Community pharmacists' perceptions of a hospital based virtual clinical pharmacy service: Findings from qualitative research

Background

A Virtual Clinical Pharmacy Service (VCPS) was introduced in selected rural and remote NSW hospitals in 2020 to address a gap in onsite clinical pharmacy services. Follow-up research determined hospital staff and patients at these locations perceived the service as a safe, effective and efficient system for delivering clinical pharmacy services. Community pharmacists are key stakeholders in medication safety and continuity of management in these regions, however, their insight on the VCPS had not yet been sought.

Objective

To understand perspectives of community pharmacists on the implementation of VCPS in rural and remote hospitals and impacts on medication management at transitions of care.

Methods

Semi-structured interviews were conducted via videoconference with seven community pharmacists with at least three months exposure to VCPS following service implementation. Thematic analysis of transcribed interviews was conducted influenced by Appreciative Inquiry.

Results

Participants identified that the VCPS had supported and enhanced their community pharmacy practice and acknowledged its future potential. Identified themes were interaction with VCPS, acceptability of VCPS, community pharmacy workflow, and involvement in patient care. Suggested improvements included involving community pharmacists early in the implementation of the service and establishing clear expectations and procedures.

Conclusions

The experiences of community pharmacists with VCPS were positive and there was a consensus that the introduction of the service had assisted interviewees in providing medication management to patients at transition of care. The ease of communication and efficiency of the service were recognised as key factors in the success of VCPS for community pharmacists.

Australian rural service learning student placements: a national survey

This preliminary national study is the first of its kind to investigate how service learning placements are implemented in real world settings in rural Australia and what factors enable or hinder their implementation. An anonymous survey was distributed to 17 University Departments of Rural Health (UDRH) in Australia. Numerical data were analysed descriptively. Textual data were analysed using a hybrid content analysis approach. Thirty seven respondents provided data representing 12 UDRHs. Responding UDRHs reported facilitating service learning programs, with experience in this context ranging from 3 months to 21 years. Service learning placements predominantly occurred in schools and aged care facilities. Occupational therapy, physiotherapy, and speech pathology were the most frequently involved professions in service learning. Enablers and barriers identified were categorised into: People, Partnerships, and Place and Space. This national-scale study provides a springboard for more in-depth investigation and implementation research focused on development of a conceptual model to support service learning across rural and remote Australia.

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

Family physicians' experiences with an innovative, community-based, hybrid model of in- person and virtual care: a mixed-methods study

BACKGROUND

Rural, remote, and underserved communities have often struggled to provide adequate access to family physicians. To bridge this gap in Renfrew County, a large, rural region in Ontario, Canada, a community- based, hybrid care model was implemented, combining virtual care from family physicians and in-person care from community paramedics. Studies have demonstrated the clinical and cost effectiveness of this model but its acceptability to physicians has not been examined. This study investigates the experiences of participating family physicians.

METHODS

A mixed-methods study, combining physician questionnaire response data and qualitative thematic analysis of focus group interview data.

RESULTS

Data was collected from n = 17 survey respondents and n = 9 participants in two semi-structured focus groups (n = 4 and n = 5 respectively). Physicians reported high satisfaction, driven by skills development and patient gratitude, and felt empowered to reduce ED visits, care for unattached patients, and address simple medical needs. However, physicians found it difficult to provide continuous care and were sometimes unfamiliar with local healthcare resources.

CONCLUSION

This study found that a hybrid model of in-person and virtual care from family physicians and community paramedics was associated with positive physician experiences in two main areas: clinical impacts, especially avoiding unnecessary ED visits, and physician satisfaction with the service. Potential improvements for this hybrid model were identified, and include better support for patients with complex needs, and more information about local health-system services. Our findings should be of interest to policymakers and administrators seeking to improve access to care through a hybrid model of in-person and virtual care.

Experiences of working as early career allied health professionals and doctors in rural and remote environments: a qualitative systematic review

Background

Maintaining a health professional workforce in rural and remote areas poses a significant challenge internationally. A range of recruitment and retention strategies have had varying success and these are  generally developed from the collective experience of all health professions, rather than targeted to professional groups with differing educational and support contexts. This review explores, compares and synthesises the evidence examining the experience of early career rural and remote allied health professionals and doctors to better understand both the profession specific, and common factors that influence their experience.

