Search results

Rural areas that are struggling to recruit and retain qualified health practitioners are caught in the crossfire of turf battles between allied health practitioners and physician groups. The most intensely political of these inter-occupational turf battles is between anesthesiologists (MDAs) and certified registered nurse anesthetists (CRNAs), who are the sole providers of anesthesia in two-thirds of rural hospitals (American Association of Nurse Anesthetists (AANA), 2007a, 2007b). The ability of many rural hospitals to provide anesthesia services is dependent on CRNAs. This study uses data collected from CRNAs in Iowa and Arizona in 2005 to focus on the impact of the turf battle on the professional interactions and opinions of CRNAs. Arizona and Iowa were chosen for this study because not only do the policies in these states contrast with each other, but the contexts in which CRNAs practice are also dissimilar. The majority of Arizona's CRNAs work in urban areas in close proximity with MDAs. Most CRNAs in Arizona report that their workplace interactions with MDAs have suffered as a result of the turf battle, despite the lack of any action to opt out of the federal Medicare requirement of physician supervision of CRNAs. While most CRNAs in Iowa perceive that job opportunities and the quality and cost of health care have improved as a result of opting out of the federal supervision requirement of CRNAs, the impact on their social interactions in the workplace depends on location and the structural context of their work. Most CRNAs in Iowa's urban areas continue to work in a structural context of de facto supervision by MDAs. As a result, only a minority report that their professional interactions in the workplace have improved. The outcome for Iowa's rural CRNAs is decidedly different. The majority function as independent practitioners and have experienced an improvement in their social interactions in the workplace and greater economic reward. These occupational privileges should improve the ability of Iowa's rural hospitals to recruit and retain CRNAs and, as a consequence, surgical services in rural areas.

Barriers to adequate healthcare in rural areas remain a grand challenge for local healthcare systems. In addition to patients' travel burdens, lack of health insurance, and lower health literacy, rural healthcare systems also experience significant resource shortages, as well as issues with recruitment and retention of healthcare providers, particularly specialists. These factors combined result in complex change management-focused challenges for rural healthcare systems. Change management initiatives are often resource intensive, and in rural health organizations already strapped for resources, it may be particularly risky to embark on change initiatives. One way to address these change management concerns is by leveraging socio-technical simulation models to estimate techno-economic feasibility (e.g., is it technologically feasible, and is it economical?) as well as socio-utility feasibility (e.g., how will the changes be utilized?). We present a framework for how healthcare systems can integrate modeling and simulation techniques from systems engineering into a change management process. Modeling and simulation are particularly useful for investigating the amount of uncertainty about potential outcomes, guiding decision-making that considers different scenarios, and validating theories to determine if they accurately reflect real-life processes. The results of these simulations can be integrated into critical change management recommendations related to developing readiness for change and addressing resistance to change. As part of our integration, we present a case study showcasing how simulation modeling has been used to determine feasibility and potential resistance to change considerations for implementing a mobile radiation oncology unit. Recommendations and implications are discussed.

This chapter examines the relationship between health service restructuring and the health care experiences of women from rural and remote areas of Canada. Data were collected from 34 focus groups (237 women), 15 telephone interviews and 346 responses from an online survey. Access to services, care quality and satisfaction are salient themes in these data. Problems include: travel, shortage of providers, turnover in personnel, delays associated in accessing care, lack of knowledge of women's health issues and patronizing attitudes of some health care providers. Health care service restructuring has led to deterioration in service availability and quality. Key areas for policy development need to address health care access and quality improvement issues, including increasing access to more (particularly female) providers who are sensitive to women's health issues.

Longitudinally (2008–2012) assess whether community-level sociodemographic characteristics were associated with patient-centered medical home (PCMH) capacity among primary care and specialty physician practices, and the extent to which variation in PCMH capacity can be accounted for by sociodemographic characteristics of the community.

Linear growth curve models among 523 small and medium-sized physician practices that were members of a consortium of physician organizations pursuing the PCMH.

Our analysis indicated that the average level of sociodemographic characteristics was typically not associated with the level of PCMH capacity, but the heterogeneity of the surrounding community is generally associated with lower levels of capacity. Furthermore, these relationships differed for interpersonal and technical dimensions of the PCMH.

Our findings suggest that PCMH capabilities may not be evenly distributed across communities and raise questions about whether such distributional differences influence the PCMH’s ability to improve population health, especially the health of vulnerable populations. Such nuances highlight the challenges faced by practitioners and policy makers who advocate the continued expansion of the PCMH as a means of improving the health of local communities.

To date, most studies have focused cross-sectionally on practice characteristics and their association with PCMH adoption. Less understood is how physician practices’ PCMH adoption varies as a function of the sociodemographic characteristics of the community in which the practice is located, despite work that acknowledges the importance of social context in decisions about adoption and implementation that can affect the dissemination of innovations.

