Dementia Care in Rural Appalachia: Multilevel Analysis of Individual- and County-Level Factors.

BACKGROUND AND OBJECTIVES: Home- and community-based services (HCBS) are underutilized, despite offering significant health benefits to both care recipients and caregivers. Drawing upon Andersen's extended behavioral model of health services use, we examined individual- and county-level factors influencing HCBS utilization for dementia care in rural Appalachia. RESEARCH DESIGN AND METHODS: We analyzed data from telephone interviews with 123 dementia family caregivers in rural Appalachian counties (Mage = 64.7, SDage = 12.2). Multilevel analyses were conducted to examine the effects of individual-level and county-level factors on the use of home-based services (home healthcare and personal care services) as well as community-based services (adult day care and transportation services). RESULTS: Results indicated that caregivers' receipt of informal support from family or friends was associated with more use of home-based services (B = 0.42, p = .003). Conversely, longer travel times to service providers were linked to use of fewer community-based services (B = -0.21, p < .001). Residing in counties with more home health agencies was associated with higher utilization of home-based services (B = 0.41, p = .046). However, higher county tax expenditures for HCBS were not linked to home-based or community-based service use. DISCUSSION AND IMPLICATIONS: Findings suggest that informal support in caring for the person living with dementia enables HCBS use in rural Appalachia. In contrast, limited geographic accessibility and service availability can impede HCBS use in rural regions. Policymakers are urged to allocate direct public funding to service providers to expand service availability in underresourced rural regions.

Availability and accessibility of opioids for pain and palliative care in Colombia: a survey study / Disponibilidad y accesibilidad de los opioides para manejo del dolor y cuidado paliativo en Colombia: estudio tipo encuesta

Abstract Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was "Pharmacies authorized by health insurance companies", where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was "Difficulty securing payment authorization for medication from health insurance companies". Significant differences were observed in terms of regions and "Cost" (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Resumen Introducción: El acceso a medicamentos esenciales, incluidos los opioides, es un componente del derecho a la salud. Objetivo: Identificar las barreras de disponibilidad y acceso a los opioides para dolor y cuidados paliativos. Métodos: Encuesta virtual a prescriptores colombianos. Las barreras de disponibilidad se analizaron para cada centro (distribución y/o dispensación) y las barreras de acceso se analizaron por tipo. Los análisis descriptivos se realizaron utilizando frecuencias relativas. La significancia dentro de categorías y regiones se midió utilizando la prueba exacta de Fischer. Resultados: De los 1208 prescriptores invitados, 806 (66.7%) respondieron la encuesta. Disponibilidad: el 76,43% reportó barreras. La barrera más citada fue la relacionada con las "farmacias autorizadas por las aseguradoras de salud", donde los opioides con frecuencia no están disponibles. Acceso: el 74,6% reportó barreras. Se citó con mayor frecuencia la "Dificultad para obtener la autorización de pago de medicamentos por parte de las aseguradoras". Se observaron diferencias significativas entre regiones y "costos" (p=0,02). La falta de coordinación entre las entidades de adquisición y distribución afecta la disponibilidad. La limitada conciencia y los procedimientos burocráticos afectan la accesibilidad. Conclusiones: Existen barreras de disponibilidad y acceso a los opioides en Colombia, las cuales están relacionadas con la estructura disponible para garantizar un suministro equitativo. Desde el punto de vista de los prescriptores, los problemas relacionados con la disponibilidad de las farmacias, la prescripción y el costo de los medicamentos, obstaculizan el tratamiento adecuado del dolor.

Métodos de investigación empleados para el análisis del acceso a los servicios de salud en contextos rurales / Research methods used for the analysis of access to health services in rural contexts

Introducción: La ruralidad y los sistemas de salud a nivel global constituyen un campo de fuerzas marcado por la pervivencia de la ruralidad y las condiciones de inequidad y desigualdad en el acceso a los servicios de salud. Objetivo: Identificar los métodos de investigación utilizados en el contexto internacional para analizar los servicios de salud en poblaciones rurales. Métodos: Se realizó un estudio de revisión sistemática que incluyó los reportes de investigación relacionados con el tema, publicados hasta diciembre de 2014. El proceso de selección de los estudios se realizó en cuatro etapas: identificación, cribado, elegibilidad e inclusión. Se recuperaron 253 referencias que muestran la diversidad metodológica de aproximación al acceso a servicios de salud en poblaciones rurales. Conclusiones: Se necesita una mirada diferenciada a la ruralidad para elaborar políticas públicas eficientes, que estén en concordancia con los contextos y necesidades de las comunidades que demandan los servicios de salud(AU)

