Chronic cardiovascular disease mortality in mountaintop mining areas of central Appalachian states

Purpose: To determine if chronic cardiovascular disease (CVD) mortality rates are higher among residents of mountaintop mining (MTM) areas compared to mining and nonmining areas, and to examine the association between greater levels of MTM surface mining and CVD mortality. Methods: Age‐adjusted chronic CVD mortality rates from 1999 to 2006 for counties in 4 Appalachian states where MTM occurs (N = 404) were linked with county coal mining data. Three groups of counties were compared: MTM, coal mining but not MTM, and nonmining. Covariates included smoking rate, rural‐urban status, percent male population, primary care physician supply, obesity rate, diabetes rate, poverty rate, race/ethnicity rates, high school and college education rates, and Appalachian county. Linear regression analyses examined the association of mortality rates with mining in MTM areas and non‐MTM areas and the association of mortality with quantity of surface coal mined in MTM areas. Findings: Prior to covariate adjustment, chronic CVD mortality rates were significantly higher in both mining areas compared to nonmining areas and significantly highest in MTM areas. After adjustment, mortality rates in MTM areas remained significantly higher and increased as a function of greater levels of surface mining. Higher obesity and poverty rates and lower college education rates also significantly predicted CVD mortality overall and in rural counties. Conclusions: MTM activity is significantly associated with elevated chronic CVD mortality rates. Future research is necessary to examine the socioeconomic and environmental impacts of MTM on health to reduce health disparities in rural coal mining areas.     

Rural physical health care services for people with serious mental illness: A nursing perspective

Objective: To understand nurse perspectives on the physical health needs of their mental health clients and how well rural services are meeting their overall care needs. Design: Focus groups with semistructured format. Setting: Community mental health care in a regional and rural district of Queensland. Participants: Thirty‐eight nurses in public mental health care. Results: The major themes were (i) stigma of mental illness, (ii) barriers to accessing physical health care services, (iii) nurse adaptations under demands, and (iv) community and integration towards better overall health. Nurses integrate overall care and foster its continuity for people with physical and mental co‐morbidity and can be supported much better in sustaining this. Conclusion: Access and continuity of physical health care experienced by all Australians is exacerbated for people in rural areas. Physical health of people with serious mental illness residing in remote Australia needs to be a national health priority.     

From “retailers” to health care providers: Transforming the role of community pharmacists in chronic disease management

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs—particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.     

Comparative quality of private and public health services in rural Vietnam

BACKGROUND: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. METHODS: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. RESULTS: There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. CONCLUSIONS: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.     

安溪县实施新型农村合作医疗的运行绩效分析

通过对福建省首批新型农村合作医疗试点的安溪县在实施新农合前后的运行情况进行调查分析,发现新农合对医疗机构未起到足够的监督和约束作用,缺乏将三级医疗机构有机地联结起来的有效管理运行机制,未能充分引导农民利用当地卫生资源,提高乡镇卫生院的服务效率,巩固基层卫生保健网。因此,应从利益机制上加强对医疗机构的监管,以保证新农合的可持续性发展。     

Issues with medication supply and management in a rural community in Queensland

Objective: To identify the key issues reported by rural health‐care providers in their provision of medication supply and related cognitive services, and in order to advise health workforce and role development and thus improve the quality use of medicines in rural communities. Design: Exploratory semistructured interview research. Setting: A rural community comprising four towns in a rural health service district in Queensland, Australia. Participants: Forty‐nine health‐care providers (medical practitioners, pharmacists, nurses and others) with medication‐related roles who serviced the study community, identified through databases and local contacts. Main outcome measures: Medication‐related roles undertaken by the health‐care providers, focusing on medication supply and cognitive services; challenges in undertaking these roles. Results: Medical and nursing providers reported challenges in ensuring continuity in supply of medications due to their existing medical workload demands. Local pharmacists were largely involved in medication supply, with limited capacity for extended cognitive roles. Participants identified a lack of support for their medication roles and the potential value of clinically focused pharmacists in medication management services. Conclusions: Medication supply may become more efficient with extended roles for certain health‐care providers. The need for cognitive medication management services suggests potential for clinical pharmacists' role development in rural areas.     

美国医疗保险药物治疗管理的介绍

目的:介绍美国药物治疗管理的主要内容.方法:利用文献材料采用综述方法介绍美国药物治疗管理的内容.结果:自2006年以来,美国药物治疗管理改变了药品的使用模式,使之演化为一个控制费用并促进医疗质量的更有效的工具.结论:美国药物治疗管理对我国医疗保险部门的工作,特别是医疗保险制度和药品安全监督工作具有借鉴意义.     

The Role of Physician Assistants in Rural Health Care: A Systematic Review of the Literature

Purpose: 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. Methods: 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. Findings: 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. Conclusions: 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.     

