Regional Service Delivery Research Articles

AYA rhabdomyosarcoma: Evolving changes in regional service delivery impacting on outcomes and meningeal disease.

e22006 Background: Rhabdomyosarcoma (RMS) is a rare and aggressive sarcoma with a variable prognosis dependent upon age, histology, PAX-FOXO1 translocation status, site, stage of disease and treatment. RMS has a peak age of incidence in adolescents and young adults (AYA). Centralisation of care in the UK has impacted on treatments given and outcome. With extended outcomes in an age associated with poor prognosis we have seen increased rates of meningeal disease as a late event. We examined factors predisposing to meningeal involvement and associated outcomes in changing treatments. Methods: Retrospective review of AYA with RMS, treated between 2004 and 2022 at a regional AYA center serving a population of 2.5 million. Results: 17 patients (9 males, 8 females) were identified (median age 18). At diagnosis, 5 patients had locally advanced disease and 11 had metastases. Meningeal disease developed in 11/17 after a median of 11 months (range 6-87) from diagnosis. Overall survival was 14 months (range 14-87) for those who developed meningeal disease versus 54 months (range 6-167, not reached in 3) in those who did not. Following meningeal involvement, survival ranged from 0-7+ months. Histology of those with meningeal disease: embryonal (5) alveolar (6). 5/6 patients with alveolar RMS (ARMS) had FOXO1 gene rearrangement. Presentation of meningeal disease included: headaches (7), visual phenomena (3), nausea/vomiting (2), unusual chest or back pain (5). Risk factors included bone marrow infiltration (2/2), para-meningeal/orbital primary (4/4), and widespread metastatic or locally advanced primary disease 10/11. 10/11 received treatment with radiotherapy and/or chemotherapy with symptomatic benefit. Conclusions: Meningeal disease in RMS occurs more frequently in those with a primary close to the brain and with bone marrow involvement. Site and extent of primary disease was more predictive than histology for meningeal disease, but not of survival. Adaptation to longer initial treatments with maintenance therapy has increased survival in AYA RMS. Early recognition of key warning symptoms is important to guide prognostication and symptom control.

Occupational therapist led environmental assessment and modification to prevent falls: Review of current practice in an Australian rural health service.

Environmental assessment and modification is an effective approach to reducing falls, particularly when provided by occupational therapists to high risk populations. Environmental assessment and modification has been incorporated into many national and international falls prevention guidelines, however, evidence suggests that it is not being implemented in practice. The aim of this study is to identify factors that support the local adoption of best practice environmental assessment for falls prevention within a rural health service. A concurrent mixed methods study using the Integrated Promoting Action on Research Implementation in Health Services framework was employed. The setting was a health service in Queensland, encompassing rural and regional populations. An audit, based on best practice, was conducted on eligible medical charts. An online survey of occupational therapists' knowledge, attitudes, confidence and experience of environmental assessment and modification was completed. Focus group discussions were also carried out. Quantitative data were presented using descriptive statistics and discussions were thematically analysed. Twenty-four occupational therapists were identified as meeting the inclusion criteria. Fourteen participated in the survey and 12 of those surveyed also participated in the focus groups. Fifty-eight patients' medical charts were audited, which included entries from occupational therapists who completed the survey and focus groups and some who did not. Survey results identified that most occupational therapists were aware of, confident, and experienced in environmental assessment and modification for falls prevention. Chartaudits, however, revealed that none of the patients received this intervention. Thematic analysis of focus group discussions identified three key themes which influenced uptake of environmental assessment and modification: confidence in, and awareness of evidence; key stakeholders' support and knowledge of occupational therapy; and, perceived impact of time and resources required for implementation. Results also suggested that several contextual issues unique to rural and regional service delivery influenced uptake, including: geographical and sociocultural diversities of communities being served; differing organisational structures which result in occupational therapists being line managed by other professions; and, limited access to professional development. Availability of local peer support, and engagement of multiple stakeholders from various professions were highlighted as key facilitators to support change. Occupational therapists reported that they carried out best practice environmental assessment and modification for falls prevention but the medical chart audit provided no evidence of this happening in practice. This discrepancy requires further investigation. This study provided an understanding of factors that influence whether occupational therapists implement best practice environmental assessment and modification in a rural health service. Findings could be used to guide the translation of evidence into practice across similar settings.