Consumer-Directed Health Plans (CDHPs) are proposed as an option to control healthcare costs. No research has addressed their applicability in rural settings. This study analyzes three years (2003–2005) of healthcare expenditure and utilization incurred by two employers and a national carrier providing data from a rural state, Kentucky. The study included two measures of expenditures (health care and prescription drugs) and three measures of utilization (physician visits, hospital admissions, and hospital inpatient days). In general, the CDHP successfully controlled the growth of medical costs. These findings suggest that CDHPs may be a viable alternative benefit structure for rural employers.

While there is established research that explores individual innovations across countries or developments in a specific health area, there is less work that attempts to match national innovations to specific systems of health governance to uncover themes across nations.

We used a cross-comparison design that employed content analysis of health governance models and innovation patterns in eight OECD nations (Australia, Britain, Canada, France, Germany, the Netherlands, Switzerland, and the United States).

Country-level model of health governance may impact the focus of health innovation within the eight jurisdictions studied. Innovation across all governance models has targeted consumer engagement in health systems, the integration of health services across the continuum of care, access to care in the community, and financial models that drive competition.

Improving our understanding of the linkage between health governance and innovation in health systems may heighten awareness of potential enablers and barriers to innovation success.

Purpose – Health information technology (HIT) holds promise for improving the quality of health care and reducing health care system inefficiencies. Numerous studies have examined HIT availability, specifically electronic health records (EHRs), and utilization among physicians in individual countries. However, no one has examined EHR use among physicians who train in one country and move to practice in another country. In the United States, physicians who complete medical school outside the country but practice within the United States are commonly referred to as International Medical Graduates (IMGs). IMGs have a growing presence in the United States, yet little is known about the availability and use of HIT among these physicians. The purpose of this study is to explore the availability and use of HIT among IMGs practicing in United States.

Design/methodology/approach – The Health Tracking Physician Survey (2008) was used to examine the relationship between availability and use of HIT and IMG status controlling for several physician and practice characteristics. Our analysis included responses from 4,720 physicians, 20.7% of whom were IMGs.

Findings – Using logistic regression, controlling for physician gender, specialty, years in practice, practice type, ownership status and geographical location, we found IMGs were significantly less likely to have a comprehensive EHR in their practices (OR=0.84; p=0.005). In addition, findings indicate that IMGs are more likely to have and use several so-called first generation HIT capabilities, such as reminders for clinicians about preventive services (OR=1.31; p=0.001) and other needed patient follow-up (OR=1.26; p=0.007).

Originality/value – This study draws attention to the need for further research regarding barriers to HIT adoption and use among IMGs.

Purpose – Use of telemedicine is increasingly prevalent in order to provide better access to expert care, and we examine telemedicine use internationally.

Design/methodology – Using Donabedian's structure, process outcome framework, we conduct an analysis of published studies in the United States, Europe, and Asia to examine the uses, conditions treated, barriers, and future of telemedicine.

Findings – We identify several similarities and challenges to telemedicine use in each region. We find use of videoconferencing between providers or providers and patients for the treatment of acute and chronic conditions. Studies in the United States are more likely to identify applications for the use of chronic conditions, whereas studies in Europe or Asia are more likely to use them for acute access to expertise. Each region reported comparable challenges in reimbursement, liability, technology, and provider licensing.

Research limitations – We compare available research articles from three diverse regions, and many of the articles were merely descriptive in nature. Furthermore, the number of articles per region varied.

Practical implications – Barriers to telemedicine use include a lack of reimbursement, language commonality, technological availability, physician licensure or credentialing, trained support staff and patient privacy, and security assurances. Practitioners and policy makers should work to address these barriers.

Originality/value – Through this work, a summary of the research to date describes telemedicine use in the United States, Asia, and Europe. Identification of use and barriers may provide impetus for improving access to care by finding ways to increase telemedicine use through standardization.

For the most part there is no rural welfare policy in Canada – just as there are few examples of rural policy. There are many examples where welfare policy has special implications for rural people, and even a few instances where welfare policy has targeted (explicitly or implicitly) rural regions, but this is rarely formulated from a position of rural policy or perspective. In addition, social welfare policy in Canada is complex. Within the Canadian Confederation, social welfare policy is primarily the responsibility of provinces and territories. For that reason, instead of a unified policy system, Canadians have a multitude of welfare policies, somewhat coordinated within a national structure.

Disparities in health care for underserved populations have raised questions about the quality of decisions made by these patients. We explored the decision-making experiences and reactions to a decision aid in focus groups of African American, Hispanic, and Rural breast cancer survivors. All groups were taped, transcribed, and thematic analysis was performed. Individual differences were more common than differences among demographic groups. Decision aids appear to be acceptable without extensive targeting to specific groups. However, translating the decision aid would increase its usefulness for Hispanic populations.