Introduction: Rurality and health systems represent globally a field of forces marked by the survival of rurality and the inequity and inequality conditions in the access to health services. Objective: Identify the research methods used in the international context to analyze health services in rural populations. Methods: It was carried out an study of systematic review that included research reports related with the topic published until December, 2014. The selection process of the studies was conducted in four stages: identification, sieving, elegibility and inclusion. 253 references were recovered and those show the methodological diversity of approaches in the access to health services in rural populations. Conclusions: It is needed a different view to rurality for creating efficient public policies that are in accordance with the contexts and needs of communities that demand health services(AU)

Supply of Certified Applied Behavior Analysts in the United States: Implications for Service Delivery for Children With Autism.

OBJECTIVE: The rising prevalence of autism spectrum disorder (ASD) underscores the importance of access to evidence-based interventions such as applied behavior analysis (ABA). Anecdotal evidence suggests limitations in the supply of ABA providers, but data remain scarce. The authors provide the first known examination of the supply of certified ABA providers in the United States. METHODS: Using 2018 data from the Behavior Analyst Certification Board, the authors compared the per capita supply of certified ABA providers in each state with a benchmark established using the Board's guidelines. Additionally, the authors examined state and regional variations in the supply of certified ABA providers. RESULTS: The per capita supply of certified ABA providers fell below the benchmark in 49 states and was higher in the Northeast than in other regions (p<0.001). CONCLUSIONS: New workforce policies are needed to increase the supply of certified ABA providers to meet the needs of youths with ASD.

Management of advanced prostate cancer in Hong Kong: Insights from an APCCC-Derived survey.

AIM: The 2017 Advanced Prostate Cancer Consensus Conference (APCCC) convened an international multidisciplinary panel to vote on controversial issues in the management of advanced prostate cancer (APC). We aimed to compare their conclusions with the opinions of local specialists and explore the practicability of international recommendations in the healthcare setting in Hong Kong. METHODS: Urologists and clinical oncologists practicing in Hong Kong were invited to complete a survey based on the original APCCC 2017 questionnaire and recently published trials in APC. A joint committee of expert key opinion leaders was convened to discuss and analyze the voting differences between local specialists and the APCCC 2017 panel. RESULTS: The respondents constituted 21% (28/132) of registered urologists and 21% (31/146) of clinical oncologists in Hong Kong. Discrepancies in three key areas were identified as being the most timely for this analysis: (a) management of metastatic hormone-sensitive/naïve prostate cancer; (b) management of metastatic castration-resistant prostate cancer; and (c) treatment monitoring and initiation of androgen-deprivation therapy. Fears of toxicity and intolerance among patients and physicians (especially urologists) may be driving the relative underuse of chemotherapy in multiple APC patient groups in Hong Kong. Local patients can face long wait times and limited access to contemporary imaging modalities compared with other developed countries. CONCLUSION: Increased collaborative efforts by urologists and clinical oncologists could ensure that patients gain wider access to the latest diagnostic, treatment and monitoring modalities for APC in Hong Kong.

[Community psychiatry in two European regions: a comparison of Bezirk Reutte (Tirol/Austria) and the Bavarian Allgäu (Germany)]. / Gemeindepsychiatrie in zwei europäischen Regionen: Vergleich des Bezirks Reutte in Tirol mit dem südlichen Oberallgäu in Bayern.

BACKGROUND: There is high variance in how mental health services across the globe are organized. OBJECTIVES: How do mental health services in an Austrian and German alpine district differ (Austria: Bezirk Reutte in Tirol; Germany: Southern Oberallgäu in Bavaria)? MATERIALS AND METHODS: Quantitative data were assessed with the European Service Mapping Schedule (ESMS). Additionally, 30 expert interviews (15 in each region) were evaluated using qualitative content analysis (Mayring). RESULTS: In both regions there is no psychiatric hospital and a lack of outpatient psychiatrists and psychotherapists. ESMS shows surprising differences in how mental health services are organized in both regions, which are reflected in the expert interviews. DISCUSSION: In regions where medical-psychiatric services tend to become sparse, there is a shift towards non-medical community services, which may cover different spheres of daily life and span from housing to self-help. CONCLUSION: The study highlights that while structural and process quality can be compared, it is difficult to find indicators for outcome quality.

Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index.

BACKGROUND: Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India's state-funded health insurance scheme covers hospital care provided by 'empanelled' private and public hospitals. OBJECTIVE: This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. METHODS: The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state's 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme - insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims - are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. RESULTS: The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state's centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. CONCLUSIONS: Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme.

General paediatricians views on their plans to leave medical practice: Has the "twelfth hour" passed?

Up to a third of general paediatricians plan to stop practicing within five years, mainly for age reasons. This finding, based on paediatricians responses, indicates potential problems that may significantly affect the availability of paediatric health services and quality of care. The age structure of the general paediatric population is already alarming in the short term, as the number of practitioners in the younger age categories is very low, and more than half are aged 60 and over. Can this alarming situation still be resolved? The article presents the results of a questionnaire-based survey conducted in mid-2018 regarding paediatricians plans to leave medical practice, as part of research looking at the consequences of the current situation and suggests possible steps to mitigate the expected negative impacts. Keywords: general paediatrics, physician ageing, generational change, reasons for ceasing to practice, availability of health services, Czechia.

Solid Organ Transplant Recipients' Opinions of Pre- and Post-Transplant Supervised Exercise Programmes: A Brief Report.

Purpose: Access to pre- and post-transplant supervised exercise programmes in Canada is not consistent across organ types. The opinions of solid organ transplant (SOT) recipients can contribute to the discussion among stakeholders regarding increasing the availability of supervised exercise programmes. The objective of the study was to determine Canadian SOT recipients' opinions of pre- and post-transplant supervised exercise programmes and the factors that influenced their participation. Method: An Internet-based questionnaire was distributed to members of the Canadian Transplant Association. It was part of a larger survey and examined seven items related to accessibility to, and opinion of, supervised exercise programmes. Results: A total of 35% (n=39) of respondents had attended a pre-transplant exercise programme, and 54% (n=61) had attended a post-transplant exercise programme. The majority of participants believed that a supervised exercise programme was beneficial to health and well-being. Perception of benefits, a physician's recommendation, and health status and symptoms were key influencing factors in the decision of whether to attend a pre- or post-transplant exercise programme. Conclusion: SOT recipients had positive opinions of supervised exercise programmes despite unequal access among organ groups. Some key influencing factors (e.g., a physician's recommendation) are modifiable and should be taken into consideration to encourage participation in such programmes.

Objectif : l'accès à un programme d'exercice supervisé avant et après une greffe au Canada est inégal selon le type d'organe. L'opinion des personnes ayant reçu une greffe d'organe plein (GOP) peut enrichir les discussions des intervenants concernant l'augmentation de l'offre de tels programmes. Cette étude vise à déterminer l'opinion des greffés sur les programmes d'exercice supervisés avant et après la greffe et les facteurs qui ont influencé leur participation. Méthodes : un questionnaire en ligne a été envoyé aux membres de l'Association canadienne des greffés. Ce questionnaire faisait partie d'un sondage plus vaste et portait sur sept aspects liés à l'accessibilité des programmes d'exercice supervisés et à l'opinion à leur égard. Résultats : au total, 35 % (n=39) des répondants avaient participé à un programme d'exercice avant leur greffe, et 54 % (n=61) avaient participé à un programme après leur greffe. La majorité des participants était d'avis qu'un programme d'exercice supervisé avait des bienfaits sur la santé et le bien-être. La décision de participer ou non à un programme d'exercice avant ou après la greffe était influencée par les facteurs suivants : la perception des bienfaits, la recommandation d'un médecin ainsi que l'état de santé et les symptômes. Conclusion : les personnes ayant reçu une GOP ont une opinion favorable des programmes d'exercice supervisés malgré l'inégalité de l'accès selon les groupes d'organes. Certains facteurs (p. ex., la recommandation d'un médecin) sont modifiables et devraient être pris en considération afin de favoriser la participation à ces programmes.

Availability of Village Health and Nutrition Day services in Uttarakhand, India.

