The rural health care workforce implications of practice guideline implementation

Rural-urban differences in obstetric care, 2002-2010, and implications for the future

BACKGROUND

Approximately 15% of the 4 million annual US births occur in rural hospitals.

OBJECTIVE

To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location.

RESEARCH DESIGN AND SUBJECTS

This was a retrospective analysis of hospital discharge records for all births in the 2002-2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N = 7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals).

MEASURES

Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated.

RESULTS

In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio = 0.79 (0.78-0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio = 1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births).

CONCLUSIONS

From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.

Improving hypertension management through pharmacist prescribing; the rural Alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods

BACKGROUND

Patients with hypertension continue to have less than optimal blood pressure control, with nearly one in five Canadian adults having hypertension. Pharmacist prescribing is gaining favor as a potential clinically efficacious and cost-effective means to improve both access and quality of care. With Alberta being the first province in Canada to have independent prescribing by pharmacists, it offers a unique opportunity to evaluate outcomes in patients who are prescribed antihypertensive therapy by pharmacists.

METHODS

The study is a randomized controlled trial of enhanced pharmacist care, with the unit of randomization being the patient. Participants will be randomized to enhanced pharmacist care (patient identification, assessment, education, close follow-up, and prescribing/titration of antihypertensive medications) or usual care. Participants are patients in rural Alberta with undiagnosed/uncontrolled blood pressure, as defined by the Canadian Hypertension Education Program. The primary outcome is the change in systolic blood pressure between baseline and 24 weeks in the enhanced-care versus usual-care arms. There are also three substudies running in conjunction with the project examining different remuneration models, investigating patient knowledge, and assessing health-resource utilization amongst patients in each group.

DISCUSSION

To date, one-third of the required sample size has been recruited. There are 15 communities and 17 pharmacists actively screening, recruiting, and following patients. This study will provide high-level evidence regarding pharmacist prescribing.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00878566.

Understanding the complex associations between patient–provider relationships, self-care behaviours, and health-related quality of life in type 2 diabetes: A structural equation modeling approach

OBJECTIVES

To assess associations between perceptions of the patient-provider relationship (PPR), BMI, and adherence to diet and exercise in a rural population with type 2 diabetes and determine how these variables relate to HRQL.

METHODS

A model of the hypothesized relationships between the constructs was proposed and tested using structural equation modeling (SEM) and data collected as part of a controlled study to improve care for individuals with type 2 diabetes in rural health regions.

RESULTS

In the final model, positive perceptions of the PPR had a direct impact on adherence to diet (beta = 0.23; p < 0.05), exercise (beta = 0.13; p < 0.05) and diabetes management attitudes (beta = 0.33; p < 0.05). The direct path from management attitudes to exercise was also significant (beta = 0.12; p < 0.05). Direct predictors of HRQL included management attitudes (beta = 0.16; p < 0.05), exercise adherence (beta = 0.14, p < 0.05) and BMI (beta = -0.23; p < 0.05). Exercise adherence predicted BMI, whereas adherence to diet did not. The final model had an acceptable fit with the measured data (chi2 = 30.6 (26, N = 372), p = 0.25; RMSEA = 0.02; TLI = 0.98; SRMR = 0.02).

CONCLUSION

Patient-provider relationship and exercise adherence appeared to be key constructs in the model. HRQL in people with type 2 diabetes was positively associated with exercise adherence, which was related to a positive PPR. Adherence to diet was also related to a positive PPR, but diet adherence had no association with HRQL.

Generalizability and persistence of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes

OBJECTIVE

Most quality improvement efforts for type 2 diabetes have neglected cardiovascular risk factors and are limited by a lack of information about generalizability across settings or persistence of effect over time.

RESEARCH DESIGN AND METHODS

We previously reported 6-month results of a controlled study of an intervention that improved cardiovascular risk factors for rural patients with type 2 diabetes. We subsequently provided the identical intervention to the control region after the main study was completed. The primary outcome was 10% improvement in systolic blood pressure, total cholesterol, or HbA(1c). We compared the previously reported 6-month effect of the original intervention with the effect of the crossed-over intervention to the former control region and remeasured outcomes in the original intervention region 12 months later.

RESULTS

Our analysis included 200 original intervention and 181 crossed-over intervention subjects. The age of the population was 62.4 +/- 12.4 years (mean +/- SD), and 54.3% were women. A similar proportion of patients in the crossed-over intervention group achieved improvement in the primary composite outcome compared with the original intervention group (38 vs. 44%, respectively; P = 0.29). In adjusted analyses, we observed less improvement in blood pressure (adjusted odds ratio 0.40 [95% CI 0.17-0.75]) but greater improvements in total cholesterol (1.86 [0.93-3.7]) with the crossed-over intervention compared with the original intervention. We observed sustained improvements in total cholesterol and HbA(1c) levels in the original intervention group, whereas previous large gains in control of blood pressure diminished over time.

