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The influence of a “culture of referral” on access to care in rural settings after myocardial infarction
ARTICLE IN PRESS Health & Place 15 (2009) 180– 185
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The influence of a ‘‘culture of referral’’ on access to care in rural settings after myocardial infarction Patricia H. Caldwell , Heather M. Arthur Faculty of Health Sciences, McMaster University, 1200 Main Street West, HSC 2J20D, Hamilton, Ontario, Canada L8N 3Z5
a r t i c l e in f o
a b s t r a c t
Article history: Received 21 December 2006 Received in revised form 6 February 2008 Accepted 1 April 2008
Access to care is an issue for rural people who require tertiary care following a myocardial infarction (MI). Access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers. Using a critical ethnographic approach, rural women, their nurses and physicians were interviewed to explore how rurality affected women’s referral and access to care following a MI. Findings reflect that a previously undocumented culture of referral that was shaped by human factors influenced access to care. The culture of referral reflected an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. The findings extend conceptual understandings of access to health care in relation to rural populations. & 2008 Elsevier Ltd. All rights reserved.
Keywords: Access Rural Cardiac Referral
Introduction Access to health care is a fundamental element of national and international policies and programs intended to increase the health of populations. In relation to health care, ‘‘access’’ is a multi-dimensional concept that is contextually modulated by the place, the players and the processes within which it is examined. In Canada, which has a universal health care system that guarantees access to all, challenges still exist for persons seeking and providing rural health care. This has resulted in the identification of access to rural health services as a priority for Canadian policy makers (Romanow Commission, 2002). Factors affecting rural persons’ access to health services include distance from emergency care (Weinert and Boik, 1995); distance to the local hospital; travel time and distance to a referral center; availability of family doctors, specialists, diagnostic testing and ambulances; weather conditions (Kralj, 2000); affordability of transportation; perceptions of geographical distances; and willingness to seek out care (Porter, 1998). There are suggestions that gender and sex-based differences may also affect access to cardiovascular care for those who live in lower socioeconomic regions such as rural places (Khaykin et al., 2002). The high burden of cardiovascular disease in rural Canada has driven patients and care providers to view access issues as key to rural cardiovascular resource planning and care (Chan and Young, 1999; O’Neill et al., 2005). Recently the access discourse in
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Canadian cardiovascular care has focused on ways to have the right patient receive the right care at the right time (O’Neill et al., 2005). This focus is particularly relevant for rural women postmyocardial infarction (MI). Age-specific hospitalization rates for rural women diagnosed with MI in Ontario, Canada, are 17% higher than those for urban areas (Chan and Young, 1999). Women who have MIs tend to be older, have more co-morbidities and are less likely to be referred for and receive coronary interventions (Shin et al., 1999) and cardiac rehabilitation than men (King et al., 2001). Importantly, although MI is an acute, life-altering and potentially life-threatening event for women, medical knowledge has been guided by studies based on urban men. For a recent and comprehensive review of the sex and gender differences and associated knowledge gaps, the reader is referred to the CMAJ supplement (Pilote et al., 2007). Historically, access to cardiovascular care has been viewed as a system issue. This has led to a focus on resource availability as an answer to access challenges and subsequently resulted in efforts to increase system capacity to manage the demand for specialized cardiovascular services. However, the failure of geographic proximity and resource availability to account for differences in angiography use in urban and rural settings has pointed to the need to investigate possible human behavioral factors that may influence use of rural cardiac resources which are measured as a referral endpoint (Alter et al., 2003a). While referral patterns and factors affecting the decision to refer to a specialist have received some attention, the referral process has not been explored from the rural cardiac patient’s perspective (Chan and Austin, 2003). Essential to understanding the human element embedded in the access discourse is the
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perspective of those who are referred for care. The perspective of rural women who require referral for post-MI care may help to explain and further understand the complexities of access to post-MI care. This report focuses on the culture of referral that emerged in a study that explored the ways in which rurality influenced women’s lives after MI. This study was designed to understand issues about rurality specifically through the voice of rural women and in relation to MI. We report about the perspectives of rural women and their professional caregivers about the culture of referral following MI and offer interpretations to extend conceptual understandings of access to health care.
