Journal Search - issue 1, 2010

full article:

Diabetes Burden and Access to Preventive Care in the Rural United States
Santosh Krishna, Kathleen N. Gillespie, Timothy M. McBride

Context: National databases can be used to investigate diabetes prevalence and health care use. Guideline-based care can reduce diabetes complications and morbidity. Yet little is known about the prevalence of diabetes and compliance with diabetes care guidelines among rural residents and whether different national databases provide similar results.
Purpose: To examine rural-urban differences in the prevalence of diabetes and compliance with guidelines, and to compare the Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditures Panel Survey (MEPS).
Methods: Data for 2001-2002 were analyzed and compared by rural-urban status. Prevalence was calculated as simple unadjusted, weighted unadjusted, and weighted adjusted using a multivariate approach. Results from the 2 databases were compared.
Findings: A slightly higher prevalence of diabetes among rural residents, 7.9% versus 6.0% in MEPS and 7.6% versus 6.6% in BRFSS, was found and persisted after adjustment for age, BMI, insurance coverage, and other demographic characteristics (adjusted OR 1.16 [1.02-1.31] in MEPS; 1.19 [1.01-1.20] in BRFSS). Rural persons in MEPS were less likely to receive an annual eye examination (aOR = 0.85) and a feet check (aOR = 0.89). A significantly (P < .05) smaller proportion of rural residents in BRFSS received an annual eye examination (aOR = 0.88), feet check (aOR = 0.85), or diabetes education (aOR = 0.83). Rural residents in both datasets were more likely to get a quarterly HbA1c test done.
Conclusion: Rural residents in both datasets had higher prevalence of diabetes. Though not always statistically significant, the trend was to less guideline compliance in rural areas.

Influence of Place of Residence in Access to Specialized Cancer Care for African Americans
Tracy Onega, Eric J. Duell, Xun Shi, Eugene Demidenko, David Goodman

Context: Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood.
Purpose: The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States.
Methods: Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004.
Findings: In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66).
Conclusions: Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.

Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel Outside Local Markets
Jayasree Basu, Lee R. Mobley

Purpose: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum.
Methods: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA.
Findings: Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity.
Conclusions: Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.

Access to and Use of Eye Care Services in Rural Arkansas
Greta Kilmer, LaTonya Bynum, Appathurai Balamurugan

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.

Depression and Geographic Status as Predictors for Coronary Artery Bypass Surgery Outcomes
Tam K. Dao, Danny Chu, Justin Springer, Emily Hiatt, Quang Nguyen

Purpose: To examine the relationships between depression, geographic status, and clinical outcomes following a coronary artery bypass grafting (CABG) surgery.
Methods: Using the 2004 Nationwide Inpatient Sample database, we identified 63,061 discharge records of patients who underwent a primary CABG surgery (urban 57,247 and rural 5,814). We analyzed 7 demographic variables, 19 preoperative medical and psychiatric variables, and 2 outcome variables (ie, in-hospital mortality and length of stay). Logistic regression and multivariable regression analyses were used to assess urban-rural status and depression as independent predictors of in-hospital mortality and length of stay.
Findings: Rural patients were more likely to have a comorbid depression diagnosis compared to urban patients (urban = 19.4%, rural = 21.4%, P < .001). After adjusting for confounding factors, having a comorbid depression diagnosis (B= 1.10, P < .001) and residing in a rural area (B= .986, P < .05) were associated with an increased length of in-hospital stay following CABG surgery. Furthermore, having a depression diagnosis (OR = 1.63, 95% CI = 1.45-2.21) and residing in a rural area (OR = 1.43, 95% CI = .896-1.45) were associated with an increased likelihood of in-hospital mortality.
Conclusions: Rural patients were more likely than urban ones to have a depression diagnosis. Depression was a significant independent predictor of both in-hospital mortality and length of stay for patients receiving CABG surgery. Also, rural patients had increased lengths of in-hospital stay as well as in-hospital mortality rates compared to those who resided in urban areas.