Methods

Qualitative studies that include early career allied health professionals’ or doctors’ experiences of working in rural or remote areas and the personal and professional factors that impact on this experience were considered. A systematic search was completed across five databases and three grey literature repositories to identify published and unpublished studies. Studies published since 2000 in English were considered. Studies were screened for inclusion and critically appraised by two independent reviewers. Data was extracted and assigned a level of credibility. Data synthesis adhered to the JBI meta-aggregative approach.

Results

Of the 1408 identified articles, 30 papers were eligible for inclusion, with one rated as low in quality and all others moderate or high quality. A total of 23 categories, 334 findings and illustrations were aggregated into three synthesised findings for both professional groups including: making a difference through professional and organisational factors, working in rural areas can offer unique and rewarding opportunities for early career allied health professionals and doctors, and personal and community influences make a difference. A rich dataset was obtained and findings illustrate similarities including the need to consider personal factors, and differences, including discipline specific supervision for allied health professionals and local supervision for doctors.

Conclusions

Strategies to enhance the experience of both allied health professionals and doctors in rural and remote areas include enabling career paths through structured training programs, hands on learning opportunities, quality supervision and community immersion.

Systematic review registration number

PROSPERO CRD42021223187.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08261-2.

"This is streets ahead of what we used to do": staff perceptions of virtual clinical pharmacy services in rural and remote Australian hospitals

BACKGROUND

The use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient's bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement.

METHODS

A qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes.

RESULTS

Focus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients.

CONCLUSIONS

The VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction.

TRIAL REGISTRATION

ANZCTR ACTRN12619001757101 , 11/12/2019.

A systematic integrative review examining the impact of Australian rural and remote maternity unit closures

BACKGROUND

Rural and remote Australian women are less able to access locally situated maternity care and birthing facilities, largely due to the gradual closures of rural and remote birthing services. Closures have occurred due to workforce issues, safety and quality issues and economic rationalisation of services to offset rising health system costs. An examination of the published literature to gain a deeper understanding of this phenomenon is warranted.

QUESTION

What are the impacts of rural and remote maternity unit closures in Australia?

METHODS

A systematic integrative review of published literature on Australian maternity unit closures was undertaken using Whittemore and Knafl's (2005) framework. A database search was conducted with date limiters of 2010 to 2020 on papers within the search parameters "maternity unit*" AND closure* AND women AND (midwife OR midwives) AND Australia, also with "birth unit", "labour ward" and "rural" in varying combinations. This search resulted in 348 papers. After applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process and the Crowe Critical Appraisal Tool (CCAT) and discarding those non-relevant, seven papers remained.

FINDINGS

A methodological analysis of seven papers occurred, three qualitative studies, three quantitative studies and one mixed methods study. Two main stakeholders were identified, the woman, and the health service. Women identified risks associated with travel, lack of access to services, costs or financial issues, safety, and emotional burdens. Women explicitly stated that access to local maternity services would negate many of their concerns. Health services indicated closures were due to safety and quality considerations and workforce issues.

CONCLUSION

Conflict exists in trying to meet the perceived needs of both stakeholder groups. Published evidence supports midwifery models for low-risk women. National policy also supports woman-centred care; however, local service uptake is minimal due to organisational barriers.

LISTEN UP (Locally Integrated Screening and Testing Ear aNd aUral Programme): a feasibility study protocol for a community pharmacy-based ear health intervention

BACKGROUND

Ear disease is a major cause of preventable hearing loss and is very common in rural communities, estimated to affect 1.3 million Australians. Rural community pharmacists are well placed to provide improved ear health care to people who are unable to easily access a general practitioner (GP). The purpose of this study is to apply an ear health intervention to the rural community-pharmacy setting in Queensland, Australia, to improve the management of ear disease. The aims are the following: (1) to evaluate the feasibility, potential effectiveness and acceptability of a community pharmacy-based intervention for ear health, (2) to evaluate the use of otoscopy and tympanometry by pharmacists in managing ear complaints in community pharmacy and (3) to evaluate the extended role of rural pharmacists in managing ear complaints, with the potential to expand nationally to improve minor ailment management in rural communities.

