Quality and costs of family planning as elicited by an adolescent mystery client trial in Nigeria

Results are presented from a rural reproductive health project in Delta State of Nigeria. A baseline survey of Family Planning clients revealed that only 2 percent of adolescents were utilising the services. Therefore four adolescents, two males and two females posing as two couples, were used as mystery clients to assess providers response to adolescents, as well as the adolescent perspectives on the quality and costs of the family planning services in the clinics they visited. This was complemented with a participatory rural appraisal of the communities. The adolescent mystery clients reported that some providers were surprised to see them, were judgemental, and engaged them in religious counselling. The adolescents found the services unsatisfactory, but the costs were affordable. In the participatory rural appraisal, the communities found the cost of contraceptives affordable despite a recent price increase of 20-150% across the different contraceptives. Emerging practices that were detrimental to adolescent reproductive health were also discovered and innovative approaches for promoting access to reproductive health information by out-of-school adolescents through the use of artisan trade associations and home videos are suggested.

A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

OBJECTIVE

To qualitatively assess the referral system at district level from the consumers' point of view and assess implications it had on efficiency and effectiveness of service delivery.

DESIGN

Descriptive study.

SETTING

Districts of Tsholotsho and Murewa.

SUBJECTS

Subjects of the study included community members, ward health team members outpatient department (OPD).

MAIN OUTCOME MEASURES

The nature and magnitude of the problem; health seeking behaviour; the perceived role of a hospital versus a health centre; knowledge on the referral system; user fees and the referral system and communication between the service and the community; and perceptions on the referral system.

RESULTS

The community does not know the functional differences between a hospital and a clinic. What is clearly known is the physical differences that exist between the two. That is one of the reasons why the choice of a point of entry into the health care delivery system is not always correct. People do understand the mechanics of referring a patient to higher levels of care but they were not happy with the high hospital charges. Although the majority are eligible for free treatment the issues of high transport and other indirect costs were mentioned. There is no effective communication system between the service and the users. This manifested itself through the lack of knowledge or the existence and role of ward health teams or clinic committees. This lack of communication seems to be a major determinant in the failures of many a good policy. The impact of the new fee structure of January 1994 was minimal at district level because the communities felt that although referred patients do not pay hospital consultation fees, once admitted the patient still has to pay or at least prove that he/she is eligible for free services. The inconvenience of proving eligibility for free care still exists.

CONCLUSION

In general, the community did not fully comprehend the purposes and intentions of the new user fees policy of January 1994 which was meant to rationalise the referral system. Generally, communities are seldom consulted in time to ensure effective policy implementation and realisation of the intended impact. Impressions generated on the impact of the problem of the referral system on resource use at hospital level show that it has been considerable, although this study did not quantify it. Unnecessary overloading of referral centres negatively affected the care of referral cases, which actually required hospital care, due to competition with primary care cases.

Change in cardiovascular risk factors during a 10-year community intervention program

The study describes changes in cardiovascular risk factors during 10 years of a community intervention program conducted in a rural area in Central Italy. Two areas were involved, one for treatment and one for reference. In 1983-84, 739 men and 859 women in the treatment area and 942 men and 1045 women in the control area, aged 20-69 years, were screened; total and HDL cholesterol, systolic and diastolic blood pressure, fasting blood glucose, smoking habit, weight and height were measured. Between 1983 and 1993 several intervention activities based on community medicine were carried out in the treatment area. They were based on interaction with the local socio-sanitary institutions and school system in order to influence individual persons, small groups and entire community. Major effort was addressed to mass health education, nutrition education, antismoking-propaganda and detection and treatment of hypertension, diabetes and hyperlipidemia.

A 10-year experience in the use of air medical transport for medical scene calls

OBJECTIVE

The objective of this retrospective descriptive study was to evaluate the use of air medical services in response to medical scene calls for transport to tertiary care in the rural setting.

METHODS

This study is a retrospective descriptive review of all medical scene calls during a 10-year study period. The cases were analyzed for demographics, transport time, medical indication, procedures, role of ground EMS services, effects on community hospitals, and patient outcomes. A case-by-case review by emergency medicine (EM) physicians was conducted to determine necessity of air medical transport.

RESULTS

A total of 8106 medical flights were conducted during the study period. Of these, 103 were scene calls for which 85 charts were available for review. The breakdown of medical scene calls is cardiac (29%), poisoning (17%), co poisoning (11%), neurologic (11%), and other (32%). Ground EMS was involved in 80% of the cases; ground advanced life support (ALS) was present in 58%. In 86% of the flights reviewed, an EM resident was aboard the helicopter. Of the 85 patients whose charts were available, 41 required admission to the ICU, five required hyperbaric oxygen (HBO) treatment, and 14 died before admission.

