A long way from home: Access to cancer care for rural Australians

In 2002, the Commonwealth Radiation Oncology Inquiry reported that access to cancer care services in Australia was seriously limited. Several recommendations were made, including improving access to cancer care in rural areas by increasing the number of comprehensive oncology facilities outside the cities. Much has changed since 2002, with the establishment of a number of Regional Integrated Cancer Centres. This has been boosted again in 2011 by further Commonwealth Government funding.Cancer is primarily a disease of the elderly and, with the ageing population access to cancer care for rural and remote Australians remains a major challenge. Cancer is the second most common cause of death in Australia, exceeded only by cardiovascular disease. It has been reported that the relative risk of dying of cancer within 5 years of diagnosis is 35% higher for those living in remote locations compared with major cities. Overall cancer mortality is significantly higher in rural and remote locations (206 deaths per 100,000) compared with urbanised areas (172 per 100,000). Cancer mortality is higher again for the Aboriginal population (230 per 100,000).The reasons for the disparity in cancer outcomes for metropolitan versus non-metropolitan Australians are varied. In general, rural and remote residents have to travel long distances and stay away from home, family and work for long periods of time to access the care they need. Hence, distance is the overriding barrier to access, compounded by the financial costs and disruption to family life, not to mention the endemic lack of specialist medical and allied health workforce outside the major cities. Some rural and remote Australians choose to compromise, accessing whatever care they can locally, although this contributes to the need for cancer care services close to where people choose to live and die, to deal with the complex associated morbidities.Recent government investment in new regional cancer care infrastructure is essential; however, it is not the entire solution. Staffing the new facilities calls for innovative solutions, including managed care pathways, outreach programs, models of shared care and the use of telemedicine. There is also a need to better address issues of Indigenous cultural safety and risk reduction in the Aboriginal population.     

Global health and national security: the need for critical engagement

The security and foreign policy communities have increasingly addressed global health problems as threats to national security. Global health is a humanitarian endeavour that seeks to improve the world's health including the most vulnerable peoples, while national security works to protect the interests of people within a given state. The major statements of security policy by the United States and United Kingdom link the self-protective interests of national security with the humanitarian objectives of global health. While there is potential to expand global health activities through partnership with the security and foreign policy communities, treating global health issues as national security threats may focus attention disproportionately on countries or diseases which pose security threats to wealthy nations, rather than on the greatest threats to global health. The global health community should carefully scrutinise areas where global health and national security interests overlap.     

Competitive co‐operation

Abstract

The security and foreign policy communities have increasingly addressed global health problems as threats to national security. Global health is a humanitarian endeavour that seeks to improve the world's health including the most vulnerable peoples, while national security works to protect the interests of people within a given state. The major statements of security policy by the United States and United Kingdom link the self-protective interests of national security with the humanitarian objectives of global health. While there is potential to expand global health activities through partnership with the security and foreign policy communities, treating global health issues as national security threats may focus attention disproportionately on countries or diseases which pose security threats to wealthy nations, rather than on the greatest threats to global health. The global health community should carefully scrutinise areas where global health and national security interests overlap.     

Access to Mental Health Services at Veterans Affairs community-based outpatient clinics

Access to care and treatment of mental disorders within the Veterans Health Administration (VHA) has seen dramatic changes in recent years. The VHA has been transformed from a hospital-based provider to one that relies on more outpatient care, although some are concerned this has compromised specialty services such as mental health care. The VHA is increasing the number of community-based outpatient clinics, which has improved access to primary care, and some are suggesting providing more mental health services at these clinics. The objective of this survey was to determine which clinics are currently providing mental health care and to identify clinics that provide little or no mental health care and their reasons for not doing so. A questionnaire was developed to answer these questions, and clinics were contacted by telephone to complete the survey. The results indicate that more clinics are providing basic mental health services than has been reported previously. The results also suggest that, before making changes in the delivery of mental health care within the VHA, a comprehensive study needs to be performed to identify current needs and establish a clear goal of how and where to provide quality mental health care for veterans.     