Depression Screening Patterns for Women in Rural Health Clinics
Fred Tudiver, Joellen Beckett Edwards, Deborah T. Pfortmiller

Context: Rates and types of screening for depression in rural primary care practices are unknown.
Purpose: To identify rates of depression screening among rural women in a sample of rural health clinics (RHCs).
Methods: A chart review of 759 women's charts in 19 randomly selected RHCs across the nation. Data were collected from charts of female patients of rural primary care providers, using trained data collectors (inter-rater reliability .88 to .93). The Women's Primary Care Screening Form, designed by the authors, was used to collect demographic, health, and screening data. Data describing the characteristics of the clinics were collected using the National Rural Health Clinic Survey. Data regarding formal screening (validated instrument used) or informal (documentation of specific questions and answers regarding depression) in the previous 5 years were recorded.
Findings: Characteristics of participating clinics and demographics of the women were similar to published data. Formal screening was documented in 2.4% of patients' charts. Informal screening was documented in 33.2% of charts. Patients with a history of anxiety were more likely to be screened (P < .001), and younger women were more likely to be screened than older women (P < .001).
Conclusions: Primary care providers in RHCs use more informal than formal depression screening with their female patients. Providers are more likely to screen younger patients or patients with a diagnosis of anxiety.

Quality of Care for Myocardial Infarction in Rural and Urban Hospitals
Laura-Mae Baldwin, Leighton Chan, C. Holly A. Andrilla, Edwin D. Huff, L. Gary Hart

Background: In the mid-1990s, significant gaps existed in the quality of acute myocardial infarction (AMI) care between rural and urban hospitals. Since then, overall AMI care quality has improved. This study uses more recent data to determine whether rural-urban AMI quality gaps have persisted.
Methods: Using inpatient records data for 34,776 Medicare beneficiaries with AMI from 2000-2001, unadjusted and logistic regression analysis compared receipt of 5 recommended treatments between admissions to urban, large rural, small rural, and isolated small rural hospitals as defined by Rural Urban Commuting Area codes.
Results: Substantial proportions of hospital admissions in all areas did not receive guideline-recommended treatments (eg, 17.0% to 23.6% without aspirin within 24 hours of admission, 30.8% to 46.6% without beta-blockers at arrival/discharge). Admissions to small rural and isolated small rural hospitals were least likely to receive most treatments (eg, 69.2% urban, 68.3% large rural, 59.9% small rural, 53.4% isolated small rural received discharge beta-blocker prescriptions). Adjusted analyses found no treatment differences between admissions to large rural and urban area hospitals, but admissions to small rural and isolated small rural hospitals had lower rates of discharge prescriptions such as aspirin and beta-blockers than urban hospital admissions.
Conclusions: Many simple guidelines that improve AMI outcomes are inadequately implemented, regardless of geographic location. In small rural and isolated small rural hospitals, addressing barriers to prescription of beneficial discharge medications is particularly important. The best quality improvement practices should be identified and translated to the broadest range of institutions and providers.

Patient Safety Outcomes in Small Urban and Small Rural Hospitals
Smruti Vartak, Marcia M. Ward, Thomas E. Vaughn

Purpose: To assess patient safety outcomes in small urban and small rural hospitals and to examine the relationship of hospital and patient factors to patient safety outcomes.
Methods: The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. To increase comparability, the study sample was restricted to hospitals with fewer than 100 beds. Out of 292 hospitals in the sample, 185 were rural hospitals and 107 were urban hospitals. AHRQ Patient Safety Indicators (PSI) were used to examine 9 common patient safety outcomes at these hospitals. The unit of analysis was the patient. Associations between hospital location and patient and hospital characteristics were determined using 1-way analysis of variance (ANOVA) and Pearson chi-square test. Multivariable analysis using generalized estimating equation regression models assessed the relationship between hospital location and PSIs.
Results: Most of the observed rates for the 9 PSIs were higher (indicating worse outcomes) for small urban hospitals than for small rural hospitals. In the multivariable analyses, after adjusting for important patient and hospital characteristics, many of these differences disappeared, except for decubitus ulcer. Small urban hospitals had significantly higher odds for decubitus ulcer than small rural hospitals.
Conclusion: These results deviate from findings in the literature that urban-rural differences in patient safety rates exist. This study highlights the importance of understanding the factors that differ between small urban and small rural hospitals while developing hospital-relevant patient safety interventions at these hospitals.