CONCLUSION

Evacuation of the rural patient with a medical emergency accounts for an extremely small percentage of an air medical service's use. ALS services, including emergency procedures at the scene and rapid transport to a tertiary care, were provided. Seventy-one percent of the flights reviewed required transport to a tertiary care facility, indicating that air medical transport was appropriate. Physician guidelines to ensure effective and cost-efficient use of these services should be developed. Responding for victims in cardiopulmonary arrest appears to provide little benefit with respect to outcome.

Status of total quality management in Australian public health organisations

Research suggests that there is some confusion among quality improvement managers about the differences between quality management and traditional quality assurance. This lack of understanding would appear to be the same among rural and urban health staff, although there is a higher percentage of staff engaged in multidisciplinary activities in the rural health services. Education of staff and commitment from top management would seem to be the factors inhibiting the health industry from incorporating quality management into their cultures.

Health human resource development in rural China

China has made significant progress in increasing the quantity of health workers in rural areas. Attention is shifting to improving the quality of health workers. This article documents several features of health workers in rural China. Many have not received formal training to a level implied by their rank and title, and there is no clear relationship between the skills of health workers and the functions they perform. Many better-qualified personnel have left lower level health facilities for more attractive employment in higher level and urban facilities. A system of professional licensing is currently being considered that will link educational requirements to employment and promotion. This article outlines some of the issues that should be taken into consideration in formulating this system. In particular, licensing may have unequal impacts on rich and poorer areas. This article argues that other regulatory measures will be necessary if licensing is to be an effective mechanism for controlling the quality of health workers, and contribute to the provision of affordable health services in both rich and poor areas.

[An ambulatory service staffed with military physicians in a rural district. Experiences from a period of 6 years]

A local rendez-vous arrangement is described retrospectively in which the medical officer on duty at the infirmary, Oksbøl military camp participated in the ambulance service and the prehospital treatment of acutely ill patients. The military ambulance supports the civilian ambulance service in the municipality of Blåvandshuk, Western Jutland. This arrangement was carried out in 430 cases and 399 patients were brought to hospital. More than 14% of the services did not result in transportation. Forty-seven percent of the services were due to accidents and 30% to illness. In 16% of all cases the response-time was less than five minutes. All the patients were classified according to the Oksbøl-score. Injuries were diagnosed in 48% and cardiovascular disease in 19%. Sixty-seven percent were treated immediately by the military ambulance. This arrangement has improved the prehospital treatment of acutely ill patients by using pre-existing resources from a military camp. We propose further cooperation between civilian health authorities and the Danish Armed Forces' Health Services when planning the prehospital services.

Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting

We evaluated blood pressure control, quality of life, quality of care, and satisfaction of patients who were monitored by specially trained community pharmacists in a group medical practice. After participating in an intensive skill development program, pharmacists performed in an interdisciplinary team in a rural clinic. The primary objective was assessed by evaluating outcome variables at 6 months compared with baseline in 25 patients randomly assigned to a study group. A control group of 26 patients was also evaluated to determine if outcome variables remained constant from baseline to 6 months. Systolic blood pressure was reduced in the study group (151 mm Hg baseline, 140 mm Hg at 6 mo, p<0.001) and diastolic blood pressure was significantly lower at 2, 4, and 5 months compared with baseline. Ratings from a blinded peer review panel indicated significant improvement in the appropriateness of the blood pressure regimen, going from 8.7 +/- 4.7 to 10.9 +/- 4.5 in the study group (p<0.01), but they did not change in the control group. Several quality of life scores improved significantly in the study group after 6 months (p<0.05). These included physical functioning (61.6 vs 70.7), physical role limitations (56.8 vs 72.8), and bodily pain (60.0 vs 71.7) at baseline and 6 months, respectively. There were no significant changes in the control group. Patient satisfaction scores were consistently higher in the study group at the end of the study. Our results indicate that when community pharmacists in a clinic setting are trained and included as members of the primary care team, significant improvements in blood pressure control, quality of life, and patient satisfaction can be achieved.

Accuracy of rural EMS provider interpretation of three-lead ECG rhythm strips

OBJECTIVE

To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system.

METHODS

An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms.

RESULTS

The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmia and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree).

CONCLUSION

In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.

