Service Quality in Rural Healthcare: An Exploration of Expectation Versus Veracity

Federal Bills Raise Cap on Medicare-Funded Residency Positions and Modify Graduate Medical Education Policies.

Temporal Trends in Rural vs Urban Sepsis-Related Mortality in the United States, 2010-2019

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Panel 3: Speaker 2

Working to make rural health matter.

CMS Finalizes Rules for Distribution of 1000 New Medicare-Funded Residency Positions and Changes to Rural Training Track Programs.

Background: The integration of mental health in primary health care, throughout its various functional units and with effective articulation between primary health care and mental health services, has been considered an essential objective of the legislative documents produced in the last three decades in Portugal, among them the National Health Plan 2011-2016.Goals: This study aimed to inquire health professionals’ perceptions about mental health care provided by public primary health care units, namely their perceptions about the mental health of their patients. It also intended to explore the difficulties perceived by the health professionals in their daily activity about the mental health problems of their patients and about the need of clinical psychologists’ activity in the public primary health care.Methods: This is an observational cross-sectional study with two non-probabilistic samples: health professionals (doctors, nurses and psychologists) and patients from two public health care units. Health professionals were interviewed (individual structured face-to-face interviews) about their perceptions of needs for improving their capacity to provide mental healthcare and about patients’ mental health conditions. Patients responded (by self-administration) to the Depression, Anxiety and Stress Scale (DASS-21), providing a characterization of patients’ stress, anxiety and symptoms of depression.Results: Health professionals in their daily practice often identify in their patients symptoms of stress, anxiety and depression (most particularly in adults),. Several issues were identified as problematic, such as: poor access of the referral system for psychiatric and clinical psychological specialized care, insufficient number of health professionals, particularly of psychologists, and lack of appropriate mental health care specialization. The results also revealed relevant levels of stress, anxiety and depression in primary health care patients (both genders), which seem to increase with age. Discussion: Difficulties identified by health professionals may relate to the centralisation of resources, resistance to change from human resources management, lack of consensus among the various decision groups linked to mental health and, at institutional level, insufficient and inadequate funding. These factors may contribute to a failure in early diagnosis of symptoms of depression, anxiety and stress. It is expected that articulation between primary health services and differentiated health services will improve, with improvement in teamwork among professionals and increase of the quality of life of users, satisfaction with work, from health professionals, and reduction of health costs.

The Unique Challenges Facing Rural Providers in the COVID-19 Pandemic.

Q: Thailand has a long tradition of investing in health, why? A: Over the last decades, we have built and maintained leadership among health professionals with a strong sense of commitment. At medical and health schools in our country, we learn the teachings of Prince Mahidol. His Royal Highness, the father of our King, is considered the father of modern medicine and health in He taught us to interests first and self-interest second. He said: don't want you to be only a doctor, I also want you to be a man. Health professionals learn his teachings by heart. Every seven years we have a national medical education conference and in 1982 it adopted a resolution that medical gradates should be four things: skilled clinicians so that they can more or less alone in rural hospitals; good teachers as they must train community health workers and volunteers; good managers as they must manage district hospitals; and good supporters of primary health care. Q: Thailand is one of the first developing countries to make major progress towards universal health coverage. Why did it pursue this goal in the midst of economic crises? A: The drive towards universal health coverage came hand-in-hand with democracy. After the student revolt against the military government in 1973 and our first democratic elections in 1975, the new government made health services available free of charge to the poor. We then started to improve health insurance coverage for people with low-incomes, the formally employed, children and the elderly. It took us from 1975 to the year 2000, to move from zero to 71% of the population covered by health insurance. Then, in the 2000 election, one of the parties promised to move from 71% to 100%--full coverage--if elected. Within a year of their victory, we closed the 29% gap and on 1 January 2002 the whole population was covered. This was largely thanks to the late Dr Sanguan Nitayaramphong, the first secretary-general of Thailand's National Health Security Office, who worked tirelessly to persuade politicians and the to embrace universal health coverage. He is considered the Father of universal health coverage in Thailand. Q: How did Thailand achieve 71 % coverage in spite of the financial crises of the 1980s and 1990s? A: When the government started to provide free health care to the poor in 1975, we soon found that service access was poor because there weren't enough rural health facilities. In the spirit of the times--of primary health care and health for all--our government started to construct more district hospitals in rural areas. In 1981, annual GDP was about US$ 390 per capita, we were a low-income country facing economic downturn. We had to negotiate an International Monetary Fund loan and had a zero growth budget for five years. Despite this, our government took the courageous decision to continue expanding the rural health infrastructure. Q: How? A: The government froze all new capital investment in urban hospitals from 1982 to 1986 and invested these funds in building rural district hospitals and health centres as well as mass training and employment of doctors and community health workers. Before this, the health ministry budget for these districts was lower than in urban provinces. After 1982, it was higher, and this trend continues today. We established a compulsory public work placement of three years for medical graduates and four years for nursing graduates. We strengthened primary health care by recruiting and training volunteers in villages across the country. Today, we have about one million volunteers. So our government put us on the path to universal health coverage by investing in the rural health infrastructure. Q: Why was health policy a vote winner in the 2000 general election? A: People wanted to have access to essential health services of good quality without facing financial ruin. …

Availability of anesthesia personnel in rural Washington and Montana.