METHODS/DESIGN

This is a longitudinal pre- and post-test study of a community-pharmacy-based intervention with a single cohort of up to 200 patients from two rural community pharmacies. Usual care practices pertaining to the management of ear complaints will be recorded prior to the intervention for 8 weeks. The intervention will then be piloted for 6 weeks, followed by a 12 month impact study. Patients aged > 13 years presenting to the pharmacies with an ear complaint will be invited to participate. Trained pharmacists will conduct an examination including a brief history, hearing screening, otoscopy and tympanometry assessments. Patients will be referred to a general practitioner (GP) if required, according to the study protocol. Patients will complete a satisfaction survey and receive a follow-up phone call at 7 days to explore outcomes including prescribed medications and referrals. Pharmacists and GPs will complete pre- and post- intervention interviews. Patient, pharmacist and GP data will be analysed using descriptive statistics and thematic analysis for the qualitative data.

DISCUSSION

This study will demonstrate the implementation of a screening and referring ear health intervention in rural community pharmacy. Feasibility, potential effectiveness and acceptability of the intervention will be assessed.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry Number: ACTRN12620001297910 .

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia

BACKGROUND

The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.

METHODS

A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant's commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.

RESULTS

Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12-60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, "People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements "People who work here are determined to implement this change", "People who work here want to implement this change", and "People who work here are committed to implementing this change.

CONCLUSION

Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Experiences of Inuit in Canada who travel from remote settings for cancer care and impacts on decision making

BACKGROUND

Inuit experience the highest cancer mortality rates from lung cancer in the world with increasing rates of other cancers in addition to other significant health burdens. Inuit who live in remote areas must often travel thousands of kilometers to large urban centres in southern Canada and negotiate complex and sometimes unwelcoming health care systems. There is an urgent need to improve Inuit access to and use of health care. Our study objective was to understand the experiences of Inuit in Canada who travel from a remote to an urban setting for cancer care, and the impacts on their opportunities to participate in decisions during their journey to receive cancer care.

METHODS

We are an interdisciplinary team of Steering Committee and researcher partners ("the team") from Inuit-led and/or -specific organizations that span Nunavut and the Ontario cancer health systems. Guided by Inuit societal values, we used an integrated knowledge translation (KT) approach with qualitative methods. We conducted semi-structured interviews with Inuit participants and used process mapping and thematic analysis.

RESULTS

We mapped the journey to receive cancer care and related the findings of client (n = 8) and medical escort (n = 6) ("participant") interviews in four themes: 1) It is hard to take part in decisions about getting health care; 2) No one explains the decisions you will need to make; 3) There is a duty to make decisions that support family and community; 4) The lack of knowledge impacts opportunities to engage in decision making. Participants described themselves as directed, with little or no support, and seeking opportunities to collaborate with others on the journey to receive cancer care.

CONCLUSIONS

We describe the journey to receive cancer care as a "decision chain" which can be described as a series of events that lead to receiving cancer care. We identify points in the decision chain that could better prepare Inuit to participate in decisions related to their cancer care. We propose that there are opportunities to build further health care system capacity to support Inuit and enable their participation in decisions related to their cancer care while upholding and incorporating Inuit knowledge.

Client perceptions of the BreastScreen Australia remote radiology assessment model

Background

Telehealth and teleradiology are increasingly used around the world to facilitate health care provision when the health care provider and clients are separated by distance. The BreastScreen Australia Remote Radiology Assessment Model (RRAM) is an initiative developed to address the challenges of inadequate access to a local radiological workforce in regional Australia. With the growth in telehealth innovations more broadly, the RRAM represents a departure from the traditional onsite model where a radiologist would be co-located with practice staff during assessment clinics. Understanding client satisfaction is an important consideration with new models. This article explores client perceptions of the RRAM including awareness, satisfaction with experiences, confidence in the quality of care being received, and preferences regarding models of service delivery.