Differences in beneficiary assessments of health care between TRICARE prime and TRICARE prime remote

OBJECTIVES: We examined differences in health care ratings and reported health care experiences for active duty uniform services personnel using health care plans other than military treatment facilities. METHODS: We used a cross-sectional mail survey of a stratified sample of 3,871 beneficiaries enrolled in TRICARE Prime (TP) and TRICARE Prime Remote (TPR). The adjusted plan mean composite and global ratings were compared between TP and TPR participants. RESULTS: There were few significant differences between the two groups. Patient satisfaction was higher when patients chose their providers (TPR), and use of some preventive services was higher in managed-care plans (TP). Respondents in metropolitan locations differed significantly from those in nonmetropolitan locations in ratings of plans, quality of health care received, and access to services. CONCLUSIONS: The military health system is achieving some success in delivering uniform benefits but faces challenges in delivering high-quality uniform benefits in rural communities.     

Organization and management of care for military veterans with human immunodeficiency virus/acquired immunodeficiency syndrome in Department of Veterans Affairs Medical Centers

OBJECTIVE: As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted. METHODS: Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services. RESULTS: HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet long-term care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts. CONCLUSIONS: Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.     

A rural CT scanner: evaluating the effect on local health care.

OBJECTIVE: The first small rural hospital in Ontario to propose a computed tomography (CT) scanner was in Walkerton, a town 160 km north of London. The Ontario Ministry of Health approved the proposal as a pilot project to evaluate the effect on local health care of a rural scanner. This evaluation study had 3 parts: a survey of physicians, a survey of patients, and an analysis of population CT scanning rates. METHOD: The physicians in the area served by the scanner were asked about its impact on their care of their patients in a mailed questionnaire and in semistructured interviews. Scanner outpatients were given a questionnaire in which they rated the importance of its advantages. The analysis of scanning rates--the ratio of number of scans to estimated population--compared rates in the area with other Ontario rates before and after the scanner was introduced. RESULTS: The physicians reported that local CT allowed them to diagnose and treat patients sooner, closer to home, and with greater confidence. On average, 75% of the patients ranked faster and closer access as very important. Scanning rates in the area rose, although they did not match urban rates. CONCLUSIONS: The study confirms that the rural scanner changed the area's health care in significant ways and that it helped to narrow the gap between rural and urban service levels. We recommend that CT be expanded to other rural regions.     

Satisfaction among soldiers with secondary medical services within military and civilian clinical settings

The medical services system of the Israel Defense Forces (IDF) is founded on a principle that by definition considers it the military's role to maintain the health of its personnel in uniform. The 1994 Compulsory Health Insurance Law, Section 55 addresses health services for soldiers, stating that a soldier is entitled to health services from the Medical Corps of the IDF or an agent operating on its behalf. In the implementation of its responsibilities, the IDF Medical Corps operates an array of medical services, including secondary care. This study deals with the scope of utilization of secondary medical services by IDF personnel visiting military medical clinics and civilian hospital outpatient clinics: their character, the subjective health status of the respondents, and their degree of satisfaction with medical services. The results indicate that most of those seeking medical treatment at military and civilian clinics are not chronically ill. Most consider their health status to be good to excellent, but many of those referred for secondary care--more than half of the respondents who visited military specialist clinics-visited the clinics many times and even visited other clinics. No problem of access to clinics was found, but availability was problematic. There was a marked preference among patients to receive secondary health sevices from outside civilian agents rather than the military system.     