The pandemic period showed uneven access of the population to quality medical care. The rural population was the most vulnerable. Accordingly, the study’s primary purpose is to determine the level of satisfaction of the rural population with the quality and accessibility of medical services (for example, the rural population of Sumy City Council), establish сausal link, and develop recommendations for improving health care in rural areas. The meta-analysis, as well as patient surveys, were used as methodological tools in the study. The sources of information were the legislative framework in health care and survey results. The study results showed that 79.4% of respondents in the area of residence could receive medical care at a medical assistant and obstetric center or hospital. For most respondents (88.5%), getting to a medical institution is not a problem. After all, they spend no more than 40 minutes on the road. However, some patients need to travel by train, which reduces their satisfaction with the facility’s location. 91.5% of respondents turn to family doctors. 69% of them are satisfied with the quality of medical services. Nevertheless, it is necessary to pay attention to the following problems: 1) the required services were not provided; 2) the doctor was not present; 3) uncomfortable conditions. It will help to increase the level of patient satisfaction. The causal link of the low level of accessibility of the rural population to quality medical care was built using the obtained results. In general, the study results helped highlight the problems in medical services organizations to the people in rural areas. Understanding these issues allows finding the best ways to solve them, which will help strengthen health care in general. Accordingly, the authors identified the most promising areas for forming the regulatory framework for health care. It also reaffirmed the need to focus on the digitalization of health care. As for now, it is a global trend. Digitalization in health care will create more favorable conditions to ensure equal access of all populations to quality health services. The authors’ findings can be used to develop and implement measures to increase the availability of health services for the rural population at the state level.

Australia's Rural Health Multidisciplinary Training program: Preparing for the rural health workforce that Australia needs.

Significant percentage of health care services for rural Nigerians is being provided in rural health facilities by rurally based doctors, nurses, midwifes and other categories of health professionals. These services include general medical and obstetric care as well elective and urgent surgeries. As a result of these, there is likelihood of a decrease in the need for rural people to travel to major centres to seek health care service except for referral purposes. Medical education and health service management policy appear to support the location of tertiary and secondary health facilities in urban areas to the detriment of rural community health care. Hence there is an assumption, without much evidence, that the quality of care in rural hospitals' is lower than that provided in larger urban hospitals. Also there is dearth of literature on the aspects of heath care to be measured to indicate quality. This article reports an exploration of multiple perspectives on what constitutes quality of care in rural community medical practice. This is a multiple perspective analytical study. Data were obtained from a series of 134 individual patient cases involving internal medicine, obstetric and surgical procedures in small to large rural hospitals. Interviews were conducted with several participants in each case and these include doctors; nurses; midwives; patients; and family members of the patients. The interviews also explored the perspectives of individuals in each group on the broader question of what constitutes quality of care in a general sense. Their comments were subjected to qualitative analysis using SPSS software package. The different groups produced different views on what might determine the quality of health care in rural community hospitals. The health professionals tended to focus on technical aspects of care, although the doctors and nurses had some different emphases, while the patients and their families were more concerned with access, interpersonal communication, convenience and cost. These factors appeared to be consistent with previous literature from general healthcare settings. Some indicators were suggested for measuring the quality of rural health care. The contribution of this study to knowledge is in area of improvement of understanding of the differing views held by rural health professionals, patients and patients' families in thinking about the quality of care provided in rural community health facilities. Consideration of the quality of procedural rural medical care should include the needs and expectations of those living and working in a smaller, more familiar environment. This has implications for health planners, and suggests that there is a continuing need for rural health professionals to be trained to provide procedural medical services in rural hospitals, and for rural hospitals to be maintained at a standard necessary to support quality service provision.Keywords: Nigeria; quality of health care; experiences; perspectives; rural community Nigerian Medical Practitioner Vol. 50 (2) 2006: pp 48-53

