An analysis of obstetric practices and outcomes in a deep rural district hospital in South Africa

Background Internationally, there has been a focus on ensuring that Caesarean deliveries are performed only when indicated, to ensure the best outcome for mother and baby. In South Africa, despite a variety of health system interventions, maternal and perinatal mortality remain unacceptably high. Objectives To describe and compare the clinical outcomes related to the mode of delivery, for patients managed at rural primary healthcare level. Methods This retrospective cross-sectional observational analytical study was conducted at a deep rural district hospital in northern KwaZulu-Natal, South Africa. Maternity Case Records and Caesarean delivery audit tools from 2018 were reviewed. Results In total, 634 files were retrieved. The Caesarean delivery rate in the sample was 30.8% (193 of 634 deliveries), and according to the Robson classification, groups 5 and 1 were the biggest contributors to Caesarean delivery. All Caesarean deliveries were deemed to have been medically indicated. As compared to those whose delivery was normal vaginal, the odds of having post-partum haemorrhage were 25 times higher, and the odds of having any complication were three times higher, if a mother delivered by Caesarean (p<0.001). In neonates who were delivered by Caesarean, the odds of being admitted to nursery were four times higher than those delivered vaginally (p<0.001). Conclusion Showing a significantly higher risk of maternal and neonatal complications, this study validated Caesarean delivery at rural primary care as a potentially dangerous undertaking, for which adequate precautions should be taken. There is a need for interventions targeting rural healthcare in South Africa, to ensure that obstetric services are offered to patients in as safe a manner as possible in this environment.

Implementation of cancer screening in rural primary care practices after joining an accountable care organisation: a multiple case study

ObjectiveTo describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).DesignThis study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.SettingThe study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5–9, in one ACO in the Midwestern United States.ParticipantsProviders, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.ResultsWith integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.ConclusionsJoining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

How 4Ms Age-Friendly Care Led to Improved Compliancy of Older Adult Fall Screenings in Rural Primary Care Clinics

Past medical history of falls and fear of falling are reliable indicators of future fall risk of an older adult (OA). As one of the HRSA funded Geriatric Workforce Enhancement recipients, the AR Geriatric Education Collaborative (AGEC) worked with a rural federally qualified healthcare clinic system to help incorporate fall screens to satisfy the Mobility factor in the 4Ms age-friendly care framework. After consultation with the practitioners, it was decided to use the Timed-Up-And-Go (TUAG) screen because it is evidence-based and appropriate for OAs. Training on the use of the TUAG was completed next as was the addition of the screen into the EMR. Fall screens in one clinic were only completed 7% before training and 7 months after the training, this rose to almost 100%. In a second clinic, the screens were completed 22% of the time and this was increased to 66% after training. Training on mobility continues to occur on a regular basis as staff turns over and as new priorities arise, but the use of the TUAG as a mobility screen has been a critical component in the process of these rural clinics providing age-friendly care. Next steps with improving fall risks will be the development of flags within the EMR that will force practitioners to complete a full falls plan of care if the OA scored within the moderate or high fall risk categories. The plan will include home safety education and/or evaluation, PT or OT referrals to further support healthy aging for the OA.

Characteristics of Our Patient Population

To date, 106 patients have completed behavioral health assessments across three sites: a rural primary care clinic (n = 32), urban federally qualified health center (n = 33), and state-certified residential rehabilitation facility (n = 41). Patients ranged from 18 to 65 years of age (M = 38.6, SD = 11.4). Approximately 51% were female and 75% were non-Hispanic White (followed by 22% African American). Over 60% had a high school degree or less and found it at least somewhat difficult to pay for basic needs. Most patients endorsed substantial (44%) or severe (39%) drug use, with 40% endorsing opioid use. There were no significant differences in substance use by age group. Moderate to severe symptoms of depression (43%) and anxiety (49%) were common. Approximately 70% endorsed adverse childhood experiences, and 44% reported clinically significant post-traumatic stress symptoms. Measures of cognitive functioning and objective health literacy are currently being collected.

