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At least 289 records · Page 16Linked to original sources

PubMed2003

Equity of access to tertiary hospitals in Wales: a travel time analysis.

BACKGROUND: The objective of the study was to investigate the implications for equity of geographical access for population subgroups arising from hypothetical scenarios of change in configuration of National Health Service tertiary hospital service provision located in Wales. METHODS: For each of three scenarios, the status quo and centralization of services to one of two locations, we used a travel time road length matrix in geographical information software to calculate the proportion of the population living within 30, 60, 90 and 120 min travel of each hospital site and the associated mean, median and 90th percentile travel times. We analysed data for the total resident population of Wales, for residents aged 75 or more years, for residents of the most deprived 10 per cent of enumeration districts, and for residents of rural areas. RESULTS: Centralization of services reduces geographical access for all population subgroups. Access varies between population subgroups, both between and within different scenarios of service configuration. A change in service configuration may improve access for one subgroup but reduce access for another. The interpretation may also vary according to whether the defined cut point for comparing access is based on short or long travel times. Measurements of absolute and relative access are sensitive to the assumed travel speeds. CONCLUSION: Access for the total population does not imply equity of access for subgroups of the population. Comparisons of access between scenarios are dependent on which measure of access is the indicator of choice. Results are sensitive to the road network travel speeds and further local validation may be necessary. This method can provide explicit information to health service planners on the effects on equity of access from a change in service configuration.

Catchment Area, Health↗

PubMed2006

Impact of increased access to emergency contraceptive pills: a randomized controlled trial.

OBJECTIVE: To assess how a strategy to maximize access to emergency contraceptive pills would affect rates of pregnancy and sexually transmitted infections. METHODS: Sexually active women, 14-24 years old, were randomly assigned to two methods of access to emergency contraceptive pills: increased access (two packages of pills dispensed in advance with unlimited resupply at no charge) or standard access (pills dispensed when needed at usual charges). Participants were followed for 1 year to assess incidence of pregnancy, gonorrhea, chlamydia, and trichomonas. RESULTS: The numbers of women enrolled in the increased and standard access groups were 746 and 744, respectively. More than 93% of participants completed a full year of follow-up. The incidence of pregnancy was similar in both groups (increased access group: 9.9/100 woman years, 95% confidence interval [CI] 7.7-12.6; standard access group: 10.5/100 woman years, 95% CI 8.2-13.2). Aggregate rates of gonorrhea, chlamydia, and trichomonas were also similar in the two groups (increased access group: 6.9/100 woman years, 95% CI 5.1-9.1; standard access group: 7.6/100 woman years, 95% CI 5.7-9.9). The increased access group used emergency contraceptive pills substantially more often and sooner after coitus than the standard access group. No other differences were noted between groups in self-reported measures of sexual behavior and contraceptive use. CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1.

Adolescent↗

PubMed2006

Personal continuity and access in UK general practice: a qualitative study of general practitioners' and patients' perceptions of when and how they matter.

BACKGROUND: Personal continuity is a core value for family practice, but policy and performance targets emphasise other aspects of care, particularly waiting times for consultation. This study examined patient and general practitioner (GP) perceptions of the value of personal continuity and rapid access, and the relationship between them. METHODS: Qualitative analysis of semi-structured interviews with a purposive sample of 16 GPs and 32 patients in the Lothian region of Scotland, to identify whether, how, why and in which circumstances personal continuity and rapid access were valued. RESULTS: From the patients' perspective, what mattered was 'access to appropriate care' depending on the problem to be dealt with. For a few patients, rapid access was the only priority. For most, rapid access was balanced against greater involvement in the consultation when seeing 'their' trusted doctor, which was particularly valued for chronic, complex and emotional problems. GPs focused on the value of personal continuity in the consultation for improving the diagnosis and management of the same kinds of problem. GPs did not perceive enabling access to be a core part of their work. There was little evidence that GPs routinely discussed with patients when or how personal continuity and access should be balanced. CONCLUSION: 'Access to appropriate care' from the patients' perspective is not fully addressed by GPs' focus on personal continuity, nor by performance targets focused only on speed of access. GPs need to make enabling access as much a part of their core values as personal continuity, and access targets need to be based on less simplistic measures that account for the appropriateness of care as well as speed of access.

