Stefan Grzybowski

Defining rational hospital catchments for non-urban areas based on travel-time

BackgroundCost containment typically involves rationalizing healthcare service delivery through centralization of services to achieve economies of scale. Hospitals are frequently the chosen site of cost containment and rationalization especially in rural areas. Socio-demographic and geographic characteristics make hospital service allocation more difficult in rural and remote regions. This research presents a methodology to model rational catchments or service areas around rural hospitals – based on travel time.ResultsThis research employs a vector-based GIS network analysis to model catchments that better represent access to hospital-based healthcare services in British Columbias rural and remote areas. The tool permits modelling of alternate scenarios in which access to different baskets of services (e.g. rural maternity care or ICU) are assessed. In addition, estimates of the percentage of population that is served – or not served -within specified travel times are calculated.ConclusionThe modelling tool described is useful for defining true geographical catchments around rural hospitals as well as modelling the percentage of the population served within certain time guidelines (e.g. one hour) for specific health services. It is potentially valuable to policy makers and health services allocation specialists.

Distance matters: a population based study examining access to maternity services for rural women

BackgroundIn the past fifteen years there has been a wave of closures of small maternity services in Canada and other developed nations which results in the need for rural parturient women to travel to access care. The purpose of our study is to systematically document newborn and maternal outcomes as they relate to distance to travel to access the nearest maternity services with Cesarean section capabililty.MethodsStudy population is all women carrying a singleton pregnancy beyond 20 weeks and delivering between April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia. Maternal and newborn data was linked to specific geographic catchments by the B.C. Perinatal Health Program. Catchments were stratified by distance to nearest maternity service with Cesarean section capabililty if greater than 1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adverse newborn and maternal outcomes.Results49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratios for perinatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100 NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served by specialists.ConclusionsDistance matters: rural parturient women who have to travel to access maternity services have increased rates of adverse perinatal outcomes.

A Follow-up Study of the Grain Elevator Workers in the Port of Vancouver

Abstract A second respiratory survey was conducted on 587 grain elevator workers in the Port of Vancouver and on 111 civic workers, 25 years after the first health survey. The prevalence of respiratory symptoms and lung function findings among grain elevator workers in the second survey were almost identical with those in the first health survey, even though the dust concentration was lower in the elevators during the second survey. The longitudinal study in 396 grain workers showed that the prevalence of respiratory symptoms increased slightly during the second health survey among workers who had the same smoking habits during both surveys. Of the smokers who had respiratory symptoms or lung function impair-ment in the first survey, 23.5% followed our advice and gave up smoking; the prevalence of cough and sputum pro-duction decreased among these workers. The annual decline in function was greater for grain workers than civic workers particularly among workes over the age of 50 years when the differences...

Safety and Community: The Maternity Care Needs of Rural Parturient Women

OBJECTIVE To investigate rural parturient womens experiences of obstetric care in the context of the social and economic realities of life in rural, remote, and small urban communities. METHODS Data collection for this exploratory qualitative study was carried out in 7 rural communities chosen to represent diversity of size, distance to hospital with Caesarean section capability and distance to secondary hospital, usual conditions for transport and access, and cultural and ethnic subpopulations. We interviewed 44 women who had given birth up to 24 months before the study began. RESULTS When asked about their experiences of giving birth in rural communities, many participants spoke of unmet needs and their associated anxieties. Self-identified needs were largely congruent with the deficit categories of Maslows hierarchy of needs, which recognizes the contingency and interdependence of physiological needs, the need for safety and security, the need for community and belonging, self-esteem needs, and the need for self-actualization. For many women, community was critical to meeting psychosocial needs, and women from communities that currently have (or have recently had) access to local maternity care said that being able to give birth in their own community or in a nearby community was necessary if their obstetric needs were to be met. CONCLUSION Removing maternity care from a community creates significant psychosocial consequences that are imperfectly understood but that probably have physiological implications for women, babies, and families. Further research into rural womens maternity care that considers the loss of local maternity care from multiple perspectives is needed.

