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Abstract Introduction: Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients. Materials and Methods: A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29^th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies. Results: The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients. Conclusions: The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

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Abstract Introduction: The recruitment and retention of family physicians in rural and remote communities has been the topic of many reviews; however, a lack of consensus among them with regard to which factors are most influential makes it difficult for setting priorities. We performed a systematic review of reviews which helped to establish an overall conclusion and provided a set of fundamental influential factors, regardless of the consistency or generalisability of the findings across reviews. This review also identified the knowledge gaps and areas of priority for future research. Methods: A literature search was conducted to find the review articles discussing the factors of recruitment or retention of rural family physicians. Results were screened by two independent reviewers. The number of times that each factor was mentioned in the literature was counted and ordered in terms of frequency. Results: The literature search identified 84 systematic reviews. Fourteen met the inclusion criteria, from which 158 specific factors were identified and summarised into 11 categories: personal, health, family, training, practice, work, professional, pay, community, regional and system/legislation. The three categories referenced most often were training, personal and practice. The specific individual factors mentioned most often in the literature were 'medical school characteristics', 'longitudinal rural training' and 'raised in a small town'. Conclusion: The three most often cited categories resemble three distinct phases of a family physician's life: pre-medical school, medical school and post-medical school. To increase the number of physicians who choose to work in rural practice, strategies must encompass and promote continuity across all three of these phases. The results of this systematic review will allow for the identification of areas of priority that require further attention to develop appropriate strategies to improve the number of family physicians working in rural and remote locations.

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Context: Telepsychiatry has become a common modality for the provision of psychiatric consultations to patients in rural regions. Aims: The aims of this study were to assess and compare patient and provider satisfaction and perceptions of access to care with telepsychiatry. Methods: Telepsychiatric consultations were given by providers based on an urban tertiary academic health centre to patients located in rural primary care clinics. Results: Patients (n = 110) and providers (n = 10) were both highly satisfied with telepsychiatry and both believed that telepsychiatry provided patients with better access to care. Paired patient and provider survey results demonstrated a high level of concordance between patients and provider responses. Conclusions: Concordance between patient and provider satisfaction may contribute to adherence and positive treatment outcomes. These results provide support for the use of telepsychiatry consultations to improve patient access to psychiatric care in rural regions.

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Introduction: This review explores a pertinent issue for healthcare professionals and recruiters alike: which factors are most important in the recruitment and retention of these professionals in rural practice in Canada. Existing research concentrates on specific factors or focused populations. This review was created to explore multiple factors and a wider population of healthcare professionals, including chiropractors, osteopaths, dentists and physiotherapists. Methods: A literature search was carried out on four databases. Data from included studies were extracted, and thematic analysis was conducted on relevant findings. The quality of individual studies was assessed, and then themes were evaluated for overall confidence based on four components, using the Confidence in the Evidence for Reviews of Qualitative Research. Results: One quantitative and four qualitative articles were identified, all of which targeted physicians. Five themes – Personal/family matters, Community factors, Professional practice factors, Professional education factors and Economic factors – were generated in two domains, recruitment and retention. Forty major codes were generated through axial coding of open codes. Codes included attraction to rural lifestyle, recreational activities, Scope of practice, rural training and incentives. Scope of practice was deemed very important as a factor of recruitment, as was attraction to rural lifestyle. Incentives were found to be of little importance in influencing the recruitment of healthcare professionals, and even less important for retention. Conclusion: Wide scope of practice and attraction to the rural lifestyle were considered the most important for recruitment and to a lesser extent, retention, among the five papers studied. A lack of research was determined in the realm of factors influencing the recruitment and retention in healthcare professionals other than medical doctors in Canada. Therefore, it is recommended that further such studies investigate specific healthcare professionals.

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There is a need to bring specialized medical expertise to rural and remote areas. Project ECHO offers a method to move knowledge from specialists in academic centres using videoconference, case-base learning, and best-practices knowledge sharing. Ontario has implemented ECHO since 2014 and has demonstrated favourable outcomes among primary care clinicians.