Adult↗

PubMed1997

Primary care and patient perceptions of access to care.

BACKGROUND: Although much is known about how insurance affects access to care, it is unclear whether good primary care contributes to access. The purpose of this study was to determine how optimal primary care given by providers at a regular place of care, defined in terms of continuity, comprehensiveness, communication, and availability, contributed to perceptions of access to care in a large population-based probability sample of adults. METHODS: Data were from a cross-sectional survey of 6674 English- and Spanish-speaking adults 18 to 64 years of age, randomly sampled from 41 urban California communities with a range of levels of access to care. RESULTS: Following adjustment for sociodemographics and need for care, we found that having "optimal" primary care contributed independently to improved self-rated access, as did having health insurance, a regular place, and a regular provider. The largest difference n access was between having any health insurance and not having insurance. Once insurance was available, each additional element contributed in a cumulative manner to self-rated access. For those with insurance and a regular place, adding optimal primary care improved self-rated access to an extent similar to adding a regular provider. CONCLUSIONS: We conclude that although providing insurance to the uninsured is the most effective means of improving self-rated access, the other elements each improve access as well. Once insurance and a regular place are provided, good primary care at that place may be equivalent to having a regular provider in terms of perceived access. Results support promotion of primary care as a model of health care that encourages good access.

Adolescent↗

PubMed1997

Making our offices universally accessible: guidelines for physicians.

OBJECTIVE: To develop recommendations for office-based physicians who wish to make their offices accessible to all patients. OPTIONS: Include taking steps to make offices more accessible, or not; offices may be accessible to varying degrees. OUTCOMES: Outcomes of accessibility involve patient-care, economic, ethical and legal issues. Stakeholders in these outcomes include patients, physicians, government and society. EVIDENCE: Data were obtained from a series of searches of MEDLINE, CINAHL and Healthstar (previously Health) databases for articles on disability and family medicine, primary (health) care and family practice, and on access and offices, and health services accessibility, and from a telephone survey of 50 stakeholders. VALUES: A high value was placed on services to persons with disabilities and on stakeholder input. Universal accessibility was valued as an overall goal; improved accessibility was also highly valued. BENEFITS, HARMS AND COSTS: Benefits to patients include improved access to care as guaranteed by the Canada Health Act and in keeping with provincial Human Rights Codes. Benefits to physicians include contact with a broader patient population and freedom from fear of litigation. Costs of improved accessibility vary depending on individual circumstances and on whether an office is being built or renovated; some improvement costs are minimal. RECOMMENDATIONS: All physicians should take measures to improve practice accessibility. Improved access should be considered in each of the following areas: transportation and entrance to the facility, entrance to the office, waiting rooms, rest rooms, examination rooms, general building features and other features. VALIDATION: No similar guidelines exist. To assess the content validity of these guidelines, the authors had a draft document reviewed by 18 stakeholders. All specific recommendations met the minimum criterion of adherence to current legislation, including national and provincial building codes. The specific recommendations are endorsed by the Canadian Paraplegic Association (national and Ontario offices), the DisAbled Women's Network (Ontario) and the Centre for Independent Living (Toronto). SPONSORS: Development of these guidelines was supported in part by the Department of Family and Community Medicine, Toronto Hospital, Toronto, Ont.

Adult↗

PubMed2004

Binge-type eating induced by limited access in rats does not require energy restriction on the previous day.

This study was designed to determine if a limited access feeding protocol would induce binge-type eating when energy intake on the day before the binge was not reduced. Rats were assigned to four groups; all groups had continuous access to chow and water throughout the 4 wk study. In addition, access to optional shortening was provided as follows: (1) Control (C): no access to shortening, (2) Regular Shortening Access-7 (RSA7): 2-h access everyday, (3) Regular Shortening Access-3 (RSA3): 2-h access every Monday, Wednesday, and Friday, (4) Irregular Shortening Access (ISA): 2-h access on various days, such that the number of shortening access (binge) sessions equaled that of RSA3, but the last three sessions were each separated by 4 days. On the days prior to the last two binge sessions, RSA3 consumed significantly less energy than any other group (p < 0.05) but ISA intakes equaled those of Control and RSA7. During the last two binge sessions, intakes of RSA3 and ISA did not differ, and both groups consumed significantly more than RSA7 or Control (p < 0.05) These results demonstrate that binge-type eating can be induced by limiting access to an optional fatty food, and does not depend upon undereating on the previous day.

