Rural-urban variation in the utilisation of publicly funded healthcare services: an age-stratified population-level observational study

AIM

To compare age-stratified public health service utilisation in Aotearoa New Zealand across the rural-urban spectrum.

METHODS

Routinely collected hospitalisation, allied health, emergency department and specialist outpatient data (2014-2018), along with Census denominators, were used to calculate utilisation rates for residents in the two urban and three rural categories in the Geographic Classification for Health.

RESULTS

Relative to their urban peers, rural Māori and rural non-Māori had lower all-cause, cardiovascular, mental health and ambulatory sensitive (ASH) hospitalisation rates. The age-standardised ASH rate ratios (major cities as the reference, 95% CIs) across the three rural categories were for Māori 0.79 (0.78, 0.80), 0.83 (0.82, 0.85) and 0.80 (0.77, 0.83), and for non-Māori 0.87 (0.86, 0.88), 0.80 (0.78, 0.81) and 0.50 (0.47, 0.53). Residents of the most remote communities had the lowest rates of specialist outpatient and emergency department attendance, an effect that was accentuated for Māori. Allied health service utilisation by those in rural areas was higher than that seen in the major cities.

CONCLUSIONS

The large rural-urban variation in health service utilisation demonstrated here is previously unrecognised and in contrast to comparable international data. New Zealand's most remote communities have the lowest rates of health service utilisation despite high amenable mortality rates. This raises questions about geographic equity in health service design and delivery and warrants further in-depth research.

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh

INTRODUCTION

Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake.

METHODS

This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA.

RESULTS

Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process.

CONCLUSION

While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Towards an Integrated Healthcare System: Evolutionary Game Analysis on Competition and Cooperation Between Urban and Rural Medical Institutions in China

Background

The game of interest is the root cause of the non-cooperative competition between urban and rural medical and health institutions. The study investigates competition and cooperation among urban and rural medical institutions using the evolutionary game analysis.

Methods

With the evolutionary game model, analysis of the stable evolutionary strategies between the urban and rural medical and health facilities is carried out. A numerical simulation is performed to demonstrate the influence of various values.

Results

The result shows that the cooperation mechanism between urban and rural medical Institutions is relevant to the efficiency of rural medical institutions, government supervision, reward, and punishment mechanism.

Conclusions

Suggestions for utilizing the government's macro regulation and control capabilities, resolving conflicts of interest between urban and rural medical and health institutions is recommended. In addition, the study again advocates mobilizing the internal power of medical institutions' cooperation to promote collaboration between urban and rural medical and health institutions.

Impact of Surgeon Type and Rurality on Treatment and Survival of Ovarian Cancer Patients

BACKGROUND

National Comprehensive Cancer Network guidelines recommend ovarian cancer patients receive cancer-directed surgery from a gynecologic oncologist surgeon. We aimed to determine if rurality impacts type of surgeon and estimate if the interaction between rurality and type of surgeon impacts cytoreductive surgery, chemotherapy initiation, and survival.

METHODS

Our population-based cohort of Iowan (N=675) ovarian cancer patients included women diagnosed with histologically confirmed stages IB-IV cancer in 2010 to 2016 at the ages of 18 to 89 years old and who received cancer-directed surgery in Iowa. Multivariable logistic regression analysis and Cox proportional hazards models were used.

RESULTS

Rural (vs. urban) patients were less likely to receive surgery from a gynecologic oncologist (adjusted odds ratio [OR]: 0.48; 95% confidence interval [CI]: 0.30-0.78). Rural patients with a gynecologic oncologist (vs. nongynecologic oncologist) surgeon were more likely to receive cytoreduction (OR: 2.84; 95% CI: 1.31-6.14) and chemotherapy (OR: 4.22; 95% CI: 1.82-9.78). Gynecologic oncologist-provided surgery conferred a 3-year cause-specific survival advantage among rural patients (adjusted hazard ratio: 0.57; 95% CI: 0.33-0.97) and disadvantage among urban patients (hazard ratio: 1.77; 95% CI: 1.02-3.06) in the model without treatment covariates. Significance dissipated in models with treatment variables.

DISCUSSION

The variation in the gynecologic oncologist survival advantage may be because of treatment, referral, volume, or nongynecologic oncologist surgeons' specialty difference by rurality. This is the first study to investigate the ovarian cancer survival advantage of having a gynecologic oncologist surgeon by rurality.

Factors associated with treatment in primary versus specialist care: A population-based study of people with type 2 and type 1 diabetes

AIMS

The objectives of this study are to identify the proportion and characteristics of people with type 1 and 2 diabetes treated in primary, specialist and shared care and to identify the proportion of persons with type 2 diabetes reaching HbA_1c treatment targets and the clinical risk factors and general practitioner and practice characteristics associated with treatment in specialist care.

METHODS

Population-based cross-sectional study including all adults ≥18 years diagnosed with diabetes in primary and specialist care in Salten, Norway. We used multivariable mixed-effects logistic regression models with level of care as outcome variable and population, general practitioner, and practice characteristics as exposure variables.

RESULTS

Of 2704 people with type 2 diabetes, 13.5% were treated in shared care and 2.1% in specialist care only. Of 305 people with type 1 diabetes, 14.4% received treatment in primary care only. The HbA_1c treatment target of 53 mmol/mol (7.0%) was reached by 67.3% of people with type 2 diabetes in primary care versus 30.4% in specialist care. HbA_1c , use of insulin, coronary heart disease, retinopathy and urban practice location were positively associated with treatment in specialist care. General practitioners' use of a structured form and a diabetes nurse were negatively associated with specialist care.

CONCLUSIONS

Of people with type 2 diabetes, 16% were treated in specialist care. They had higher HbA_1c and more vascular complications, as expected from priority guidelines. The use of a structured diabetes form and diabetes nurses seem to support type 2 diabetes follow-up in primary care.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.

RESULTS

Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.

CONCLUSION

Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.

[Prevalence and degree of control of cardiovascular risk factors in patients with ischemic cardiopathy of an urban health center.]

OBJECTIVE

Compliance with the therapeutic objectives recommended in the clinical practice guidelines on cardiovascular prevention and changes in lifestyle, such as smoking cessation, reduce the morbidity and mortality of patients with ischemic heart disease. The objective of this study was to analyze the prevalence and degree of control of the main cardiovascular risk factors in patients with ischemic heart disease.

METHODS

A total of 200 patients with ischemic heart disease randomly selected between the years 2008-2018. The degree of control of the cardiovascular risk factors and the achievement of the recommended objectives in secondary cardiovascular prevention were analyzed during a mean follow-up of 5 years. A descriptive and inferential analysis of the data was performed with the SPPS version 22.0 program.

