Search

Background: Given the low usage of virtual health care prior to the COVID‐19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID‐19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. Methods: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID‐19 pandemic onset. Results: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre‐ to post‐COVID‐19 onset (32.5–16.0% and 44.7–24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in‐person visits compared with the rural cohort (96.6–45.0 vs. 98.0–66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre‐ to post‐COVID‐19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. Conclusions: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits). [ABSTRACT FROM AUTHOR]

Background: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. Methods: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. Results: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round‐trip to access care if those FPs were to stop delivering. Conclusions: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families. [ABSTRACT FROM AUTHOR]

Purpose: Rural areas of the United States have experienced outbreaks of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among people who use drugs (PWUD). Pharmacy‐based interventions may play a crucial role in prevention and entry into care, especially when traditional health care access is limited. The willingness of rural PWUD to use pharmacies for HIV/HCV‐related services remains unknown. The purpose of this study was to describe the factors associated with the perceived likelihood of participating in free pharmacy‐based HIV and HCV testing among PWUD living in rural Kentucky. Methods: Baseline data from the CARE2HOPE study in five Appalachian counties in eastern Kentucky were used. Participants were recruited using respondent‐driven sampling and completed interviewer‐administered surveys. Guided by the Andersen and Newman Framework of Health Services Utilization, we examined distributions and correlates of items regarding willingness to participate in free pharmacy‐based HIV/HCV testing using logistic regression. Analyses included individuals who reported being HIV (N = 304) or HCV (N = 185) negative. Findings: Seventy‐five percent of PWUD reported being "very likely" to participate in free pharmacy‐based HIV testing and 80% for HCV testing. Two factors were associated with being less willing to participate in free HIV testing: PWUD who previously tested for HIV (OR: 0.47, CI: 0.25–0.88) and PWUD who obtained a high school diploma or equivalent compared to those who completed less (OR: 0.50, CI: 0.26–0.99). Conclusion: Free pharmacy‐based HIV and HCV testing was invariably acceptable among most of the rural PWUD in our sample, suggesting that pharmacies might be acceptable testing venues for this population. [ABSTRACT FROM AUTHOR]

Background: The aim of this article is to describe older people's perceptions of caring relations in the context of rural eHealth, as well as to explore how such relations can facilitate engagement in digital primary health care. There is an ongoing implementation of eHealth in Western health care, and rural areas and older people are specifically targeted. eHealth is said to be a solution to emergent problems and a technology that will facilitate people's opportunities to achieve good and equal health. From this perspective, it is crucial that older people engage in eHealth services, but there are barriers for use, and care providers need to adapt to the preferences of older people. Methods: Semi-structured interviews with 19 individuals aged 61-85 were conducted. The participants were using digital services at two primary healthcare centres located in northern Sweden. Qualitative content analysis was used. An important theoretical tenet was that older people's perceptions of and engagements in eHealth are affected by the specific rural conditions. Ethical approval for the study has been obtained. Results: The analysis rendered a total of three themes: inperson interaction was central to people's perceptions of good caring relations; patient--nurse relations were particularly emphasised; and caring relations in rural eHealth appeared to be multi-directional and fuelled by a shared sense of rural community. Altogether, this facilitated participants' engagement in local eHealth initiatives. Conclusions: eHealth is an opportunity for primary health care and for rural communities. However, the results provide insight into matters that can affect the quality, access, and equality of rural primary health care. Participants' engagement in eHealth was almost always facilitated by close caring relations with local Registered Nurses. Digital care needs to be approached as a combination of digital and in-person presence. Separating digital and physical task assignments among different personnel could make older people refrain from seeking health care. [ABSTRACT FROM AUTHOR]

This paper leverages the expansion of the United States' Community Health Center program over the 21st century to investigate whether improved access to health care reduces disability insurance (DI) participation at the county level. I find that the introduction of a health center that specializes in mental health and substance abuse services is associated with a 0.09 to 0.40 percentage point reduction in working‐age DI enrollment in rural counties. A cost‐benefit analysis indicates that the money saved from reduced program participation can account for more than a third of the cost the federal government faces in funding well‐targeted health care access initiatives. [ABSTRACT FROM AUTHOR]

