Showing papers by "Russell L. Gruen published in 2003"

Specialist outreach clinics in primary care and rural hospital settings.

Abstract: Background Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services. Objectives To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs. Search methods We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles. Selection criteria Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost. Data collection and analysis Four reviewers working in pairs independently extracted data and assessed study quality. Main results 73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services wasassociated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. Authors' conclusions This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Indigenous surgical admissions.

Abstract: He has shown that, compared with other Australians, Indigenous people have lower admission rates for surgical procedures and that greater proportions of these are emergency admissions. However, two crucial factors (one technical, the other more fundamental in Indigenous health research and policy) have been overlooked in attributing these findings to ‘cultural aversion’ to surgery and ‘substitute’ admissions to medical units. As a technical issue, it appears as though admissions for dialysis were included in the analysis. If so, they are likely to have confounded the results regarding substitute admissions. Although they are not ‘new’ conditions, they account for 13% of all public hospital admissions, 2 and are 6–10 times more common in Indigenous people. 3 Their inclusion exacerbates the difference between medical and surgical admissions for Indigenous and nonindigenous patients, a major component of Ishak’s argument. Of greater concern, however, is attributing the findings to Indigenous cultural beliefs. Lower admission rates and more emergency admissions may reflect inability to obtain appropriate treatment more than aversion to that treatment. While hospital admissions data provide no information about patient perceptions, other evidence points to significant barriers to hospital care. First, 55% of the Indigenous population, but only 23% of the Australian population overall, live outside the major urban centres where most surgeons and hospitals are located. 4 Rural and Indigenous people use hospital-based surgical services less than urban and non-indigenous people 5 but they are not referred to surgeons less often, 6 providing no evidence of aversion at the stage of referral to specialists. Indigenous people, especially those from rural and remote areas, do face substantial barriers when accessing hospital-based specialist care, however. In a longitudinal study of 2566 surgical problems presenting in Indigenous communities in the Northern Territory, we have shown that 22% of patients referred for specialist opinion never presented to the outpatient clinic (Gruen et al . unpubl. data, 2003). In interviews with patients, remote providers and specialists, barriers were described that related to difficulties with transport, poor hospital–primary care and provider–patient communication (especially without interpreters), culturally naïve hospital practices that Indigenous people found hostile, and poverty of resources in remote areas, including adequate primary health care. 7 The beneficial effect of visiting specialists provides further support for the argument that lower hospital presentation and admission rates are caused by access problems. The Specialist Outreach Service, an initiative involving the Royal Australasian College of Surgeons, has led to a fourfold increase in the number of consultations 7,8 and improved the rate of completion of surgical referrals and provision of appropriate treatment. (Gruen et al . unpubl. data, 2003). In the past, attributing poor Indigenous health to aspects of Indigenous character and belief has diverted attention from the need to ensure appropriate, accessible and high-quality health services. 9 Ishak’s analysis demonstrates important disparities in care but the conclusions fail to consider equally important contextual factors. In Indigenous health in particular, the need is not to ‘educate communities’ but rather to work with them to ensure that patients have access to optimal surgical care when they need it. Only with this approach will specialists and hospitals help to improve Indigenous peoples’ health status.