All-Terrain Vehicle Safety and Use Patterns in Central Illinois Youth
John W. Hafner, Scott M. Hough, Marjorie A. Getz, Yvette Whitehurst, Richard H. Pearl

Context: All-terrain vehicles' (ATVs) popularity and associated injuries among children are increasing in the United States. Currently, most known ATV use pattern data are obtained from injured youth and little documented data exist characterizing the typical ATV use patterns and safety practices among American children in general.
Purpose: To describe the typical ATV safety and use patterns of rural youth.
Methods: A cross-sectional anonymous mail survey was conducted of youth participants (ages 8-18) in the 4-H Club of America in four Central Illinois counties. Questions examined ATV use patterns, safety knowledge, safety equipment usage, crashes, and injuries.
Findings: Of 1,850 mailed surveys, 634 were returned (34% response rate) with 280 surveys (44% of respondents) eligible for analysis. Respondents were principally adolescent males from farms or rural locations. Most drove ≤1 day per week (60.2%) and used ATVs for recreation (36%) or work (22.6%) on farms and/or private property (53.4%). Most never used safety gear, including helmets (61.4%), and few (14.6%) had received safety education. Of the 67% who experienced an ATV crash, almost half (44%) were injured. Children with safety training had fewer crashes (P= .01), and those riding after dark (P= .13) or without adult supervision (P= .042) were more likely injured.
Conclusions: ATV use is common in a rural 4-H population. Most child ATV users were adolescent boys, had little safety training and did not use safety equipment or helmets. ATV injury prevention efforts should focus on these areas.

Urban-Rural Disparities in Injury Mortality in China, 2006
Guoqing Hu, Susan P. Baker, Timothy D. Baker

Context: Urban-rural disparity is an important issue for injury control in China. Details of the urban-rural disparities in fatal injuries have not been analyzed.
Purpose: To target key injury causes that most contribute to the urban-rural disparity, we decomposed total urban-rural differences in 2006 injury mortality by gender, age, and cause.
Methods: Mortality data came from the Chinese Vital Registration data, covering a sample of about 10% of the total population. The chi-square test was used to test the significance of urban-rural disparities.
Findings: For all ages combined, the injury death rate for males was 60.1/100,000 in rural areas compared with 40.9 in urban areas; for females, the respective rates were 31.5 and 23.6/100,000. The greatest disparity was at age <1 year for both sexes, where the rate from unintentional suffocation in rural areas was more than twice the urban rate. The higher mortality from drowning among males of all ages and among females ages 1-24 and 35+ contributed substantially to the age-specific urban-rural disparities. For both sexes, transportation incidents and suicide were the most important contributors to higher rates among rural residents ages 15+.
Conclusions: Unintentional suffocation, drowning, transportation incidents, and suicide not only are the major causes of injury death, but also play a key role in explaining the urban-rural disparities in fatal injuries. Further research is needed to identify factors leading to higher rural death rates and to explore economical and feasible interventions for reducing injuries and narrowing the urban-rural gap in injury mortality.