The Differences in the Prevalence of Cardiovascular Disease, Its Risk Factors, and Achievement of Therapeutic Goals among Urban and Rural Primary Care Patients in Poland: Results from the LIPIDOGRAM 2015 Study

A nationwide cross-sectional study, LIPIDOGRAM2015, was carried out in Poland in the years 2015 and 2016. A total of 438 primary care physicians enrolled 13,724 adult patients that sought medical care in primary health care practices. The prevalence of hypertension, diabetes mellitus, dyslipidaemia, and CVD were similar in urban and rural areas (49.5 vs. 49.4%; 13.7 vs. 13.1%; 84.2 vs. 85.2%; 14.4 vs. 14.2%, respectively). The prevalence of obesity (32.3 vs. 37.5%, p < 0.01) and excessive waist circumference (77.5 vs. 80.7%, p < 0.01), as well as abdominal obesity (p = 43.2 vs. 46.4%, p < 0.01), were higher in rural areas in both genders. Mean levels of LDL-C (128 vs. 130 mg/dL, p = 0.04) and non-HDL-C (147 vs. 148 mg/dL, p = 0.03) were slightly higher in rural populations. Altogether, 14.3% of patients with CVD from urban areas and 11.3% from rural areas reached LDL <70 mg/dL (p = 0.04). There were no important differences in the prevalence of hypertension, diabetes, dyslipidaemia, and CVD, or in mean levels of blood pressure, cholesterol fractions, glucose, and HbA1c between Polish urban and rural primary care patient populations. A high proportion of patients in cities and an even-higher proportion in rural areas did not reach the recommended targets for blood pressure, LDL-C, and HbA1c, indicating the need for novel CVD-prevention programs.

Follow-up care delivery in community-based hypertension and type 2 diabetes management: a multi-centre, survey study among rural primary care physicians in China

Background Follow-up care is crucial but challenging for disease management particularly in rural areas with limited healthcare resources and clinical capacity, yet few studies have been conducted from the perspective of rural primary care physicians (PCPs). We assessed the frequency of follow-up care delivered by rural PCPs for hypertension and type 2 diabetes – the two most common long-term conditions. Methods We conducted a multi-centre, self-administered survey study built upon existing general practice course programmes for rural PCPs in four provinces. Information on follow-up care delivery were collected from rural PCPs attending centralised in-class teaching sessions using a set of close-ended, multiple choice questions. Binary logistic regression analysis was performed to examine physician-level factors associated with non-attainment of the target frequency of follow-up care for hypertension and type 2 diabetes, respectively. The final sample consisted of rural PCPs from 52 township-level regions. The Complex Samples module was used in the statistical analysis to account for the multistage sample design. Results The overall response rate was 91.4%. Around one fifth of PCPs in rural practices did not achieve the target frequency of follow-up care delivery (18.7% for hypertension; 21.6% for type 2 diabetes). Higher education level of physicians, increased volume of daily patients seen, and no provision of home visits were risk factors for non-attainment of the target frequency of follow-up care for both conditions. Moreover, village physicians with less working experiences tended to have less frequent follow-up care delivery in type 2 diabetes management. Conclusions Efforts that are solely devoted to enhancing rural physicians’ education may not directly translate into strong motivation and active commitment to service provision given the possible existence of clinical inertia and workload-related factors. Risk factors identified for target non-attainment in the follow-up care delivery may provide areas for capacity building programmes in rural primary care practice.

Developing a Co-Production Strategy to Facilitate the Adoption and Implementation of Evidence-Based Colorectal Cancer Screening Interventions for Rural Health Systems: A Pilot Study

Background: Evidence-based colorectal cancer screening (CRCS) interventions exist, but have not been broadly adopted in rural primary care settings. Participatory adoption and implementation strategies may be promising in closing this gap through a clinical-academic partnership to guide rural practitioners to locate, select, and implement CRCS interventions that align with local context. We developed a prototype strategy adapted from the National Cancer Institute’s ‘Putting Public Health Evidence in Action’ curriculum in collaboration with two rural clinics to facilitate systems change related to CRCS. This paper describes the process of co-development and delivery of a systems-focused strategy to improve adoption, implementation, and sustainability of CRCS interventions. Methods: We used a bundle of implementation strategies with a core focus on academic-clinical partnership development and Plan-Do-Study-Act cycles to identify clinical partner interests/preferences on delivery methods and content needed to facilitate intervention identification and systems-change processes that improve CRCS rates. Clinic physicians and staff (n=7) at the rural clinics were asked to evaluate the approach based on overall reactions and perceptions of innovation characteristics using 5-point Likert scale. After completing the systems-change process, we conducted key-stakeholder interviews (n=5) to assess feasibility and acceptability on content/delivery format and plans for ongoing implementation of CRCS evidence-based interventions (EBIs). Results: Electronic blueprints for CRCS EBI selection and implementation (8 modules) were developed and followed by an online forum/live-streaming conference to allow for CRCS tailoring. The two clinics used different learning approaches: one completed the modules together while the other completed the modules separately to cover material before a group video conference. Across all modules, participants in both clinics reported positive reactions toward the systems-change modules. Both clinics reported improvements in how they perceived the characteristics of the modules and the participatory approach to tailor selected CRCS EBIs. Through the process both clinics developed a specific EBI implementation plan. Interview participants reported that the approach was feasible and acceptable, and provided suggestions for further improvements on content, delivery, and format of the approach.Conclusions: The bundle of implementation strategies used were feasible and acceptable in rural primary care practices to facilitate the use of evidence-based approaches to improve CRCS.