RESULTS

77.9% of patients (mean age 65.6 years, 63.2 men and 70.5 women, p<0.01) had high blood pressure, 69.3% dyslipidemia, 48.2% obesity and 32.3% diabetes. 34.8% were smokers (39.2% of men versus 25.4% of women, p=0.06). During the follow-up, a slight decrease in smoking was observed (from 34.8% to 21.6%, p<0.01), with a greater percentage reduction in men versus women (42.9% versus 21.3%, p<0.01). In the follow-up, he also highlighted the decrease in blood pressure, total cholesterol and LDL-cholesterol. Optimal compliance with therapeutic objectives was achieved in 21.7% of patients.

CONCLUSIONS

The objectives of secondary cardiovascular prevention are reached in a low percentage of patients with ischemic heart disease, with a lower rate of smoking cessation in women.

Equity of Health Services Utilisation and Expenditure among Urban and Rural Residents under Universal Health Coverage

Worldwide countries are recognising the need for and significance of universal health coverage (UHC); however, health inequality continues to persist. This study evaluates the status and equity of residents' demand for and utilisation of health services and expenditure by considering the three components of universal health coverage, urban-rural differences, and different income groups. Sample data from China's Fifth Health Service Survey were analysed and the 'five levels of income classification' were used to classify people into income groups. This study used descriptive analysis and concentration index and concentration curve for equity evaluation. Statistically significant differences were found in the demand and utilisation of health services between urban and rural residents. Rural residents' demand and utilisation of health services decreased with an increase in income and their health expenditure was higher than that of urban residents. Compared with middle- and high-income rural residents, middle- and lower-income rural residents faced higher hospitalisation expenses; and, compared with urban residents, equity in rural residents' demand and utilisation of health services, and annual health and hospitalisation expenditures, were poorer. Thus, equity of health service utilisation and expenditure for urban and rural residents with different incomes remain problematic, requiring improved access and health policies.

Community-based HIV testing services in an urban setting in western Kenya: a programme implementation study

BACKGROUND

Some countries are struggling to reach the UNAIDS target of 90% of all individuals with HIV knowing their HIV status, especially among men and youth. To identify individuals who are unaware of their HIV-positive status and achieve testing saturation, we implemented a hybrid HIV testing approach in an urban informal settlement in western Kenya. In this study, we aimed to describe the uptake of HIV testing and linkage to care and treatment during this programme.

METHODS

The Community Health Initiative involved community mapping, household census, multidisease community health campaigns, and home-based tracking in the informal settlement of Obunga in Kisumu, Kenya. 52 multidisease community health campaigns were held throughout the programme coverage area, at which HIV testing by certified testing service counsellors was one of the health services available. Individuals aged 15 years or older who were not previously identified as HIV-positive, children younger than 15 years who reported being sexually active or for whom testing was requested by a parent or guardian, and individuals who tested HIV-negative within the past 3 months but who reported a recent risk were all eligible for testing. Health and counselling services were tailored for men and youth to encourage their participation. Individuals identified during the census who did not attend a community health campaign were tracked using global positioning system data and offered home-based HIV testing services. We calculated the previously unidentified fraction, defined as the number of individuals who were newly identified as HIV-positive as a proportion of all individuals previously identified and newly identified as HIV-positive.

FINDINGS

Between Jan 11 and Aug 29, 2018, the Community Health Initiative programme reached 23 584 individuals, of whom 11 526 (48·9%) were men and boys and 5635 (23·9%) were aged 15-24 years. Of 12 769 individuals who were eligible for HIV testing, 12 407 (97·2%) accepted testing, including 3917 (31·6%) first-time testers. 101 individuals were newly identified as HIV-positive out of 1248 total individuals who were HIV-positive, representing an 8·1% previously unidentified fraction. The previously unidentified fraction was highest among men (9·8%) and among people aged 15-24 years (15·3%).

INTERPRETATION

Community-based hybrid HIV testing was successfully implemented in an urban setting. Innovative approaches that make HIV testing more accessible and acceptable, particularly to men and young people, are crucial for achieving testing and treatment saturation. Focusing on identifying individuals who are unaware of their HIV-positive status in combination with monitoring the previously unidentified fraction has the potential to achieve the UNAIDS Fast Track commitment to end AIDS by 2030.

FUNDING

US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

The reliability of a rapid molecular detection method in determining the prevalence of rifampicin-resistant Mycobacterium tuberculosis in an urban district health facility in Malaysia

INTRODUCTION

Rifampicin is a key first-line antimycobacterial agent employed for the treatment of pulmonary tuberculosis (PTB). This study sought to obtain prevalence data on rifampicin-resistant Mycobacterium tuberculosis among smear-positive PTB patients in the Klang District of Malaysia.

MATERIALS AND METHODS

A total of 103 patients from the Chest Clinic of Hospital Tengku Ampuan Rahimah with sputum smears positive for acid-fast bacilli were included in this cross-sectional study. All sputa were tested using Xpert MTB/RIF to confirm the presence of M. tuberculosis complex and detect rifampicin resistance. Sputa were also sent to a respiratory medicine institute for mycobacterial culture. Positive cultures were then submitted to a reference laboratory, where isolates identified as M. tuberculosis complex underwent drug susceptibility testing (DST).

RESULTS

A total of 58 (56.3%) patients were newly diagnosed and 45 (43.7%) patients were previously treated. Xpert MTB/RIF was able to detect rifampicin resistance with a sensitivity and specificity of 87.5% and 98.9%, respectively. Assuming that a single resistant result from Xpert MTB/RIF or any DST method was sufficient to denote resistance, a total of 8/103 patients had rifampicinresistant M. tuberculosis. All eight patients were previously treated for PTB (p<0.05). The overall prevalence of rifampicin resistance among smear-positive PTB patients was 7.8%, although it was 17.8% among the previously treated ones.

CONCLUSION

The local prevalence of rifampicin-resistant M. tuberculosis was particularly high among previously treated patients. Xpert MTB/RIF can be employed in urban district health facilities not only to diagnose PTB in smear-positive patients, but also to detect rifampicin resistance with good sensitivity and specificity.

Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States

BACKGROUND

Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population.

OBJECTIVE

This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship.

STUDY DESIGN

Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries.

RESULTS

Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications.

CONCLUSION

Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey

BACKGROUND

HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing.

METHODS

Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey.

RESULTS

Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing.