From 'problem-describing' to 'problem-solving': challenging the 'deficit' view of remote and rural health

Objective: Rural and remote health research has highlighted the many problems experienced in the bush. While attention to problems has raised awareness of the needs of rural and remote health, embedding a deficit perspective in research has stereotyped rural and remote health as poor environments to work in and as inherently problematic. The objectives of this paper are to challenge this thinking and suggest that a more balanced approach, acknowledging strengths, is beneficial. Design: This discussion identifies why the deficit approach is problematic, proposes a strengths‐based approach and identifies some key strengths of rural and remote health. Results: This study suggests alternative ways of thinking about rural and remote practice, including the rewards of rural and remote practice, that rural and remote communities can act as change agents, that these disciplines actively address the social determinants of health, that rural and remote areas have many innovative primary health care services and activities and that rural and remote contexts provide opportunities for evaluation and research. It is proposed that rural and remote health can be viewed as problem‐solving, thus dynamic and improving rather than as inherently problematic. Conclusion: Critical of a deficit approach to rural and remote health, this paper provides alternatives ways of thinking about these disciplines and recommends a problem‐solving perspective of rural and remote health.     

New Zealand rural primary health care workforce in 2005: more than just a doctor shortage

OBJECTIVE: To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists. DESIGN: Postal questionnaires, November 2005. SETTING: NZ-wide rural general practices and community pharmacies. PARTICIPANTS: Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists. MAIN OUTCOME MEASURES: Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice. RESULTS: General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%). CONCLUSION: This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

Rural secondary school students living in a small community: their attitudes,beliefs and perceptions towards general practice

Objective: To study the attitudes and beliefs towards general practice of rural secondary school students, in particular, their perception of the barriers to the effective delivery of primary health care. Setting: Students attending a government‐funded secondary school in a rural community of less than 4000 people. Subjects: 250 students in years 7–12 were surveyed, with 177 (71%) replying, 45% of these being male. Design: Cross‐sectional, self‐administered questionnaire survey. Results: The study found that most students value general practitioners (GPs) as valuable sources of health care, feel they have reasonable access to care and in most instances appear to attend appropriately for their health problems. Most felt their doctor would be an empathetic listener, would provide sufficient time to provide effective care and communicated in a language they could understand. Confidentiality issues were considered important, especially by females. Conclusion: Although students have very positive attitudes about general practice, the findings could be used to improve a number of GP services for young people in small rural communities. This is particularly so for presentations which require a high degree of confidentiality and skilful counselling, such as psychological problems and risk‐taking behaviours.     

The allocation of health (and other professional) personnel to rural areas of poor countries

The availability of health personnel in the rural areas of poor countries is generally seen as problematic. This paper contrasts a lottery‐based assignment of personnel between rural and urban areas to a free‐market solution in which personnel are paid a premium to accept a rural posting. The lottery system can lower total cost and increase the number of personnel in rural areas. The model benchmarked with published estimates of the premium that would be required under a free market suggests gains from the lottery could be substantial.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Role of multi-purpose service programs providing residential aged care in rural Australia: a discussion paper

Objective: To determine if multi‐purpose service (MPS) Programs deliver improved residential aged care as opposed to traditional rural hospitals. Design: A variation on comparative–experimentalist: type 4. In this design 2 groups providing different service models of rural health services are compared. Setting: Six MPS Programs and three traditional hospitals in rural New South Wales. Subjects: Key stakeholders – area representatives, health service managers, MPS managers, doctors, staff, MPS or hospital committee members and consumer groups including residents. Main outcome measure: To analyse the ability of MPS Programs to deliver quality residential aged care as opposed to using traditional hospitals for such services. Results: Multi‐purpose service programs provided better residential environments and greater flexibility of service provision. There were few apparent differences between the two service models in regard to organisational culture and training. Conclusions: The findings of this evaluation suggest that in the provision of residential aged care in rural communities, MPS Programs demonstrated better standards of care than traditional hospital based services. What is already known on the subject: The development of multi‐purpose service programs to replace the older traditional rural hospitals is a relatively new practice in Australia. With the introduction of MPS programs there has been little evaluative research to demonstrate their effectiveness in health service delivery and the provision of residential aged care. Multi‐purpose service programs aim to integrate and coordinate acute, aged and community rural health services under one structure and so it is imperative that evaluative studies such as this one takes place. What does this study add?: The findings of this study demonstrate that the MPS model provides a better solution than hospitals to the problem of providing residential aged care in rural communities. With Australia looking to further develop MPS Programs in rural areas, it is hoped quality aged care services will be enhanced allowing older adults to remain in the communities of their choice.     

Neighbourhood rural medicine: an experience of rural doctors in Mali

The main constraint to improving access to health services of quality in rural areas is to attract qualified health personnel in these areas. A fifteen years experience in rural health in Mali has shown that it is possible to develop community medicine practices in an African context that do integrate individual care and public health activities. The policy of decentralization of health services encouraged local communities and municipalities to recruit rural doctors themselves. An initiative of rural doctors materialized with this event as they founded a national association and adhere to the principles of a Charter to provide quality health care at an affordable cost. A mechanism of quality improvement was established with the participation of several partners: a professional association, a funding non-governmental organization, and groups of academic staff and health managers. This paper describes the evolution of the rural doctors' experience, its philosophy, conditions that made it successful, constraints it had to overcome and the attitude of partners. It highlights the potential of health care personnel in Africa to provide primary health care well beyond traditional programs on prevalent diseases and to respond to both urgent individual needs and pressing public health requirements.     

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan,Canada

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.