Nonurban Location Research Articles

Evaluation of a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) State Agency's Vendors to Comply With Regulatory Competitive Price Requirements.

The Inter Tribal Council of Arizona, Inc (ITCA) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition services for families by partnering with local vendors. In 2009, the US Department of Agriculture (USDA) instituted the WIC Vendor Cost Containment Final Rule, which required WIC programs to group vendors with similar characteristics. USDA issued guidance for evaluating and constructing vendor peer grouping systems in 2017. We constructed vendor peer groups using USDA recommended methods. We used ITCA WIC vendor and redemption data to construct composite variables for mean food basket cost as the outcome in linear models using the following predictors: business model, Supplemental Nutrition Assistance Program (SNAP) store type, WIC total sales, number of Universal Product Codes (UPCs) redeemed, number of cash registers, store square footage, rural-urban commuting area codes, 2010 Frontier and Remote (FAR) area codes, distance to the closest interstate in miles, and urban or nonurban location. We developed an ITCA WIC vendor peer group system. We examined 146 ITCA WIC vendors. Final complete vendor peer groups for ITCA WIC in linear regression models included SNAP store type (P < .001), number of cash registers (P < .017), and FAR codes (P < .001). FAR codes were important, while other geography measures were not. Using vendor peer groups can improve cost containment measures and the integrity of WIC services. Other WIC programs can use FAR codes as a USDA-required geography measure for local vendor peer group evaluations.

Revictimisation of Women in Non-Urban Areas: A Scoping Review

Literature widely acknowledges that women who experience Child Sex Abuse (CSA) have a higher risk of experiencing sexual revictimisation later in life, yet less is known about experiences of revictimisation in non-urban areas. The aim of this review is to examine what is known internationally regarding revictimisation of non-urban women, and to provide future research, practice and policy recommendations. A total of 2414 articles were identified through a comprehensive search across five broad health sciences and humanities databases; 11 articles met inclusion criteria and were included in this review. This review found a general lack of qualitative revictimisation studies, and limited research focusing on non-urban women. While existing studies included non-urban research samples, few articles (n = 3) explored how non-urban location contextualises revictimisation experiences. Most peer-reviewed articles identified within this paper (n = 7) examined intimate partner violence (IPV) revictimisation, highlighting a significant lack of research on sexual revictimisation within non-urban settings. Findings from the review indicate that experiences of violence in childhood and adulthood are frequent among non-urban women, and that experiencing child abuse is associated with a heightened likelihood of poor mental health and IPV in adulthood. The review also found that non-urban women faced significant structural disadvantage including low levels of employment and income, limited-service sector resources, unsafe family environments and exposure to community violence. Additional qualitative research is needed to better understand the experiences and needs of non-urban revictimised women, particularly within an Australian context.

Racial and Ethnic Disparities in Access to Mental Health Services for African and Arab American Youth: An Audit Study

ABSTRACT Racial disparities exist in the quality of and access to mental health services for people of color. Provider bias has been found to avert African American adults from accessing services. However, it is unknown whether provider bias affects service access for African and Arab American youth. Moreover, little is known about the role of client gender and community variables such as urbanicity (i.e., urban versus non-urban) in access to care for youth. Audit methodology examined whether client race/ethnicity and gender predicted providers’ responses to help-seeking messages in an urban and non-urban area of Michigan. Voice actresses created audio recordings portraying a White, African American, or Arab American mother requesting a therapy appointment for her adolescent. Recordings were left on providers’ voicemails in Metro Detroit and Southwest Michigan. Data were collected on whether the providers: (i) called back, and (ii) initiated or denied services. The effect of client characteristics on the odds of a provider calling back differed by location. In the non-urban location, White clients had a 3.4–3.8 times greater odds of receiving a callback than the African and Arab American clients. Additionally, in the urban location, female clients had a 2 times greater odds of receiving a callback than the male clients. Findings from this study suggest that provider bias limited access to mental health services for African and Arab American adolescents in the non-urban location, highlighting the need for strategies to address disparities in access to mental health services for youth of color.

