Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals.

BACKGROUND: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited. OBJECTIVE: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs. DESIGN: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals. SUBJECTS: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017). MEASURES: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year. RESULTS: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ. CONCLUSIONS: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

BACKGROUND: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Evaluation of the 2020 Pediatric Emergency Physician Workforce in the US.

Importance: Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however. Objective: To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US. Design, Setting, and Participants: This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020. Main Outcomes and Measures: The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates. Results: A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population. Conclusions and Relevance: This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Management of Traumatic Brain Injury at a Medium Complexity Hospital in a Remote Area of Amazonas, 2017-2019.

OBJECTIVE: To describe the traumatic brain injury (TBI) care in the city of Coari, Amazonas, from 2017-2019. METHODS: Ecological study based on the analysis of the data obtained by the Epidemiology Service of the Regional Hospital of Coari regarding TBI attendances in the emergency room from January 2017 to October 2019. According to the Glasgow Coma Scale, TBI was classified as mild, moderate, or severe. Other variables analyzed were sex, age, main causes of TBI, hospitalizations at the admission unit, and transfers to another health center and means of transport used. RESULTS: One hundred ten admissions were registered: 24 mild TBI, 51 moderate, and 35 severe; higher prevalence among men (70%); and age between 20 and 29 years (29%). The main causes were motorcycle accidents (42.7%), falls (29%), and physical aggression (21%). Some 69% of the patients admitted required to be transferred to another health center, with aerial intensive care unit (ICU) as the most significant means of transport (48.7%). Thirty patients hospitalized at the admission unit progressed with hospital discharge and 4 died. CONCLUSIONS: The profile of patients affected by TBI in the city of Coari was characterized by male victims of motorcycle accidents with age between 20 and 29 years. The high transfer rates indicates the need for a better neurotrauma assistance. Further investigations and studies associated with regional specificities are essential to recommend changes on the scope of public health and therefore decrease the incidence of TBI.

A survey on the current status of clinical resources for diagnosis and treatment of breast cancer in rural hospitals of the Tohoku region in Japan.

BACKGROUND: We administered a questionnaire survey to assess the available clinical resources for the diagnosis and treatment of breast cancer and identify the issues faced by rural hospitals in the Tohoku region in Japan. METHODS: The term rural hospital was defined by the following three criteria: the facility is a certified regional cancer center and hospital, no breast specialist is on staff, and ≥ 10 breast surgeries per year have been performed. Thirty-eight rural hospitals were eligible, and each was sent a self-administered questionnaire consisting of 26 questions by mail. RESULTS: Responses were received from 29 of the 38 hospitals. Most of the hospitals had adequate facilities for diagnosis and treatment, but they needed specialists' support for ≥ 2 days per month. Approximately half of the hospitals indicated that applying resources for diagnosis and treatment of breast cancer, especially during planning of treatment and management of advanced breast cancer patients, was a burden. Interestingly, the hospitals felt that being able to provide treatment to their patients was more ideal rather than referring them to urban hospital like the prefectural cancer center and hospital providing specialized cancer treatment. CONCLUSIONS: The surveyed rural hospitals needed practical and knowledge-based support from specialists. Unfortunately, the number of specialists is currently insufficient in Tohoku. Increased number of certified physicians, clinical pathways for sharing patient's information and updated knowledge, and information and communication technology for treatment with specialists' intervention in rural hospitals may solve issues in Tohoku.

Project to improve storage, access and incorporation of advance care plans in a regional Australian hospital.

PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent. DESIGN: Quality improvement study. SETTING: A Western Australian regional hospital. KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care. STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education. EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described. LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.

The Impact of Hospital Characteristics on the Availability of Radiology Services at Critical Access Hospitals.

PURPOSE: Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities. METHODS: Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location. RESULTS: Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88). CONCLUSIONS: Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas.

Spatial access to inpatient health care in northern rural India.

Access to health care in rural areas is a major concern for local populations as well as for policy makers in developing countries. This paper examines spatial access to in-patient health care in northern rural India. In order to measure spatial access, impedance-based competition using the Three-Step floating Catchment Area (3SFCA) method, a modification of the simple gravity model, was used. 3SFCA was chosen for the study of the districts of Pratapgarh and Kanpur Dehat in the Uttar Pradesh state and Vaishali in the Bihar state, two of India's poorest states. This approach is based on discrete distance decay and also considers more parameters than other available methods, hence is believed to be a robust methodology. It was found that Vaishali district has the highest spatial access to in-patient health care followed by Pratapgarh and Kanpur Dehat. There is serious lack of health care, in Pratapgarh and Kanpur Dehat with 40% and 90% of the villages having shortage of in-patient care facilities in these respective districts. The most important factor affecting spatial access was found to be the distance to the nearest major urban agglomeration.

[Analysis of health seeking behavior based on the planned-action theory in rural area of China].

OBJECTIVE: To explore the influencing factors on patients' health seeking behavior in rural China by employing the theory of planned action. METHODS: Data from cross-sectional household-based health survey carried out in 2008 were used in the study. Correlations between outcomes and explanatory variables were studied by Logistic regression. RESULTS: The studying population included 19 389 adult patients over the age of 15. Illness awareness, medical experience and structural restriction factors had strong effect on whether the patients chose medical service. People in different socioeconomical status suffered different influences. CONCLUSION: Responding to the changing trend of health service demand among rural residents, we should recognize the differentiation and allocate the healthcare resources more rationally.

An aged persons mental health service in remote Victoria.

OBJECTIVE: To describe an aged persons mental health service in the Sunraysia district in remote Victoria. CONCLUSION: The aged persons mental health community team undertakes the bulk of the service's work. The data for 2 years are presented and demonstrate how effective the team is. Good relationships and linkages have been built with the local hospital, general practitioners, aged residential care services and the local aged care assessment service. During the 2 year period, very few elderly patients were admitted to the inpatient psychiatric facility and patients suffering from dementia were rarely admitted.

Critical access hospitals.

A variety of factors are coming together that will ignite an explosion of conversions to critical access hospital status. What hospitals are eligible to become CAHs, what are the benefits to converting and what should hospital leaders consider before taking the plunge?