Issues in Rural Palliative Care: Views From the Countryside
Carole A. Robinson, Barbara Pesut, Joan L. Bottorff

Context: Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation.
Purpose: To better understand experiences and issues related to rural palliative care.
Methods: Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique.
Findings: Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care.
Conclusion: Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

Rural Idaho Family Physicians' Scope of Practice
Ed Baker, David Schmitz, Ted Epperly, Ayaka Nukui, Carissa Moffat Miller

Context: Scope of practice is an important factor in both training and recruiting rural family physicians.
Purpose: To assess rural Idaho family physicians' scope of practice and to examine variations in scope of practice across variables such as gender, age and employment status.
Methods: A survey instrument was developed based on a literature review and was validated by physician educators, practicing family physicians and executives at the state hospital association. This survey was mailed to rural family physicians practicing in Idaho counties with populations of less than 50,000. Descriptive, bivariate and multivariate analyses were employed to describe and compare scope of practice patterns.
Results: Responses were obtained from 92 of 248 physicians (37.1% response rate). Idaho rural family physicians reported providing obstetrical services in the areas of prenatal care (57.6%), vaginal delivery (52.2%) and C-sections (37.0%); other operating room services (43.5%); esophagogastroduodenoscopy (EGD) or colonoscopy services (22.5%); emergency room coverage (48.9%); inpatient admissions (88.9%); mental health services (90.1%); nursing home services (88.0%); and supervision to midlevel care providers (72.5%). Bivariate analyses showed differences in scope of practice patterns across gender, age group and employment status. Binomial logistic regression models indicated that younger physicians were roughly 3 times more likely to provide prenatal care and perform vaginal deliveries than older physicians in rural areas.
Conclusion: Idaho practicing rural family physicians report a broad scope of practice. Younger, employed and female rural family medicine physicians are important subgroups for further study.

Assessment of Pharmacists' Perception of Patient Care Competence and Need for Training in Rural and Urban Areas in North Dakota
David M. Scott

Context: Few studies have examined pharmacists' level of patient care competence and need for continuous professional development in rural areas.
Purpose: To assess North Dakota pharmacists' practice setting, perceived level of patient care competencies, and the need for professional development in urban and rural areas.
Methods: A survey was mailed to all 686 North Dakota pharmacists and included items regarding practice setting, competency areas, and the need for certificate programs.
Findings: Overall, 401 of 686 (58.5%) surveys were returned and 364 responses were usable. Three practice settings (independent community pharmacies [47.3%], chain stores [13.2%], and hospital pharmacies [22.8%]) comprised 83.3% of the sample. More independent community pharmacists were located in rural areas than urban areas (P < .01). More respondents had a Doctor of Pharmacy (PharmD) degree in urban areas (40.8%) compared to those in rural areas (15.1%) (P < .01). Pharmacists in urban areas rated 18 of 33 competencies higher than did pharmacists in rural areas (P < .01). Pharmacists with a Bachelor of Science degree reported a lower level of preparation than did PharmD trained pharmacists. Although not statistically significant, 28.2% of pharmacists perceived a patient care certificate as a need and a greater percentage were from rural than urban areas.
Conclusion: The findings should be interpreted to be primarily due to differences in practice setting and degree earned that were most prevalent in urban and rural areas. Training mode needed most is through the certificate program, particularly by rural pharmacists who reported a lower level of preparation on perceived patient care-related items than did urban pharmacists.

Just What Are Rural Premedical Students Thinking? A Report of the First 6 Years of a Pathways Program
William J. Crump, R. Steve Fricker, Allison M. Crump

Purpose: To assess outcomes of the first 6 years of a program designed to facilitate medical school admission for rural premedical students.
Methods: Students completing the University of Louisville School of Medicine Trover Rural Scholar program were surveyed using a 23-item survey.
Findings: Twenty-two of the 24 (92%) students responded. Overall, 12 (55%) were in the physician pipeline (medical students or re-applying to medical school) and 10 (45%) had left the physician pipeline for other careers (7 were pursuing other health care careers). Differences between the 2 groups included income expectations and perceptions of intellectual challenges and physicians' job satisfaction.
Conclusions: Attrition can be explained by student interests, maturation and influences of pre-professional advisors and practicing physicians. Successful pipeline programs should address these issues.