Methods A critical ethnographic approach was taken for this study. The purpose of critical ethnography is to foster social change through examination of the influences that give rise to the status quo (Thomas, 1993). The methodology was specifically utilized to generate knowledge about issues for women who have been marginalized from cardiovascular research in relation to their sex, gender and place of residence. The methodology has been reported in detail elsewhere (Caldwell et al., 2005) and will therefore be reported in brief. The study was approved by the research ethics board of the associated university. Participants were women living in four rural communities in southwestern Ontario, Canada. The region is characterized by small towns, villages and farmland. There is a system of paved and gravel roads that connect communities. Public transportation within the rural areas and to referral centers is non-existent. Referral centers used by study participants were approximately 50–200 km from rural sites. Participants were recruited by nurses and physicians working in the rural communities and by word of mouth. Potential participants contacted the researcher via a tollfree telephone line or gave their verbal permission to be contacted by the researcher. Women who declined to participate said they were intimidated by participating in research, were themselves feeling very unwell or they were caring for another family member who was not well and did not believe they had energy to participate. Those who participated stated they were more relaxed and shared their perspectives more freely when they were given information that the interviewer was also a rural resident and a nurse. The researcher was not employed by health institutions in which women received care, nor involved in their care or access to it. Inclusion criteria were: women diagnosed with MI, living in a rural community having a population of less than 150 people per square kilometer (Health Canada, 2001), consented to an audiotaped interview and able to speak English. Additional data were obtained from fieldwork that included participant observation and interviews with family members, five nurses and two rural physicians drawn from the study region. Data were collected by the first author using semi-structured interviews, field notes from participant observation, immersion in the communities by the first author over the 7-month study period, and examination of health and lay publications regarding the communities in general and in relation to cardiovascular issues and care. The referral process was a focus in the post-MI experience of every woman. Consistent with the ethnographic approach, the referral process was subsequently explored in greater depth. This included interview questions with women such as: Tell me about how you came to be referred for care. How did those decisions get made? What was your understanding as to how that process happened? How did being referred affect you and your family? Tell me about what the referral process was like for you.
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Interviews with physicians and nurses began with the question ‘‘Tell me about how it works when you refer a woman for care after a heart attack.’’ Data were manually scrutinized by two members of the research team to identify recurring themes until no new themes were generated by interview or additional data sources. Critique and discussion about the referral process and its influences occurred among the research team until consensus was achieved and themes describing the cultural process of referral were generated. Lincoln and Guba (1985) identified the following issues as essential to establishing rigor in qualitative research: credibility, transferability, dependability and confirmability. Credibility was established by reviewing interview audiotapes with transcripts; field notes and data from observation and interviews with rural health professionals were used to triangulate data sources. Women were consulted in follow-up interviews to ensure that interpretations of their perspectives were accurate. To ensure dependability and confirmability of findings, an audit trail was established. Detailed records of the analysis process and decisions by the team were maintained.