Purpose: To investigate (1) all‐payer inpatient volume changes at rural hospitals and (2) whether trends in inpatient volume differ by organizational and geographic characteristics of the hospital and characteristics of the patient population. Methods: We used a retrospective, longitudinal study design. Our study sample consisted of rural hospitals between 2011 and 2017. Inpatient volume was measured as inpatient average daily census (ADC). Additional measured hospital characteristics included census region, Medicare payment type, ownership type, number of beds, local competition, total margin, and whether the hospital was located in a Medicaid expansion state. Measured characteristics of the local patient population included total population size, percent of population aged 65 years or older, and percent of population in poverty. To identify predictors of inpatient volume trends, we fit a linear multiple regression model using generalized estimating equations. Findings: Rural hospitals experienced an average change in ADC of −13% between 2011 and 2017. We found that hospital characteristics (eg, census region, Medicare payment type, ownership type, total margin, whether the hospital was located in a Medicaid expansion state) and patient population characteristics (eg, percent of population in poverty) were significant predictors of inpatient volume trends. Conclusions: Trends in inpatient volume differ by organizational and geographic characteristics of the hospital and characteristics of the patient population. Researchers and policy makers should continue to explore the causal mechanisms of inpatient volume decline and its role in the financial viability of rural hospitals. [ABSTRACT FROM AUTHOR]

Purpose: For individuals with cancer, palliative care improves quality of life, mood, and survival. Rural residents experience limited access to palliative care. In eastern North Carolina, a rural area, little is known about access to inpatient cancer‐related palliative care. This study describes access to inpatient palliative care and developed a predictive model of who was most likely to be admitted to an inpatient facility without a palliative care provider. Methods: A descriptive, exploratory design was used to examine demographics, clinical variables, and inpatient admissions from 2017 and 2018, in a major regional teaching hospital system that included 8 hospitals (7 rural hospitals). Descriptive statistics and a binary logistic regression were used to analyze data. Findings: The mean age was 62.2 years (N = 2,161, range: 18‐88, SD = 15.52): 49.4% were female, 54% lived in a rural county, and 44.4% were black. The outlying rural hospitals, with no palliative care providers on staff, had 388 admissions (18%). Only gender (P =.0128), county (P <.0001), and age (P <.05) contributed to the logistic model. The predicted probability of being admitted to an inpatient facility with a palliative care provider is higher for younger males living in urban counties. That probability decreases with age regardless of the gender or type of county. Conclusions: These findings highlight the limited availability of inpatient palliative care for those with cancer. Women, older adults, and rural residents are more likely to be admitted to 1 of the 7 rural hospitals with no palliative care provider on staff. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper was to use current stroke care guidelines to identify and discuss current stroke care challenges in rural Australian health care and potential solutions for delivery of evidence‐based practice. Design and setting: A review of national guidelines since 2002 for organised stroke care was undertaken to determine best practice for delivering primary stroke care. We then employed a narrative literature review strategy looking at relevant articles, based on keywords, outlining current stroke service availability in Australia, highlighting the challenges of implementing evidence‐based stroke care in rural areas in Australia based on the current guidelines. Results: Delivery of evidence‐based stroke care in rural Australia is fraught with challenges. Although national best‐practice guidelines for stroke care are well established, the recommendations made in these guidelines do not always reflect the resource availability in rural Australia. Redesigning processes and utilising available resources, such as telemedicine or local clinical pathways, can achieve an evidence‐based standard; however, ultimately better resourcing of these areas is required. Conclusion: Evidence‐based stroke care, aligned with current national standards is the key to providing adequate stroke services in rural Australia. Improved health service resourcing and better utilisation of currently available resources are options for achieving elements of evidence‐based stroke care. Implications for public health: Availability of adequate services for stroke patients directly impacts public health as it determines health outcomes for these patients. Indirect implications for public health include the effects on health professionals and the general public. [ABSTRACT FROM AUTHOR]