Analysis of big patient mobility data for identifying medical regions, spatio-temporal characteristics and care demands of patients on the move

BackgroundPatient mobility can be defined as a patient’s movement or utilization of a health care service located in a place or region other than the patient’s place of residence. Mobility provides freedom to patients to obtain health care from providers across regions and even countries. It is essential to monitor patient choices in order to maintain the quality standards and responsiveness of the health system, otherwise, the health system may suffer from geographic disparities in the accessibility to quality and responsive health care. In this article, we study patient mobility in a national health care system to identify medical regions, spatio-temporal and service characteristics of health care utilization, and demands for patient mobility.MethodsWe conducted a systematic analysis of province-to-province patient mobility in Turkey from December 2009 to December 2013, which was derived from 1.2 billion health service records. We first used a flow-based regionalization method to discover functional medical regions from the patient mobility network. We compare the results of data-driven regions to designated regions of the government in order to identify the areas of mismatch between planned regional service delivery and the observed utilization in the form of patient flows. Second, we used feature selection, and multivariate flow clustering to identify spatio-temporal characteristics and health care needs of patients on the move.ResultsMedical regions we derived by analyzing the patient mobility data showed strong overlap with the designated regions of the Ministry of Health. We also identified a number of regions that the regional service utilization did not match the planned service delivery. Overall, our spatio-temporal and multivariate analysis of regional and long-distance patient flows revealed strong relationship with socio-demographic and cultural structure of the society and migration patterns. Also, patient flows exhibited seasonal patterns, and yearly trends which correlate with implemented policies throughout the period. We found that policies resulted in different outcomes across the country. We also identified characteristics of long-distance flows which could help inform policy-making by assessing the needs of patients in terms of medical specialization, service level and type.ConclusionsOur approach helped identify (1) the mismatch between regional policy and practice in health care utilization (2) spatial, temporal, health service level characteristics and medical specialties that patients seek out by traveling longer distances. Our findings can help identify the imbalance between supply and demand, changes in mobility behaviors, and inform policy-making with insights.

Looking at Regional Governance Institutions in Other Countries as a Possible Model for U.S. Metropolitan Areas: An Examination of Multipurpose Regional Service Delivery Districts in British Columbia

General purpose or multipurpose governments at the metropolitan level have proven extremely difficult to create and sustain in the United States. In their absence, a range of institutions have evolved to address problems of regional fragmentation and to promote interlocal cooperation and collaboration. These include single-purpose regional special districts, interlocal contracts and agreements, and voluntary regional organizations of local governments such as councils of government. However, several countries make use of another institutional form, multipurpose special districts, rather than or in addition to single-purpose special districts, as a mechanism for facilitating regional governance and intermunicipal collaboration. This essay examines one example of such an institution: regional districts in British Columbia. It analyzes what accounts for their successful creation and institutionalization and considers whether such an institutional model is potentially adoptable in the United States. It focuses particularly on the perceived reduction in transaction cost for achieving intermunicipal agreements.

P17.45 Assessing the use of a peer-led mobile van for effective hiv service delivery in regional queensland: a whole of community approach

Background While Queensland rates of HIV are increasing, regional Queenslanders have reduced access to HIV-related information, rapid testing and clinical services. Men who have sex with men are less likely to access services due to HIV-related stigma and discrimination. The aim of this project was to assess the effectiveness of using a peer-led mobile van for regional service delivery. Methods Rapid Roadshow was a whole of population awareness-raising initiative of the CHEP program. In November 2014, two vans stopped at predetermined locations between Port Douglas and Gold Coast providing HIV information through discussion, resources, merchandise and quizzes, with rapid HIV and STI testing in some locations. Evaluation forms were provided to all rapid test participants. Results HIV information was provided via 1696 resources and promotional items, 1094 condom packs and 427 conversations. Of the 39 rapid HIV tests performed; 89.7% (35) participants identified as male, 61.5% (24) as non-heterosexual and 5 received STI screening. 37 participants completed evaluation forms; 72.9% (27) last tested over 6 months ago and 24.3% (9) had never tested before. 75.7% (28) preferred a non-clinical setting for testing with 81% (30) identifying that they would test more frequently with rapid test availability. Visits to www.endhiv.org.au increased by 298% (Nov - Jan), compared to the previous quarter (Aug - Oct), with the testing locator and quiz pages increasing by 49% and 138% respectively. Conclusion We can assume that the increased website visits are attributed to online promotion during Rapid Roadshow. While the sample size was small, the people tested for HIV identified an increased likelihood for continued testing with increased rapid testing availability outside of a clinical setting. A more regular presence in regional Queensland will allow us to collect more data and maintain our online presence, while directly supporting regional areas with localised data. Disclosure of interest statement The CHEP program and all projects of the CHEP program are funded by the HIV Foundation Queensland and hosted by Queensland Positive People. Financial support was provided by Alere for the Rapid Roadshow project.