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Objective: The objective is to determine the use of health-care services (physician visits, emergency department use and hospitalisations) in rural areas and examine differences in four geographic areas on a rural to urban spectrum. Methods: We conducted a secondary analysis of cross-sectional data from a population-based prospective cohort study, the Canadian Longitudinal Study on Aging (CLSA). Participants included community-dwelling adults aged 45–85 years old from the tracking cohort of the CLSA (n = 21,241). Rurality was classified based on definitions from the CLSA sampling frame and similar to the 2006 census. Main outcome measures included self-reported family physician and specialist visits, emergency department visits and hospitalisations within the previous 12 months. Results were compared for four geographic areas on a rural-urban continuum. Univariate and bivariate analyses were performed on data from the 'tracking cohort' of the CLSA, Chi-square tests were used for categorical variables. Logistic regression models were created for the main outcome measures. Results: Participants in rural and mixed rural and urban areas were less likely to have seen a family physician or a specialist physician compared to urban areas. Those living in rural and peri-urban areas were more likely to visit an emergency department compared to urban areas. These differences persisted after adjusting for sociodemographic and health-related variables. There were no significant rural-urban differences in hospitalisations. Conclusion: Rural-urban differences were found in visits to family physicians, specialists and emergency departments.

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Introduction: While 12.4% of British Columbians live rurally, only 2.0% of specialists practise rurally, making interfacility transport of high-acuity patients vital. Decision-making aids have been identified as a way to improve the interfacility transfer process. We conducted a pilot study to explore the potential of the Standardised Early Warning Score (SEWS) as a decision-making aid for staff at sending facilities. Methods: SEWSs were calculated from a database of 418 transfers from sending facilities in rural, small and medium population centres to larger receiving facilities. The SEWSs were compared against one another over time using McNemar's and the Wilcoxon signed-ranks tests. The SEWSs were then tested for their association with six outcomes using Pearson's or Fisher's Chi-squared test and the Mann–Whitney U-test. Results: While at the sending facility, both the number of SEWSs that was four or greater and the average SEWS decreased over time (P < 0.001 for both). A first SEWS of four or greater was predictive of more intervention categories during transport (P = 0.047), an adverse event during transport (P = 0.004), an adverse event within 30 min of arrival at the receiving facility (P = 0.004) and death before discharge from the receiving facility (P = 0.043) but not deterioration during transport, or the length of stay at the receiving facility. Conclusion: Overall, the performance of the SEWS in the context of rural interfacility transport suggests that the tool will have utility in supporting decision-making.

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Abstract Introduction: The Canadian island of Newfoundland has a long history of fishing; however, no study to date has developed a regional profile of fishhook injuries on its east coast. Methods: To this end, we conducted a retrospective review of fishhook injuries at all Newfoundland East coast emergency departments from 2013 to 2015. Patient presentations were reviewed for the date of arrival, sex of the patient, location of fishhook injury, tetanus immunisation status, anaesthetic utilisation, diagnostic imaging, antibiotic management and technique of removal. Results: Information was retrieved for 165 patients. Most injuries occurred to the hand (80.6%), and out of five documented techniques, “advance and cut” was the most common extraction method (55.5%). There was a high percentage of prophylactic oral antibiotics prescribed (57%) and X-ray imaging (20%) utilised. Consultation was required for 4.2% of the fishhook injuries including consultation to a local fire department service. Conclusions: On the east coast of Newfoundland, fishhook injuries are addressed inconsistently, with potentially suboptimal methods for removal, coupled with unnecessary imaging and antibiotics. We believe that there is a role for education and other initiatives to improve the care delivered.

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Introduction: We estimate the screening and prevalence of gestational diabetes mellitus (GDM) in a primarily first nations obstetrical population in Northwestern Ontario. Methods: The study is an 8-year retrospective analysis of all gestational glucose challenge and tolerance tests performed at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) laboratory from 1 January, 2010 to 31 December, 2017. Test, gestational timing and completion rate of screening were recorded, and GDM prevalence was calculated on the tested population. Screening completion rates were recorded for the subset of women who delivered at SLMHC from 2014 to 2017. Results: The average annual GDM prevalence was 12%, double the Ontario rate. Over the 8-year period, 513 patients were diagnosed with GDM among the 4298 patients screened. Patients were screened with the 2-step (90%) or the 1-step (10%) protocol. Screening occurred <20 weeks in 3%; 54% occurred in <28 weeks and 40% >28 weeks. Seventy percent of the tests were from remote nursing stations. The screening completion rate for women delivering at SLMHC in 2017 was 80.8%. Conclusion: The prevalence of GDM in Northwestern Ontario is twice the provincial rate. Most screening used the 2-step protocol; early screening was underused. Improvements in screening programming are underway and future research may match surveillance rates and results to GDM outcomes.