Analysis of Variance↗

PubMed2006

Use of lower pole nephrostomy drainage following endorenal surgery through an upper pole access.

PURPOSE: PNL via an UP puncture is efficient for treating complex stone disease. Access via the UP can provide better visualization, allowing greater stone clearance with a rigid instrument due to its more favorable alignment with the axis of the intrarenal collecting system. However, the presence of a NT through the upper pole tract, especially with a supracostal puncture, can generate significant patient discomfort. We reviewed our experience with a technique using tubeless UP access for PNL with concomitant placement of a NT via a LP calix. MATERIALS AND METHODS: We performed a retrospective review of our experience using tubeless UP access for PNL with concomitant placement of an LP NT for postoperative drainage. Patient demographics, the number and location of accesses, stone size, stone-free rates, concurrent/additional procedures and complications were recorded. RESULTS: A total of 63 tubeless UP accesses were performed in 62 patients undergoing PNL, including unilateral access in 61 and bilateral access in 1. Supracostal UP punctures were used in 58 patients, including 40 above the 12th, 17 above the 11th and 1 above the 10th rib. Each patient underwent at least 2 accesses and 3 had 3 or more accesses placed. LP access was nondilated in 37 patients and dilated in 26. Of the patients 56.6% were stone-free after a single procedure, increasing to 96.2% following secondary procedures. Three of the 62 patients (4.8%) required transfusion, 3 (4.8%) required intervention for pleural morbidity and 1 (1.6%) required a stent for a nonsealing upper pole access. CONCLUSIONS: Tubeless UP access provides maximal efficiency for stone clearance during PNL, while minimizing the morbidity of an intercostal tube.

Adolescent↗

PubMed2002

Genetic variation in three species of Hordeum, and the selection of accessions for the Barley Core Collection.

Starch gel electrophoresis of isozymes was used to investigate the level and distribution of genetic variation in accessions of three wild, diploid Hordeum species. Allelic variation was assessed for seven isozyme loci and used in the statistical analysis of 18 accessions of Hordeum brachyantherum subsp. californicum, 29 accessions of H. murinum subsp. glaucum and 11 accessions of H. pusillum. A major purpose with this study was to evaluate the selection of accessions for the international Barley Core Collection, complementing existing passport data. Allelic variation was found in all three species. The variation was mainly between accessions, as most accessions were fixed for certain alleles. Since all three species are self-pollinated, this was anticipated. The fact that the accessions have undergone one or several regeneration cycles from a rather limited number of individuals, after being collected, likely also have reduced the variation. The accessions were clustered by subjecting the genetic distances between them to UPGMA statistical treatment. The clusters in the dendrograms displayed for H. brachyantherum subsp. californicum and H. pusillum distinct patterns related to the geographical origin of the accessions. The accessions of H. murinum subsp. glaucum were less variable than the other two, and did not reveal such a clear pattern. By comparing the already made, geographically based, selection of accessions with the results from this study, it was evident that the selection had worked fairly well for H. brachyantherum subsp. californicum, but less so for the other two species.

Aconitate Hydratase↗

PubMed2004

Strategies of arteriovenous dialysis access.

Surgical management of the patient who requires hemodialysis access, while continuing to demand more attention from the vascular surgeon, suffers from discrepancies of approach and strategy. With the increase in incidence of dialysis dependent renal failure among our population, many have attempted to present a uniform, logical strategy with which the vascular surgeon can most effectively treat the hemodialysis patient in the long term. Most notably, the multidisciplinary Dialysis Outcomes Quality Initiative (DOQI) guidelines present the surgeon with a rough outline of hemodialysis access insertion strategy, and it has become nationally recognized as an acceptable summary of treatment strategy and goals. The decision as to the most appropriate surgical access to offer a patient depends on immediate need for hemodialysis, history and physical examination findings, and suitability of available veins in the extremity. While percutaneous, catheter based access affords the luxury of immediate access, these devices suffer from several complicating factors, such as infection, and damage to large, proximal veins. For long-term access, the autogenous access, while perhaps less successful in the immediate short term, is always the preferred access type given its favorable longevity. The surgeons should focus on sites distally on the extremity, reserving proximal sites for potential future access insertions should the primary access fail. In the absence of suitable vein, prosthetic access may be considered. When both the upper and lower aspects of both upper extremities have been exhausted, the surgeon should consider access insertion elsewhere, such as the lower extremity.