Didgeridoo Playing and Singing to Support Asthma Management in Aboriginal Australians
Robert Eley, Don Gorman

Context: Asthma affects over 15% of Australian Aboriginal people. Compliance in asthma management is poor. Interventions that will increase compliance are required.
Purpose: The purpose of the study was to determine whether Aboriginal children, adolescents and adults would engage in music lessons to increase their knowledge of asthma and support management of their asthma.
Methods: Participants were recruited from schools and through the local Aboriginal Medical Service. All participants identified as Aborigines and were diagnosed as being asthmatic. The intervention was a 6-month program of once weekly music lessons using a culturally significant wind instrument, the didgeridoo, for males and singing lessons for females.
Findings: High school students enthusiastically engaged and had excellent retention in what they considered to be a most enjoyable program. Respiratory function improved significantly in both junior and senior boys who also reported a noticeable improvement in their health. Similar but less significant improvement was seen in the high school girls, although like the boys, they too perceived an improvement in their asthma.
Conclusions: The project demonstrated that music has great potential for engaging and thus supporting asthma. Furthermore, cultural awareness was increased by those playing the didgeridoo and social skills were noticeably improved in the girls. Similar culturally appropriate activities have applications far beyond Aboriginal communities in Australia.

Multidisciplinary chronic pain management in a rural Canadian setting
Robert Burnham; Jeremiah Day; Wallace Dudley

Introduction: Chronic pain is prevalent, complex and most effectively treated by a multidisciplinary team, particularly if psychosocial issues are dominant. The limited access to and high costs of such services are often prohibitive for the rural patient. We describe the development and 18-month outcomes of a small multidisciplinary chronic pain management program run out of a physician's office in rural Alberta.
Methods: The multidisciplinary team consisted of a family physician, physiatrist, psychologist, physical therapist, kinesiologist, nurse and dietician. The allied health professionals were involved on a part-time basis. The team triaged referral information and patients underwent either a spine or medical care assessment. Based on the findings of the assessment, the team managed the care of patients using 1 of 4 methods: consultation only, interventional spine care, supervised medication management or full multidisciplinary management. We prospectively and serially recorded self-reported measures of pain and disability for the supervised medication management and full multidisciplinary components of the program.
Results: Patients achieved clinically and statistically significant improvements in pain and disability.
Conclusion: Successful multidisciplinary chronic pain management services can be provided in a rural setting.

Evaluation of a novel model for rural obstetric care
Eliseo Orrantia, Heather Poole, Jessica Strike, Barbara Zelek

Introduction: The group practice physicians in Marathon, a small rural community in northwestern Ontario, discovered general lifestyle dissatisfaction with the traditional model for obstetric practice. The old model of doing the follow-up and delivery for one's own patients created perceived onerous on-call responsibilities. The providers created a new model of obstetric care. This involved the local providers of obstetric care each taking 1 month of the year in rotation and following up any woman due in that month for prenatal and intrapartum services. This study is an investigation of patient and provider satisfaction with this model.
Methods: Patient survey: We surveyed all 73 women who received obstetric care under the new model during its first 14 months of implementation. We collected data on patient demographics and patients' satisfaction with their obstetric experience using Likert scale, yes/no and short-answer questions. Physician survey: We surveyed the 9 physicians of Marathon Family Practice using Likert scale, yes/no and short-answer questions. We collected information on demographics, history of involvement with obstetric service, and comparison of old and new models with regard to patient care, and professional and personal issues.
Results: Patient survey: The response rate was 56%. Of the respondents, 97% reported their expectations for their obstetric care were met, if not surpassed, and 100% were satisfied with their obstetric care. Physician survey: All the physicians responded and found the new model to cause less disruption of their family practice (Wilcoxon signed rank test, p = 0.041), to improve scheduling of personal activities (p = 0.017) and to improve their satisfaction with on-call hours (p = 0.027). Overall, the physicians were satisfied with the new model and preferred it to the old model.
Conclusion: This obstetric care model meets patients' expectations and provides patient satisfaction. It provides practitioners with an increased quality of life and greater satisfaction. It is a viable paradigm for the provision of obstetric care in the appropriate setting.