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Introduction: This study seeks to explore influential factors leading to physician turnover in designated Rural Northern Physician Group Agreement (RNPGA) communities in Northern Ontario, as well as physician's perceptions of the RNPGA contract and effects of the Northern Ontario School of Medicine (NOSM) on physician retention in these communities. Methods: Twelve qualitative semi-structured interviews were completed with rural physicians who had RNPGA contracts within the past 5 years but had left their practice community. Data collected from recorded interviews were analysed using a thematic analysis approach in order to identify common themes. Results: A range of factors influencing physician's decisions to leave were identified including lack of partner career prospects, burnout and lack of opportunities and amenities. Common challenges were sometimes also perceived as rewards of rural practice. The concern of lack of flexibility of the RNPGA contract was identified, as well as a perceived lack of presence of NOSM graduates in RNPGA communities. Conclusion: A variety of factors influence physician turnover in RNPGA communities. These may be considered by communities hoping to inform recruitment and retention policy. Renewal of the RNPGA contract may require consideration for availability of part-time positions, increasing the number of physicians funded and incentivising physician wellness. NOSM may consider mandatory postgraduate programme placements in RNPGA communities and further development of infrastructure in these communities to improve learner, graduate and institutional engagement.

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Introduction: Physicians are often challenged with accessing relevant up-to-date arthritis information to enable the delivery of optimal care. An online continuing medical education programme to disseminate arthritis clinical practice guidelines (CPGs) was developed to address this issue. Methods: Online learning modules were developed for osteoarthritis (OA) and rheumatoid arthritis (RA) using published CPGs adapted for primary care (best practices), input from subject matter experts and a needs assessment. The programme was piloted in two rural/remote areas of Canada. Knowledge of best practice guidelines was measured before, immediately after completion of the modules and at 3-month follow-up by assigning one point for each appropriate best practice applied to a hypothetical case scenario. Points were then summed into a total best practice score. Results: Participants represented various professions in primary care, including family physicians, physiotherapists, occupational therapists and nurses (n = 89) and demonstrated significant improvements in total best practice scores immediately following completion of the modules (OA pre = 2.8/10, post = 3.8/10, P < 0.01; RA pre = 3.9/12, post = 4.6/12, P < 0.01). The response rate at 3 months was too small for analysis. Conclusions: With knowledge gained from the online modules, participants were able to apply a greater number of best practices to OA and RA hypothetical case scenarios. The online programme has demonstrated that it can provide some of the information rural/remote primary care providers need to deliver optimal care; however, further research is needed to determine whether these results translate into changes in practice.

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Introduction: Hepatobiliary iminodiacetic acid (HIDA)-radionuclear scans are used to diagnose biliary dyskinesia, the treatment for which is a laparoscopic cholecystectomy (LC). However, the predictive value of the HIDA scan for LC candidacy is debated. Case: A physical, ultrasound, and blood test for a 53-year-old woman with biliary dyskinesia-like symptoms were normal, contradicting a textbook history. A HIDA-scan was ordered but the results suggested she was not eligible for a LC. The patient insisted on receiving the procedure and gave informed consent to undergo an elective LC. Results: Six-weeks post-surgery, the patient's symptoms had ceased besides one short episode of abdominal pain. Conclusion: A LC relieved the patient's symptoms, suggesting that negative HIDA-scans can mislead correct decisions to perform a LC. Surgeons who receive inconclusive HIDA scan results should consult their patients, and when necessary and agreed-upon, take an informed risk together in an attempt to improve the patient's quality of life.

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Introduction: Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described. Methods: This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented. Results: Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively. Conclusion: Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.