Regional Service Delivery among Pacific Island Countries: An Assessment

AbstractPacific Island countries face a range of development challenges, including smallness, distance from major markets and capacity constraints. Regional service delivery, or pooling, has been advocated as a means of addressing these challenges. This article presents the findings from the first comprehensive study of pooling initiatives in the Pacific. It draws on a review of the literature pertaining to 20 pooling initiatives identified in the region and on interviews with stakeholders involved in many of those initiatives. The study finds that experience with pooling among Pacific Island countries has not met the optimistic expectations of advocates, including development partners. This is the result of the challenges inherent in voluntary regionalism, which are exacerbated by the diversity of Pacific Island states and political economy constraints. The article concludes that an incremental approach to expansion of regional service provision in the Pacific is both likely and appropriate given these factors.

Regional Service Delivery Among Small Island Developing States of the Pacific: An Assessment

Small Island Developing States (SIDS) of the Pacific face a range of development challenges, including smallness, distance from major markets, and capacity constraints. Regional service delivery, or pooling, has been advocated as a means of addressing these challenges. This paper presents the findings from the first comprehensive study of pooling initiatives in the Pacific. It draws on a review of the literature pertaining to all 20 pooling initiatives identified in the region, and on interviews of stakeholders involved in many of those initiatives. The study finds that experience with pooling among Pacific SIDS has not met the optimistic expectations of advocates, including development partners. This is the result of the challenges inherent in voluntary regionalism, which are exacerbated by the diversity of Pacific island states, political economy factors, and issues of accountability and legitimacy. The analysis suggests that expansion of regional service provision in the Pacific will be slow, although prospects at the sub-regional level are more positive.

Development and implementation of a regional intensive care health service model

PurposeThe purpose of this paper is to present a case study of a healthcare service redesign. Before 1998, five community hospitals in Winnipeg each managed their intensive care units (ICUs) independently, providing virtually no access to patients in rural and remote regions of the province of Manitoba; and two tertiary university affiliated hospitals were left with insufficient intensive care beds to service the rest of the provincial population in addition to their tertiary service responsibilities. The authors resolved to create a city‐wide integrated critical care services model, in order to improve patient access, quality of care and cost effectiveness.Design/methodology/approachA population demand analysis was performed and service objectives were defined. A gap analysis became the basis of an integrated service model design and an implementation plan was formulated.FindingsBeds were redistributed among community hospital ICUs to match available nursing resources. A credentialing process was developed to establish medical competency for attending physicians. A central bed registry and a referral triage system were implemented, to ensure that any Manitoban requiring an ICU admission acquired an appropriate bed in a timely manner. A regional computerized critical care database was introduced to all ICUs. The total number of beds was reduced from 92 to 84 and total occupancy fell from 65 to 58. The new model was entirely funded from bed reductions.Originality/valueThis paper describes the integration of a group of hospital‐based ICUs into a regional service delivery model developed to meet the needs of a provincial population.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