Purpose This study explored the role of the Health Belief Model in predicting breast cancer screening among women in rural Appalachia. Health beliefs (perceived susceptibility to breast cancer, severity of breast cancer, and benefits and barriers to screening) were used to predict health behavior (mammogram frequency). Method A total of 170 women aged 18-78 were recruited at a free health clinic in central Appalachia. Women completed surveys that assessed demographic characteristics, mammogram frequency, and perceived susceptibility, severity, and benefits and barriers to mammography. Findings Consistent with expectations, women with objectively elevated risks for breast cancer (history of abnormal mammograms or family history of breast cancer) perceived themselves to be at higher risk for breast cancer, and those with a history of abnormal mammograms were more likely to receive mammograms regularly. In addition, older women expected their prognosis to be marginally poorer following a diagnosis, perceived greater benefits and fewer barriers to mammography, and were significantly more likely to receive mammograms regularly. Consistent with the Health Belief Model, fewer perceived barriers to mammography predicted greater mammogram frequency. However, the model was not fully supported because perceived susceptibility, severity, and benefits to mammography did not predict mammogram frequency. Conclusions Results highlight the importance of reducing real and perceived barriers to screening in order to improve mammography rates among rural populations. [ABSTRACT FROM AUTHOR]

Objective: To describe the distribution of Veterans in areas of the United States where there are potentially inadequate supplies of health professionals, and to explore opportunities suggested by this distribution for fostering health workforce flexibility.Data Sources: County-level data from the 2015-2016 Health Resources and Services Administration's (HRSA's) Area Health Resources Files (AHRF) were used to estimate Veteran populations in HRSA-designated health professional shortage areas (HPSAs). This information was then linked to 2015 VA health facility information from the Department of Veterans Affairs.Study Design: Potential Veteran populations living in Shortage Area Counties with no VHA facilities were estimated, and the composition of these populations was explored by Census division and state.Principal Findings: Nationwide, approximately 24 percent of all Veterans and 23 percent of Veterans enrolled in VHA health care live in Shortage Area Counties. These estimates mask considerable variation across states.Conclusions: An examination of Veterans residing in Shortage Area Counties suggests extensive maldistribution of health services across the United States and the continued need to find ways to improve health care access for all Veterans. Effective avenues for doing so may include increasing health workforce flexibility through expansion of nurse practitioner scopes of practice. [ABSTRACT FROM AUTHOR]

In this article, the author discusses the national shortage of general surgeons in the U.S. It state the need for surgeons in rural areas while mentioning that medical students are choosing surgery as a residency. It also mentions the working of the Accreditation Council of Graduate Medical Education (ACGME) for emergency operations and trauma.

Objective: To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers.Data Sources: Experimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services.Study Design: We generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates' sensitivity to the inclusion of control variables.Data Collection: The primary data are from a large field study.Principal Findings: Approximately 80 percent of Medicaid callers receive an appointment in rural areas-a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment.Conclusions: Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees. [ABSTRACT FROM AUTHOR]

Purpose: This study estimates whether physicians in rural Pennsylvania have higher odds of career dissatisfaction and plans to leave patient care in the next 6 years, compared to their urban counterparts. Rural‐urban differences were estimated across specific subgroups of physicians (gender, race, and specialty) and with regard to specific sources of career dissatisfaction. Methods: The 2012 Pennsylvania Health Workforce Survey of Physicians allowed for analysis of 17,444 physicians younger than 55 years old actively practicing patient care. Multivariate, logistic regression was performed to estimate the associations with 2 outcome areas: career dissatisfaction and plans to leave patient care in the next 6 years. Controls included rural setting, age, sex, race, work hours, specialty, and practice characteristics. Results: Over 12% of under‐55 physicians are dissatisfied with their careers and over 18% report plans to leave patient care in the next 6 years. Rural physicians in Pennsylvania have 18.6% higher odds of reporting career dissatisfaction and 29.5% higher odds of leaving patient care in the next 6 years (P <.01 for each) versus their urban counterparts. Conclusions: Rates of dissatisfaction and potential attrition among younger physicians are not insignificant, with a stronger association with rural practice. Given the large number of rural health shortage areas, better understanding this association is important to health care providers and policy makers. Regression results suggest that higher rural odds are related more to physician work (ie, stress, practice demands, and lack of autonomy) and family situations and less related to income concerns. [ABSTRACT FROM AUTHOR]