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Introduction: Point-of-care ultrasound (POCUS) is used for diagnostic and procedural guidance by physicians in Newfoundland and Labrador (NL). POCUS use is largely limited to urban locations and the training is variable amongst physicians. The primary aim of this study was to determine the prevalence of POCUS devices in NL and the secondary aim was to characterise the patterns of POCUS use amongst physicians in NL. Methods: This is a mixed-methods cross-sectional study. We determined the prevalence of POCUS devices from purchase records and the patterns of POCUS use through theme-based interviews. The interviews were transcribed, coded and analysed using standardised qualitative methods. Results: Ten physicians (3 females, 5 rural) participated in the interviews. The overall prevalence of POCUS devices in NL was 12.5/100,000 population. Participants in urban areas had more access to POCUS training and devices. Participants used POCUS on a daily or weekly basis to rule in or out life-threatening conditions and improve access to specialist care. The benefits of POCUS included expedited investigations, decreased radiation and increased patient satisfaction. The barriers to using POCUS were lack of training, time, devices, image archiving software, difficulty generating and interpreting images and patient body habitus. Conclusion: This is the first study to our knowledge to report the prevalence of POCUS devices in Canada. Physicians who practise in rural NL have limited access to POCUS devices and have identified barriers to POCUS training. Connecting physicians in rural areas with POCUS experts through a province-wide POCUS network may address these barriers and improve healthcare access.

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Introduction: Primary care reform in Ontario that provides accessible, comprehensive patient-centred care has been a work in progress for more than a decade. With the recent emergence of Ontario Health Teams and the conclusion of the Rural Health Hub (RHH) pilot project, insight into the philosophy, culture and expectations of rural and remote centres with regard to primary care delivery is required. The concept of the patient medical home (PMH) and the RHH offers frameworks that emphasise positive attributes towards quality care systems – continuity, accessibility, comprehensiveness and localisation of services and funding for system efficiency. Methods: The application of these frameworks to rural and remote centres was explored via semi-directed face-to-face and phone interviews with physicians, patients and healthcare administrators at six rural centres in Northern Ontario. Results: Continuity of care, local integration and healthcare culture reform were cited by participants as the most important aspects of optimisation of primary care in their environments. Conclusion: These concepts support the RHH and PMH models and their further implementation as part of healthcare system transformation in Northern Ontario.

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Introduction: Due to high rates of obesity in Canada, weight loss is an important primary care challenge. Recent innovations in strategies include intermittent fasting and low-carbohydrate diets, with limited research in a rural setting. Methods: This prospective 1-year observational study provided patients in Sioux Lookout, Northwestern Ontario with information on fasting and low-carbohydrate diets. Patients were recommended to attend every 3 months for measurements of weight, waist circumference, body mass index (BMI) and blood pressure. Initial and 6-month bloodwork included A1c and Lipids. A survey of health status and diet was administered at 6 months. Results: Of the 94 initial registrants, 36 participants completed 1 year and achieved a 9% weight loss and an 8.6% decrease in BMI and waist circumference. Most participants were female with an average age of 60 years. Clinically insignificant changes in blood pressure and serology were observed. Participants reported few side effects and good compliance with intermittent fasting, averaging 15 h/day, 6 days/week. As in other dietary studies, the dropout rate was high at 62%. Conclusion: This low-resource initiative was successful in assisting self-selected patients at a rural primary care clinic to achieve significant weight loss at 1-year. This approach is practical and is fertile ground for ongoing research.

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Introduction: Diabetes in pregnancy confers increased risk. This study examines the prevalence and birth outcomes of diabetes in pregnancy at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) and other small Ontario hospitals. Methods: This was a retrospective study of maternal profile: age, parity, comorbidities, mode of delivery, neonatal birth weight, APGARS and complications. Data were compared to other Ontario hospitals offering an equivalent level of obstetrical services. Results: Type 2 diabetes mellitus in pregnancy is far more prevalent in mothers who deliver at SLMHC (relative risk [RR]: 20.9, 95% confidence interval [CI]: 16.0–27.2); the rates of gestational diabetes (GDM) are double (RR: 2.0, 95% CI: 1.7–2.3). SLMHC mothers with diabetes were on average 5 years younger and of greater parity with increased substance use. Neonates largely had equivalent outcomes except for increased macrosomia, neonatal hypoglycaemia and hyperbilirubinaemia in GDM pregnancies. Conclusion: Patients with diabetes in pregnancy at SLMHC differ substantially from mothers delivering at Ontario hospitals with a comparable level of service. Programming and resources must meet the service needs of these patients.