Trial of rural practice evaluation: mutual rotation by family physicians

OBJECTIVES

We aimed to investigate the usefulness of mutual rotation by family physicians in providing an evaluation of rural medical practices.

METHODS

Between June and October 1994, each of four family physicians rotated to the practices of the other three, where they worked as a transient locum for 4-5 days and evaluated each practice. They were field faculty physicians of the Department of Community and Family Medicine, Jichi Medical School, and based at general practices accredited for undergraduate and postgraduate training. Two school-based faculty physicians also participated in the study as spare members.

RESULTS

The rotation was conducted four times to complete the mutual rotation programme. There was some difference in evaluation among the practices, which indicated the characteristics of the practices. The evaluation accorded relatively well among the participants.

CONCLUSIONS

Mutual rotation by family physicians provides an objective and practicable evaluation of general practices and contribute to upholding their quality, which is crucial to medical education.

Acceptance, efficacy, and side effects of Norplant implants in four counties in north China

This report attempts to present a comprehensive analysis of the acceptability, side effects, and efficacy of Norplant as used in rural areas, based on a field experiment conducted in four counties in Hebei and Shandong Provinces, China. The initial acceptance of Norplant was relatively high but waned after the first year in three of the four counties. Compared with clinical trials, the current study shows a lower prevalence but similar patterns of side effects. The pregnancy rate during the first two years of use is similar to that found in large-scale clinical trials conducted in China, but discontinuation due to other reasons is lower. A three-level logistic regression analysis shows significant variation in the probability of discontinuation due to side effects across counties. It also indicates an increase in the conditional probability of discontinuation with the duration of use. Whereas introducing Norplant and achieving a very low failure rate and high continuation rate in rural areas is feasible under diverse socioeconomic conditions, the results vary significantly across different areas. Particular attention should be paid to the local factors that may affect results.

An obstetric and gynecologic clerkship's influence on a medical community. The Washington, Alaska, Montana, and Idaho Anchorage obstetric and gynecologic clerkship

OBJECTIVES

Our purpose was to explore the influences of an obstetric and gynecologic medical student clerkship on a remote medical community. Return of physicians to Alaska and faculty perceptions of their experience were central foci.

STUDY DESIGN

Data were obtained on former clerks to determine choice of specialty and location of practice. Data regarding all physicians new to Alaska was correlated with the University of Washington Medical School graduate data. Additionally, a questionnaire with a Likert-type scale evaluated the 10 clinical faculty members participating in the clerkship.

RESULTS

Between 1978 and 1991 we trained 266 clerks. A total of 77 of 374 (21%) new physicians in Alaska (1978 to 1991) were graduates of the University of Washington; 26 of those 77 (34%) were our former Anchorage obstetrics and gynecology clerks. The clinical faculty reported both positive and negative effects of their participation in the clerkship.

CONCLUSION

The desired benefit, the return of new physicians to Alaska, seemed supported. Questionnaire results hinted at additional benefits for the supervising faculty physicians in this isolated community. The formal affiliation effected by the clerkship seemed to have a positive impact on patient care, communication, consultation, and shared action among the participating physicians.

Reducing perinatal mortality in developing countries

The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR.

Evaluation of a model for improving emergency medical and trauma services for children in rural areas

STUDY OBJECTIVE

To evaluate the effectiveness of a rural emergency medical and trauma services project in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children.

METHODS

This prospective, quasi-experimental study used an untreated control group design with pretest and posttest of pre-hospital and hospital-based emergency care personnel in two rural counties in central Ohio. Project evaluation compared 50 emergency care providers from the intervention county with 43 emergency care providers from the control county. Changes in knowledge and confidence of these personnel in the assessment and management of pediatric emergencies were compared.

RESULTS

Providers in the intervention county demonstrated a significantly greater increase in test scores regarding knowledge of pediatric emergencies than did providers in the control county (P = .001). Significantly greater improvement was also seen when comparisons of test scores were made for field (P = .02) and hospital (P = .03) emergency care personnel separately. Self-reports on a visual analog scale indicated that providers in the project intervention county had a significantly greater decrease in anxiety than did control subjects when presented a scenario of a child experiencing a respiratory arrest (P = .01). On the basis of scores from a five-point Likert scale, emergency personnel in the intervention county had a greater increase in confidence regarding management of the pediatric airway (P = .0003) and a greater increase in the belief that they had adequate pediatric training (P = .000001) after participating in the project than emergency personnel in the control county.

CONCLUSION

The rural pediatric emergency medical and trauma services project was effective in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children. This project offers a model that can be replicated in other rural areas nationally.