Teleradiology: part of a comprehensive telehealth system

Present technologic limitations do not allow completely accurate reproduction of a chest film, the gold standard of teleradiology. Although interpretation accuracy of broad-band teleradiographs is reasonably good and encouraging, the low level of confidence engendered by teleradiology interpretations in narrow-band transmission is self-evident in view of the tendency to provide an immediate provisional report followed later by a signed report after direct viewing of the film. Despite this, the important observation, putting things into perspective, was made by Andrus and Bird, namely that "the question is not whether teleradiology is preferable to direct visualization when either is available, but whether teleradiology offers an acceptable universally applicable method to augment the usefulness of the radiologist." Although fiberoptic guides may well lace the country in a few years, providing ample capacity and superb transmitted images, there are several options presently worth investigating now. These could provide teleradiology services to remote and rural communities, depending on the level of need and skills at the remote site, the availability and cost of transmission, and the need for access to 24-hour consultation services. The future role of teleradiology on a much larger scale within a regional network of health care facilities has yet to be defined, based on the perceived need for reasonable access to expensive but precise imaging methods. On the face of it, it would seem unlikely that small community hospitals will be able to afford the cost and maintenance of CT and MR scanners, digital angiography, and other useful and accepted imaging services.(ABSTRACT TRUNCATED AT 250 WORDS)     

Redesigning the nuclear medicine reading room

The process of image review and interpretation has become increasingly complex and challenging for today's nuclear medicine physician from many perspectives, especially with regard to workstation integration and reading room ergonomics. With the recent proliferation of hybrid imaging systems, this complexity has increased rapidly, along with the number of studies performed. At the same time, clinicians throughout the health care enterprise are expecting remote access to nuclear medicine images whereas nuclear medicine physicians require reliable access at the point of care to the electronic medical record and to medical images from radiology and cardiology. The authors discuss the background and challenges related to integration of nuclear medicine into the health care enterprise and provide a series of recommendations for advancing successful integration efforts. Also addressed are unique characteristics of the nuclear medicine environment as well as ergonomic, lighting, and environmental considerations in the design and redesign of the modern reading room.     

Securing health and human rights: Sandwell's community health network

Minority communities face discrimination and abuse. The main health problems they face are those of severe and early chronic disease and poor well-being due to inequality in jobs, education and access to health care. The Sandwell community health network provides support workers to six major minority groups in Sandwell, providing information and access to skilled health services. Without securing health as a basic right for our minorities we perpetuate divisions in our society which cause mistrust, conflict and violence. The health system has a vital role to play in securing people's rights and campaigning for equality and justice for all our communities, to enhance community cohesion.     

Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities

National smoking cessation guidelines include recommended strategies for providers and health care organizations, but they offer little guidance on how to structure care. We conducted a cross-sectional survey at 40 Veterans Health Administration facilities, to describe the structure of smoking cessation care, to assess adherence to national guidelines, and to assess facilities' preferred approach to providing smoking cessation treatment. We categorized sites as those using a primary care approach (most smokers treated by the primary care provider) versus a specialty approach (medication restricted to smoking cessation clinics, to which most patients were referred). Nearly all sites reported systematic screening for smoking and counseling of smokers, usually by both nursing staff members and the primary care provider. Most sites used a specialty approach, restricting medication access to smokers attending a cessation program. Future research should evaluate whether this approach provides adequate access and responsiveness to patient preferences for the full population of smokers in primary care.     

Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan

OBJECTIVE: This study examines risk factors for post-traumatic stress disorder (PTSD), depression, and mental health care use among health care workers deployed to combat settings. METHODS: Anonymous surveys were administered to previously deployed workers at a military hospital. PTSD and depression were assessed by using the PTSD Checklist and the Patient Health Questionnaire depression scale, respectively. Deployment exposures and perceived threats during deployment were also assessed. RESULTS: There were 102 respondents (36% response rate). Nine percent (n=9) met the criteria for PTSD and 5% (n=5) met the criteria for depression. Direct and perceived threats of personal harm were risk factors for PTSD; exposure to wounded or dead patients did not increase risk. Those who met the criteria for PTSD were more likely to seek mental health care after but not before their deployment. CONCLUSIONS: For health care workers returning from a warfare environment, threat of personal harm may be the most predictive factor in determining those with subsequent PTSD.     