Objective: To identify and compare the factors affecting the knowledge of, attitude towards and use of antibiotics between urban and rural residents in China.Methods: A total of 3631 urban and rural residents in Heilongjiang Province, China, were selected using random sampling. Questionnaires recorded demographic characteristics and participant knowledge of, attitude towards and use of antibiotics. The responses of rural and urban residents were compared, and logistic regression analysis was applied to identify the factors that may contribute to the knowledge of, attitude towards and use of antibiotics.Results: The majority of the participants (>60%) were aware that antibiotics could be used to treat bacterial infections and that bacteria could be resistant to antibiotics. However, only roughly half (40-60%) of the participants were aware that bacterial resistance to antibiotics had become a problem in China. Urban participants reported a more adequate knowledge of, attitude towards and use of antibiotics than rural participants. Logistic regression analysis indicated that urban residency, female gender and level of education were associated with knowledge of, attitude towards and use of antibiotics.Conclusions: Within our sample in Heilongjiang Province, the knowledge of, attitude towards and use of antibiotics were suboptimal in roughly half of all urban and rural residents, but better in urban than in rural residents. Targeted interventions to educate rural residents in particular may reduce the misuse of antibiotics. [ABSTRACT FROM AUTHOR]

Rationale and Aim While interprofessional practice has been promoted as a solution to the challenges besetting rural health services, current evidence does not offer a clear explanation as to why it is effective in some domains and yet is not successful in others. At the same time, rural clinicians are frequently faced with major workforce pressures and this has a significant influence on professional practice. The aim of this study was to explore how these pressures impact on rural interprofessional practice. Method This study is part of a larger project investigating factors that enhance and detract from effective interprofessional working. We utilised a modified realistic evaluation approach to analyse the context, mechanisms and outcomes of rural interprofessional practice. Approval for this study was granted by an accredited research ethics committee. Semi-structured interviews were conducted with 22 rural clinicians who were purposively recruited from a range of settings, roles, locations and professions. Findings and Discussion We found that clinicians often invested in interprofessional practice because of the need to manage intense workloads and this necessitated sharing of responsibilities across disciplines and blurring of role boundaries. Paradoxically, participants noted that workload pressures hampered interprofessional working if there were long-term skill shortages. Sharing workload and responsibility is an important motivator for rural practitioners to engage in interprofessional practice; however, this driver is only effective under circumstances where there are sufficient resources to facilitate collaboration. In the context of intransient resource challenges, rural health service managers would be best to focus on enabling IPP through facilitating role understanding and respect between clinicians. This is most feasible via informal workplace learning and allowing time for teams to reflect on collaborative processes. [ABSTRACT FROM AUTHOR]

Community research and action projects undertaken by community-university partnerships can lead to contextually appropriate and sustainable community improvements in rural and urban localities. However, effective implementation is challenging and prone to failure when poorly executed. The current paper seeks to inform rural community-university partnership practice through consideration of first-person accounts from five stakeholders in the Rural Embedded Assistants for Community Health (REACH) Network. The REACH Network is a unique community-university partnership aimed at improving rural health services by identifying, implementing, and evaluating innovative health interventions delivered by local caregivers. The first-person accounts provide an insider's perspective on the nature of collaboration. The unique perspectives identify three critical challenges facing the REACH Network: trust, coordination, and sustainability. Through consideration of the challenges, we identified several strategies for success. We hope readers can learn their own lessons when considering the details of our partnership's efforts to improve the delivery infrastructure for rural healthcare. [ABSTRACT FROM AUTHOR]