Methods

Clients in four BreastScreen services across three Australian states and territories were invited to provide feedback on their experiences of the RRAM. Brief face-to-face interviews based on a survey were conducted at the conclusion of assessment clinic visits. Clients also provided feedback through surveys completed and returned by post, and online.

Results

144 clients completed the survey regarding their experiences of the RRAM. The majority were aged between 50 and 59 years (55/144, 38.2%). Most had attended a BreastScreen service for either screening or assessment on a total of two to five occasions (85/142, 59.9%) in the past. Nearly all women who attended a RRAM clinic expressed satisfaction with their experience (142/143, 99.3%). Clients were aware that the radiologist was working from another location (131/143, 91.6%) and the majority believed there wouldn’t be any difference in the care they received between the RRAM and the onsite model (120/142, 84.5%). Clients generally had no particular preference for either the onsite or RRAM model of service delivery.

Conclusions

Clients’ high satisfaction with their clinic experiences, high confidence in care being received, and the majority having no preference for either the onsite or remote model indicates their acceptance of the RRAM. Client acceptance of the model supports continuation of the RRAM at these sites and expansion. Findings may inform future telehealth innovations where key health care team members are working remotely.

Acceptability of real-time video counselling compared to other behavioural interventions for smoking cessation in rural and remote areas

BACKGROUND

This study evaluated the acceptability of real-time video counselling compared to a) telephone counselling and b) written materials in assisting rural and remote residents to quit smoking.

METHODS

Participants were recruited into a three-arm, parallel group randomised trial and randomly allocated to either: a) real-time video counselling; b) telephone counselling; or c) written materials. At 4-months post-baseline participants completed an online survey that examined self-reported acceptability and helpfulness of the support.

RESULTS

Overall, 93.5 % of video counselling participants and 96.2 % of telephone counselling participants who received support thought it was acceptable for a smoking cessation advisor to contact them via video software or telephone respectively. There were significant differences between video counselling and telephone counselling groups on three of 10 acceptability or helpfulness measures. Video counselling participants had significantly lower odds of reporting the number of calls were about right (OR 0.50, 95 % CI 0.27-0.93), recommending the support to family and friends (OR 0.18, 95 % CI 0.04-0.85) and reporting the support helped with motivation to try quitting (OR 0.24, 95 % CI 0.07-0.76) compared to telephone counselling participants. Video counselling participants had significantly greater odds than written materials participants of rating the support favourably on all seven acceptability and helpfulness items compared.

CONCLUSIONS

Real-time video counselling for smoking cessation is acceptable and well-received by those living in rural and remote locations. Further research is required to enhance the three attributes that were less acceptable for video counselling than telephone counselling.

"From the technology came the idea": safe implementation and operation of a high quality teleradiology model increasing access to timely breast cancer assessment services for women in rural Australia

Breast cancer is the most commonly diagnosed cancer in Australian women. Providing timely diagnostic assessment services for screen-detected abnormalities is a core quality indicator of the population-based screening program provided by BreastScreen Australia. However, a shortage of local and locum radiologists with availability and appropriate experience in breast work to attend onsite assessment clinics, limits capacity of services to offer assessment appointments to women in some regional centres. In response to identified need, local service staff developed the remote radiology assessment model for service delivery. This study investigated important factors for establishing the model, the challenges and enablers of successful implementation and operation of the model, and factors important in the provision of a model considered safe and acceptable by service providers.

METHODS

Semi-structured interviews were conducted with service providers at four assessment services, across three jurisdictions in Australia. Service providers involved in implementation and operation of the model at the service and jurisdictional level were invited to participate. A social constructivist approach informed the analysis. Deductive analysis was initially undertaken, using the interview questions as a classifying framework. Subsequently, inductive thematic analysis was employed by the research team. Together, the coding team aggregated the codes into overarching themes.

RESULTS

55 service providers participated in interviews. Consistently reported enablers for the safe implementation and operation of a remote radiology assessment clinic included: clinical governance support; ability to adapt; strong teamwork, trust and communication; and, adequate technical support and equipment. Challenges mostly related to technology and internet (speed/bandwidth), and maintenance of relationships within the group.