The training and development needs of midwives in Indonesia: paper 2 of 3

BackgroundThere is a shortfall in midwives in Indonesia (an estimated 26 per 100 000 people), which means that the quality of antenatal, perinatal and postnatal care varies widely. One consequence of this is the high rate of maternal and perinatal mortality, which has prompted a number of health initiatives. The current study was part of a review of the existing complex system of midwifery training and the development of a coherent programme of continuing professional development, tighter accreditation regulations and clearer professional roles. Its aims were to identify the occupational profiles and development needs of the participating midwives, and to establish whether any differences existed between grades, geographical location and hospital/community midwives.MethodsA psychometrically valid training-needs instrument was administered to 332 midwives from three provinces, covering both hospital and community staff and a range of midwifery grades. The instrument had the capacity to identify occupational roles and education/training needs of the respondents.ResultsThe occupational roles of the midwives varied significantly by province, indicating regional service delivery distinctions, but very little difference in the roles of hospital and community midwives. The most educated midwives attributed more importance to 35 out of the 40 tasks, suggesting an implicit role distinction in terms of level of activity. All midwives reported significant training needs for all 40 tasks. The most-educated midwives recorded training needs for 24 tasks, while the less-educated had training requirements for all tasks, which suggests that new training programmes are effective. Few differences in training needs were revealed between hospital and community midwivesConclusionThe results from this survey suggest important regional differences in how the midwife's role is discharged and underline the importance of this sort of research, in order to ensure the suitability of basic and postbasic educational provision. The study also highlights the need for further development and training of midwives in a wide range of tasks. These results provide a systematic and reliable overview of current midwifery roles and development needs and could serve to inform future training.

Regional University Access

Access to appropriate training is a key to developing human resource is and enhancing quality of life in regional areas. Yet like many other service providers, universities are faced with the high costs of delivering services in regions with a small and scattered client pool. Thus, the challenge: how can universities serve regional communities and promote regional development while remaining cost effective and sustainable? Distance education technologies appear to offer a solution yet they may fail to respond to the underground needs of regional students.&#x0D; In late 2000, Edith Cowan University commissioned a study to consider the challenge of regional service delivery, in the context of Warren-Blackwood region of South West Australia. This isolated, in land region has been undergoing economic displacement in the wake of timber industry restructuring; Improved training access has been identified as a regional development priority (Warren-Blackwood Action Plan, 2000) this paper presents the results of the study examining the demand for, and delivery of, university services in the Warren Blackwood region.&#x0D; Surveys, focus groups and interviews with students and former students highlighted key trends, such as the pre university (year 10) exodus of youth from the region and the tendency for regionally based students to be mature aged. The paper identifies challenges, both logistical and psychological facing people who undertake long distance university studies (whether as distance-ed or commuting students). Finally, the paper suggests low-cost ways to facilitate the learning experience of students based in regional areas, by understanding the culture of learning and providing access to basic support resource is, regardless of the technological sophistication of course delivery.

Regional Impulses

ABSTRACT:Spurred by fiscal pressure, persistent city-suburban disparities, and the imperatives of the global economy, public and academic interest in metropolitan regionalism is as vigorous now as it was in the 1950s. The resurgence of interest compels analysis in this article of 10 regional impulses—natural resource, macroeconomic, centrality, growth, social, fiscal, equity, political, legal, and historical—the operation of which determine regional outcomes, such as regional service delivery, partnerships, and practices, in metropolitan areas. A case study of regional service delivery, partnerships, and practices, in metropolitan areas. A case study of regional impulses in the Buffalo metropolitan area finds that fiscal, legal, political, and historical impulses are most salient in influencing regional outcomes. The study demonstrates the utility of the regional impulses framework for comparative metropolitan analysis and understanding why some regions function more regionally than others.

Coproduction in Emergency Medical Services

Coproduction arrangements are being used in a number of places and in a number of forms. Yet, little research exists on assessing the effectiveness of citizen involve ment in the production of public services, which is the focus of this paper. First, drawing upon organizational theory, a method for determining the effectiveness of coproductive activities is proposed. Then the framework is applied to a citizen volunteer emergency medical response (EMS) organization operating in a small rural community as part of a regional response system. The volunteer group is examined in its relationships to the overall EMS system of which it is part, to specific governmental agencies and private emergency response firms it works with and its own members. Variables considered include its contribution to the needs of the system, cost effectiveness, emergency response capacity, interorganizational compatibility, skill levels of participants, and their motivation for volunteering. The study finds that benefits generated by the citizen group exceed its costs and dis cusses how the group successfully integrated itself into a high-skill regional service delivery system and expanded the services it produces to meet other community needs.

School Psychology Service Configurations: A Regional Approach

Because of uneven local funding resources, uneven distribution of federal funding, lack of qualified staff and programs, and mandates for educational services, especially in identifying and serving handicapped children, regional service delivery systems have been a predominant model of providing services in rural areas. Many of the diversities of regional models (e.g., governance, scope of program and funding) are discussed utilizing programs of various states as examples. The findings of the literature review and a survey indicate that while these regional educational service models may proliferate in rural areas, the provision of a full range of school psychological services through a regional model may be changing in its nature.