Timeout? The Epidemiology of Pediatric Sports Injuries During the COVID-19 Pandemic.

Background:The COVID-19 pandemic resulted in closure of schools and playgrounds while requiring social distancing, changes that likely affected youth sports participation. The purpose of this study was to identify changes in the epidemiology of pediatric sports injuries during the COVID-19 pandemic.Methods:This retrospective cohort study included patients between the ages of 4 and 18 years who presented to orthopaedic clinics within a single children's hospital network with an acute injury sustained during athletic activity between March 20, 2020, and June 3, 2020 (the strictest period of state-level shelter-in-place orders). These patients were compared with those within the same dates in 2018 and 2019. Chi square and Mann-Whitney U tests were used, as appropriate.Results:Significantly less sports injuries were seen during the pandemic (n = 257) compared with the same dates in 2018 (n = 483) and 2019 (n = 444) despite more providers available in 2020 (P < 0.001). During the pandemic, patients with sports injuries were younger (median age 11 versus 13 years, P < 0.001) and had less delay in presentation (median 5 versus 11 days, P < 0.001). A higher proportion were White (66.9% versus 47.7%, P < 0.001), privately insured (63.4% versus 48.3%, P < 0.001), and seen at a nonurban location (63.4% versus 50.2%, P < 0.001). Most sports injuries during the pandemic were fractures (83.7%). Although 71.4% of all injuries in the prepandemic period occurred in the context of formal sports, only 15.2% were sustained in a formal athletic context in 2020 (P < 0.001). The frequency of surgical treatment was higher during the pandemic (14.8% versus 7.8%, P = 0.001), mainly because most of these injuries were fractures requiring surgical intervention.Conclusions:Fewer sports injuries were seen in the outpatient setting during the COVID-19 pandemic, and most of these injuries were fractures and occurred outside of organized sports settings. Patients were more likely to be White, privately insured, and seen at a nonurban location.

Factors associated with the time to transition from suicidal ideation to suicide plans and attempts in the Australian general population.

Suicide plans and attempts rarely occur without prior suicidal ideation but are hard to predict. Early intervention efforts need to focus on subgroups of the population who are more likely to transition from ideation to suicidal plans and attempts. The current study utilised data from a large nationally representative sample to investigate the time taken to transition and the demographic and mental health correlates of transitioning to suicidal plans and attempts among those with suicidal ideation. Data were from 1237 Australians aged 16-85 years who reported suicidal thoughts at some point in their life. Discrete time survival analysis was used to retrospectively examine the time in years and correlates of transitioning from suicidal ideation to suicide plans and suicide attempt. The majority of those who transitioned to suicide plans or attempts typically did so within 2 years of first experiencing suicidal ideation. Several factors were independently associated with increased speed to transition, including alcohol use disorder, drug use disorder, major depressive episode, obsessive compulsive disorder, sexual minority status, and non-urban location. Older age, being male, older age of first ideation and greater family support were associated with a slower transition. The current study suggests that pre-existing mental or substance use disorders, particularly drug use disorder, as well as sexual minority status, sex and greater family support play an important role in the transition from suicidal ideation to plans or attempts. These results highlight the potential importance of suicide prevention programs that aim to improve social connectedness.

Abstract P113: Impact of Covid-19 Pandemic on the Pre-Hospital Evaluation and Presentation of Ischemic Stroke at a Non-Urban Comprehensive Stroke Center

Introduction: Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on non-urban areas with minimal community transmission is less well understood. Methods: Using a prospectively maintained pre-hospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results: In January, February, March, and April 2019 10, 11, 17 and 19 patients, respectively were transported in comparison to 19, 14, 10 and 8 during the same months in 2020. From January through April 2019 there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020. The slopes of these trend lines are significantly different (3.30; 95%CI 0.48 - 6.12 versus -3.70; 95%CI -5.76 - -1.64, P = 0.001). There were no significant differences in demographics, comorbidities, symptom severity, or stroke discharge diagnoses between the two time periods. However, the median interval from LKW to time of EMS dispatch was significantly longer in January to April 2020 (12 + 273 min) compared to the same time period of January through April in 2019 (7 + 115 min). Conclusion: Our data indicate not only a decrease in patient transport volumes but more alarmingly, significantly longer intervals to EMS activation for suspected stroke care. These results suggest that even in a non-urban location without widespread community transmission patients were delaying or avoiding care for severe illness such as stroke.