The adoption of telehealth in healthcare delivery has transformed patient treatment options. Urban and rural hospitals are increasingly using telehealth to reach more patients, improve patient engagement, and increase healthcare quality. Hospitals experience the operational benefits of adopting telehealth through improving clinical workflow, increasing efficiency, and improving patient satisfaction. These benefits may have financial implications through increases in patient volume and revenue, and reductions in provider overhead and costs. The overall effect of telehealth adoption on hospital financial performance is currently unknown. This study examines the association of telehealth adoption with the financial performance of rural and urban hospitals. This study uses retrospective data to examine the differences between urban and rural hospitals and community characteristics, profitability, and telehealth adoption from 2009 to 2019 in the United States. Data were obtained from the American Hospital Association Annual Survey and the Information Technology Supplement, the Centers for Medicare & Medicaid Services Healthcare Cost Report Information Systems, and the Area Health Resource File. Telehealth adoption status was determined using the American Hospital Association Annual Survey and the Information Technology Supplement Survey. Hospitals were classified into three categories, according to telehealth adoption status: (1) telehealth persistent nonadopters, (2) telehealth persistent adopters, and (3) telehealth switchers. Hospital financial performance was measured using operating margin and total margin. Descriptive statistics were used to evaluate the variation between the three categories of telehealth adoption status and hospital characteristics, hospital financial performance, and community characteristics. The study sample of 1,530 hospitals consisted of 56% rural hospitals and 44% urban hospitals. The results reveal disparities in financial performance between rural and urban hospitals. From 2009 to 2019, both rural and urban hospitals, identified as telehealth persistent adopters, exhibited higher operating and total margins compared to telehealth persistent nonadopter hospitals. Hospitals that transitioned from telehealth nonadopters to telehealth adopters, started with operating and total margins that closely aligned with telehealth persistent nonadopters. However, as hospitals adopted telehealth, both operating and total margins followed closely to telehealth persistent adopters. The results indicate that while hospital financial performance is associated with telehealth adoption, inferring causation is beyond the scope of these results. The telehealth adoption status has unveiled noticeable patterns in hospital financial performance. In both rural and urban settings, hospitals persistently lacking telehealth capacity have the worst financial performance when compared to hospitals that persistently maintained telehealth services or hospitals that adopted telehealth over the study period. Overall, urban hospitals had better financial performance, which is likely associated with higher caseloads and payer mix compared to rural hospitals. Hospitals that adopted telehealth over the study period showed an increase in financial margins similar to hospitals with persistent telehealth adoption. Targeted policies that address the specific financial challenges of hospitals with a history of poor performance could effectively increase telehealth adoption in these settings. Future research should examine whether adoption among hospitals persistently lacking telehealth can influence the quality and accessibility of services, along with associated health outcomes to determine whether more aggressive policy action is warranted.

Voice over Internet Protocol (VoIP) has been an interactive subject chosen by most studies. The increase of using Real Time Applications service such as (VoIP) is resulting in the high growth of Telecom and broadband field to meet the request of providing high quality of VoIP at any place, the prime Goal of this paper is to analyze and evaluate of an appropriate voice (CODEC) schemes depending on the Quality of service (QoS) of VoIP in Universal Mobile Telecommunication system (UMTS), network was implemented in OPNET Modeler 14.5. The quality is evaluated based on some QoS parameters such as Jitter , MOS, end-to-end delay and packet loss to investigate the performance of different codecs QoS scheme in UMTS VoIP network. The VoIP codecs used in the measurements of QoS are: G.711, G.723.1, GSM-FR and G.729A. Simulations showed that G.711 and GSM-FR are the best schemes provide best quality of voice. G.723.1 can be selected and use in UMTS depending on conditions. The results analyzed and the performance evaluated will give network Planners an opportunity to select the codec for VoIP performance enhancement which lead to the satisfactions of customers . I. Introduction Day by day Internet technology has changed the Way and behaviours of people communicate With the rapid growth of wireless Packet-switched networks , sending data through the Internet Rather than the Public Switched Telephone Network (PSTN) has become a better option in terms of cost for users and Service providers, leading to huge growth of voice applications Over IP networks. With the new emerging set of mobile phones VoIP has become a factual standard for Voice applications in the Internet. Mobile phone users can make a voice/video call through the Internet anywhere anytime with better communication quality and less cost than PSTN. With the telecom industry moving towards the next generation Wireless networks which are going to provide high quality Service and higher down-link/up-link speed, VoIP continues to improve its QoS, mainly for long distance calls. This Improvement is going to impact businesses like Multinational companies, as well as the normal users to a great Extent than ever imagined . Deployment of Universal Mobile Telecommunications System (UMTS) as a part of 3G network. As a complete Network system, it provides wider coverage and high mobility to fulfil the user demands in any places including office, Home, urban and rural areas. UMTS supports packet-based Applications including real-time multimedia applications such As VoIP with a peak down-link data rate in this paper, we take VoIP as an application scenario to analyze and evaluate UMTS VoIP QoS using different Codecs, in Order to investigate how well those codecs cope with Real-time multimedia applications. This analysis will help identify the strengths and weaknesses of the codec in terms of QoS and can guide the applications to choose the best codec we have designed and implemented UMTS simulation module in OPNET and carried out extensive simulations to analyze the Mean Opinion Score (MOS), packet end-to-end delay, jitter And packet delay variation for different type of VoIP traffic with different Codec. Our simulation results show that UMTS has better QoS to support VoIP performance enhancement. The rest of the paper is organized as follows Section II briefly gives background VoIP. UMTS. Section III deals with the simulation setup used in OPNET for UMTS .Section IV evaluates and analyzes the Simulation results of the VoIP application running on UMTS. Section V discusses the related work. Finally In Section VI we conclude this paper. II. VoIP Within the context of VoIP communications, audio codecs play most crucial part in processing voice elements from analogue to digital and then from digital to analogue again. Though the performance of audio codecs is not the only driving and determining factor for the performance of any VoIP scenario, it can be well admitted that the performance of the audio codecs and their related features dominantly govern the degree of performance of any VoIP application. Thus, the performance of audio codecs is one of the most important aspects to consider while dealing with VoIP communication and its deployment. This paper presents the evaluate of VoIP under different audio codecs.