BACKGROUND: Village Health and Nutrition Day (VHND) was identified to provide primary care services (health, nutrition and sanitation) at village level under National Rural Health Mission. AIM: The study aimed to assess availability of health, nutrition and sanitation services, required instruments/equipment and medicines at VHND with client satisfaction from the VHND services. MATERIALS AND METHODS: A cross-sectional study was conducted in three districts of Uttarakhand at Nainital, Tehri-Garhwal and Chamoli involving 24 villages in six blocks using multistage stratified sampling using predesigned pretested observation checklists (quantitative data). All the concerned functionaries of health, Integrated Child Development Services and Panchayati Raj Institution were interviewed (qualitative data) to understand the gap in services and remediation. RESULTS: Of the 24 VHNDs observed, blood pressure measurement was done at 11 (45.83%) and weight at 13 (54.17%) sites in ante-natal care services; non-availability of blood pressure instrument and adult weighing machine were 45.83% and 41.66% sites, respectively. Immunization for children was provided at 22 sites; however, availability of other services were poor-vitamin A (three), growth monitoring of children (seven); supplementary nutrition (five); identification of households for construction of toilet (eight). Yet, one-third of clients provided three and four for satisfaction from VHND services on the scale score of 1-5. CONCLUSION: It was noted that none of the VHND site was providing all the stipulated services, though immunization was provided mostly. Anganwadi centers were lacking availability of various essential instruments and equipment. So regular orientation of village functionaries for ensuring all the VHND services with the availability of required logistic is recommended.

[Stock based medicine: the patient waiting in a weary medical procedure]. / Medicina basada en existencias: la espera del paciente en un acto médico agotado.

This essay attempts to bring on a new perspective for healthcare professionals regarding the problems that surround this institutionalized profession, based on a system of stock balances and not on the real needs of patients and their community. The healthcare professional not only engages in biomedical healing but also possesses knowledge and expertise regarding the dialectical process of health/disease. Thus, his or her practice and actions should be centered on social practices and not just the healing process.

Este ensayo pretende ser el parteaguas de una nueva mirada de los profesionales de la salud respecto a la problemática real que apremia a esta profesión institucional, la cual está basada en una medicina de existencias del sistema, y no en la necesidad real del paciente y el colectivo. No solo el profesional de la salud es portador de un binomio biomédico curativo sino que es portador de conocimientos técnicos y especializados respecto al proceso dialéctico salud/enfermedad, por lo que su práctica y actuar deberían estar enfocados como prácticas sociales y no solo curativas.

Using business intelligence to analyze and share health system infrastructure data in a rural health authority.

BACKGROUND: Health care organizations gather large volumes of data, which has been traditionally stored in legacy formats making it difficult to analyze or use effectively. Though recent government-funded initiatives have improved the situation, the quality of most existing data is poor, suffers from inconsistencies, and lacks integrity. Generating reports from such data is generally not considered feasible due to extensive labor, lack of reliability, and time constraints. Advanced data analytics is one way of extracting useful information from such data. OBJECTIVE: The intent of this study was to propose how Business Intelligence (BI) techniques can be applied to health system infrastructure data in order to make this information more accessible and comprehensible for a broader group of people. METHODS: An integration process was developed to cleanse and integrate data from disparate sources into a data warehouse. An Online Analytical Processing (OLAP) cube was then built to allow slicing along multiple dimensions determined by various key performance indicators (KPIs), representing population and patient profiles, case mix groups, and healthy community indicators. The use of mapping tools, customized shape files, and embedded objects further augment the navigation. Finally, Web forms provide a mechanism for remote uploading of data and transparent processing of the cube. For privileged information, access controls were implemented. RESULTS: Data visualization has eliminated tedious analysis through legacy reports and provided a mechanism for optimally aligning resources with needs. Stakeholders are able to visualize KPIs on a main dashboard, slice-and-dice data, generate ad hoc reports, and quickly find the desired information. In addition, comparison, availability, and service level reports can also be generated on demand. All reports can be drilled down for navigation at a finer granularity. CONCLUSIONS: We have demonstrated how BI techniques and tools can be used in the health care environment to make informed decisions with reference to resource allocation and enhancement of the quality of patient care. The data can be uploaded immediately upon collection, thus keeping reports current. The modular design can be expanded to add new datasets such as for smoking rates, teen pregnancies, human immunodeficiency virus (HIV) rates, immunization coverage, and vital statistical summaries.