When a community hospital becomes an academic health centre
Maureen Topps, Roger Strasser

With the burgeoning role of distributed medical education and the increasing use of community hospitals for training purposes, challenges arise for undergraduate and postgraduate programs expanding beyond traditional tertiary care models. It is of vital importance to encourage community hospitals and clinical faculty to embrace their roles in medical education for the 21st century. With no university hospitals in northern Ontario, the Northern Ontario School of Medicine and its educational partner hospitals identified questions of concern and collaborated to implement changes. Several themes emerged that are of relevance to any medical educational program expanding beyond its present location. Critical areas for attention include the institutional culture; human, physical and financial resources; and support for educational activities. It is important to establish and maintain the groundwork necessary for the development of thriving integrated community-engaged medical education. Done in tandem with advocacy for change in funding models, this will allow movement beyond the current educational environment. The ultimate goal is successful integration of university and accreditation ideals with practical hands-on medical care and education in new environments.

Equipping patients for a time of helplessness: An educational intervention
Simon Holliday

Objectives: Quantify rates of awareness about, and ownership of, End-of-Life Planning (ELP) instruments. Examine whether this rate is increased by brief education during routine team care. Measure the time required by this exercise.
Design: Quality Improvement Activity.
Setting: General Practice on Mid-North Coast, New South Wales.
Participants: Forty-two consecutive, consenting elderly patients undertaking a Home Health Assessment.
Main outcome measures: This study assessed rates of ELP instruments at baseline, at 2 weeks, at 2 months and at 2 years following the provision and discussion of a fact sheet while measuring the clinicians' time required.
Results: This education exercise increased the number of patients with ELP instruments from one to ten (24%). On average it took 5.6 min of nursing time and 3.9 min for the GP.
Conclusions: Brief education during Home Health Assessments may empower patients to prepare for a scenario where they lost competency to make fully informed decisions. This may alleviate patient's fears about causing problems between those close to them and having treatments against their wishes.

Rural pharmacist perceptions of a project assessing their role in the management of depression
Judith Crockett, Susan Taylor

Objective: This paper explores pharmacist perceptions of a pilot study assessing the impact of specialist training on depression for rural community pharmacists on their understanding of treatment and psychological well-being of patients.
Design: Mixed method survey.
Setting: Rural community pharmacies.
Participants: Thirty-two rural based community pharmacists.
Interventions: Recruited pharmacists were allocated to either the 'control' or 'intervention' group. Intervention pharmacists were given training in depression and asked to dispense medication with extra advice and support, while control pharmacists provided usual care.
Outcome measures: Understanding of depression, current involvement in patients with depression, changes in practice.
Results: All pharmacists were more likely to initiate conversation, discuss medication and its side effects, point out the importance of remaining on the medication, provide ongoing follow-up and encourage patients to talk with their GPs and pharmacists by the end of the project. Intervention pharmacists were more likely than the control pharmacists to initiate conversation on dispensing a repeat prescription and to discuss extended support.
Conclusion: Response to the project by pharmacists was generally very positive. It is recommended that a longitudinal study based on this project be undertaken which involves pharmacists, GPs and other mental health professionals and trials a holistic approach to mental health care.

Mediating and moderating effects of work-home interference upon farm stresses and psychological distress
Connar Jo McShane, Frances Quirk

