Anticipated response to three common injuries by rural and remote area residents

Trauma patients who present in a delayed fashion: a unique and challenging population

BACKGROUND

A proportion of trauma patients present for evaluation in a delayed fashion after injury, likely due to a variety of medical and nonmedical reasons. There has been little investigation into the characteristics and outcomes of trauma patients who present delayed. We hypothesize that trauma patients who present in a delayed fashion are a unique population at risk of increased trauma-related complications.

MATERIALS AND METHODS

This was a retrospective review from 2010-2015 at a Level I trauma center. Patients were termed delayed if they presented >24 hours after injury. Patients admitted within 24 hours of their injury were the comparison group. Charts were reviewed for demographics, mechanism, comorbidities, complications and outcomes. A subgroup analysis was done on patients who suffered falls.

RESULTS

During the 5-y period, 11,705 patients were admitted. A total of 588 patients (5%) presented >24 h after their injury. Patients in the delayed group were older (65 versus 55 y, P < 0.001) and more likely to have psychiatric comorbidities (33% vs. 24%, P = 0.0001) than the control group. They were also more likely to suffer substance withdrawal (8.9% vs. 4.1%, P < 0.001) but had toxicology testing for drugs and alcohol done at significantly lower rates. Patients that presented delayed after falls were similar in age and injury severity score (ISS) but more likely to suffer substance withdrawal when compared to those with falls that presented within 24 hours. Patients with falls that presented delayed had toxicology testing at significantly lower rates than the comparison group.

CONCLUSIONS

Trauma patients that present to the hospital in a delayed fashion have unique characteristics and are more likely to suffer negative outcomes including substance withdrawal. Future goals will include exploring strategies for early intervention, such as automatic withdrawal monitoring and social work referral for all patients who present in a delayed fashion.

Anticipated Choices Among Self-, Informal, and Formal Care by Older Canadians

The present research investigated factors related to the health care choices seniors anticipated making in response to hypothetical illness symptoms (e.g. rectal bleeding). After collecting demographic data, 80 seniors were presented various illness symptoms. Directly following each symptom they were asked whether they anticipated using self-, informal, or formal care to deal with the potential problem. In general, seniors with higher perceived health status anticipated using self-care. Being male and having a lower perceived health status was predictive of choosing informal care, whereas being female was predictive of anticipating using formal care. When individual symptoms were analyzed, additional predictors were identified. Judged seriousness of a symptom, experience with a symptom, and social network status were related to different anticipated health care choices for some, but not all, symptoms. Perhaps the most striking finding was the difference between males and females. Since health status between males and females was not significantly different, this difference in anticipated choice of care seemed to be linked to personal preference rather than health status per se.

Which dimensions of access are most important when rural residents decide to visit a general practitioner for non-emergency care?

OBJECTIVE

Access to primary healthcare (PHC) services is key to improving health outcomes in rural areas. Unfortunately, little is known about which aspect of access is most important. The objective of this study was to determine the relative importance of different dimensions of access in the decisions of rural Australians to utilise PHC provided by general practitioners (GP).

METHODS

Data were collected from residents of five communities located in 'closely' settled and 'sparsely' settled rural regions. A paired-comparison methodology was used to quantify the relative importance of availability, distance, affordability (cost) and acceptability (preference) in relation to respondents' decisions to utilise a GP service for non-emergency care.

RESULTS

Consumers reported that preference for a GP and GP availability are far more important than distance to and cost of the service when deciding to visit a GP for non-emergency care. Important differences in rankings emerged by geographic context, gender and age.

CONCLUSIONS

Understanding how different dimensions of access influence the utilisation of PHC services is critical in planning the provision of PHC services. This study reports how consumers 'trade-off' the different dimensions of access when accessing GP care in rural Australia. The results show that ensuring 'good' access requires that policymakers and planners should consider other dimensions of access to services besides geography.

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the 'wobbly hub and double spokes' project

BACKGROUND

Policy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia.

METHODS/DESIGN

The project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability. Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation. Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences. Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects. Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages.

DISCUSSION

The project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.

Does one size really fit all? Why the mental health of rural Australians requires further research

In this paper the need for further investigation into the mental health of rural Australians will be discussed. It will be argued that while research to date has yielded valuable information, the volume and scope of existing studies has been inadequate to address the needs of the diverse and dynamic communities in non-metropolitan Australia. The diversity that exists within rural Australia is examined and the potential effects of this diversity on mental health status are highlighted. Then a number of issues that are relevant to people living in non-metropolitan areas that underscores the need for further study into rural mental health are identified. Finally, some specific areas that require further examination are outlined and some guiding principles for future mental health research are proposed.