Objective. To test whether nonprofit, for-profit, or government hospital ownership affects medical service provision in rural hospital markets, either directly or through the spillover effects of ownership mix. Data Sources/Study Setting. Data are from the American Hospital Association, U.S. Census, CMS Healthcare Cost Report Information System and Prospective Payment System Minimum Data File, and primary data collection for geographic coordinates. The sample includes all nonfederal, general medical, and surgical hospitals located outside of metropolitan statistical areas and within the continental United States from 1988 to 2005. Study Design. We estimate multivariate regression models to examine the effects of (1) hospital ownership and (2) hospital ownership mix within rural hospital markets on profitable versus unprofitable medical service offerings. Principal Findings. Rural nonprofit hospitals are more likely than for-profit hospitals to offer unprofitable services, many of which are underprovided services. Nonprofits respond less than for-profits to changes in service profitability. Nonprofits with more for-profit competitors offer more profitable services and fewer unprofitable services than those with fewer for-profit competitors. Conclusions. Rural hospital ownership affects medical service provision at the hospital and market levels. Nonprofit hospital regulation should reflect both the direct and spillover effects of ownership. [ABSTRACT FROM AUTHOR]

A literature review was performed to assess the role of physician assistants (PAs) in rural health care. Four categories were examined: scope of practice, physician perceptions, community perceptions, and retention/recruitment. A search of the literature from 1974 to 2008 was undertaken by probing the electronic bibliographic databases of English language literature. Criterion for inclusion was original data published on rural PAs. Each paper was assessed and assigned to the four categories. A total of 51 papers were identified; 28 papers had a primary focus on research and specified PAs in a rural setting. Generally, the literature suggests that PAs provide cost-efficient and supplemental medical services to underserved rural populations and that these services are valued. It also appears that rural PAs possess a larger scope of practice than urban PAs. This broad range of skills and procedures may be necessary to match the extensive health care needs of underserved rural populations. Over a 35-year period of examination, the literature improved in numbers of PAs studied and the quality of research. However, the lack of longitudinal studies was considered a shortcoming of rural health PA observational research. Through this review, some insights about the role of PAs emerged. Overall, they seem well adapted to rural health. Important issues regarding the recruitment and retention of PAs to rural populations also emerged. Improvement in enabling legislation contributes to the utilization of PAs in America. [ABSTRACT FROM AUTHOR]

We examine the implications of health-seeking behavior on access to quality health care using a unique dataset that combines a household survey from rural Tanzania with the location and quality of all health facilities available to households. Patients do not always visit the nearest facility, but choose from among multiple facilities, improving the quality of care they receive by bypassing low quality facilities. Recognizing this behavior alters the projected benefits to health interventions, reducing the value of focusing on the staff qualifications and increasing the value of focusing on travel time and the motivation of current staff. [ABSTRACT FROM AUTHOR]

This paper describes the evaluation of a mental health liaison (MHL) role in a rural community in Alberta, Canada. The role provides advocacy, education, indirect and direct client intervention, and follow up. It was developed to eliminate gaps in mental health care and build collaborative cultures between the local hospital, physicians' offices, mental health clinics, and community agencies. Obtaining stakeholder feedback was an important step in assessing initial service impact while providing directions for role refinement and future programme development. A total of 116 questionnaires were distributed to physicians, hospital staff, and community mental health assessing stakeholder perception relating to various functions of the MHL. A 50% ( n = 58) response rate was achieved with broad representation from different partners, including 75% of local physicians. The majority of respondents positively perceived the roles, functions, and impact of the MHL, including relationship development across the hospital community, improved access to services, and perceived improved client outcomes. The results reinforced that the MHL service meets a previously unmet need in this rural setting. Findings are being used to refine roles, provide local learning and resource development, understand issues relating to programme development in other areas, and develop client level outcomes relating to the services delivered. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this qualitative study was to investigate the experiences of nurse practitioners (NPs) 1 year after they were first introduced to a mostly rural Canadian province. Data sources: Qualitative analyses of individual 45-min interviews with seven of the nine NPs in the province were carried out. Conclusions: Three main themes of importance were identified. First, a nursing philosophy with a holistic approach was described as being clearly different from medical care. Second, difficulties and barriers encountered in the establishment of the profession in the province were described. Third, despite these barriers, a pioneering outlook characterized by a sense of excitement and pride in the work was expressed. Implications for practice: For NPs to work effectively to reduce healthcare costs and increase access to health care, they need to be accepted by both the public and the other healthcare professionals. Moreover, it may be difficult for NPs to maintain their philosophy of care in the face of the expectations placed upon them. [ABSTRACT FROM AUTHOR]