CONCLUSIONS

We found that our intervention was generalizable across settings, and its effect persisted over time. Nevertheless, without ongoing intervention or reinforcement, we noted some loss of the original benefits that had accrued. Future translational work should incorporate interventions such as ours into ongoing systems of rural care.

Improvements in patient-reported outcomes associated with an intervention to enhance quality of care for rural patients with type 2 diabetes: results of a controlled trial

OBJECTIVE

The aim of this study was to examine patient-reported outcomes in a controlled trial of a multifaceted provider-level intervention to improve quality of care for rural patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted a before/after intervention study with concurrent controls in two rural regions in Alberta, Canada. The intervention consisted of six monthly visits by a multidisciplinary health care team and was primarily directed at primary care providers. Clinical and patient-reported outcomes were assessed after 6 months. Patient-reported outcomes included changes in health-related quality of life (Health Utilities Index Mark 3 [HUI3]), satisfaction with care, lifestyle (Diabetes Lifestyle Form), and adherence to self-care activities. Analysis of covariance was used to assess differences over time between the control and intervention regions.

RESULTS

A total of 200 intervention and 172 control subjects were included in this analysis. After adjusting for important clinical and demographic differences, a statistically significant and clinically important improvement in the overall HUI3 score was seen at the 6-month follow-up in the intervention region (0.06 [95% CI 0.02-0.10]) compared with the control region (0.01 [-0.04 to 0.04]) (P = 0.03 for the difference between groups). Satisfaction with general medical care (P < 0.001 between groups) and diabetes care (P < 0.001 between groups) increased among patients in the intervention region compared with the control region. Self-efficacy, attitudes, and beliefs about diabetes control all increased in the intervention region when compared with the control region, but adherence to self-care activities did not.

CONCLUSIONS

A provider-level intervention directed at improving quality of clinical care for patients with type 2 diabetes also had a favorable impact on overall health-related quality of life, satisfaction with care, and other humanistic outcomes.

Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes

OBJECTIVE

Despite good evidence and clinical practice guidelines, studies document that treatment of type 2 diabetes is less than optimal. Lack of resources or limited access may put patients in rural communities at particular risk for suboptimal care.

RESEARCH DESIGN AND METHODS

We conducted a prospective, before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service (intervention) for improving the quality of care for rural patients with type 2 diabetes. Our intervention consisted of six monthly visits by a traveling team of specialist physicians, nurses, dieticians, and a pharmacist. The core of this service was specialist-to-rural primary care physician academic group detailing. Two comparable regions in Northern Alberta were randomly allocated to control or intervention. Data were collected before and 6 months after intervention in a representative volunteer sample. The primary outcome was a 10% improvement in any one of the following: blood pressure, total cholesterol, or HbA(1c).

RESULTS

Our analysis included 200 intervention and 179 control subjects; 14 subjects were at all three primary outcome targets at baseline. The intervention was associated with a trend toward improvement in primary outcome at 6 months (44% intervention vs. 37% control; odds ratio 1.32, 95% CI 0.87-1.99). The intervention was associated with a significant improvement in blood pressure (42% intervention vs. 25% control, P = 0.004); however, there were only small, nonsignificant changes in cholesterol or HbA(1c). The intervention was associated with a significant increase in satisfaction with diabetes care. Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results.

CONCLUSIONS

A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients. Future studies need to involve longer timelines and larger sample sizes.

Compliance with clinical practice guidelines for type 2 diabetes in rural patients: treatment gaps and opportunities for improvement

The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self-report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes--hemoglobin A1c (A1C), blood pressure, and low-density lipoprotein cholesterol (LDL)--has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean +/- SD values for this cohort of patients were as follows: A1C 7.25% +/- 1.54%, blood pressure 131.7 +/- 18.2/76.2 +/- 12.7 mm Hg, and LDL 105.2 +/- 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients.

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE

Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care.

RESEARCH DESIGN AND METHODS

Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age.

RESULTS

Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance.

CONCLUSIONS

Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

The changing nature of rural health care

The rural health care system has changed dramatically over the past decade because of a general transformation of health care financing, the introduction of new technologies, and the clustering of health services into systems and networks. Despite these changes, resources for rural health systems remain relatively insufficient. Many rural communities continue to experience shortages of physicians, and the proportion of rural hospitals under financial stress is much greater than that of urban hospitals. The health care conditions of selected rural areas compare unfavorably with the rest of the nation. The market and governmental policies have attempted to address some of these disparities by encouraging network development and telemedicine and by changing the rules for Medicare payments to providers. The public health infrastructure in rural America is not well understood but is potentially the most fragile aspect of the rural health care continuum.