CONCLUSIONS

Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

Imaging Volume Trends and Recovery During the COVID-19 Pandemic: A Comparative Analysis Between a Large Urban Academic Hospital and Its Affiliated Imaging Centers

Rationale and Objectives

While affiliated imaging centers play an important role in healthcare systems, little is known of how their operations are impacted by the COVID-19 pandemic. Our goal was to investigate imaging volume trends during the pandemic at our large academic hospital compared to the affiliated imaging centers.

Materials and Methods

This was a descriptive retrospective study of imaging volume from an academic hospital (main hospital campus) and its affiliated imaging centers from January 1 through May 21, 2020. Imaging volume assessment was separated into prestate of emergency (SOE) period (before SOE in Massachusetts on March 10, 2020), “post-SOE” period (time after “nonessential” services closure on March 24, 2020), and “transition” period (between pre-SOE and post-SOE).

Results

Imaging volume began to decrease on March 11, 2020, after hospital policy to delay nonessential studies. The average weekly imaging volume during the post-SOE period declined by 54% at the main hospital campus and 64% at the affiliated imaging centers. The rate of imaging volume recovery was slower for affiliated imaging centers (slope = 6.95 for weekdays) compared to main hospital campus (slope = 7.18 for weekdays). CT, radiography, and ultrasound exhibited the lowest volume loss, with weekly volume decrease of 41%, 49%, and 53%, respectively, at the main hospital campus, and 43%, 61%, and 60%, respectively, at affiliated imaging centers. Mammography had the greatest volume loss of 92% at both the main hospital campus and affiliated imaging centers.

Conclusion

Affiliated imaging center volume decreased to a greater degree than the main hospital campus and showed a slower rate of recovery. Furthermore, the trend in imaging volume and recovery were temporally related to public health announcements and COVID-19 cases.

Pilot Randomized Controlled Trial of an Interconception Intervention Provided by Public Health Nurses

OBJECTIVES

Preconception health impacts perinatal outcomes, but the difficulty in engaging reproductive-aged individuals in health promotion activities is a barrier to effective implementation of preconception interventions. Since most women have more than one pregnancy and many risk factors repeat across pregnancies, the time between pregnancies-the interconception period-may be an opportune time to improve health. Our objective was to examine the feasibility and acceptability of an interconception intervention delivered by public health nurses.

METHODS

We conducted a pilot randomized controlled trial in three small urban and rural public health units in Ontario, Canada, in 2017-2018 among women who were ≥ 18 years of age and between 2 and 12 months postpartum after a first birth. Women randomly allocated to the intervention group received a preconception risk assessment, tailored health education, and referral for clinical follow-up as needed, while those in the control group received standard care. Primary outcomes were intervention feasibility, adherence, and acceptability.

RESULTS

Of 66 eligible women, 61% agreed to participate and were randomized to the intervention (n = 16) or control (n = 24) groups. The follow-up rate was 78% at 1 month and 71% at 3 months. Most women (83%) were satisfied with the intervention, including the number and length of sessions and content of recommendations.

CONCLUSIONS FOR PRACTICE

Results demonstrate the potential feasibility and acceptability of an interconception intervention delivered in a public health setting. The short- and long-term impacts of the intervention on knowledge, behavior, and health should be tested in a larger sample.

Analysis of Geographical Density of Dermatologists Compared to Dermatology Physician Assistants

In the past decade, the number of dermatologists in the United States (US) has increased, but distribution is skewed, with higher concentrations in academic centers and urban areas, resulting in a shortage in dermatological care.1,2 Non-physician practitioners, including, physician assistants (PAs), may fill this need, however, they are also unevenly situated.3 Therefore, our goals were to examine the distribution and ratio of dermatologists to dermatology PAs across the US.

Medical students on long-term rural clinical placements and their perceptions of urban and rural internships: a qualitative study

BACKGROUND

There is some anecdotal evidence that anxiety about the responsibility of an intern influences rural future intentions. Additionally, research has shown that urban interns have reported that they are worried about being 'forced' to work in non-metropolitan hospitals in their first year after graduation. This study sought to explore rural medical students' perceptions and expectations of a rural internship and how local health services and/or their medical school can prepare them best for a rural intern position.

METHODS

Four focus groups were conducted with 62 final-year medical students upon completion of a 12-month rural clinical school placement. Focus groups were audio-recorded and transcribed verbatim for thematic analysis to identify key themes.

RESULTS

Most students have high levels of anxiety around starting work but they acknowledge that this may be exaggerated. They believe that in rural areas they get higher quality supervisory support than in urban hospitals as people know you better, whereas in the city you are more anonymous. However, the level of responsibility placed on rural interns was considered to be a double-edged sword. While rural interns were allowed to do more than be a 'paper-pusher' this level of responsibility means they are more accountable. The majority felt that doing your first training years in a metropolitan hospital can be crucial to getting on a training program in your chosen speciality.

CONCLUSIONS

There appears to be a relatively high level of anxiety about rural internships amongst final-year medical students. Students need more targeted information around specialisation, particularly around regional training hubs, if we want to achieve higher levels of interns choosing a rural career path.

[The role of the old age psychiatrist in a mobile geriatric team: an example in Tours city area (France)]

BACKGROUND

Demographic changes require an adaptation of the geriatric care offer, which is readily oriented towards the community and including the development of out-of-hospital mobile geriatric team (MGT). Although psychiatric disorders of older persons require a comprehensive, integrative and multidisciplinary approach, geriatrics and old age psychiatry mobile units often work in parallel without concertation for the management of complex pathologies. The aim of this paper is to present the organisation and the results of a out-of-hospital MGT with a geriatrician and old age psychiatrists (OAP) in a same unit.

METHOD

Data were collected during the first-year (2018) of the out-of-hospital MGT of Tours University hospital. After initial geriatric assessment and when old age psychiatry (OAP) intervention was needed, referral mode and justification, patient's characteristics and recommendations made by the team were collected.

RESULTS

During the study period, 151 patients were assessed, 53% (n=80) had out-of-medical follow-up or difficulties to access to healthcare; 40% (n=60) had behavioural and psychological symptoms of dementia (BPSD), 30% (n=45) falls, 15% (n=23) social problems, 10% (n=15) alteration of overall health status and 5% (n=7) drug conciliation; 40% (n=60) benefited from an OAP evaluation; 100% (n=60) had out of medical follow-up, 83% (n=50) had severe BPSD, 17% (n=10) psychological symptom with psychiatric condition, 10% (n=6) misused psychotropic medications in charge of general comorbidities decompensation; 32% (n=19) had geriatric, OAP consultations and 33% (n=20) were in denial of care; 23% (n=14) with severe BPSD had a second OAP consultation.