Arteriovenous Shunt, Surgical↗

PubMed2003

Studying "exposure" to firearms: household ownership v access.

BACKGROUND: Firearm ownership has often been used to measure access to weapons. However, persons who own a firearm may not have access to it and conversely, persons who do not own a firearm may be able to access one quickly. OBJECTIVES: To examine whether using firearm ownership is a reasonable proxy for access by describing the demographic characteristics associated with ownership and access. METHODS: Data are from the 1994 Injury Control and Risk Survey, a national, random digit dial survey. Information about household firearm ownership and ready access to a loaded firearm were collected and weighted to provide national estimates. Adjusted odds ratios for three separate models were calculated using logistic regression. RESULTS: A total of 1353 (27.9%) respondents reported both having a firearm in the household and ready access to one. An additional 313 respondents (8.1%) reported having a firearm, but were not able to access these weapons. Another 421 respondents (7.2%) did not have a firearm in or around their home, yet reported being able to retrieve and fire one within 10 minutes. Based on the logistic regression findings, the demographic characteristics of this latter group are quite different from those who report ownership. Those who do not have a firearm, but report ready access to one, are more likely to be ethnic minorities, single, and living in attached homes. CONCLUSIONS: Asking only about the presence of a firearm in a household may miss some respondents with ready access to a loaded firearm. More importantly, those who do not own a firearm, but report ready access to one, appear to be qualitatively different from those who report ownership. Caution should be exercised when using measures of ownership as a proxy for access.

Adult↗

PubMed2004

Establishment and maintenance of vascular access in incident hemodialysis patients: a prospective cost analysis.

Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail. A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type. Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001. A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained. Costs are reported in 2002 Canadian dollars (1 CAN dollar = 0.69 US dollar). A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively. In year 1, 18.4% of all hospital admissions were for vascular access-related complications. The mean cost of all vascular access care in year 1 was 6890 CAN dollars(median 4020 dollars; interquartile range [IQR] 2440 dollars to 7540 dollars). The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was 9180 dollars (median 3812 dollars; IQR 2250 dollars to 7762 dollars), 7989 dollars (median 4641 dollars ; IQR 3035 dollars to 8832 dollars), and 11,685 dollars (median 8152 dollars; IQR 3395 dollars to 12,908 dollars), respectively (P = 0.01). Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results support clinical practice guidelines that recommend preferential placement of a native fistula.

Aged↗

PubMedDate not supplied

[Vascular access in Spain: analysis of its distribution, morbidity, and monitoring systems].

Vascular access disfunction causes a therapeutic emergency with different implications in patients and care givers. The aim of this study was to know the distribution of different kinds of vascular access between prevalent hemodialysis patients, the proportion of incident patients that holds a permanent vascular access, the monthly hospital ratio for access repair and the use of surveillance systems of vascular access adequacy in the different Centers. This is a National survey that shows results of a questionnaire sent to all hemodialysis units in Spain on september 1999. Eighty-eight units answered the questionnaire (42%) providing information about 5,476 prevalent patients. Of these patients, 81% receives treatment through an arteriovenous fistula, 10% uses a central catheter and 9% a graft. Only 56% of incident patients have a permanent vascular access. Reasons for catheter use between prevalent patients were exhaustion of vascular sites in 42%, maduration of permanent access in 24%, thrombosis of the access in 14% and another reasons in 19%. Patients monthly hospitalization ratio for vascular repair was 3%, that might represent more than 5,600 hospital ingress by year. More than 80% of the Units releases different surveillance programs of access adequacy, 69% by fiscal detection problems, 47% by dynamic alterations and 18% by dilution and imaging procediments. The conclusions of this survey are that arteriovenous fistula is the most used vascular access in Spain. Almost half of the patients do not have vascular access in use for the beginning of hemodialysis. Exhausted vascular sites is the primary reason for central catheter using. A great proportion of Units are employing programs for access monitoring.

Catheters, Indwelling↗

PubMed2004

A controlled trial of an advanced access appointment system in a residency family medicine center.

