Abstract
BackgroundThe precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review.MethodsThis paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014.ResultsTwo hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians.ConclusionFindings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1629-6) contains supplementary material, which is available to authorized users.
Highlights
The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders
In the case of cesarean section, these conditions have created a response from General Practitioners with Enhanced Surgical Skills (GPESS) training to meet the operative needs of the population in many jurisdictions
GPESS is synonymous with decentralized perinatal surgical care in BC, this review considered all models in jurisdictions with a comparable health services context
Summary
The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. The primary care focus of their work alongside their availability for limited procedural work addresses the challenges of low surgical volume in conjunction with the primary care needs of rural communities This solution has been recognized and integrated into rural health care planning in jurisdictions such as Australia, the United States, Norway, Scotland, and in more ad-hoc ways in Canada and other jurisdictions, a review of the international literature on the safety and outcomes of GPESS has not been undertaken. In 2012, the BC Ministry of Health held province-wide consultations with key stakeholders in order to establish a set of consensus-driven action items for a provincial primary maternity care agenda, known as the BC Primary Care Plan. These consultations resulted in a series of short-term “action items.” Health care decision makers recognized that any reasoned debate about these issues demanded a rigorous review of the international literature
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