DISCUSSION

Relationship between geriatrician and OAP in the same MGT enables to deliver comprehensive care, including organic, psychiatric and cognitive comorbidities and collaborative assessment of iatrogenicity. A strengthened relationship with general practitioners is a possible option for these frail older patients, out-of-medical follow-up allowing their reintegration in the geriatric healthcare system.

Environmental and Patient Impact of Applying a Point-of-Care Ultrasound Model in Primary Care: Rural vs. Urban Centres

Motor vehicles are a major contributor to air pollution, and the exposure to this human-caused air pollution can lead to harmful health effects. This study evaluates the impact of the provision of point-of-care ultrasounds (POCUS) by primary care (PC) to avoid the patient's need to travel to a specialized service. The study estimates the costs and air pollution avoided during 2019. The results confirm that performing this ultrasound at the point of care reduces the emission of 61.4 gr of carbon monoxide, 14.8 gr of nitric oxide and 2.7 gr of sulfur dioxide on each trip. During the study, an average of 17.8 km, 21.4 min per trip and almost 2000 L of fuel consumed in a year were avoided. Performing POCUS from PC reduces fuel consumption and the emission of air pollutants and also saves time and money. Furthermore, only 0.3% of the scans had to be repeated by radiologists. However, more studies with more participants need to be done to calculate the exact impact that these pollution reductions will have on human health.

Strategies to support HIV literacy in the roll-out of pre-exposure prophylaxis in Scotland: findings from qualitative research with clinical and community practitioners

OBJECTIVES

Limited understanding of pre-exposure prophylaxis (PrEP), coupled with negative public discourse, are significant barriers to its introduction. What works to support PrEP awareness and broader HIV literacy among diverse communities in the context of biomedical HIV prevention remains unclear. This article considers how PrEP can be translated across diverse communities and what the HIV literacy challenges might be in the current context of PrEP provision.

SETTING

We developed an HIV literacy informed community tool to support the roll-out of PrEP in Scotland. We undertook qualitative research with practitioners in urban and rural settings across nine Scottish health boards.

PRIMARY OUTCOME MEASURE

To examine HIV literacy challenges in the context of PrEP provision.

PARTICIPANTS

Interviews and focus groups with community (n=19) and clinical (n=13) practitioners working with gay and bisexual men and African communities were undertaken between March and October 2017 concerning PrEP support, stigma and HIV literacy.

RESULTS

HIV literacy in the context of PrEP needs to consider more than the provision of individually targeted information. Practitioners identified and responded to stratified communities and social norms of knowledge, which influenced messaging, support and informed how practitioners enabled PrEP engagement and dialogue. Social barriers in HIV literacy, including structural stigmas relating to HIV and homophobia, shaped practitioner concerns and support for community members' willingness to engage with PrEP.

CONCLUSION

Critical HIV literacy in the age of PrEP is a complex social practice. Attention needs to be paid to how information is provided and facilitates engagement, rather than simply what information is given.By exploring practitioner use of the Know about PrEP tool, we have shown how consideration of the patterns of access to services and information, the delivery of and support for engagement with PrEP information and the wider strategies employed to negotiate ongoing structural social barriers can support more equitable and diverse PrEP community conversations.

Barriers to treatment of chronic hepatitis C with direct acting antivirals in an urban clinic

INTRODUCTION AND AIM

Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting.

MATERIALS AND METHODS

A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates.

RESULTS

Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period.

CONCLUSION

In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.

Residential urban tree canopy is associated with decreased mortality during tuberculosis treatment in California

Trees can sequester air pollutants, and air pollution is associated with poor tuberculosis outcomes. However, the health impacts of urban trees on tuberculosis patients are unknown. To elucidate the effects of urban tree canopy on mortality during tuberculosis treatment, we evaluated patients diagnosed with active tuberculosis in California from 2000 through 2012, obtaining patient data from the California tuberculosis registry. Our primary outcome was all-cause mortality during tuberculosis treatment. We determined percent tree cover using 1 mresolution color infrared orthoimagery categorized into land cover classes, then linked tree cover to four circular buffer zones of 50-300 m radii around patient residential addresses. We used the Kaplan-Meier method to estimate survival probabilities and Cox regression models to determine mortality hazard ratios, adjusting for demographic, socioeconomic, and clinical covariates. Our cohort included 33,962 tuberculosis patients of median age 47, 59% male, 51% unemployed, and 4.9% HIV positive. Tuberculosis was microbiologically confirmed in 79%, and 1.17% were multi-drug resistant (MDR). Median tree cover was 7.9% (50 m buffer). Patients were followed for 23,280 person-years with 2370 deaths during tuberculosis treatment resulting in a crude mortality rate of 1018 deaths per 10,000 person-years. Increasing tree cover quintiles were associated with decreasing mortality risk during tuberculosis treatment in all buffers, and the magnitude of association decreased incrementally with increasing buffer radius: In the 50 m buffer, patients living in neighborhoods with the highest quintile tree cover experienced a 22% reduction in mortality (HR 0.78, 95%CI 0.68-0.90) compared to those living in lowest quintile tree cover; whereas for 100, 200, and 300 m buffers, a 21%, 13%, and 11% mortality risk reduction was evident. In conclusion, urban tree canopy was associated with decreased mortality during tuberculosis treatment even after adjusting for multiple demographic, socioeconomic, and clinical factors, suggesting that trees might play a role in improving tuberculosis outcomes.

Knowledge, attitudes and practices towards viral haemorrhagic fevers amongst healthcare workers in urban and rural public healthcare facilities in the N'zérékoré prefecture, Guinea: a cross-sectional study

BACKGROUND

The 2013-2016 Ebola epidemic in West Africa began in Guinea's Forest region, a region now considered to be at high risk for future epidemics of viral haemorrhagic fevers (VHF). Good knowledge, attitudes and practices towards VHF amongst healthcare workers in such regions are a central pillar of infection prevention and control (IPC). To inform future training in IPC, this study assesses the knowledge, attitudes and practices (KAP) towards VHF amongst healthcare workers in public healthcare facilities in the most populated prefecture in Forest Guinea, and compares results from urban and rural areas.

METHODS

In June and July 2019, we interviewed 102 healthcare workers in the main urban and rural public healthcare facilities in the N'zérékoré prefecture in Forest Guinea. We used an interviewer-administered questionnaire adapted from validated KAP surveys.

RESULTS

The great majority of respondents demonstrated good knowledge and favourable attitudes towards VHF. However, respondents reported some gaps in preventive practices such as VHF suspect case detection. They also reported a shortage of protective medical equipment used in everyday clinical work in both urban and rural healthcare facilities and a lack of training in IPC, especially in rural healthcare facilities. However, whether or not healthcare workers had been trained in IPC did not seem to influence their level of KAP towards VHF.