BACKGROUND AND OBJECTIVES: The implementation of advanced access appointment systems has improved continuity of care, patient and physician satisfaction, physician productivity, and average physician panel size in private practice and group-model HMO settings. This study's purpose was to document the patient care benefits, practice management benefits, and educational outcomes from the controlled implementation of an advanced access appointment system in a residency family medicine center. METHODS: Two faculty-resident teams were created. One team adopted the advanced access system while the other team continued using a traditional access system. Outcome measures included length of time needed to obtain an appointment (days to third available appointment), continuity (percentage of visits with the patient's designated provider), no-show rates, productivity, visits lost to outside providers, panel sizes, and patient satisfaction. Outcomes were measured at baseline and quarterly for 1 year after initial implementation. RESULTS: After implementation, the "days to third available appointment" for the advanced access group was 5 days, compared to 21 days for the traditional access group. A significant improvement in continuity (ie, a match between the primary care physician and patient) for the advanced access team was found. Comparison of no-show rates between the advanced access and traditional access teams revealed significant between-subjects effect, but controlling for within-subject variation using repeated measures ANOVA eliminated this effect. Advanced access residents increased their continuity above 50% while increasing provider satisfaction with office practice and scope of practice. CONCLUSIONS: Faculty and residents can successfully use advanced access. Advanced access can enhance residency education by reducing appointment delays and significantly increasing the patient-primary care physician match.

Analysis of Variance↗

PubMed1999

CQI: hemodialysis vascular access flow monitoring.

One of the main ongoing challenges in nephrology is maintaining a good, well-functioning vascular access. Vascular access problems lead to complications such as access recirculation causing decreased adequacy of dialysis as shown by kinetic modelling and access clotting. Access flow measurement using ultrasound dilution technique is an accurate and better indicator of impending access stenosis than recirculation (urea method). The measurement is non-invasive, the procedure simple, and the monitor accessible at the bedside. The Adam Linton Dialysis Unit of the London Health Sciences Centre, Victoria Campus is currently monitoring access flows (Qa) as a continuous quality initiative using ultrasound dilution technique. Access recirculation (AR) is determined and Qa measurements are done bimonthly on all chronic in-centre and self-care dialysis patients with either arteriovenous fistula or Gore-tex grafts. Qa's of <550 ml/min or 20% decrease in flows are investigated by angiography and early intervention is instituted either by angioplasty or fistula repair. Our unit's goal is to be proactive in our investigation and in our nursing and medical interventions. From our experience, the problem with responding to poor clearances by checking for recirculation after the fact is that valuable time is lost for proactive intervention to preserve the access site and may in fact be too late. In four different patient situations we are able to show how our different interventions have improved Qa's and eliminated AR resulting in increased Kt/V. The intent of this article is to show that Qa measurement can be an ideal way to monitor hemodialysis vascular accesses over time. It provides a means to detect impending access dysfunction before the Qa has decreased enough to have induced AR and/or under-dialysis. By early intervention, optimum dialysis efficiency is achieved and the prescribed Kt/V [urea] is delivered.

Angiography↗

PubMed1989

[Access to psychiatric and child psychiatric case records in the Copenhagen County Hospital in Nordvang in 1987].

Commencing on 1.1.1987, all requests for access to case records were registered prospectively in all of the Copenhagen County Hospitals. In the Copenhagen County Hospital, Nordvang, 103 requests were made for access to the case records in the course of 1987. Ninety-five requests in the adult departments resulted in complete access in 90 cases, limited access in one case while access was refused in three cases. One person making the request did not turn up. Eight requests concerning patients in the child psychiatric department resulted in complete access in one case, limited access in five cases while access was refused in two cases. This corresponds to 3.0% in the departments for child psychiatry and 2.7% in the departments for adults. No deterioration in health was observed in any of the 97 cases where access was permitted. In many cases, insight into the case records may, on the other hand, be a good therapeutic measure. On two cases only, access to the case records was given to a third person with the patient's permission, and the majority of the patients did not request a copy of the case records but accepted access to the case records in the form of the right to read the case records with assistance, if necessary. It is concluded that in the first year after introduction of the Danish legislation concerning access to the case records, this ran very smoothly with fewer difficulties than anticipated in a large psychiatric hospital in the region of the capital.