Abstract 29: Urban versus Non-Urban Hospital Location Impacts on Stroke Outcomes

Introduction: Stroke care provision differs between urban and provincial hospitals predominantly due to economy of scale, which is correlated with resources available and degree of specialisation. We assessed the impact of urban versus non-urban hospital location on stroke outcomes. Methods: REGIONS Care is a New Zealand (NZ) nationwide prospective observational study that included consecutively admitted stroke patients involving all NZ stroke hospitals between 1 May and 31 October 2018. Patients were followed-up at 3, 6, and 12 months. The primary outcome was favourable modified Rankin Score of 0-2. Results were adjusted for age, stroke severity, pre-morbid level of independence and other potential confounders using multivariate logistic regression. Results: Of the 2,379 patients (mean age (SD), 75 (13.7)), 1,963 (82.6%) had ischaemic strokes and 291 (12.3%) haemorrhagic strokes. The odds of achieving a favourable outcome at 3 and 6 months was significantly lower for patients treated in non-urban compared to urban hospitals: aOR 0.72 (95%CI:0.56-0.93; p=0.012) and aOR 0.71 (95%CI:0.52-0.96; p=0.028), respectively. At 12-months this difference was less pronounced (aOR 0.77, 95%CI:0.57-1.04; p=0.089). Similarly, death was significantly more likely at 3 and 6 months, and borderline statistically significant at 12 months: aOR 1.64, 95%CI:1.30-2.29, p=0.001; 1.54, 95%CI:1.12-2.11, p=0.008; and 1.36, 95%CI:0.99-1.87, p=0.06, respectively. Stroke recurrence was similar between urban and non-urban settings at 3 and 6 months, but more likely in the non-urban setting at 12 months (aOR 1.94, 95%CI:1.14-3.29, p=0.014. In the non-urban setting, eligible patients were less likely to receive reperfusion therapy (aOR 0.5, 95%CI:0.28-0.91, p=0.023); acute stroke unit care was less consistently accessed (aOR 0.58, 95%CI:0.48-0.70, p&lt;0.001); and appropriate secondary preventive therapy was less frequently prescribed (aOR 0.50, 95%CI:0.28-0.91, p=0.023). Conclusion: This first comprehensive prospective NZ nationwide stroke study showed significant differences in stroke outcomes and access to key acute stroke interventions between urban and non-urban hospitals. This inequity requires urgent intervention from health system funders and providers.

Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center.

Introduction Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 (50 ± 11.7 min) compared to the same time period in 2019 (42 ± 8.2 min, p = 0.01). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Factors Affecting the Interest in a Surgical Career among Medical Students at a Nonurban, Tertiary Care Academic Institution