Objective: This study investigated whether work-home (WHI) or home-work interference (HWI) explained or affected the strength of the relationship between farmers' stresses and reported psychological distress.
Design: Distribution of questionnaire package; included Work-Home Conflict Scale, Farm Stress Survey, Depression Anxiety Stress Scale. Participants recruited via advertising in newsletters and newspapers, and distribution through businesses and meetings.
Participants: The majority of farmers (N = 51, male = 45, female = 5) were recruited from the one district. Farmers were individuals who identified their occupation as a farm owner, farm manager, or farm hand.
Main outcome measures: It was predicted farmers would report higher levels of WHI than HWI; time, a determinant of interference, would mediate the relationship between farmers' stresses and psychological distress; WHI and HWI would moderate farmers' stresses and their psychological distress; overall reported level of psychological distress would be in normal to mild range because of positive general economic conditions.
Results: Farmers reported significantly higher levels of WHI than HWI (M = 3.21, M = 2.76, P < 0.001 respectively). WHI and time-based WHI mediated farmers' stresses and psychological distress, particularly anxiety. WHI, time and strain, determinants of WHI mediated personal finances and subcomponents of psychological distress (stress, anxiety, depression). Time-based HWI mediated personal finances and stress. No moderating effects were found for WHI (r = −0.02, P = 0.882) or HWI (r = 0.15, P = 0.306).
Conclusions: Farmers of this specific sample presented a unique work-home interface. Limitations include the small sample size, recruitment methods, and culturally irrelevant measures as well as only assessing work-related stresses. Future research should aim to develop measures appropriate for farmers of Australia.

All-terrain vehicle crashes and associated injuries in north Queensland: Findings from the Rural and Remote Road Safety Study
Teresa O'Connor, Heather Hanks, Dale Steinhardt

Objective: To define characteristics of all-terrain vehicle (ATV) crashes occurring in north Queensland from March 2004 till June 2007 with the exploration of associated risk factors.
Design: Descriptive analysis of ATV crash data collected by the Rural and Remote Road Safety Study.
Setting: Rural and remote north Queensland.
Participants: Forty-two ATV drivers and passengers aged 16 years or over hospitalised at Atherton, Cairns, Mount Isa or Townsville for at least 24 hours as a result of a vehicle crash.
Main outcome measures: Demographics of participants, reason for travel, nature of crash, injuries sustained and risk factors associated with ATV crash.
Results: The majority of casualties were men aged 16-64. Forty-one per cent of accidents occurred while performing agricultural tasks. Furthermore, 39% of casualties had less than one year's experience riding ATVs. Over half the casualties were not wearing a helmet at the time of the crash. Common injuries were head and neck and upper limb injuries. Rollovers tended to occur while performing agricultural tasks and most commonly resulted in multiple injuries.
Conclusions: Considerable trauma results from ATV crashes in rural and remote north Queensland. These crashes are not included in most general vehicle crash data sets, as they are usually limited to events occurring on public roads. Minimal legislation and regulation currently applies to ATV use in agricultural, recreational and commercial settings. Legislation on safer design of ATVs and mandatory courses for riders is an essential part of addressing the burden of ATV crashes on rural and remote communities.

Correlates of comorbid mental disorders in a regional community-based sample
Katharine E. Heathcote, Brian Kelly, Arul Earnest, John R. Beard

Objective: The common coexistence of psychiatric disorders has been identified as a significant factor contributing to the disability associated with mental illness. Identifying indicators to the development of coexisting disorders has potential clinical implications. This study aimed to investigate the correlates and impact of coexisting disorders in a rural setting.
Design: Cross-sectional analyses of data from a cohort interviewed in two phases.
Setting: A regional community sample in Northern New South Wales, Australia.
Participants: A total of 1407 participants were interviewed and 968 were re-interviewed at follow up.
Main outcome measures: Multinomial logistic regression modelling compared subjects with multiple psychiatric disorders with those with a single disorder for sociodemographic characteristics, measures of personal and social vulnerability, psychological distress, functional disabilities and help-seeking behaviours.
Results: Participants with coexisting disorders were more likely to be male, report a history of severe childhood assault and had higher levels of neuroticism, psychological distress and help-seeking behaviour.
Conclusions: The findings suggest the role of early developmental factors on the complexity and severity of adult mental illness in a rural setting and the significant clinical consequences of comorbidity.