Results Women ranged from 43 to 80 years of age and were 3 months to 4 years post first MI. Seven women lived with their spouses; five lived on their own. Rural access to tertiary care in urban centers was contingent on obtaining and getting a referral for consultative, diagnostic, interventional and rehabilitative purposes. Referral to an urban center was a cultural norm that was accepted by patients, their communities and institutions. Access issues arose at four sequential points in the post-MI trajectory and from the women’s viewpoints these were (1) ‘‘getting in’’, (2) ‘‘getting there’’, (3)’’being there’’ and (4) ‘‘coming home’’. Collectively these points reflected aspects of the culture of referral in which post-MI women, their families and practitioners gained access to specialist cardiovascular care. Referral was described by women and their professional caregivers as both a process and an outcome. The referral process involved an interplay between the rural physician referee, the woman who required referral and the tertiary referral center. When a tertiary institution or service accepted a referral, access to care was deemed to be obtained. While this would traditionally be regarded as a positive outcome, participants in this study described other important issues related to referral that have received little attention, yet point to fundamental and understudied aspects of the access/referral discourse. ‘‘Getting in’’ referred to the process by which women were accepted by a tertiary center or by a specialist following a diagnosis of MI. Depending on a woman’s state of health when the referral was attempted, this could be a very stressful time. All women, irrespective of age, who were alert and aware of their need for urgent tertiary care waited for news of a successfully negotiated referral anxiously. They described this as true for their families as well. Rural physicians were the gatekeepers who could initiate referral for tertiary cardiac services and therefore the referral process was physician dependent. Without a successfully negotiated referral to a tertiary center, access could not be obtained. The skill of the rural physician in negotiating the referral was therefore critical and was valued by women, their families and nursing staff. These ‘‘access skills’’ were learned through experience when practitioners were in the position of requesting a referral. Several women believed their physicians had ‘‘pulled strings’’ or done something out-of-the-ordinary to secure a referral, even though they were accessing what was considered
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‘‘usual’’ post-MI care. This was accompanied by a general feeling on the part of the women that successful referral was due to their good luck and not because the system was working. Access to all post-MI services was a negotiated outcome and not the result of a simple request for consultation. The women understood that the health care system was overloaded, and that their rural physician was working hard to advocate for their access to tertiary care and they were grateful. All women recognized their physicians as their valued and necessary advocates. Although it was commonly held that a referral was ‘‘made’’, the nature of that process varied depending on the service required. If a referral was not accepted within time limits that the rural physician found acceptable, more rural physician time was needed to find and negotiate alternative access. One woman described waiting a week after her MI when her family physician requested her case be accepted urgently; she eventually gained access to a referral in another city. Another who was taken by air ambulance urgently was certain that she gained access because people she knew in the hospital had advocated for her. Whether luck or preferential treatment existed or not, the perception was that successful referral could require such forces to be operational. There were different routes to ‘‘getting in’’, to accessing tertiary care. Although each rural hospital had usual referral routes for acute care, rural centers in the study region were not restricted to specific practitioners or centers. When a specialist or bed was unavailable in a specific tertiary agency, negotiation of a referral to another practitioner or institution in another city was necessary. Despite the challenge getting in sometimes presented, physicians appreciated the flexibility afforded when they were not obliged to refer to a particular place or person. However, this approach also left the rural areas in a situation where no referral center was obliged to take rural patients. As one rural family practitioner who routinely provided emergency care said, People who live near tertiary centers arrive at the Emergency Room door and they are in the system. If you’re at the periphery (rural areas) there’s no room. When you’re out far enough they (tertiary centers) can put you off—that’s the reality. Study participants believed the relationship and credibility a rural physician had with a referral center or practitioner influenced their willingness to accommodate referral requests. The necessity of urban–rural relationships to be based on mutual respect as well as the rural physician’s judgment and care was identified by women and health professionals as key for successful referral. Participants reported that new rural practitioners who did not have those relationships could be challenged to get the referrals they wanted. ‘‘Getting there’’ referred to the process by which women got to their referral destination. There was no specific protocol that was known to study participants regarding transportation to tertiary care. It was perceived that transport decisions were made on an individual basis and were dependent on the patient’s condition, family availability and weather. When hospitalized patients were deemed stable, families were asked to take the patient to and from a referral appointment. For some women this included transportation from hospital via family car to a cardiac catheterization or surgery. Women who had families able to transport them described the stress involved in getting to a referral, particularly when perceptions of weather conditions and patient acuity were severe. This was true for women of all ages and living arrangements. Depending on the family’s perceptions about the acuity of the woman’s health, getting there could be a stressful