CONCLUSIONS

Three years after the end of the Ebola epidemic, our findings suggest that public healthcare facilities in the N'zérékoré prefecture in Forest Guinea still lack essential protective equipment and some practical training in VHF suspect case detection. To minimize the risk of future VHF epidemics and improve management of outbreaks of infectious diseases in the region, current efforts to strengthen the public healthcare system in Guinea should encompass questions of supply and IPC training.

Dental emergency: Scoping review

Part of the oral health care in the care network encompasses users in emergency cases. This study proposed mapping the determinants of the use of dental care services within the health care network to address dental emergencies within the Brazilian Unified Health System (UHS) and to verify the main gaps in the research in this area. This is a scoping review that took place in 2018 using Andersen's behavioral model as a reference. A total of 16 studies, out of 3786 original articles identified, were included and reviewed. Two reviewers independently conducted the selection process and the decision was consensually made. The mapping of the determinants revealed a greater number of enabling factors and a larger gap in the results. Greater use of the emergency service was registered by people in pain, women, adults, those from an urban area, people with a lower income, and those with less education. In future studies, primary surveys are recommended, which include all ages, and analyze different groups of needs and users that take into account the country's northern region and the different subjects pointed out by this review.

The effect of rurality on the risk of primary amputation is amplified by race

OBJECTIVE

Primary amputation (ie, without attempted revascularization) is a devastating complication of peripheral artery disease. Racial disparities in primary amputation have been described; however, rural disparities have not been well investigated. The purpose of this study was to examine the impact of rurality on risk of primary amputation and to explore the effect of race on this relationship.

METHODS

The national Vascular Quality Initiative amputation data set was used for analyses (N = 6795). The outcome of interest was primary amputation. Independent variables were race/ethnicity (non-Latinx whites vs nonwhites) and rural residence. Multivariable logistic regression examined impact of rurality and race/ethnicity on primary amputation after adjustment for relevant covariates and included an interaction for race/ethnicity by rural status.

RESULTS

Primary amputation occurred in 49% of patients overall (n = 3332), in 47% of rural vs 49% of urban patients (P = .322), and in 46% of whites vs 53% of nonwhites (P < .001). On multivariable analysis, nonwhites had a 21% higher odds of undergoing primary amputation overall (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.05-1.39). On subgroup analysis, rural nonwhites had two times higher odds of undergoing primary amputation than rural whites (AOR, 2.06; 95% CI, 1.53-2.78) and a 52% higher odds of undergoing primary amputation than urban nonwhites (AOR, 1.52; 95% CI, 1.19-1.94). In the urban setting, nonwhites had a 21% higher odds of undergoing primary amputation than urban whites (AOR, 1.21; 95% CI, 1.05-1.39).

CONCLUSIONS

In these analyses, rurality was associated with greater odds for primary amputation in nonwhite patients but not in white patients. The effect of race on primary amputation was significant in both urban and rural settings; however, the effect was significantly stronger in rural settings. These findings suggest that race/ethnicity has a compounding effect on rural health disparities and that strategies to improve health of rural communities need to consider the particular needs of nonwhite residents to reduce disparities.

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review

BACKGROUND

Voluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify.

METHODS

We systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility.

RESULTS

Four randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies.

CONCLUSIONS

Innovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.

A Needs Assessment and Educational Intervention Addressing the Care of Sexual Assault Patients in the Emergency Department

Emergency department (ED) providers serve as the primary point-of-contact for many survivors of sexual assault but are often ill-prepared to address their unique treatment needs. Sexual assault nurse examiners (SANEs) are therefore an important resource for training other ED providers. The objective of this project was to create a SANE-led educational intervention addressing this training gap. We achieved this objective by (a) conducting a needs assessment of ED providers' self-reported knowledge of, and comfort with, sexual assault patient care at an urban academic adult ED and, (b) using these results to create and implement a SANE-led educational intervention to improve emergency medicine residents' ability to provide sexual assault patient care. From the needs assessment survey, ED providers reported confidence in medical management but not in providing trauma-informed care, conducting forensic examinations, or understanding hospital policies or state laws. Less than half of the respondents felt confident in their ability to avoid retraumatizing sexual assault patients, and only 29% felt comfortable conducting a forensic examination. On the basis of these results, a SANE-led educational intervention was developed for emergency medicine residents, consisting of a didactic lecture, two standardized patient cases, and a forensic pelvic examination simulation. Preintervention and postintervention surveys showed an increase in respondents' self-perceived ability to avoid retraumatizing patients, comfort with conducting forensic examinations, and understanding of laws and policies. These results show the value of an interprofessional collaboration between physicians and SANEs to train ED providers on sexual assault patient care.

Caregiver Medication Management and Understanding After Pediatric Hospital Discharge

OBJECTIVES

Caregivers frequently make mistakes when following instructions on discharge medications, and these instructions often contain discrepancies. Minimal literature reflects inpatient discharges. Our objective was to describe failures in caregiver management and understanding of inpatient discharge medications and to test the association of documentation discrepancies and sociodemographic factors with medication-related failures after an inpatient hospitalization.

METHODS

This study took place in an urban tertiary care children's hospital that serves a low-income, minority population. English-speaking caregivers of children discharged on an oral prescription medication were surveyed about discharge medication knowledge 48 to 96 hours after discharge. The primary outcome was the proportion of caregivers who failed questions on a 10-item questionnaire (analyzed as individual question responses and as a composite outcome of any discharge medication-related failure). Bivariate tests were used to compare documentation errors, complex dosing, and sociodemographic factors to having any discharge medication-related failure.

RESULTS

Of 157 caregivers surveyed, 70% had a discharge medication-related failure, most commonly because of lack of knowledge about side effects (52%), wrong duration (17%), and wrong start time (16%). Additionally, 80% of discharge instructions provided to caregivers lacked integral medication information, such as duration or when the next dose after discharge was due. Twenty five percent of prescriptions contained numerically complex doses. In bivariate testing, only race and/or ethnicity was significantly associated with having any failure (P = .03).

CONCLUSIONS

The majority of caregivers had a medication-related failure after discharge, and most discharge instructions lacked key medication information. Future work to optimize the discharge process to support caregiver management and understanding of medications is needed.

Multiple chronic conditions at a major urban health system: a retrospective cross-sectional analysis of frequencies, costs and comorbidity patterns

OBJECTIVE

To (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs.

DESIGN

Retrospective cross-sectional study.

SETTING

Mount Sinai Health System, set in all five boroughs of New York City, USA.