Experiences and findings of a medical officer on Tristan da Cunha, February 1994-February 1995

DESIGN

A descriptive report on Tristan de Cunha, the most remote Inhabited island in the world, with emphasis on changes in health parameters since the eruption of the volcano in 1961 necessitated the evacuation of the entire island population to the UK.

RESULTS

Results of a retrospective 6-month consultation analysis are given as well as the results of screening programmes, particularly for risk factors for ischaemic heart disease.

FINDINGS

The high prevalence of asthma among the islanders, possibly the highest in the world, and the management thereof are described.

A pragmatic approach to educating rural health services on quality management

Despite the popularity of Total Quality Management (TQM) with its use of multidisciplinary process improvement teams, little appears to have been achieved in rural health services using this approach. Reviewing the literature suggests few publications. Even traditional Quality Assurance (QA) activities in many of the smaller rural health services are reasonably undeveloped. Against this backdrop, the Rural Health Education and Research Centre successfully marketed and ran several experiential TQM workshops for rural health workers across NSW, resulting in 60 TQM projects being successfully completed. The purpose of this paper is to present the model we use to enable more rural health workers to participate in and benefit from quality management.

An assessment of two upstate New York rural counties to determine unmet health needs of the Medicaid population

Despite an influx of new providers in the primary care arena, there remains a documented need in rural areas for additional services. Using Health People 2000 as an organizing framework, data from two upstate rural counties were analyzed to develop county profiles focusing on demographics, economics, morbidity, mortality, unemployment, and available health-related services. A survey based on these data was designed to examine reports of perceived health status and utilization of health care services. Results indicate a lack of providers and transportation, inaccessible office hours, unavailability of child/elder care, and excessive waiting time at the office or clinic as the greatest barriers perceived by rural Medicaid patients to receiving health care.

Professional perceptions of availability and quality of mental health services in Wisconsin

Eighty-six county coordinators and psychiatrists from predominantly rural counties reported their perceptions of availability and quality of 21 types of inpatient, outpatient, and transitional living services in Wisconsin for five target populations: adult, children, adolescent, geriatric, and minority. Their ratings and priorities for addressing needs indicated (a) that transitional living services are insufficient and of inadequate quality for all populations; (b) that availability and quality of inpatient and outpatient services are better for adults; (c) that general needs across all populations for additional and higher quality services are for services that address specialized problems, both inpatient and outpatient; (d) that children, adolescent, minority, and geriatric populations have limited access to needed services; (e) that available services for these four groups are most often inadequate; and (f) that the needs of children and adolescents should be given highest priority, particularly their needs for transitional services and inpatient and outpatient services for special problems. Actions and recommendations are discussed for professionals and advocates to increase awareness of needs for quality services for children and adolescents, for expanding public information, and for design of local-county quality programs, including professional education and continuing outreach to important constituencies and advocates.

Are rural family physicians comfortable performing cesarean sections?

BACKGROUND

Provision of obstetric care in the United States requires the capacity to perform cesarean sections. It is unknown who actually performs these procedures in rural hospitals and whether nonobstetricians feel comfortable performing cesarean sections.

METHODS

We conducted a telephone survey of the 41 rural hospitals in Washington State, asking about the obstetric services offered and the composition and obstetrical practices of physician staff. A supplementary questionnaire was sent to the 112 family physicians providing obstetric services in the subset of hospitals with 50 or fewer beds, asking whether they performed cesarean sections. Eighty-six responded, for a response rate of 75%.

RESULTS

Thirty-one (75%) of the rural hospitals provide obstetric services; of the 31 hospitals, 19 (61%) had no obstetricians on staff. In these hospitals the majority of physicians on staff both practice obstetrics and perform cesarean sections. Family physicians performed the majority of cesarean sections in all but the eight largest rural hospitals; even in these large hospitals (mean annual deliveries, 785), family physicians performed 28% of the cesarean sections. Most family physicians who performed cesarean sections felt very comfortable performing these operations. There was a strong association between the number of cesarean sections performed in formal residency training settings and the family physician's comfort level.

CONCLUSIONS

Cesarean sections remain an important service in those rural hospitals providing obstetric services. Most Washington State rural hospitals depend on family physicians for this operative intervention. Physicians' comfort in doing cesarean sections appears to be closely related to prior formal training during residency. This relationship suggests that training programs preparing future rural physicians need to ensure adequate training in this area for their residents.

Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.