event. One woman described how her anxious husband enlisted a nurse friend to accompany them to the cardiac catheterization. Air and land ambulance services were used for unstable patients. Nurses said that some families felt pressured into transporting women to a referral but complied with the request for fear of losing the appointment. The daughter of a hospitalized elderly woman described how the appointment time for an angiogram was made in the city but the logistics were left for the family to work out. I, of course had to take her, as it costs less for a family member to take themyand then I brought her back (to the rural hospital). The first appointment for an angiogram was 9 am, so my husband took the day off work because I don’t like to drive in the city. Another woman was driven 212 h home to await further treatment decisions 5 days after air evacuation following her MI. The 5-h round trip from home to hospital was repeated four more times in the following weeks. We went down to see the cardiologist, then another day to the surgeon, then to a (pre-op) clinic for my surgery. As we’re leaving, they said we want you back here the next day. We’re doing your surgery tomorrow. The stress of finding their way to referral centers was accepted by women as part of the referral package. Patients and families sometimes booked into overnight accommodations to ensure bad weather did not result in cancellation of the referral appointment. In many cases women understood the referral to be important to their lives and those of their families and that its outcome could shape the rest of their lives. These concerns prevailed during the journey to the referral destination, but women sometimes felt their concerns were not appreciated at the tertiary center. ‘‘Being there’’ described women’s experiences while at the referral appointment or institution. For some women, being in a referral center produced anxiety, despite the gratitude they felt for the tertiary services. Women described feeling like ‘‘outsiders’’ during some of their interactions and experiences in tertiary settings. Sometimes this occurred in response to an interaction with a health professional who made what were perceived as negative comments about rural life or who gave information that had little or no relevance to their rural context. Urban caregivers’ lack of familiarity with the rural region from which women came served to create psychological distance between some patients and their urban caregivers. One woman reported a conversation with a cardiologist that reflected his lack of understanding of the context of her recovery. She tried to tell him there was nowhere she felt she could safely start a walking program in the farming community in which she lived. Walk? Where? I was surprised when the doctor said that. They would say you get out and walk. Like they think it’s so easy to just go out there and walk down a highway. I am afraid that somebody won’t know that I am there (if I need help). Like I don’t want to lay there for a half or an hour (if I need help). The lack of knowledge about the services available in rural areas contributed to some women feeling that instructions they received in the tertiary center might not be relevant to their life contexts. Some perceived that the time spent away from home or for travel was not appreciated by caregivers in tertiary settings. For women who were referred for an appointment and who were not transferred for hospitalization, the time spent traveling to and from the referral was disproportionate to the time spent in the referral appointment. The following quote illustrates that for those with referral appointments, the time spent getting to and
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from the referral center was disproportionate to the time spent ‘‘being there’’. We’d be about two and a half hours. If we leave here at 8:45 we are pretty well there by eleven, it’s a long drive. If you’re lucky you wait ten minutes and you go in and you come out. You go all day for that short time, and when you come out you have to eat, and then back 2 1/2 hours again. So it is five hours that you are wasting the whole day. In winter it’s not that great a trip sometimes. It’s hard being on a road you’re not familiar with. Concerns arose regarding the lack of positive regard women sometimes perceived from nurses in tertiary centers towards rural health care and the abilities of rural providers. Rural women were quick to defend the credentials of their nurses and physicians against any criticisms, although this created questions about the cohesiveness of the cardiac care community. Women often came directly home from the city following a cardiac procedure instead of returning to the rural hospital. The homecoming could either be filled with relief or stressful, depending on the outcome of the referral. Preparation and support for the patient and family with regard to the trip home were seen as necessary by participants who had undergone procedures. One woman described going home the day following an angioplasty that was complicated by bleeding and required additional intervention. My husband drove me home. It was winter. It was a very long, trying ride. It’s about a couple of hours and I was still having a fair bit of pain where the catheter went through and actually for almost a week after I had pain there. My husband was nervous and no one gave him information to make him feel better about being responsible for me. They just told me if I had any problems, I was just to go to emergency. They didn’t really prepare me for coming home. Women expressed concern about their preparation for the journey home and for the time that came after their return. Issues such as pain control, fears about re-infarction and the stress placed on their families because of their cardiac status were foremost on the minds of women. Sometimes women returned to their homes from a referral center to await future surgery. Being told that the key to survival was the surgical intervention and then having to wait for it at some distance and time away produced anxiety for them and their families. Following referral, most women were uncertain about their need for follow-up and with whom that should occur. They did not know what or how information was shared between practitioners. Some specialists were also unfamiliar with the resources to which they could refer women in rural communities. One woman described her concern that exercise-based cardiac rehabilitation programs were unavailable in her community upon returning home and how she came to know that. So the doctor (in the tertiary center) said to me, just where is (your rural community) anyway? And then I told him. So he asked me a few questions like, well how far is that to (City A)? How far is at to (City B)? How far to (City C)? Then he says well, I guess that won’t work then. There isn’t anything around you. Despite the lack of tertiary cardiac resources in their communities, women seldom chose to view their rural care situations as under-serviced. Instead they framed their rural contexts in terms of the capacity they and their rural health providers had to manage the challenges created by referral. For instance, some women devised their own exercise programs to meet what they understood to be the rehabilitation requirements when referral was not possible. Nurses viewed this chosen approach as a coping
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mechanism women used to decrease their anxiety about possible system gaps.