Present day medical students are inherently different from those in the past by growing up in a uniquely different environment that shapes their personal and professional values which affects their career decisions. Vascular surgery (VS) task force is facing a shortage in the near future. The purpose of this analysis is to gain a better understanding of the medical students' perceptions about surgery in general and VS in particular. Our institution is a large, tertiary care medical center, which is in a nonurban location. Our goal was to identify any barriers in the recruitment of prospective students to VS and to implement directives to address such barriers. An online questionnaire was distributed to Penn State Hershey College of Medicine medical students. Our institution has an established 0+5 VS residency program and a VS interest group. It was designed to understand potential barriers in the recruitment of medical students choosing VS as a career. Survey consisted of 23 questions, which were carefully designed to collect information about student demographics, interest in medical profession in general, opinions about the field of surgery, and reasons for having an interest or no interest in VS. Five hundred sixty medical students at Penn State Hershey College of Medicine were surveyed, of whom 143 (26%) completed the survey. About 58.7% were females and two-thirds of the respondents were in the age range of 21-25years. The following factors were significantly associated with pursing surgical career: Medical Student Year III (odds ratio [OR] 0.36, confidence interval [CI] 0.19-0.69), surgical mentorship (OR 6.01, CI 1.30-28), wanting more exposure to VS (OR 6.15, CI 2.07-18.23), and opportunity to complete training within 5years (OR 1.14, CI 1.03-1.25) (all P<0.05). Specifically, for VS, following factors were found to be associated with increased likelihood of choosing a VS career: variety of operative cases, ability to operate on multiple anatomic areas of the body, and opportunity to complete training within 5years (all P<0.05). Following factors were associated with not choosing a VS career: surgical career not for me, long duration of surgical training, financial aid burden, marital status, and complexity of operations (all P<0.05). Students cited following concerns for choosing a surgical career: burnout (61%), stress (12.8%), work hours (12.1%), and stressful life style (5.7%). Potential barriers of students in choosing a surgical career are fundamentally grounded in their overall perception of surgery but are independently associated with their level of education (medical student-III versus others), strong surgical mentorship, the desire to be exposed to VS, and the opportunity to complete subspecialty surgical training within 5years. For VS, attractive factors were variety of operative cases, ability to operate on multiple anatomic areas of the body, and opportunity to complete training within 5years. Overall, burnout associated with surgical career is the most common concern for medical students.

Barn Owls and Black Rats from a Rural Roman Villa at Gatehampton, South Oxfordshire

ABSTRACT A large assemblage of small mammal and other small vertebrate bones was excavated within a relatively small area of a single room in a Roman villa close to the River Thames in South Oxfordshire. It is argued that these bones are the remains of barn owl pellets and that their presence shows that the roof on this room at least had remained intact for some time after either the entire building or this particular part of it had been abandoned as human habitation. The remains of several juvenile black rats were contained within the assemblage, making this the first record of black rats from a rural Romano-British setting in Oxfordshire and adding to the extremely small corpus of records of this species from a non-urban location anywhere in the country. Radiocarbon dates place the presence of rats and the abandonment of the villa during the second half of the fourth century.

Influence of Black Carbon Aerosol on the Atmospheric Instability

AbstractTo date, influence of aerosols on the atmospheric stability and hence on the convection/precipitation is not well understood. From the detailed analysis carried out using high‐accuracy radiosonde and Aethalometer measurements, a significant decrease in the convective available potential energy has been noticed in association with the increase in surface concentration of black carbon (BC) for a restricted range of precipitable water vapor and under similar environmental background (wind speed, direction, and cloud cover) over Gadanki (13.5°N, 79.2°E), a tropical rural site in southern peninsular India. A number of case studies along with statistical analysis indicate a notable perturbation in the temperature profile associated with high‐surface BC concentration conditions compared to the regional mean concentration of the same. A discernible fall in the temperature lapse rate within and above the local boundary layer in association with the higher BC concentration has been observed, which in turn reduces the available potential energy for convection decreasing the positive buoyancy required for a rising moist air parcel. This observation has been noticed over a nonurban location, but the phenomenon is not location dependent and is more applicable to the urban regions where BC concentration is likely to be much higher.

Parent and family factors associated with service use by young people with mental health problems: a systematic review.