The ethics of non-sexual dual relationships: a dilemma for the rural mental health professional

This paper reviews some of the issues that affect the rural mental health professional who wishes to maintain an ethical position with respect to non-sexual dual relationships. Although the ethical codes of professional regulating bodies provide general guidelines for professional conduct, they do not offer specific guidance for practical decision-making. Furthermore, there appear to be some contrasting opinions between the various ethical codes with respect to what would be considered unethical behavior in a non-sexual dual relationship. Alternative decision making models that may be of help to a rural practitioner for assessing the ethics of such a relationship are reviewed.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

PURPOSE

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress.

METHODS

Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay.

RESULTS

Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays.

CONCLUSIONS

Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

An inter district quality partnership: the experience of a large rural health service

Despite the proliferation of healthcare literature on the subject of quality programs, there is very little on the subject which considers it in a rural context. This paper is a case study outlining the efforts of six facilities within a large rural health service of South West NSW to establish a partnership in the planning, development and management of quality issues.

Patients' perception of public, voluntary and private dispensaries in rural areas of Tanzania

Eighty percent of rural dispensaries are run by the government and 19% by voluntary organisations that charge for some services. After the re-legalisation of the private health sector in 1991, private dispensaries are also emerging in villages. Privatisation is among the health reform policies of the country. Moreover, cost-sharing will be introduced at public dispensaries soon. Perception of 320 patients in the Coast Region of Tanzania on services delivered by the three health sectors has been investigated. Results show that patients are generally satisfied with the services and they would go back to the same dispensaries for treatment. Polydrug prescription was common in all sectors, while lack of prescribed drugs was a main complaint among public dispensaries patients. Voluntary dispensaries patients were less satisfied with long waiting time and with staff that did not give them enough information about the treatment. Currently, health service in public dispensaries is free but cost-sharing will be introduced soon. Most of voluntary and private dispensaries patients stated that the fees for service were moderate. The paper discusses the need for monitoring the implementation of cost sharing in public dispensaries to ensure equity in access to services by rural patients.

Pediatric prehospital care: epidemiology of use in a predominantly rural state

The objective of this study was to analyze, by retrospective review, the pediatric population utilizing emergency medical services (EMS) throughout Kentucky, with particular emphasis on differences between urban and rural areas. The source of the data used was from all prehospital runs in children less than 17 years of age reported in Kentucky in a computerized database to the state EMS branch. There were no interventions. We found that pediatric calls were more frequent in adolescents than younger children. Trauma was more frequent in older children and in rural settings and accounted for nearly 50% of all calls. Motor vehicle accidents were the most frequent cause of traumatic injuries. Run times were prolonged in the rural setting, but this was a reflection of transport rather than scene times. The use of basic life support (BLS) and advanced life support (ALS) procedures was dependent on the patient's age and the level of care of the provider. ALS procedures were infrequently performed, especially in younger patients, although the performance of these procedures did not prolong scene times. We conclude that educational initiatives for pediatric care in the prehospital setting should include assessment and stabilization of children, including appropriate procedures, both for ALS and BLS providers. Prehospital data should be linked with police reports and emergency department data to provide means of assessing the impact of prehospital services on outcome in pediatric patients.

Radiology services for remote communities: cost minimisation study of telemedicine

OBJECTIVES

To determine the social costs of providing a rural population with radiology services under three different systems: the existing system (a small x ray unit at the remote site and all other examinations at the nearest radiology department (the host site)); a teleradiology system (most examinations at the remote site and more advanced examinations at the host site); and all examinations at the host site.

DESIGN

Cost minimisation study.

SETTING

Primary health care in a remote community in Norway.

SUBJECTS

A randomly selected sample (n = 597) of all patients (n = 1793) having radiological examinations in 1993.

MAIN OUTCOME MEASURES

Annual direct medical costs, direct non-medical (travel) costs, and indirect costs (lost production) of the three options.

RESULTS

After exclusion of costs common to the three systems the direct medical, direct non-medical, and indirect costs of the three options were, respectively, 9000 pounds, 51,000 pounds, and 31,500 pounds (total 91,500 pounds) for the existing system; 108,000 pounds, 2,000 pounds, and 13,500 pounds (total 123,500 pounds) for the teleradiology option; and 0 pounds, 75,000 pounds, and 42,000 pounds (117,000 pounds in total) for the "all at host" option. Sensitivity analyses indicated that the existing system is the least costly option except when lost leisure is valued as highly as lost production.

CONCLUSION

The teleradiology option did not seem to be cost saving in the study community. Such systems, however, may be justified on the grounds of equity of access and quality of care.