PARTICIPANTS

192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014.

METHODS

We classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected.

RESULTS

61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%.

CONCLUSIONS

In this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts.

Testing gene by community disadvantage moderation of sexual health outcomes among urban women

We examined whether the interplay between community disadvantage and a conduct disorder polygenic risk score (CD PRS) was associated with sexual health outcomes among urban women. Participants (N = 511; 75.5% African American) were originally recruited to participate in a school-based intervention and were followed into adulthood. Community disadvantage was calculated using census data when participants were in first grade. At age 20, blood or saliva samples were collected and participants reported on their condom use, sexual partners, and sexually transmitted infections. A CD PRS was created based on a genome-wide association study conducted by Dick et al. [2010]. Higher levels of community disadvantage was associated with greater sexually transmitted infections among women with a higher CD PRS. Implications of the study findings are discussed.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

[The effect of a falls prevention program in elderly people in primary health care. What does Tai Chi practice provide?]

OBJECTIVE

Falls in the elderly are a major health problem. There are multiple experiences of intervention in primary care. Aim: To evaluate the impact of a multifactorial intervention in the prevention of falls in elderly people. To compare the differential effect of the practice of Tai Chi.

METHODS

Non-randomized before-after quasi-experimental design in an urban health center between the years 2014-2017. The study population was those over 65 years old with a high risk of falls. The intervention consisted of an individual assessment of risk factors: sensory problems, balance, orthostatic hypotension, treatments (psychotropic drugs, hypotensive drugs), barriers, technical aids. It was intervened in its correction. Tai Chi group participation is proposed. The dependent variables (baseline and year measurements) were Barthel, Unipodal Station Test (TEU), number of falls per year, Anxiety/Depression Goldberg Scale (EADG), number of medical consultations per year, walking aids, Daily Dose Defined of analgesics (DDD)/ year. The before-after analysis was performed using the Chi2 and T Student statistics for paired samples.

RESULTS

A total of 93 patients participated with an average age of 76+06,65, 84.9% women. Falls/year baseline 1.65 + 0.24; no significant differences between groups with or without Tai Chi in any baseline variable. At one year, average reduction of falls/year 0.53 (IC95% 0,07-0,99) (p=0.023), EADG anxiety 1.4±0.33 points (p<0.0001), EAGD depression 0.73±0.26 points (p=0.007). 44 patients practiced Tai Chi; finding: reduction of 1.88 (IC95% 0.90-2.80) points (p<0.0001) in EADG anxiety and 0.86 points (IC95% 0.12-1.60) (p=0.024) in EADG depression; 30.9% of patients abandoned technical aids (p<0.0001); 11% started psychotropic drugs. 49 patients did not practice Tai Chi; of them: EADG anxiety reduction of 1,020 points (IC95% 0.07-1.96) (p=0.035); 41.2% of patients initiated psychotropic drugs (p=0.001); none of the patients abandoned technical aids and 14.3% started them (p<0.001).

CONCLUSIONS

The intervention reduced the number of falls, anxiety, the use of psychotropic drugs, depression, and the use of walking aids, with differential benefit of Tai Chi in these last three aspects.

Exploring network structure and the role of key stakeholders to understand the obesity prevention system in an Australian metropolitan health service: study protocol

INTRODUCTION

Little progress has been made to address the increasing obesity prevalence over the past few decades, and there is growing concern about the far-reaching consequences for health and well-being related to obesity on a global scale. Systems thinking is emerging as a suitable approach for obesity prevention, as it allows health researchers, practitioners and policy-makers to systematically synthesise existing data, expose gaps, inform priority setting and identify leverage points in the system. The aim of this study is to trial a systems thinking approach to better understand the local obesity prevention system, and identify gaps and viable opportunities for health promotion activities to strengthen obesity prevention efforts in an Australian metropolitan health service.

METHODS AND ANALYSIS

A mixed methods design will be undertaken in a metropolitan health service area in Perth, Western Australia in 2019-2020. A systems inventory audit will be used to identify physical activity, nutrition and overweight/obesity prevention activities taking place in the study area. An organisational network survey will be administered, and a social network analysis undertaken to examine relationships between organisations in the network. The relationships and interactions will compare the level and type of interactions each organisation has within the network. Parameters including density, centrality and betweenness will be computed using UCINET and Netdraw.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Curtin University Human Research Ethics Committee (approval number HRE2017-0862). Results will be reviewed with members of the advisory group, submitted to relevant journals and presented at relevant conferences to health promotion practitioners and policy-makers. The area health service, as co-producers of the research, will use findings to inform policy and strategy across the study area.

Developing New Zealand's medical workforce: realising the potential of longitudinal career tracking

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Use and completion of partograph during labour is associated with a reduced incidence of birth asphyxia: a retrospective study at a peri-urban setting in Ghana

BACKGROUND

Morbidity of birth asphyxia has been estimated to be 42 million disability-adjusted life years. The study sought to assess the impact of the use and completion of partograph during labour on reducing birth asphyxia at the St Anthony's Hospital, Dzodze, in the Volta Region of Ghana.

METHODS

A retrospective study design using a quantitative approach was adopted for the study. A simple random sampling technique was used to select a total of 200 folders of labouring women who were admitted and delivered at St Anthony's Hospital, Dzodze, between 1st May 2015 and 30th April 2016. A structured checklist, which was developed by using labour and foetal monitoring parameters based on the standards of the World Health Organization partograph usage, was used to review all the 200 existing maternal records.

RESULTS

The findings revealed that partographs were used by midwives at St Anthony's Hospital with the majority of the maternal folders fully completed. The use and completion of partograph were found to be associated with less non-asphyxiated birth outcomes. Labours which were monitored with partograph were 4.29 times less likely to result in birth asphyxia [AOR (95% CI) 4.29 (1.35-14.81)], and those that were monitored with a completed partograph were 5.3 times less likely to result in birth asphyxia [AOR (95% CI) 5.31 (2.011-16.04)].

CONCLUSION

Midwives used partographs during labour at St Anthony's Hospital. The use and completion of partograph were significantly associated with a reduced incidence of birth asphyxia at the hospital. Birth asphyxia could be reduced if partographs are used and completed by midwives during labour in all cases.

Feedback learning opportunities from medical student logs of paediatric patients

BACKGROUND

Feedback can alter medical student logging practices, although most learners feel feedback is inadequate. A varied case mix in rural and urban contexts offers diverse clinical encounters. Logs are an indicator of these clinical experiences, and contain opportunities for feedback, which can greatly influence learning: we labelled these 'feedback learning opportunities' (FLOs). We asked: How often do FLOs occur? What are the case complexities of rural compared to urban paediatric logs? Do more complex cases result in more FLOs?

