing phantom scores at the inspection prior to the intervention had passing scores at the inspection after the intervention. There was a statistically significant increase in the sum of the phantom scores for the facilities offered this intervention compared with those not offered it (P = .03).

CONCLUSION

This educational program improved mammography quality at participating facilities.

Prehospital oral endotracheal intubation by rural basic emergency medical technicians

STUDY OBJECTIVE

To determine whether basic emergency medical technicians (EMT-B) can perform prehospital oral endotracheal intubation with success rates comparable to those of paramedics.

METHODS

This was a nonrandomized, controlled trial using historical controls. Seven basic life support emergency medical services systems in six counties and their corresponding emergency departments in rural Indiana participated. Eighty-seven full-time EMTs with no prior or concurrent paramedic training volunteered for intubation training. Apneic prehospital patients aged 16 years or older without an active gag reflex or massive facial trauma were eligible for intubation and study enrollment. The EMTs completed a 9-hour didactic and airway manikin training course in direct laryngoscopic endotracheal intubation. The course was adapted from the national paramedic curriculum.

RESULTS

Thirty-four (39%) of the EMT-Bs attempted to intubate 57 eligible patients. In 49.1% of these patients, successful endotracheal tube placement was confirmed by the receiving physician (95% confidence interval, 36.4% to 61.9%); in contrast, the prehospital intubation success rates from three previous studies of manikin-trained paramedics ranged from 76.9% to 90.6% (P < .001). Complications included five (9%) inadvertent extubations, two endotracheal tube cuff ruptures, two prolonged intubation attempts, and one mainstem bronchus intubation. There were no unrecognized esophageal intubations. Two of the seven EMS agencies did not report any intubation data.

CONCLUSION

Rural EMTs with didactic and airway manikin training failed to achieve prehospital intubation success rates comparable to those of paramedic controls. Possible explanations include training deficiencies, poor skill transference from manikin to human intubation, infrequent intubation experiences, and inconsistent supervision.

Impact of Medicaid managed mental health care on delivery of services in a rural state: an AMI perspective

In March 1995 Iowa implemented a statewide mental health carve-out program under a Medicaid Section 1915b waiver. A goal was to provide equal access across counties for Medicaid recipients by introducing a statewide network of service providers. Problems have included the contractor's authorizing only services considered medically necessary for persons with serious mental illness, who also need community supports; contractor staff's lack of knowledge about regional resources and the limited availability of community-based services in most rural areas; clients' difficulty in gaining access to the new system; denial of inpatient hospitalization; untimely provider payments; and lack of education for providers, consumers, and families.

Quality differences between rural and urban primary care: the case of a cervical cancer screening programme

OBJECTIVE

To measure the difference between rural and urban primary care quality in terms of an early cervical cancer detection programme.

LOCATIONS

Seven hundred and fifty smear reports from rural primary care units and 750 from urban primary care units were selected at random from three institutions: the Ministry of Health, the largest Mexican social security institution, and one University Hospital, during August 1995-March 1996. Excluded were reports from women who were pregnant, menopausal or those who had undergone hysterectomy, as well as those tested positive for dysplasia and cancer.

ACTIVITIES

Quality was measured through indicators and standards set by consensus of recognized field experts, based mainly on recommended national and international parameters.

RESULTS

There was no difference between the overall quality of the urban and rural units. Both registered fairly satisfactory levels (achievement: 76.2%; 95% CI: 72.7-77.0%, versus 75.2; 95% CI: 69.8-78.9%, respectively). The quality of the smear sampling was highly unsatisfactory in rural units and unsatisfactory in urban units (achievement: 64.2%; 95% CI: 58.2-70.0%, versus 47.3%, 95% CI: 42-52.7%; P < 0.00001). Quality of coverage was unsatisfactory for both regions. Quality of smear processing and timeliness were highly satisfactory for both rural and urban units.

RECOMMENDATIONS

Efforts should be directed toward smear quality improvement, especially in rural units. Health care workers who take smears need training programmes and better instruments. They should receive feedback on smear adequacy from the laboratory. Health education is necessary to improve utilization and programme coverage quality.

Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso

After implementation of a nation-wide essential drug programme in Burkina Faso a prospective study was undertaken consisting of non-participant observation in the health centre and in the village pharmacy, and of household interviews with the patients. The study covered all general consultations in nine health centres in three districts over a two-week period as well as all client-vendor contacts in the corresponding village pharmacies; comprising 313 patients in consultations and 498 clients in eight village pharmacies with 12 vendors involved in dispensing 908 drugs. Additionally patients were interviewed in their households. Performance and utilization of the village pharmacy: 82.0% of the drugs prescribed in the health centres were actually dispensed at the village pharmacy, 5.9% of the drugs were not available at the village pharmacy. Wrong drugs were dispensed in 2.1% of cases. 41.3% of the drugs dispensed in the village pharmacy were bought without a prescription. Differences are seen between the district and are put in relation to different onset of the essential drug programme. Patient compliance: Patients could recall the correct dosage for 68.3% of the drugs. Drug taking compliance was 63.1%, derived from the pills remaining in the households. 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The study demonstrates the success of the essential drug programme not only in performance but also in acceptability and utilization by the population.

Satisfaction with outpatient health care services in Manica Province, Mozambique

The objective of the study was to describe ambulatory health care services, determine the level of client satisfaction, and identify obstacles to care in a rural area of Mozambique. Exit surveys at 34 health clinics in Manica Province were completed on a sample of 879 adults representing between 1% and 2% of the average monthly visit totals at each clinic. Eighty-three per cent of interviewees were women. Just over half of the visits were for paediatric patients. Men were more likely to be at the clinic for their own health care needs than women (81% vs. 40%, p < 0.001). Of patients seen for acute illness, 45% were examined, 22% received preventive education, and 23% received prognostic information. Overall, 55% of interviewees believed that the service they received was good or very good, 32% rated it as fair, and 13% as poor. Satisfaction was positively associated with increased training level of the provider (p < 0.005), and shorter waiting times (p < 0.001). The most common complaints about the clinic visits were lack of adequate transportation, long waiting times, lack of physical examinations, and failure to receive prescribed medications. These findings suggest that the majority of Mozambicans interviewed are moderately satisfied with the available outpatient services in Manica. Provider training, provider availability and distribution of medicines were areas identified by respondents as needing improvement.

Evidence-based practice and rural nursing: a literature review

This literature review is an exploration of issues related to evidence-based practice and rural nursing. Given the contribution that nursing research can make to improved client care in rural areas, it is important that nurses' awareness and understanding of evidence-based practice be enhanced, and that strategies for fostering the development of clinically relevant programs of nursing research be identified for rural health services. The review highlights the deficiencies in the current metropolitan-based approaches to evidence-based practice that may disadvantage rural clients and nursing practitioners, because they do not accommodate the inherent differences in rural and metropolitan healthcare cultures. It emphasises the need to seek approaches to research-based practice that arise from the specific needs of the rural setting.