Influences on doctors' prescribing: Is geographical remoteness a factor?

Objective: To identify factors influencing the prescribing of medicines by general practitioners in rural and remote Australia. Design: A qualitative study using a questionnaire to determine attitudes about prescribing, specific prescribing habits and comments on prescribing in ‘rural practice’. Setting: General practice in rural and remote Queensland. Subjects: General practitioners practising in rural and remote settings in Queensland (n = 258). Main outcome measures: The factors perceived to influence the prescribing of medicines by medical practitioners in rural environments. Results: A 58% response rate (n = 142) was achieved. Most respondents agreed that they prescribe differently in rural compared with city practice. The majority of respondents agreed that their prescribing was influenced by practice location, isolation of patient home location, limited diagnostic testing and increased drug monitoring. Location issues and other issues were more likely to be identified as ‘influential’ by the more isolated practitioners. Factors such as access to continuing medical education and specialists were confirmed as having an influence on prescribing. The prescribing of recently marketed drugs was more likely by doctors practising in less remote rural areas. Conclusion: Practising in rural and remote locations is perceived to have an effect on prescribing. These influences need to be considered when developing quality use of medicines policies and initiatives for these locations. What is already known: Anecdotal and audit based studies have shown that rural general practice differs to urban-based practice in Australia, including some limited data showing some variations in prescribing patterns. No substantiated explanations for these variations have been offered. It is known that interventions to change prescribing behaviour are more likely to be effective if they are perceived as relevant and hence increasing our knowledge of rural doctors’ perceptions of differences in rural practice prescribing is required. What this study adds: Rural doctors believed that they prescribe differently in rural compared with city practice and they described a range of influences. The more remotely located doctors were more likely to report the ‘rural’ influences on prescribing, however, most results failed to reach statistical significance when compared to the less remotely located doctors. These perceptions should be considered when developing medicines policy and education for rural medical practitioners to ensure it is perceived rurally relevant.

Infestation of people with lice in Kathmandu and Pokhara, Nepal

The prevalence of infestation with head lice and body lice, Pediculus spp. (Phthiraptera: Pediculidae) and pubic (crab) lice Pthirus pubis (L.) (Phthiraptera: Pthiridae), was recorded from 484 people in Nepal. The prevalence of head lice varied from 16% in a sample of people aged 10-39 years of age, to 59% in street children. Simultaneous infestations with head and body lice (double infestations) varied from 18% in slum children to 59% in street children.

A feasibility study of email communication between the patient's family and the specialist burns team

We investigated whether the parents of burns patients could capture suitable clinical images with a digital camera and add the necessary text information to enable the paediatric burns team to provide follow-up care via email. Four families were involved in the study, each of whom sent regular email consultations for six months. The results were very encouraging. The burns team felt confident that the clinical information in 30 of the 32 email messages (94%) they received was accurate, although in I I of these 30 cases (37%) they stated that there was room for improvement (the quality was nonetheless adequate for clinical decision making). The study also showed that low-resolution images (average size 37 kByte) were satisfactory for diagnosis. Families were able to participate in the service without intensive training and support. The user survey showed that all four families found it easy and convenient to take the digital photographs and to participate in the study. The results suggest that the technique has potential as a low-cost telemedicine service in burns follow-up, and that it requires only modest investment in equipment, training and support.

Paediatric outreach services

Paediatric outreach services are provided in Australia and overseas to regional and rural communities. More recently telehealth services have been established to support the delivery of paediatric services and clinical management at distant sites. It is suggested that with the large distances separating centres in Australia that a combination of telehealth clinics and outreach visits may provide the most efficient means of delivering paediatric specialty and subspecialty care to these centres.

A review of three years experience using email and videoconferencing for the delivery of post-acute burns care to children in Queensland

A virtual outpatient service has been established in Queensland for the delivery of post-acute burns care to children living in rural and remote areas of the state. The integration of telepaediatrics as a routine service has reduced the need for patient travel to the specialist burns unit situated in Brisbane. We have conducted 293 patient consultations over a period of 3 years. A retrospective review of our experience has shown that post-acute burns care can be delivered using videoconferencing, email and the telephone. Telepaediatric bums services have been valuable in two key areas. The first area involves a programme of routine specialist clinics via videoconference. The second area relates to ad-hoc patient consultations for collaborative management during acute presentations and at times of urgent clinical need. The families of patients have expressed a high degree of satisfaction with the service. Telepaediatric services have helped improve access to specialist services for people living in rural and remote communities throughout Queensland. (C) 2003 Elsevier Ltd and ISBI. All rights reserved.