METHODS

In Western Australia, 25% of medical students are dispersed in a Rural Clinical School (RCSWA) up to 2175 miles (3500 km) from the city. Urban students logged 20 written cases; rural students logged a minimum of 25 paediatric cases electronically. These were reviewed to identify FLOs, using a coding convention. FLO categories provided a structure for feedback: medical, professionalism, insufficient, clinical reasoning, student wellbeing, quality and safety, and sociocultural. Each log was assigned an overall primary, secondary or tertiary case complexity.

RESULTS

There were 76 consenting students in each urban and rural group, providing 3034 logs for analysis after exclusions. FLOs occurred in more than half the logs, with significantly more rural (OR 1.35 95% CI 1.17, 1.56; p < 0.0001). Major FLOs occurred in over a third of logs, but with no significant difference between rural and urban (OR 1.10 95% CI 0.94, 1.28; p = 0.24). Medical FLOs were the most common, accounting for 64.0% of rural and 75.2% of urban FLOs (OR 1.71 95% CI 1.37, 2.12; p < 0.0001). Students logged cases with a variety of complexities. Most cases logged by urban students in a tertiary healthcare setting were of primary and secondary complexity. Major medical FLOs increased with increasing patient complexity, occurring in 32.1% of tertiary complexity cases logged by urban students (p < 0.001).

CONCLUSIONS

Case logs are a valuable resource for medical educators to enhance students' learning by providing meaningful feedback. FLOs occurred often, particularly in paediatric cases with multiple medical problems. This study strengthens recommendations for regular review and timely feedback on student logs. We recommend the FLOs categories as a framework for medical educators to identify FLOs.

The implementation of a team training intervention for school mental health: Lessons learned

Children obtain more mental health services through schools than through any other system. In urban, low-resource schools, mental health care often is provided by teams of contracted community mental health workers. Implementation of intended services may struggle in the context of challenges related to team functioning. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an efficacious approach for improving team functioning in health care. In collaboration with stakeholders, we adapted TeamSTEPPS for school mental health teams and pilot-tested it in 3 schools participating in an ongoing implementation of cognitive-behavioral therapy. In total, 3 teams randomized to receive TeamSTEPPS were compared with 3 teams who did not participate in TeamSTEPPS. Feasibility and acceptability of the adapted TeamSTEPPS and the impact on team skills and behavior were assessed through qualitative interviews and field notes and quantitatively over the course of 1 school year. In this article, we describe the process of adapting and implementing TeamSTEPPS. In addition to providing the researchers' perspective, we illustrate participant perspectives using qualitative data when possible. Key challenges included leader and staff turnover, logistical barriers (e.g., difficulty securing private space for qualitative interviews in schools), and navigating the protection of participant rights and autonomy given that prospective participants were employed by an agency with a vested interest in their participation. Concrete suggestions for overcoming challenges are provided to guide future research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Tobacco Smoking, Substance Use, and Mental Health Symptoms in People with HIV in an Urban HIV Clinic

The prevalence of tobacco smoking among people with HIV (PWH) ranges from 40% to 70%. Additionally, tobacco smoking is higher among low-income individuals, yet few studies have examined tobacco smoking in low socioeconomic status PWH. Using data from a cohort of PWH receiving care in an urban HIV clinic, we characterized factors associated with current and former smoking and with initiation/re-initiation and cessation of tobacco use. Among a study sample of 1,607 PWH, the prevalence of current smoking was 46.6% among men and 46.0% among women. Current smoking in men and women was associated with Medicaid insurance status, substance use, and panic symptoms. In women, but not men, hazardous alcohol use decreased the likelihood of quitting smoking and increased the risk of initiation/re-initiation. Smoking interventions for low-income, urban PWH may need to be tailored to address mental health and substance use comorbidities.

Connecting Community to Research: A Training Program to Increase Community Engagement in Research

BACKGROUND

The Boston University Clinical & Translational Science Institute (BU CTSI) identified a local need to increase the capacity of members of a diverse inner-city community with no prior knowledge of research to partner with researchers along the research continuum.

OBJECTIVES

To design, implement, and evaluate an introductory- level capacity-building training using community pedagogy and providing information about current research and opportunities to partner with local researchers.

METHODS

Guided by two advisory boards of community-engaged professionals and patients, the community engagement team of the BU CTSI designed, implemented, and evaluated the Connecting Community to Research (CCR) training program. We targeted existing community groups in Boston interested in partnering with an academic institution to advance the health of their community. Interactive trainings focused on principles of community-engaged research (CEnR), and how individual experiences might influence research. Each session offered real-time opportunities for participants to engage with local researchers on existing research such as joining a local research advisory group or institutional review board. Self-administered surveys captured participant experiences.

CONCLUSIONS

Over 1 year, we trained 100 community members and almost all participants felt that the objectives of the training program were met and the information was relevant. More than 50% of the participants took advantage of partnership opportunities with local researchers. A toolkit was designed and disseminated to support others to replicate the program. We demonstrated that an interactive training curriculum designed with a community-engaged pedagogy and supported by opportunities for engagement has the ability to successfully partner community members with academic researchers.

Many Shades of Disparities in Myeloma Care

Treatment of multiple myeloma (MM) has notably evolved with improved patient outcomes over the past few years. Several new drugs have become available, and large national and international clinical trials have set the stage for evidence-based medicine guidelines for the treatment of patients with MM. Although patient outcomes have undoubtedly improved, data increasingly show that several disparities exist at varying levels of health care and that these disparities make the care of patients heterogenous and potentially result in inferior outcomes. These disparities have been described with regard to patient age, race/ethnicity, rural-urban residence, socioeconomic status, and insurance type, among other factors. Looking at the global picture of MM care, there is substantial variation among different countries, primarily depending on the disparate availability of anti-MM drugs and access to quality health care across the world, limiting the delivery of innovative therapeutic approaches at the individual patient level. The causes of these national and international disparities could be multifactorial, intricate, and difficult to isolate. Yet the ongoing research in this field is encouraging, and there seems to be growing momentum to understand such disparities and their causes. It is hoped that this research will lead to solutions that can be implemented in the near future. This review focuses on certain aspects of disparities in MM care, highlighting disparities among different racial/ethnic subgroups, rural-urban differences in America, and global disparities at an international level.