To conduct a systematic review of parent and family factors associated with service use for young people with mental health problems, to inform early intervention efforts aimed at increasing service use by young people. A systematic search of academic databases was performed. Articles were included in the review if they had: a sample of young people aged between 5 and 18 years; service use as the outcome measure; one or more parental or family variables as a predictor; and a comparison group of non-service using young people with mental health problems. In order to focus on factors additional to need, the mental health symptoms of the young person also had to be controlled for. Stouffer's method of combining P-values was used to draw conclusions as to whether or not associations between variables were reliable. Twenty-eight articles were identified investigating 15 parental or family factors, 7 of which were found to be associated with service use for a young person with mental health needs: parental burden, parent problem perception, parent perception of need, parent psychopathology, single-parent household, change in family structure and being from the dominant ethnic group for the United States specifically. Factors not found to be related to service use were: family history of service use, parent-child relationship quality, family functioning, number of children, parent education level, parent employment status, household income and non-urban location of residence. A number of family-related factors were identified that can inform effective interventions aimed at early intervention for mental health problems. Areas requiring further research were also identified.

A Decomposition of Hospital Profitability: An Application of DuPont Analysis to the US Market.

Objectives:This paper evaluates the drivers of profitability for a large sample of U.S. hospitals. Following a methodology frequently used by financial analysts, we use a DuPont analysis as a framework to evaluate the quality of earnings. By decomposing returns on equity (ROE) into profit margin, total asset turnover, and capital structure, the DuPont analysis reveals what drives overall profitability.Methods:Profit margin, the efficiency with which services are rendered (total asset turnover), and capital structure is calculated for 3,255 U.S. hospitals between 2007 and 2012 using data from the Centers for Medicare & Medicaid Services’ Healthcare Cost Report Information System (CMS Form 2552). The sample is then stratified by ownership, size, system affiliation, teaching status, critical access designation, and urban or non-urban location. Those hospital characteristics and interaction terms are then regressed (OLS) against the ROE and the respective DuPont components. Sensitivity to regression methodology is also investigated using a seemingly unrelated regression.Results:When the sample is stratified by hospital characteristics, the results indicate investor-owned hospitals have higher profit margins, higher efficiency, and are substantially more leveraged. Hospitals in systems are found to have higher ROE, margins, and efficiency but are associated with less leverage. In addition, a number of important and significant interactions between teaching status, ownership, location, critical access designation, and inclusion in a system are documented. Many of the significant relationships, most notably not-for-profit ownership, lose significance or are predominately associated with one interaction effect when interaction terms are introduced as explanatory variables. Results are not sensitive to the alternative methodology.Conclusion:The results of the DuPont analysis suggest that although there appears to be convergence in the behavior of NFP and IO hospitals, significant financial differences remain depending on their respective hospital characteristics. Those differences are tempered or exacerbated by location, size, teaching status, system affiliation, and critical access designation. With the exception of cost-based reimbursement for critical access hospitals, emerging payment systems are placing additional financial pressures on hospitals. The financial pressures being applied treat hospitals as a monolithic category and, given the delicate and often negative ROE for many hospitals, the long-term stability of the healthcare facility infrastructure may be negatively impacted.

Urinary Catheter Use and Appropriateness in U.S. Emergency Departments, 1995–2010

Catheter-associated urinary tract infection (CAUTI) is the most prevalent hospital-acquired infection, yet little is known about emergency department (ED) use of urinary catheters. The objective was to describe use of urinary catheters in U.S. EDs and determine the proportion that was potentially avoidable. The National Hospital Ambulatory Medical Care Survey (NHAMCS), a weighted probability sample of U.S. ED visits, was analyzed from 1995 through 2010 for use of urinary catheters in adults. Use of a urinary catheter was a specific chart review element and was classified as potentially avoidable if none of the Centers for Disease Control and Prevention (CDC) list of appropriate indications were met by ED visit diagnoses or patient disposition. Annual frequency of urinary catheter use and appropriateness were calculated. Predictors of ED-placed urinary catheters for admitted patients were assessed with multivariate logistic regression. The annual rate of ED-placed urinary catheters varied from 2.2 to 3.3 per 100 adult ED visits. Among admitted patients, 8.5% (95% confidence interval [CI] = 8.0% to 9.1%) received urinary catheters; 64.9% (95% CI = 56.9% to 72.9%) were potentially avoidable. Among discharged patients 1.6% (95% CI = 1.5% to 1.7%) received urinary catheters. There was no significant trend over time in the use of urinary catheters or potentially avoidable urinary catheters (PAUCs). Predictors of catheter use in admitted patients included indicators of patient severity, female sex, and race/ethnicity. Hospital characteristics predicting catheter use included region, ownership type, and urban location. Predictors of potentially avoidable urinary catheter use were lower patient severity, female sex, care by a midlevel practitioner, and nonurban location. Reducing use of urinary catheters outside of CDC guideline criteria in ED patients is a promising strategy to reduce CAUTIs.