Describes the implementation of a computerised information system to collect workload data and discusses feedback from staff evaluation of use and value. Feedback interviews following service implementation. Remote rural primary health care, Scotland. Thirty-three primary health care staff. Not relevant, as the study was service development with qualitative evaluation. Findings of evaluation interviews indicate a number of themes common to remote rural practice that make implementing a computerised information system problematical. These include: logistical problems caused by small practice teams and wide areas covered; inadequate allowance for recording of blurred roles and the wide range of non-clinical duties carried out; lack of local contextual and cultural information, which is necessary to make sense of data collected. Remote rural health professionals found reports from the system of limited value as they felt they already had good knowledge of local activities and had few opportunities, due to small teams, to use data for service redesign. Remote rural primary care is underpinned by a number of organisational and philosophical features that require understanding when considering the implementation of initiatives developed in an urban working environment. A small number of studies have evaluated the implementation of information systems in primary health care, but there is little information about the feasibility and value of routinely gathering data in rural areas. This work was required to assess the extent to which information systems developed in urban practice can be implemented and are applicable to rural practice. This evaluation shows that certain features of rural practice may mean that data gathering has to be adapted and that, in any case, rural practices may find less value in the outputs of information systems compared with urban counterparts. Those considering the dissemination of national initiatives should consider the need to adapt their policies for implementation in rural settings. [ABSTRACT FROM AUTHOR]

Introduction: Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting. Methods: A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-based service. Results: An estimated saving of AU$1077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time. Conclusion: The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available. [ABSTRACT FROM AUTHOR]

This paper explores issues concerning the development of linkages across the interface between acute and community aged care services in a small regional Australian city. It addresses a participatory action research project that took place over a 2 year period involving an Aged Care Assessment Team (ACAT). Aged Care Assessment Teams are multidisciplinary teams whose members mediate between hospitals and the aged care system in the community and have a key role in developing networks and linkages between various service providers in the field. In an age of economic rationalist-inspired reform agendas in health and community care, rural infrastructures have been compromised to such a degree that the role of rural ACAT in developing linkages between sectors has never been more important. This paper takes up this issue and addresses the project findings, which highlight a field characterised by ineffective linkages within and between the various sectors, a lack of understanding of the operation of the rural aged care system among nurses working in regional hospitals, and the efficacy of ACAT working collaboratively with nurses to create new and more effective linkages in aged care. [ABSTRACT FROM AUTHOR]

SUMMARYIn remote areas, telemedicine services can improve the quality of access to specialist medical care and dermatology is well suited to the use of this technology. There is no published work on teledermatology services in Australia. Our purpose was to investigate the reliability of dermatological diagnoses obtained using a store and forward telemedicine system, which is being developed to offer specialist consultative services to patients in remote areas of Western Australia. We report on a small prospective non-randomized pilot study conducted at Royal Perth Hospital, Western Australia which compared diagnoses reached following telemedicine consultations with diagnoses reached following traditional face-to-face consultations. In 25 out of 30 consultations, identical diagnoses were reached. In the remaining five cases, the preferred diagnosis and first differential diagnosis were reversed in order of preference. We feel this system is sufficiently promising to trial more extensively in the field. [ABSTRACT FROM AUTHOR]

In response to many scientific discoveries linking cancer in certain families to inherited factors, the Vermont Cancer Center established the Familial Cancer Program (FCP) in December 1993. This multifaceted program combines the expertise of clinicians and researchers in many disciplines, including genetics, oncology, psychology, and molecular biology. The program's goals are identification of families in its region with excess cancer, provision of clinical services to such families, and use of research protocols when available and appropriate. This article describes the experience of setting up a familial cancer program in a rural area and discusses both successes and challenges in such an endeavor. [ABSTRACT FROM AUTHOR]