High prevalence disorders in urban and rural communities

OBJECTIVE

High prevalence disorders (anxiety, depressive and substance use) are generally assumed to be more common in urban than rural dwellers. The aims of this paper are (i) to critically review studies measuring prevalence in rural as opposed to urban location, and (ii) to argue the need to look beyond the 'quantity' question to the quality question: how does urban or rural place influence mental health?

METHOD

A literature review (Medline and PsychLIT) was carried out using the words 'rural, urban, mental/psychiatric, illness/disorders and prevalence', as well as a review of relevant papers and publications known to the authors.

RESULTS

Many studies examining urban/rural differences in the rate of high prevalence disorders have been reported. Most use a 'one size fits all' definition of urban and rural, which assumes location is the key issue. The majority fail to show the purported difference in prevalence between the two settings. In general, studies have not examined interaction effects, but have simply treated the independent variables as main effects. Available data suggest that a variety of socio-demographic factors are more powerful predictors of difference in prevalence than is the location of residence.

CONCLUSION

Further studies are required to understand if and how rural or urban place contributes to the development of psychiatric morbidity. These studies should mirror the clinical situation by taking into account a variety of individual and community-based (including urban/rural place) risk factors which may be important determinants of mental health and mental illness, and examining the interaction between them. This may then identify the nature of any differences or what issues are specific to, or especially important, in the rural setting.

Ambulatory care sensitive hospitalization rates in the aged Medicare population in Utah, 1990 to 1994: a rural-urban comparison

The objective of this study is to compare the likelihood of hospitalization for conditions that are related to the adequacy and use of ambulatory health care services for Medicare beneficiaries residing in rural and urban regions in Utah. The Health Care Financing Administration's (HCFA) hospital discharge database (Utah hospitals: 1990 to 1994) was used to estimate hospitalization rates (with adjustment for out-of-state admissions) for ambulatory care sensitive conditions. Population estimates were obtained from HCFA beneficiary files. Regional hospitalization rates were obtained through ZIP code matching of the hospital discharge and beneficiary files. Medicare beneficiaries aged 65 and older residing in Utah during 1990 to 1994 are the subjects for the study. The main outcome measures include age and sex-adjusted hospitalization rates by region for the entire state and rate ratio estimates for nonurban regions. The results of the study show that Medicare beneficiaries residing in two rural-frontier regions were more likely than urban beneficiaries to be hospitalized for ambulatory care sensitive conditions. Rate ratio estimates were greater than 1.4 for both regions during the study period. These findings suggest a pattern of an increased burden of avoidable secondary complications and disease progression among Utah Medicare beneficiaries residing in some rural regions. This increased burden may be the result of limitations in the ambulatory care system, medical care provider supply, and/or beneficiary propensity to seek care. Variation in disease prevalence or hospital use patterns for these conditions also may be responsible for all or part of the observed variation in ambulatory care sensitive admission rates.

Sociocultural variations in help-seeking behavior for everyday symptoms and chronic disorders

In this study, we test the assumption that sociocultural differences in use of health services will only occur below a certain level of illness severity. Data are derived from the Curaçao Health Study (n = 2248). Subjects' educational level and degree of proto-professionalization are used as indicators of their sociocultural background. Differences in the likelihood of seeking professional care for several common health problems are analyzed, and are compared with the help-seeking behavior for chronic disorders. As hypothesized, higher educated and proto-professionalized people are less likely to seek care for everyday symptoms. In addition, proto-professionalization is accompanied by a greater likelihood of using over the counter medication. Increasing empowerment of patients appears to lead to increased self care for everyday symptoms. When conditions reach a more serious stage, the differences in help-seeking behavior disappear: for most of the chronic conditions studied, the higher educated and more proto-professionalized individuals are just as likely to seek professional treatment as the less advantaged groups. However, there is a difference as to the type of professional consulted for chronic health problems. Proto-professionalized individuals more often receive specialist treatment, probably because they are better equipped to persuade GPs to refer. The adverse side of patient empowerment may be increasing consumerism: a situation in which patient demands, not medical necessity, determine the care delivered.