Experiences with a prototype tracking and verification system implemented within an imaging center

RATIONALE AND OBJECTIVES: Most health care facilities currently struggle with protecting medical data privacy, misidentification of patients, and long patient waiting times. This article demonstrates a novel system for a clinical environment using wireless tracking and facial biometric technologies to automatically monitor and identify staff and patients to address these problems. MATERIALS AND METHODS: The design of the location tracking and verification system (LTVS) was based on a workflow study which was performed to observe the physical location and movement of patient and staff at the Healthcare Consultation Center II (HCC II) running hospital information systems, radiology information systems, picture archive and communication systems, and a voice recognition system. Based on the results from this workflow study, the LTVS was designed using a wireless real-time location system and a facial biometric system integrated with the radiology information system. The LTVS was tested for its functionality in a laboratory environment, then evaluated at HCC II. RESULTS: Experimental results in the laboratory and clinical environments demonstrated that patient and staff real-time location information and identity verification can be obtained from LTVS. Warning messages can immediately be sent to alert staff when patient's waiting time is over a predefined limit, and unauthorized access to a security area can be audited. Additionally, patient misidentification can be prevented during the course of examinations. CONCLUSIONS: The system enabled health care providers to streamline the patient workflow, protect against erroneous examinations and create a security zone to prevent, and audit unauthorized access to patient health care data required by the Health Insurance Portability and Accountability Act mandate.     

Advances in Navy pharmacy information technology: accessing Micromedex via the Composite Healthcare Computer System and local area networks.

The pharmacy profession has long used technology to more effectively bring health care to the patient. Navy pharmacy has embraced technology advances in its daily operations, from computers to dispensing robots. Evolving from the traditional role of compounding and dispensing specialists, pharmacists are establishing themselves as vital team members in direct patient care: on the ward, in ambulatory clinics, in specialty clinics, and in other specialty patient care programs (e.g., smoking cessation). An important part of the evolution is the timely access to the most up-to-date information available. Micromedex, Inc. (Denver, Colorado), has developed a number of computer CD-ROM-based full-text pharmacy, toxicology, emergency medicine, and patient education products. Micromedex is a recognized leader with regard to total pharmaceutical information availability. This article discusses the implementation of Micromedex products within the established Composite Healthcare Computer System and the subsequent use by and effect on the international Navy pharmacy community.     

The implementation of a longitudinal POCUS curriculum for physicians working at rural outpatient clinics in Chiapas,Mexico

Background

Medical care in resource limited settings is challenging, particularly with limited access to diagnostic and imaging studies. The most portable and cost effective diagnostic imaging in these areas is ultrasound. Ultrasound is a very teachable skill with a short, single intensive training course and hands-on teaching; however, there are limited data on a longitudinal point-of-care ultrasound (POCUS) curriculum in resource limited settings. The goal of this intervention is to develop an effective longitudinal POCUS curriculum for local physicians working in rural clinics in the state of Chiapas, Mexico, and evaluate its effectiveness on patient care.

Methods

This is a 12-month longitudinal ultrasound educational curriculum for local supervising physicians working in rural clinics in Chiapas, Mexico. The 10 clinics are a collaboration of the Mexican government and Compañeros En Salud with limited access to any diagnostic imaging or laboratory studies. The investigators assisted in obtaining four portable ultrasound machines for use in the clinics. Next, they organized four point-of-care ultrasound (POCUS) teaching sessions over a year, each session focusing on several distinct concepts. The sessions included lectures and hands-on teaching with both healthy volunteers and with patients in the various communities. Over the 12 months, the POCUS were logged and the majority of images saved. The logs were analyzed to determine if POCUS affected the medical management of the patients. The primary investigator reviewed 35.2% of the total ultrasounds completed, which was 52.2% of the save images, for quality assurance and feedback.

Results

Over the 12 months, there were 584 ultrasound studies documented. The most common study was a transabdominal obstetric examination (45.5%) followed by abdomen/pelvis (26.6%) and musculoskeletal (5.7%) and skin and soft tissue (5.7%). The use of POCUS changed the patient diagnosis after 194 scans (34%) and changed the clinical management for the patient encounter in 171 (30%) scans. In the 194 scans in which POCUS changed the diagnosis, the clinical management was changed, as a direct result of the scan results, in 152 (78.4%) of those patient encounters.