Linkage, coordination and integration: Evidence from rural palliative care
Malcolm Masso, Alan Owen

Objective: Review the findings from the evaluations of three rural palliative care programs.
Design: Review by the authors of the original material from each evaluation. The conceptual framework for the review was provided by the work of Leutz, including his distinction between linkage, coordination and full integration.
Setting: Community-based palliative care in rural Australia.
Interventions: Fifteen projects across all six states of Australia that focused on integration between general practitioners and other community-based health providers.
Results: The projects set out to improve networking and collaboration between providers; improve coordination and integration of care for patients; reduce duplication of services; and achieve a multidisciplinary, collaborative approach to palliative care. The most common interventions were establishment of formal governance structures, provision of education programs, case conferencing, dissemination of information, development of formal arrangements, development of protocols and use of common clinical assessment tools. The terms 'integration' and 'coordination' were used frequently but without clear definitions. Coordination required someone specifically designated to do the coordinating, usually a nurse. Formal arrangements to improve linkage and coordination were difficult to maintain. The main mechanism to achieve full integration was the development of common clinical information systems.
Conclusions: The 'laws' proposed by Leutz and the concepts of linkage, coordination and full integration provide a useful framework to understand the barriers to integrating GPs and other health providers. It is important to be clear on what level of integration is required. Improving links might be sufficient (and realistic), rather than striving for full integration.

Kids with confidence: A program for adolescents living in families affected by mental illness
Faye M. Hayman

Objective: To provide information about a peer support program for adolescents living in families affected by mental illness.
Design: This is a descriptive article about the Kids with Confidence Adolescent Program.
Setting: The program operates in rural Victoria using a variety of community venues.
Participants: Young people aged between 12-18 years, living in families affected by mental illness.
Interventions: The program provides respite, education, support and fun through monthly, semistructured activities. The adolescents are encouraged to talk openly about their circumstances and any difficulties they might be having. They learn appropriate social skills, and provide and receive peer support.
Results: The group consistently attracts between 7 and 15 adolescents, with an average attendance of 11.25. Verbal feedback from the young people involved and their families has been very positive, with reported improvements in confidence, self-esteem and the formation of strong, trusting friendships.
Conclusions: The Kids with Confidence Adolescent Program provides young people living in families affected by mental illness with peer and worker support, respite, and an opportunity to learn social and mental health skills. This might enhance young people's resilience and ability to cope with difficult situations.

Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia
Leanne McCann, Patrick Groot, Chris Charnley, Anne Gardner

Objective: To assess the effectiveness of a formalised stroke service in a regional hospital.
Design: A pretest post-test design.
Setting: An acute stroke unit in a regional health service.
Participants: Overall sample comprised 80 patients with 36 (45.0%) men. Forty patients (19 men, 21 women) comprised pre-intervention group and 40 (17 men, 23 women) post-intervention group.
Interventions: Establishment of an acute stroke unit.
Main outcome measure(s): Increased frequency in meeting key performance indicators for acute stroke care as recommended by National Stroke Foundation.
Results: On discharge, fewer survivors in the pre-intervention group were independent (n = 5) and returned home (n = 9) than the post-intervention group (n = 13) for both independent and returned home. More survivors in the pre-intervention group were discharged to aged care or inpatient rehab (n = 22) than the post-intervention group (n = 12). Within required time frames, the frequency of CT scans (χ2 (1, 80) = 4.1, P < 0.05), swallow assessments (χ2 (1, 80) = 9.0, P < 0.01), occupational therapy assessments (χ2 (1, 80) = 14.5, P < 0.0001), multidisciplinary meetings involving patient and family (χ2 (1, 80) = 19.9, P < 0.0001) and self-management plans (χ2 (1, 80) = 10.9, P < 0.05) all increased significantly.
Conclusions: Our evaluation demonstrated that introduction of formalised stroke care to a regional hospital resulted in improved compliance with key performance indicators and better patient outcomes. Thus evidence-based specialised stroke care can be offered with confidence in regional populations.