Child↗

PubMedDate not supplied

Detecting vascular access dysfunction.

Access flow (QACC) is a major determinant of patency. Access recirculation (AR > 2%), normalized venous intra-access pressure (vPIA/MAP), and QACC are used to detect access dysfunction. We compared these three measures of access function (ultrasound dilution to measure AR and QACC). A total of 779 measurements were performed on 58 arteriovenous fistulas (AVFs) and 114 polytetrafluoroethylene (PTFE) grafts (1-8/access) over 13 months, and the access parameters at the beginning of each period were related to access events within that period. Pump blood flow averaged > 420 ml/min. AR occurred uncommonly (3.8%), and in half the cases, resulted from technical error by staff. In accesses that thrombosed or underwent intervention for stenosis, AR was present in only 3 of 11 AVFs and 8 of 57 PTFE accesses. When AR was present in grafts, QACC averaged 270 +/- 23, and access thrombosis followed unless intervention occurred. In grafts, vPIA/MAP averaged 0.34 +/- 0.01 in those remaining patent, 0.52 +/- 0.08 in those that had undergone intervention, and 0.54 +/- 0.04 in those that had thrombosed. QACC averaged 1,121 +/- 26, 605 +/- 45, and 550 +/- 65 ml/min, respectively, in the three groups. By contrast, QACC differed significantly in patent AVFs (1,053 +/- 35) compared with failing AVFs (363 +/- 48), but vPIA/MAP did not. AR is thus a late manifestation of access failure. QACC is the best diagnostic test of access dysfunction in AVFs. Interpretation of vPIA/MAP in grafts is enhanced by periodic QACC measurements.

Arteriovenous Shunt, Surgical↗

PubMed2026

Access to palliative care in rural settings: A mixed-methods systematic review.

BACKGROUND: Rural populations experience persistent inequities in access to palliative care. Existing evidence often describes individual barriers separately, with less attention to how access breaks down across the care pathway or how different service configurations shape access. OBJECTIVES: To synthesise evidence on access to palliative care in rural settings and examine how access barriers, service models, and implementation conditions interact across the care pathway. METHODS: A mixed-methods systematic review using a convergent integrated approach searched nine databases (PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO, CNKI, WanFang, SinoMed) from inception to 15 March 2026, supplemented by hand-searching. Eligible studies were primary qualitative, quantitative, and mixed-methods studies on access to palliative care for adults in rural or non-urban settings. Two reviewers independently screened studies, extracted data, and assessed quality using the Mixed Methods Appraisal Tool. Findings were mapped to the Levesque access framework, analysed using the updated Consolidated Framework for Implementation Research, and integrated through mixed-methods synthesis, with additional coding of service models. RESULTS: Thirty-four studies were included, of which 26 were conducted in high-income countries and eight in low- and middle-income countries. Service configurations included specialist or hospice-oriented care, generalist or primary-care-oriented care, mixed specialist-generalist models, home-based and caregiver-centred care, nurse-coordinated services, telehealth-supported care, and community or implementation-oriented approaches. Access broke down cumulatively across four interdependent stages: recognition, entry, reach, and use and continuity, with affordability constraining every stage. Recognition was limited by low awareness, poor service visibility, and delayed identification of need. Entry was shaped by stigma, trust, family expectations, and unclear referral processes. Reach was constrained by distance, transport, workforce shortages, limited specialist capacity, and weak infrastructure. Use and continuity were affected by fragmented coordination, weak transitions, unstable follow-up, and reliance on family caregivers. Access problems varied across service configurations. Evidence on service innovations was methodologically less certain, and the overall evidence base remained concentrated in high-income countries. CONCLUSIONS: Access to palliative care in rural settings is best understood as a pathway and service-configuration problem rather than simply a deficit in service availability. Improving access requires earlier recognition, clearer referral routes, stronger specialist-generalist and nursing links, better support for family caregivers, and greater attention to affordability, continuity, and rural settings with limited resources. REGISTRATION: International Prospective Register of Systematic Reviews: CRD420261340783.

Health Services Accessibility↗

PubMed1998

The prospective effect of access to medical care on health-related quality-of-life outcomes in patients with symptomatic HIV disease.

OBJECTIVES: This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease. METHODS: A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life. RESULTS: Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics. CONCLUSIONS: Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.

Adult↗