CONCLUSIONS

Understanding the key factors for supporting innovation, and implementing new and safe models of service delivery that incorporate telemedicine, will become increasingly important as technology evolves and becomes more accessible. It is possible to take proposed telemedicine solutions initiated by frontline workers and operationalise them safely and successfully: (i) through strong collaborative relationships that are inclusive of key experts; (ii) with clear guidance from overarching bodies with some flexibility for adapting to local contexts; (iii) through establishment of robust teamwork, trust and communication; and, (iv) with appropriate equipment and technical support.

Rural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: a systematic integrative review

Background

People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.

Methods

An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.

Results

Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.

Conclusions

This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.

Increasing access to breast reconstruction for women living in underserved non-metropolitan areas of Australia

PURPOSE

The potential quality of life benefits of breast reconstruction (BR) for women who have undergone mastectomy for breast cancer have long been recognised. While many women will not want to have BR, international best-practice guidance mandates that all should be given the choice. The aim of this article is to highlight potential policies to support patients' informed discussion of BR options and to improve access to BR for women living in underserved locations.

METHODS

Ninety semi-structured interviews were conducted from May 2015 to May 2017 with a convenience sample of 31 breast reconstructive surgeons, 37 breast cancer health professionals and a purposive sample of 22 women who underwent mastectomy as part of their breast cancer treatment. Breast, plastic reconstructive surgeons and health professionals based in major cities also provided information about how they cared for patients from more remote areas.

RESULTS

Analysis of interview data revealed a range of barriers that were grouped into four major categories describing issues for women living outside major cities: population characteristics associated with lower socioeconomic status; locational barriers including limited health services resources and distance; administrative barriers such as hospital policies and inadequate support for women who need to travel; and surgical workforce recruitment barriers.

CONCLUSIONS

Suggestions for potential solutions included the following: greater geographical centralisation of BR services within major cities; the creation of designated breast centres with minimum caseload requirements similar to the UK's system; and a buddy system, whereby smaller hospitals network with multidisciplinary teams based in larger hospitals.

A study of macro-, meso- and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia

BACKGROUND

Shortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions.

METHODS

Semi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives.

RESULTS

Fifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles.

CONCLUSIONS

For communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team.

What is the overall impact or effectiveness of visiting primary health care services in rural and remote communities in high-income countries? A systematic review

BACKGROUND

Visiting services address the problem of workforce deficit and access to effective primary health care services in isolated remote and rural locations. Little is known about their impact or effectiveness and thereby the extent to which they are helping to reduce the disparity in access and health outcomes between people living in remote areas compared with people living in urban regions of Australia. The objective of this study was to answer the question "What is the impact or effectiveness when different types of primary health care services visit, rather than reside in, rural and remote communities?"

METHOD

We conducted a systematic review of peer-reviewed literature from established databases. We also searched relevant websites for 'grey' literature and contacted several key informants to identify other relevant reference material. All papers were reviewed by at least two assessors according to agreed inclusion and exclusion criteria.

RESULTS

Initially, 345 papers were identified and, from this selection, 17 papers were considered relevant for inclusion. Following full paper review, another ten papers were excluded leaving seven papers that provided some information about the impact or effectiveness of visiting services. The papers varied with regard to study design (ranging from cluster randomised controlled trials to a case study), research quality, and the strength of their conclusions. In relation to effectiveness or impact, results were mixed. There was a lack of consistent data regarding the features or characteristics of visiting services that enhance their effectiveness or impact. Almost invariably the evaluations assessed the service provided but only two papers mentioned any aspect of the visiting features within which service provision occurred such as who did the visiting and how often they visited.

CONCLUSIONS

There is currently an inadequate evidence base from which to make decisions about the effectiveness of visiting services or how visiting services should be structured in order to achieve better health outcomes for people living in remote and rural areas. Given this knowledge gap, we suggest that more rigorous evaluation of visiting services in meeting community health needs is required, and that evaluation should be guided by a number of salient principles.

Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia

BACKGROUND

Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10-30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations.