Stress and anxiety associated with lack of access to maternity services for rural parturient women.

OBJECTIVE The objective of this study is to compare the level of stress and anxiety between women resident in communities with different degrees of access to local maternity services. DESIGN   Cross-sectional survey. SETTING Fifty-two communities across rural British Columbia with different levels of access to maternity care services (ranging from no services to local specialist obstetrician). PARTICIPANTS A total of 187 women, 40 of whom were from communities with no local access to services. MAIN OUTCOME MEASURES Stress score on the R ural Pregnancy Experience Scale including financial and continuity of care subscales. RESULTS Parturient women who had to travel more than one hour to access services were 7.4 times more likely to experience moderate or severe stress when compared to women who had local access to maternity services. CONCLUSIONS Lack of access is strongly associated with stress in rural parturient women.

Planning the optimal level of local maternity service for small rural communities: A systems study in British Columbia

OBJECTIVES To develop and apply a population isolation model to define the appropriate level of maternity service for rural communities in British Columbia, Canada. METHODS Iterative, mathematical model development supported by extensive multi-methods research in 23 rural and isolated communities in British Columbia, Canada, which were selected for representative variance in population demographics and isolation. Main outcome measure was the Rural Birth Index (RBI) score for 42 communities in rural British Columbia. RESULTS In rural communities with 1h catchment populations of under 25,000 the RBI score matched the existing level of service in 33 of 42 (79%) communities. Inappropriate service for the rural population was postulated and supported by qualitative data available on 6 of the remaining 9 communities. CONCLUSIONS The RBI is a potentially pragmatic tool in British Columbia to help policy makers define the appropriate level of maternity service for a given rural population. The conceptual structure of the model has broad applicability to health service planning problems in other jurisdictions.

Tuberculosis in recent Asian immigrants to British Columbia, Canada: 1982–1985

The prevalence and incidence of active tuberculosis among 21,959 recently arrived (1982-1985) immigrants from 7 selected Asian countries into British Columbia (BC), Canada, were reviewed. Among these newly arrived immigrants, 1173 (5.3%) were judged to have inactive tuberculosis at the immigration examination in their country of origin. In this subgroup, 14 of 932 (1.5%) were found to have active tuberculosis at the initial examination after arrival in Canada. Subsequently, 7 further cases arose in this group of inactive cases giving an average annual incidence rate of 0.33% over the 4-year period of study. Only 3 of these 21 cases had had previous antituberculosis chemotherapy. The remaining 20,786 recent immigrants with normal X-rays at the immigration examination contributed 30 cases during the next 4 years--an average annual incidence rate of 0.08% or 8 times the comparable rate for BC (0.01%). The limitations of the immigration screening process are illustrated and the value of early surveillance of immigrants designated as having inactive tuberculosis is underlined. The apparent failure to exclude active disease prior to the arrival of these immigrants is one factor elevating the incidence of active tuberculosis in the first few years after arrival in the host country. Other factors include the relatively high prevalence of inactive tuberculosis among the immigrants from certain countries and their high rate of early relapse after entry, especially in those not previously treated. Such immigrants should be considered for chemoprophylaxis immediately after entry.

Does Distance Matter? Increased Induction Rates for Rural Women Who Have to Travel for Intrapartum Care

OBJECTIVES Although there has been a devolution of local rural maternity services across Canada in the past 10 years in favour of regional centralization, little is known about the health outcomes of women who must travel for care. The objective of this study was to compare intervention rates and outcomes between women who live adjacent to maternity service with specialist (surgical) services and women who have to travel for this care. METHODS The BC Perinatal Database Registry provided data for maternal and newborn outcomes by delivery hospital for 14 referral hospitals (selected across a range of 250-2500 annual deliveries) between 2000 and 2004. Three hospitals were selected for sub-analysis on the basis of almost complete capture of the satellite community population (greater than 90%) to avoid referral bias. RESULTS Women from outside the hospital local health area (LHA) had an increased rate of induction of labour compared with women who lived within the hospital LHA. Sub-analysis by parity demonstrated that multiparous women had increased rates of induction for logistical reasons. CONCLUSION Rural parturient women who have to travel for care are 1.3 times more likely to undergo induction of labour than women who do not have to travel. Further research is required to determine why this is the case. If it is a strategy to mitigate stress incurred due to separation from home and community, either a clinical protocol to support geographic inductions or an alternative strategy to mitigate stress is needed.