Developing a Co-Production Strategy to Facilitate the Adoption and Implementation of Evidence-Based Colorectal Cancer Screening Interventions for Rural Health Systems: A Pilot Study

Background: Evidence-based colorectal cancer screening (CRCS) interventions exist, but have not been broadly adopted in rural primary care settings. Participatory adoption and implementation strategies may be promising in closing this gap through a clinical-academic partnership to guide rural practitioners to locate, select, and implement CRCS interventions that align with local context. We developed a prototype strategy adapted from the National Cancer Institute’s ‘Putting Public Health Evidence in Action’ curriculum in collaboration with two rural clinics to facilitate systems change related to CRCS. This paper describes the process of co-development and delivery of a systems-focused strategy to improve adoption, implementation, and sustainability of CRCS interventions. Methods: We used a bundle of implementation strategies with a core focus on academic-clinical partnership development and Plan-Do-Study-Act cycles to identify clinical partner interests/preferences on delivery methods and content needed to facilitate intervention identification and systems-change processes that improve CRCS rates. Clinic physicians and staff (n=7) at the rural clinics were asked to evaluate the approach based on overall reactions and perceptions of innovation characteristics using 5-point Likert scale. After completing the systems-change process, we conducted key-stakeholder interviews (n=5) to assess feasibility and acceptability on content/delivery format and plans for ongoing implementation of CRCS evidence-based interventions (EBIs). Results: Electronic blueprints for CRCS EBI selection and implementation (8 modules) were developed and followed by an online forum/live-streaming conference to allow for CRCS tailoring. The two clinics used different learning approaches: one completed the modules together while the other completed the modules separately to cover material before a group video conference. Across all modules, participants in both clinics reported positive reactions toward the systems-change modules. Both clinics reported improvements in how they perceived the characteristics of the modules and the participatory approach to tailor selected CRCS EBIs. Through the process both clinics developed a specific EBI implementation plan. Interview participants reported that the approach was feasible and acceptable, and provided suggestions for further improvements on content, delivery, and format of the approach.Conclusions: The bundle of implementation strategies used were feasible and acceptable in rural primary care practices to facilitate the use of evidence-based approaches to improve CRCS.

Exploring Pharmacy Trainee Experiential Learning in a Full Scope Collaborative Rural Primary Care Practice: A Retrospective Chart Review

Despite reported benefits of pharmacy trainees (e.g., pharmacy students, pharmacy residents) in hospital settings, limited research on the impact of these trainees has been conducted in rural primary care. To explore the potential benefits and impact of pharmacy trainees practicing in a supervised collaborative rural primary care setting, a retrospective chart review was conducted. Drug therapy problems (DTPs) were classified using the Pharmaceutical Care Network Europe (PCNE V9) system. Valuation was measured using a validated tool developed by Overhage and Lukes (1999). Over 16 weeks on a part-time basis, pharmacy trainees (n = 3) identified 366 DTPs during 153 patient encounters. The most common causes for DTPs were related to patient transfers and the need for education. Drug level interventions carried out directly by trainees under supervision accounted for 13.1% of total interventions. Interventions that required prescriber authorization had an acceptance rate of 83.25% higher than previous acceptance rates found in urban primary care settings. About half (51%) of the interventions proposed and made by pharmacy trainees were classified as significant or very significant, suggesting these trainees added significant value to the pharmacy service provided to rural community residents. This study suggests that pharmacy trainees can be effective resources and contribute meaningfully to patient care in a collaborative rural primary care team setting.