Conclusion

A longitudinal POCUS educational curriculum is an effective way to equip local physicians in resource limited countries with a tool to improve their clinical management of patients.

     

The provision for health needs in less developed countries with reference to Bophuthatswana

The concept of health for all by the year 2000 envisioned by the WHO can be achieved only by making strides against poverty-linked population growth and economic stagnation. 80% of the 1.9 million population of Bophuthatswana that became independent from South Africa in 1977 live in rural areas. Before independence virtually no health service existed. The Department of Health and Social Services envisions health care for all by providing a treatment center in every village; 3 beds/1000 population is targeted by 1992; and a doctor-patient ratio of 1/10,000 people (the ratio in South Africa is 1/1423). Most doctors are foreigners on contract and their qualifications are often inadequate. The shortfall of black doctors and nurses is attributable to apartheid policies. The health services structure has 3 branches: medical and paramedical, preventive and promotive, and social welfare. Primary health care is developed with traditional healers. 50% of children aged 12-36 months are immunized by the preventive branch. Alcoholism is a serious issue, and glue sniffing is frequent among delinquent children in shanty towns. In less developed countries good medical care tends to vary inversely with the needs of the population. Africa's debt situation and the freeze on new loans has pushed the idea of privatization of health services into the forefront. The US example has shown that commercial medicine is expensive because of entrenched medical and insurance interests often leading to superfluous operations. The state should allow private entrepreneurship in health care while guaranteeing protection for the patients and recycling taxes imposed into rural clinics.     

Early pregnancy confirmation--the role of urine pregnancy test in military primary care clinics

Pregnancy detection is a common procedure in primary care and can be challenging in the setting of military primary care clinics. The objective of this study was to determine whether the introduction of urine pregnancy tests to military primary care clinics is associated with earlier pregnancy detection. We conducted a cross-sectional study using data from female soldiers, aged 18 to 20 years. Pregnancy was diagnosed using urine pregnancy tests. Ultrasonographic gestational age at presentation was compared between pregnant soldiers diagnosed in primary care clinics and pregnant soldiers diagnosed in gynecology secondary care clinics. A total of 150 female soldiers performed urine pregnancy tests in 5 different primary care clinics, from which 28 (19%) were pregnant. Mean gestational age at diagnosis was significantly lower among patients diagnosed in primary care clinics as compared with patients diagnosed in gynecology secondary care clinics (41.07 days (SD, 6.72) vs. 48.42 days (SD, 21.94), p < 0.001). In conclusion, the availability of urine pregnancy tests in the setting of military primary care clinics was strongly associated with early pregnancy detection at a time point in which presentation for both antenatal care and abortion services potentially improve maternal and neonatal health.     

A comparison of MEDRETE practice content to U.S. ambulatory care

A U.S. military medical team spent 2 weeks providing medical care in a rural area in Bolivia. Records of presenting complaints and physician diagnoses were kept for 2,169 patients seen during the exercises. Patients seen in Bolivia were younger than in typical U.S. clinics, with 53% being less than 15 years old. Digestive system complaints were the reason for 35% of the visits, compared to 5% in U.S. clinics. Diagnoses made more often than expected on the Bolivian expedition included gastroenteritis, peptic diseases, low back pain, and headaches. Supply and personnel needs are greatly influenced by these patient characteristics.     

A comparison of patient populations between two types of military primary care health clinics

A cross-sectional survey was conducted of 993 patients treated at either a Primary Care for the Uniformed Services health clinic or a nearby free-standing primary care health clinic operated directly by the Army Medical Department. The study found the clinics significantly different in terms of the patients' age, race and the sponsors' ranks. The clinics were not significantly different in terms of the patients' sex, medical diagnosis, and visit status. This study recommends that the location, capabilities, staffing, and operations of primary health care clinics be contingent on the characteristics of the patient population. Also, additional research should be conducted to identify other significant patient characteristics.