METHODS

CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance.

RESULTS

Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators.

CONCLUSION

Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed.

Pediatric hospital admissions in Indigenous children: a population-based study in remote Australia

BACKGROUND

We analysed hospital admissions of a predominantly Aboriginal cohort of children in the remote Fitzroy Valley in Western Australia during the first 7 years of life.

METHODS

All children born between January 1, 2002 and December 31, 2003 and living in the Fitzroy Valley in 2009-2010 were eligible to participate in the Lililwan Project. Of 134 eligible children, 127 (95%) completed Stage 1 (interviews of caregivers and medical record review) in 2011 and comprised our cohort. Lifetime (0-7 years) hospital admission data were available and included the dates, and reasons for admission, and comorbidities. Conditions were coded using ICD-10-AM discharge codes.

RESULTS

Of the 127 children, 95.3% were Indigenous and 52.8% male. There were 314 admissions for 424 conditions in 89 (70.0%) of 127 children. The 89 children admitted had a median of five admissions (range 1-12). Hospitalization rates were similar for both genders (p = 0.4). Of the admissions, 108 (38.6%) were for 56 infants aged <12 months (median = 2.5, range = 1-8). Twelve of these admissions were in neonates (aged 0-28 days). Primary reasons for admission (0-7 years) were infections of the lower respiratory tract (27.4%), gastrointestinal system (22.7%), and upper respiratory tract (11.4%), injury (7.0%), and failure to thrive (5.4%). Comorbidities, particularly upper respiratory tract infections (18.1%), failure to thrive (13.6%), and anaemia (12.7%), were common. In infancy, primary cause for admission were infections of the lower respiratory tract (40.8%), gastrointestinal (25.9%) and upper respiratory tract (9.3%). Comorbidities included upper respiratory tract infections (33.3%), failure to thrive (18.5%) and anaemia (18.5%).

CONCLUSION

In the Fitzroy Valley 70.0% of children were hospitalised at least once before age 7 years and over one third of admissions were in infants. Infections were the most common reason for admission in all age groups but comorbidities were common and may contribute to need for admission. Many hospitalizations were feasibly preventable. High admission rates reflect disadvantage, remote location and limited access to primary healthcare and outpatient services. Ongoing public health prevention initiatives including breast feeding, vaccination, healthy diet, hygiene and housing improvements are crucial, as is training of Aboriginal Health Workers to increase services in remote communities.

What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study

BACKGROUND

Diabetic retinopathy (DR) is the commonest cause of preventable blindness in working age populations, but up to 98% of visual loss secondary to DR can be prevented with early detection and treatment. In 2012, an innovative outreach DR screening model was implemented in remote communities in a state of Australia. The aim of this study was to explore the acceptability of this unique DR screening model to patients, health professionals and other key stakeholders.

METHODS

This descriptive qualitative study used semi-structured interviews with patients opportunistically recruited whilst attending DR screening, and purposefully selected health care professionals either working within or impacted by the programme. Interviews were audiotaped, transcribed and analysed using NVIVO. An iterative process of thematic analysis was used following the principles of grounded theory.

RESULTS

Interviews were conducted with fourteen patients with diabetes living in three remote communities and nine health professionals or key stakeholders. Nine key themes emerged during interviews with health professionals, key stakeholders and patients: i) improved patient access to DR screening; ii) efficiency, financial implications and sustainability; iii) quality and safety; iv) multi-disciplinary diabetes care; v) training and education; vi) operational elements of service delivery; vii) communication, information sharing and linkages; viii) coordination and integration of the service and ix) suggested improvements to service delivery.

CONCLUSIONS

The Remote Outreach DR Screening Service is highly acceptable to patients and health professionals. Challenges have primarily been encountered in communication and coordination of the service and further development in these areas could improve the programme's impact and sustainability in remote communities. The service is applicable to other remote communities nationally and potentially internationally.

Development of a behaviour rating system for rural/remote pre-hospital settings

BACKGROUND

Remote and Rural pre-hospital care practitioners manage serious illness and injury on an unplanned basis, necessitating technical and non-technical skills (NTS). However, no behaviour rating systems currently address NTS within these settings. Informed by health psychology theory, a NTS-specific behaviour rating system was developed for use within pre-hospital care training for remote and rural practitioners.