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Introduction: Fluoroquinolones (FQs) are a commonly prescribed class of antibiotics in Canada. Evidence of a constellation of possible adverse events is developing. Central and peripheral nervous system abnormalities and collagen-related events (including aortic aneurysm/dissection, tendinopathy/rupture and retinal detachment) are associated with FQ exposure in large population-based aftermarket studies. In 2017, Health Canada warned about rare FQ-related persistent or disabling side effects. This study explores FQ use in a rural community. Methods: Antibiotic prescriptions (including FQs) in the over 18 adult population (5416) were measured in the town of Sioux Lookout for 5 years, January 2013 to 31 December 2017. Results: FQ prescriptions accounted for 16.0% of adult antibiotics, superseded by penicillins (21.1%) and macrolides (18.2%). Ciprofloxacin accounted for one half of FQ use (51.2%), followed by levofloxacin (36.7%) and norfloxacin (13.3%). FQs were commonly used for respiratory (33%) and urinary tract infections (18%). Conclusion: Aftermarket evidence reports increased risk of 'disabling and persistent serious adverse events'(Health Canada) in patients using FQs. Appropriate clinical caution should be exercised in the prescribing of FQs. Common overuse seems to occur in the treatment of uncomplicated community-acquired pneumonia and cystitis, despite recommendations to use other antimicrobial agents as first-line treatments.

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Introduction: The prevalence of diabetes and its complications in the Innu community of Sheshatshiu is high. We wanted to determine if shared medical appointments (SMAs) could provide culturally appropriate, effective treatment to Innu patients with relatively well-controlled diabetes, as an alternative to standard, 'one-on-one' care. Methods: We conducted a mixed-method study including a randomised controlled trial comparing standard care versus SMAs for patients aged 18–65 years with haemoglobin A1C (HbA1C) of ≤7.5%, followed by a qualitative study using semi-structured interviews with patients who attended SMAs. Results: Among 23 patients, 13 received the intervention. There were no significant differences of HbA1C level or HbA1C percentage of change between intervention and control groups at baseline, 6 months or 12 months. There were no statistical differences between standard care and SMA groups, concerning mortality or the need for haemodialysis. The qualitative analysis found that patients generally enjoyed the SMA model and the peer support and learning benefits of the SMAs. Patients did not believe that the SMA model was more or less culturally appropriate than standard care, but the majority said they felt that the SMAs were good for the community and could be a good venue for incorporating Innu healthy–lifestyle knowledge into medical diabetes care. Conclusions: SMAs may be an efficient way to manage well-controlled diabetic patients in the Innu community of Sheshatshiu and to provide peer support and opportunities for learning and incorporating community-specific knowledge into care.

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Introduction: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario. Methods: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014–31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults. Results: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%). Conclusion: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security.

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Introduction: This study was conducted to examine the use of the HEART score for risk stratification of chest pain patients presenting to rural Ontario emergency departments (EDs), assessing both its validity in a rural context and its utility in health-care resource management. Methods: This study was a retrospective chart review of adult patients presenting to the ED with chest pain. The HEART score was assessed for its ability to risk-stratify patients (high, moderate and low) in terms of the likelihood of a major adverse cardiac event (MACE) within 6 weeks. The prevalence of follow-up testing for each risk category of patients was then determined such that the potential impact on health resource management was estimated based on the number of tests ordered in low-risk patients. Results: Of the 215 charts included, 24 (11.2%) patients experienced a MACE within 6 weeks. None of the patients with a low HEART score experienced a MACE. In comparison, the incidence of MACE in moderate- and high-risk groups was calculated to be 13.9% (95% confidence interval [CI] [5.91% and 21.89%, respectively]) and 66.7% (95% CI [46.54% and 86.86%, respectively]). Eighteen percent of the low-risk patients received follow-up testing with no positive results suggestive of acute coronary syndrome. Conclusion: Our results provide external validation of the predictive value of the HEART score in determining the risk of MACE in patients presenting to a rural ED with chest pain. Our results also suggest that rates of follow-up testing in low-risk patients may be reduced in communities with limited access to resources.

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