Implementation of the NHLBI Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Rationale and study design for Young Hearts, Strong Starts, a cluster-randomized trial targeting body mass index, blood pressure, and tobacco

BackgroundCardiovascular disease (CVD) and the underlying atherosclerosis begin in childhood, and their presence and intensity are related to known cardiovascular disease risk factors. Attention to risk factor control in childhood has the potential to reduce subsequent risk of CVD. ObjectiveThe Young Hearts Strong Starts Study was designed to test strategies facilitating adoption of the National, Heart, Lung and Blood Institute supported Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. This study compares guideline-based quality measures for body mass index, blood pressure, and tobacco using two strategies: a multifaceted, practice-directed intervention versus standard dissemination. Study DesignTwo primary care research networks recruited practices and provided support for the intervention and outcome evaluations. Individual practices were randomly assigned to the intervention or control groups using a cluster randomized design based on network affiliation, number of clinicians per practice, urban versus nonurban location, and practice type. The units of observation are individual children because measure adherence is abstracted from individual patient's medical records. The units of randomization are physician practices. This results in a multilevel design in which patients are nested within practices. The intervention practices received toolkits and supported guideline implementation including academic detailing, an ongoing e-learning group. This project is aligned with the American Board of Pediatrics Maintenance of Certification requirements including monthly physician self-abstraction, webinars, and other elements of the trial. SignificanceThis trial will provide an opportunity to demonstrate tools and strategies to enhance CV prevention in children by guideline-based interventions.

Space-Time Granger Analysis of the War in Iraq: A Study of Coalition and Insurgent Action-Reaction

We investigate insurgent-coalition interaction using the WikiLeaks dataset of Iraq war logs 2004–2009. After a review of existing theoretical interventions on the dynamics of insurgency and presenting a baseline model of violent events, we test a conceptual model of reciprocity using an innovative space-time Granger causality technique. Our estimation procedure retains predicted probabilities of reaction in response to a previous opponent's action across different temporal and spatial configurations in Iraq and in Baghdad. Our conclusions about conflict in Iraq are based on these profiles of risk—what we call space-time signatures. We find strong evidence of “tit-for-tat” associations between coalition/Iraq forces on one side and insurgents/militants on the other. Specifically, we find that the action-reaction association varies strongly by majority ethnic region across Iraq and in Baghdad, by urban and nonurban location, and within Sunni-dominated areas, by district income. While violence is strongly temporally dependent in the same location, the effect of distance varies significantly across the different subsets of the Iraq data.

Predictors of Quality-of-Care Processes in Geriatric Assessment Units: Toward a Better Organizational Framework

To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. Retrospective study. Forty-four Geriatric Assessment Units (GAU). Patients aged 65 and older who were admitted to a GAU for a fall with trauma. Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.

Motivations, expectations and experiences of Australian rural and regional planners

Despite playing an extremely important role in shaping communities, the role and contribution of planners is not widely understood or acknowledged. At the same time, there is a shortage of planners in Australia, especially in non-urban areas. Thus, through an online survey of 185 rural and regional planners, this research explores the motivations, expectations and experiences of these planners. Most enjoyed and felt confident in their role, explaining that they valued the relaxed family orientated rural lifestyle and the varied nature of the planning work. Although they sometimes felt isolated, the non-urban location provided quicker progression to senior roles, the ability to engage directly with the community and to see the consequences of their decisions. Only half felt their education had prepared them well for their role, citing gaps in terms of computerised modelling, team leadership and conflict resolution skills. Their feedback centred on providing a more practical course, focusing more on regional planning, and encouraging urban and rural experience placements. As the first study to quantifiably explore rural and regional Australian planners’ perceptions of their role and challenges, the findings illustrate current experiences, key planning challenges, perceived educational gaps and future priorities.