Effects of China's urban basic health insurance on preventive care service utilization and health behaviors: Evidence from the China Health and Nutrition Survey

Background

Lifestyle choices are important determinants of individual health. Few studies have investigated changes in health behaviors and preventive activities brought about by the 2007 implementation of Urban Resident Basic Health Insurance (URBMI) in China. This study, therefore, aimed to explore whether URBMI has reduced individuals’ incentives to adopt healthy behaviors and utilize preventive care services.

Methods

Data were drawn from two waves of the China Health and Nutrition Survey. Respondents were categorized according to their insurance situation before and after the URBMI reform in 2006 and 2011. Propensity score matching and difference-in-differences methods were used to measure levels of preventive care and behavior changes over time. Estimations were also made based on gender, self-reported health, and income.

Results

We found that URBMI implementation did not change residents’ utilization of preventive care services or their smoking habits, drinking habits, or other risky behaviors overall. However, the likelihood of sedentariness did increase by five percentage points. Females tended to be more sedentary while males were less likely to drink soft drinks. Residents with poor self-reported health exercised less while those who reported good health were more likely to be sedentary. Low- and middle-income residents were likely to be sedentary while middle-income people tended to smoke after becoming insured.

Conclusion

Since URBMI implementation, some unhealthy behaviors like sedentariness have increased among those who were newly insured, and different subgroups have reacted differently. This suggests that the insurance design needs to be optimized and effective measures need to be adopted to help improve people’s lifestyle choices.

The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale

BACKGROUND

Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research.

METHODS/DESIGN

Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation.

DISCUSSION

The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.

Knowledge, perception and practice towards oxytocin stability and quality: A qualitative study of stakeholders in three resource-limited countries

Background

Oxytocin is the gold standard drug for the prevention of postpartum haemorrhage, but limitations in cold chain systems in resource-constrained settings can severely compromise the quality of oxytocin product available in these environments. This study investigated the perspectives and practices of stakeholders in low and lower-middle income countries towards oxytocin, its storage requirements and associated barriers, and the quality of product available.

Methods

Qualitative inquiries were undertaken in Ethiopia, India and Myanmar, where data was collected through Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). A total of 12 FGDs and 106 IDIs were conducted with 158 healthcare providers (pharmacists, midwives, nurses, doctors and obstetricians) and 40 key informants (supply chain experts, program managers and policy-makers). Direct observations of oxytocin storage practices and cold chain resources were conducted at 51 healthcare facilities. Verbatim transcripts of FGDs and IDIs were translated to English and analysed according to a thematic content analysis framework.

Findings

Stakeholder awareness of oxytocin heat sensitivity and the requirement for cold storage of the drug was widespread in Ethiopia but more limited in Myanmar and India. A consistent finding across all study regions was the significant barriers to maintaining a consistent cold chain, with the lack of refrigeration facilities and unreliability of electricity cited as major challenges. Perceptions of compromised oxytocin quality were expressed by some stakeholders in each country.

Conclusion

Knowledge of the heat sensitivity of oxytocin and the potential impacts of inconsistent cold storage on product quality is not widespread amongst healthcare providers, policy makers and supply chain experts in Myanmar, Ethiopia and India. Targeted training and advocacy messages are warranted to emphasise the importance of cold storage to maintain oxytocin quality.

Comparing the needs and utilization of health services between urban residents and rural-to-urban migrants in China from 2012 to 2016

BACKGROUND

With a large population of internal migrants from all over the world, China has the largest number of internal floating migrants, and most of them (up to 169 million in 2016) are rural-to-urban migrants. Those migrants have difficulty accessing essential health care services because of Hukou, leading to disparities in health needs and utilization between rural-to-urban migrants and residents. To compare the needs and utilization of health services between urban residents and rural-to-urban migrants in China from 2012 to 2016.

METHOD

We used longitudinal data from the Chinese Labor Dynamic Survey (CLDS) with three waves in 2012, 2014 and 2016. Descriptive analysis was employed to show self-reported illnesses and health services utilization among locals and migrants in the most recent 2 weeks in China. Chi-square tests and log binomial regression models were constructed to explore factors influencing health care needs and utilization.

RESULT

A total of 19.97% of respondents were rural-to-urban migrants, with an upward trend from 2012 to 2016. Rural-to-urban migrants (11.99%) had higher needs for health services than urban residents (10.47%) in general, while urban residents and migrants had no differences in needs in 2012. Besides, there was no difference in the utilization of health services between residents and migrants in 2012, 2014 or 2016. In addition, increased age, male sex, poor medical insurance coverage and dissatisfaction with income were found to have negative effects on health care needs.

CONCLUSION

This study has shown that the rural-to-urban migrants had higher health care needs but the same health care utilization compared with urban residents in China. Health policies focusing on equitable health outcomes should pay more attention to rural-to-urban migrants in China's health care system reform.

Rural Doc Hopes to Build Ties With Big Cities

Jacksonville OB-Gyn hopes rural docs and big centers can build collegiality.

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania

BACKGROUND

Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania.

METHODS

This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency.

RESULTS

We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively.

CONCLUSION

In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

Prognostic Utility of Initial Lactate in Patients With Acute Drug Overdose: A Validation Cohort

STUDY OBJECTIVE

Previous studies have suggested that the initial emergency department (ED) lactate concentration may be an important prognostic indicator for inhospital mortality from acute drug poisoning. We conduct this cohort study to formally validate the prognostic utility of the initial lactate concentration in a larger, distinct patient population with acute drug overdose.

METHODS

This observational, prospective, cohort study was conducted during 5 years at 2 urban teaching hospitals. Consecutive adult ED patients with acute drug overdose had serum lactate levels tested as part of clinical care. The primary outcome was inpatient fatality. Receiver operating characteristics were plotted to determine optimal cut points, test characteristics, area under the curve, odds ratios, and 95% confidence intervals (CIs).

RESULTS

Of 3,739 patients screened, 1,406 were analyzed (56% women; mean age 43.1 years) and 24 died (1.7%). The difference in mean initial lactate concentration was 5.9 mmol/L (95% CI 3.4 to 8.1 mmol/L) higher in patients who died compared with survivors. The area under the curve for prediction of fatality was 0.85 (95% CI 0.73 to 0.95). The optimal lactate cut point for fatality was greater than or equal to 5.0 (odds ratio 34.2; 95% CI 13.7 to 84.2; 94.7% specificity). Drug classes for which lactate had the highest utility were salicylates, sympathomimetics, acetaminophen, and opioids (all area under the curve ≥0.97); lowest utility was for diuretics and angiotensin-converting enzyme inhibitors.

CONCLUSION

Initial lactate concentration is a useful biomarker for early clinical decisionmaking in ED patients with acute drug overdose. Studies of lactate-tailored management for these patient populations are warranted.