METHOD

The Immediate Medical Care Behaviour Rating System (IMCBRS), was informed by literature, expert advice and review and observation of an Immediate Medical Care (IMC) course. Once developed, the usability and appropriateness of the rating system was tested through observation of candidates' behaviour at IMC courses during simulated scenarios and rating their use of NTS using the IMCBRS.

RESULTS AND CONCLUSION

Observation of training confirmed rating system items were demonstrated in 28-62% of scenarios, depending on context. The IMCBRS may thus be a useful addition to training for rural and practitioners.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population

OBJECTIVES

To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population.

SETTING

A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada.

PARTICIPANTS

A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities.

OUTCOMES

The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres.

RESULTS

No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy.

CONCLUSIONS

Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

The closure of rural and remote maternity services: Where are the midwives?

Decisions to close small maternity units in rural and remote communities have often precipitated a community response as women and families rally to save local services. But where are the midwives? We argue here that professional bodies such as colleges of midwives have a responsibility to advocate more strongly at a political level for evidence-based decisionmaking regarding the allocation of rural services. We suggest that adopting a comprehensive definition of maternity services risk that considers both social and health services risks and their impact on clinical risk, could provide a solid basis for effective advocacy by professional bodies.

A comprehensive health service evaluation and monitoring framework

OBJECTIVE

To develop a framework for evaluating and monitoring a primary health care service, integrating hospital and community services.

METHOD

A targeted literature review of primary health service evaluation frameworks was performed to inform the development of the framework specifically for remote communities. Key principles underlying primary health care evaluation were determined and sentinel indicators developed to operationalise the evaluation framework. This framework was then validated with key stakeholders.

RESULTS

The framework includes Donabedian's three seminal domains of structure, process and outcomes to determine health service performance. These in turn are dependent on sustainability, quality of patient care and the determinants of health to provide a comprehensive health service evaluation framework. The principles underpinning primary health service evaluation were pertinent to health services in remote contexts. Sentinel indicators were developed to fit the demographic characteristics and health needs of the population. Consultation with key stakeholders confirmed that the evaluation framework was applicable.

CONCLUSION

Data collected routinely by health services can be used to operationalise the proposed health service evaluation framework. Use of an evaluation framework which links policy and health service performance to health outcomes will assist health services to improve performance as part of a continuous quality improvement cycle.

Contact lens wearers' experiences while trekking in the Khumbu region/Nepal: a cross-sectional survey

BACKGROUND

Safe contact lens wear depends on a hygiene regime and lens-appropriate wear patterns which may be compromised during travel in remote and wilderness areas. The purpose of this study was to describe the experience of contact lens wearers while trekking at high-altitude in Nepal.

METHODS

For this descriptive study, trekkers with contact lenses were recruited in Lukla and invited to complete an online-questionnaire on trip preparation, contact lens use, care and experiences, and possible changes for future travel. Quantitative data were analysed using SurveyMonkey; content analysis applied to qualitative responses.

RESULTS

The majority of the 158 participants (124; 78.48%) reported no problems with their lenses (daily disposables, soft lenses, extended-wear lenses, hard/rigid lenses) during their stay although dry air, dust, wind, cold temperatures, and difficult hygiene maintenance were challenging. Freezing lenses and freezing solutions were additional challenges. Thirty-four (21.52%) experienced a variety of problems. Improvements were requested from manufacturers. Lodges should provide better access to clean water, mirrors and lighting. Almost 60% of participants had not sought any pre-travel health advice.

CONCLUSIONS

Remote and wilderness areas provide a challenge for appropriate contact lens wear and care. The decision between the potential risk of infection due to touching lenses (daily disposables, soft/hard lenses) and the potential risk of corneal erosion (extended-wear lenses) needs to be made in pre-travel consultations. Travel health professionals and travel agencies should remind CL-wearing trekkers to carefully assess their wear and care routine to accommodate potentially challenging conditions.