Injuries in Nonurban Areas are Associated With Increased Disability at Hospital Discharge

Mortality is worse after injuries occurring in rural areas. However, most trauma patients survive their injuries, and little is known about functional outcomes after nonfatal injuries that occur in rural areas compared with those that happen in the urban setting. We hypothesized that disability at hospital discharge is worse for those injured in nonurban areas. Data from version 6.1 of the National Trauma Data Bank for patients admitted during the years 2001 to 2005 were used. Injury location data were transformed into urban influence codes by the National Trauma Data Bank administration. The independent variable was location of injury grouped into urban, suburban, and rural based on urban influence codes. The dependent variable was functional disability at hospital discharge as measured by the modified Functional Independence Measure. Rural site of injury was associated with a worse functional outcome at hospital discharge (odds ratio [OR] = 1.27) when compared with urban site of injury. Suburban injuries were also associated with an increased risk of poor functional outcome (OR = 1.12). When fatal injuries were excluded, the magnitude of effect of location of injury was greater: rural OR = 1.52; suburban OR = 1.27. Injuries in a nonurban location are associated with worse functional outcomes at hospital discharge. The magnitude of risk of a poor functional outcome is highest for patients who are injured in a rural location. These findings are important when considering allocation of trauma resources.

Is the diagnosis of physical abuse changed when Child Protective Services consults a Child Abuse Pediatrics subspecialty group as a second opinion?

Objectives To characterize the changes regarding the diagnosis of physical abuse provided to Child Protective Services (CPS) when CPS asks a Child Abuse Pediatrics (CAP) specialty group for a second opinion and works in concert with that CAP group. Methods Subjects were reported to CPS for suspected physical abuse and were first evaluated by a physician without specialized training in Child Abuse Pediatrics (non-CAP physician). Subjects were then referred to the area's only Child Abuse Pediatrics (CAP physician) group, located in a large metropolitan pediatrics center in the United States, for further evaluation. The diagnoses regarding abuse provided by CAP physicians working in concert with CPS were compared to those provided to CPS by other physicians. Results Two hundred consecutive patients were included in the study. In 85 (42.5%) cases, non-CAP physicians did not provide a diagnosis regarding abuse, despite initiating the abuse report to CPS or being asked by CPS to evaluate the child for physical abuse. Of the remaining 115 cases, the diagnosis regarding abuse differed between non-CAP physicians and CAP physicians working in concert with CPS in 49 cases (42.6%; κ = .14; 95% CI, −.02, .29). In 40 of the 49 cases (81.6%), CAP assessments indicated less concern for abuse when compared to non-CAP assessments. Differences in diagnosis were three times more likely in children from a nonurban location (OR 3.24; 95% CI, 1.01, 11.36). Conclusions In many cases of possible child physical abuse, non-CAP providers do not provide CPS with a diagnosis regarding abuse despite initiating the abuse investigation or being consulted by CPS for an abuse evaluation. CPS consultation with a CAP specialty group as a second opinion, along with continued information exchange and team collaboration, frequently results in a different diagnosis regarding abuse. Non-CAP providers may not have time, resources, or expertise to provide CPS with appropriate abuse evaluations in all cases. Practice implications Though non-CAP providers may appropriately evaluate many cases of physical abuse, the diagnosis regarding abuse provided to CPS may be changed in some cases when CAP physicians are consulted and actively collaborate with CPS investigators. Availability of Child Abuse Pediatrics subspecialty services to investigators is warranted.