Trial of low-cost teledermatology in primary care

We examined the feasibility of a low-cost, store-and-forward teledermatology service for general practitioners (GPs) in regional Queensland. Digital pictures and a brief case history were transmitted by email. A service coordinator carried out quality control checks and then forwarded these email messages to a consultant dermatologist. On receiving a clinical response from the dermatologist, the service coordinator returned the message to the referring GP. The aim was to provide advice to rural Gps within one working day. Over six months, 63 referrals were processed by the teledermatology service, covering a wide range of dermatological conditions. In the majority of cases the referring doctors were able to treat the condition after receipt of email advice from the dermatologist; however, in 10 cases (16%) additional images or biopsy results were requested because image quality was inadequate. The average time between a referral being received and clinical advice being provided to the referring GPs was 46 hours. The number of referrals in the present study, 1.05 per month per site, was similar to that reported in other primary care studies. While the use of low-cost digital cameras and public email is feasible, there may be other issues, for example remuneration, which will militate against the widespread introduction of primary care teledermatology in Australia.

Wireless telemedicine for the delivery of specialist paediatric services to the bedside

A mobile interactive online health system was used to conduct virtual ward rounds at a regional hospital which had no specialist paediatrician. The system was wireless, which allowed telepaediatric services to be delivered direct to the bedside. Between December 2004 and May 2005, 43 virtual ward rounds were coordinated between specialists based in Brisbane and local staff at the Gladstone Hospital. Eighty-six consultations were provided for 64 patients. The most common conditions included asthma (27%), chest infections (12%), gastroenteritis (10%) and urinary tract infections (10%). In the majority of cases, there were partial (67%) or complete changes (11%) in the clinical management of patients. Specialist services were offered by a team of 13 clinicians at the Royal Children's Hospital: 10 general paediatricians, two physiotherapists and one registered nurse. Feedback from all consultants involved in the service and local staff in Gladstone was extremely positive. In 43 videoconference calls there were three technical problems, probably due to an intermittent mains power supply at the regional hospital. There appears to be potential for other rural and regional hospitals to adopt this model of service delivery.

Realtime telemedicine for paediatric otolaryngology pre-admission screening

We conducted a feasibility study to examine whether a paediatric patient at a regional hospital could be assessed by an ear, nose and throat (ENT) specialist via videoconference, therefore saving at least one journey to the tertiary hospital for a pre-admission appointment. A video-otoscope was used with standard videoconference equipment, and realtime images were transmitted at a bandwidth of 384 kbit/s. In all, 13 telepaediatric ENT clinics were conducted between November 2003 and April 2005, and 98 consultations were facilitated for 64 patients. The main reasons for referral were recurrent tonsillitis (25%) and obstructive sleep apnoea (23%). Of the 64 patients examined by telemedicine, 42 (66%) were recommended for surgery and placed on the surgical waiting list. About 12 patients (19%) required travel to the tertiary centre for further investigations and tests not available locally, while four patients (6%) were reviewed via videoconference during a scheduled clinic. Six patients (9%) required no further follow-up after their initial telepaedliatric consultation. Videoconferencing is an effective method of assessing ENT conditions of paediatric patients and for pre-screening potential surgical admissions to a tertiary hospital. Careful consideration of a number of economic and logistical factors needs to be made before large investments are made to expand the service.

Evaluation of the healthy village program in Kapit district, Sarawak, Malaysia

Sarawak, Malaysia has a large population of ethnic minorities who live in longhouses in remote rural areas where poverty, non-communicable diseases, accidents and injuries, environmental hazards and communicable diseases all contribute to a lower quality of life than is possible to achieve in these regions. To address these issues and improve the quality of life for longhouse people, the Kapit Divisional Health Office implemented the World Health Organization's Healthy Village programme in 2000. An evaluation was undertaken in 2003 to determine physical and behavioural changes resulting from the programme. The main changes evaluated were those involving smoking habits, exercise habits, health screening, fire safety, environmental improvements and food preparation and hygiene. A qualitative evaluation was conducted using participant observation and key-informant interviews, focus groups and observation. Results indicate that the programme is inspiring changes in various behavioural and physical characteristics of the study population. It is clear that the Healthy Village programme is a widely accepted way of improving health outcomes in longhouses, and that it is succeeding in making beneficial health changes.