Early diagnosis of carcinoma of the lung. Simultaneous screening with chest X-ray and sputum cytology.

Two thousand one hundred and twelve male cigarette smokers over the age of 40, who either suffered from chronic bronchitis, showed long standing radiologic abnormalities, or recently recovered from pneumonia—or who showed another factor making them particularly prone to development of cancer of the lung—were screened with sputum cytology and chest x‐ray. Incidence of lung cancer was high: 17 cases (1 in 125 persons screened) were discovered. Eight of these cases were detected by x‐ray alone, 7 by cytology alone, and only 2 by both of these methods. This suggests that these screening techniques are deficient when used alone. Further confirmation of this is derived from investigation of 228 patients who were screened with negative results in 1965—9 of them developed and then succumbed to lung cancer, and at least 5 of them presumably had it at the time of initial screening. In screening programs an effort should be made not to give the participants a false sense of security concerning absence of lung cancer when results of screening tests are negative. Of the 17 cases, 13 died from cancer of the lung and one from another cause. Three are alive and well. The poor survival in this group was due, to an appreciable extent, to the fact that the same selective factors, such as chronic bronchitis, which rendered these patients liable to lung cancer precluded the possibility of surgical treatment.Two thousand one hundred and twelve male cigarette smokers over the age of 40, who either suffered from chronic bronchitis, showed long standing radiologic abnormalities, or recently recovered from pneumonia—or who showed another factor making them particularly prone to development of cancer of the lung—were screened with sputum cytology and chest x-ray. Incidence of lung cancer was high: 17 cases (1 in 125 persons screened) were discovered. Eight of these cases were detected by x-ray alone, 7 by cytology alone, and only 2 by both of these methods. This suggests that these screening techniques are deficient when used alone. Further confirmation of this is derived from investigation of 228 patients who were screened with negative results in 1965—9 of them developed and then succumbed to lung cancer, and at least 5 of them presumably had it at the time of initial screening. In screening programs an effort should be made not to give the participants a false sense of security concerning absence of lung cancer when results of screening tests are negative. Of the 17 cases, 13 died from cancer of the lung and one from another cause. Three are alive and well. The poor survival in this group was due, to an appreciable extent, to the fact that the same selective factors, such as chronic bronchitis, which rendered these patients liable to lung cancer precluded the possibility of surgical treatment.

Commitment to change instrument enhances program planning, implementation, and evaluation.

Introduction: This study investigates the use of a commitment to change (CTC) instrument as an integral approach to continuing medical education (CME) planning, implementation, and evaluation and as a means of facilitating physician behavior change. Methods: Descriptive statistics and grounded theory methods were employed. Data were collected from 20 consecutive CME programs. Physicians were asked to list up to three things they intended to change in their clinical practice as a result of the program. A copy was sent 3 weeks later as a reminder. Six months later, a summary of peer‐intended changes was sent to reinforce intended behavior change. Results: Of 602 participants, 291 (48%) completed CTC forms, resulting in 803 citations. Responses were congruent with the educational objectives and intentions of the program planners. Using the constant comparative method of analysis, a framework was identified for interpreting physician learning strategies. It included change strategies and motivation, learning issues, better doctoring, changes to clinic practice, and diffusion. Discussion: CTC was useful as a multipurpose tool providing planners with meaningful feedback to (1) assess congruence of intended changes in physician behavior with program objectives, (2) document unanticipated learning outcomes, and (3) enable and reinforce intended behavior change.