Discussion Given that access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers, interventions targeted to increase access for citizens in rural areas must consider issues related to referral. Guidelines for timely referral have been proposed for diagnostic testing, specialist consultation, surgical and electrophysiologic intervention and cardiac rehabilitation (O’Neill et al., 2005, Dafoe et al., 2006; Graham et al., 2006; Munt et al., 2006). The focus of these guidelines has largely been on establishing benchmarks for wait times for cardiac services and not specifically on human social factors affecting referral or urban–rural issues. It has been suggested that some differences in care may reflect referral disparities that may occur early in the referral chain and prior to the time specialists actually offer treatment alternatives (Shin et al., 1999). Thus it is possible that in addition to known challenges to care in rural settings, rural women’s access to postMI care may be influenced by the referral practices that exist within the care culture. While the focus of referral has traditionally been on access to referral destinations and on the outcome of the referral procedure(s), these findings focus on the patient who is moving through the referral process and the culture of referral that existed in the rural context. In comparison to traditional notions of referral, in this study referral was not a simple request for access to care, nor was it merely the transfer of care from one practitioner or institution to another. While there were system processes and structures that were vital for the referral process to work, it was apparent that human factors were both vital to the referral process and critical to generating the referral culture. According to Wellstood et al. (2006), sociocultural factors affect access to care; however, human factors that are necessary for the system structures to function most effectively have not been well explored. Accounts of the referral process in this study suggested that practice divisions existed within the cardiac care culture, that referral attempted to bridge urban and rural cardiac care subcultures and that a cultural gradient existed between urban and rural practice contexts. This gradient was evident in the communication patterns between urban–rural practitioners as well as urban practitioners and rural patients. It is possible these complexities influenced (a) the access rural patients had to tertiary cardiac care, (b) that once in, perceptions of such gradients interfered with patient’s experiences of care and (c) that once home, inconsistencies (perceived or real) in the flow of information from urban to rural settings affected women’s follow-up. While the complex dynamics of patient–physician interactions may explain some differences in access to care (Barnhart et al., 2006), the dynamics of the urban–rural referral process have not been scrutinized. Knudston et al. (2006) have identified the need for improved communication between referring physicians and specialists so that timely access to care can be gained. They suggested that effective communication at the time of the referral was necessary for appropriate patientcentered cardiac resource allocation, particularly between referring physicians and specialists. While hegemony may exist in physician practice regarding generalists and specialists, it is possible this may be compounded when the generalist is from a rural setting. Future discussions need to further examine how communication between physicians with different levels of expertise and in urban and rural practice settings affects accessibility to tertiary cardiac care. Rural Canadian women have
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also identified that access to tertiary care often results in significant financial, social and emotional costs to them and their families when care is accessed in geographically distant locations (Sutherns et al., 2004). At all post-MI referral points, women’s experiences were affected by the referral culture. Issues were consistent with those reported by rural women across Canada about accessing general and specialty health care (Sutherns et al., 2004). Women’s gratitude for having any access to care and their beliefs that they could be self-sufficient upon return home contributed to their acceptance of the referral process. This phenomenon has been seen in other rural populations and attributed to rural resident’s lower expectations about how the system should meet their needs (Bain and Campbell, 2000). This makes it unlikely that those who view themselves in this way will advocate for system change or challenge the aspects of the process that were difficult for them. Changes in the referral culture would therefore be left to those in the culture who were perceived to have greater power such as physicians and health care institutions. There are indications that the referral journey could be more ‘‘rural friendly’’. The perception that rural people, rural practitioners and institutions are outside of the system and that significant effort must be made to ‘‘get in’’ and access the continuum of cardiac care required post-MI requires change. The negotiating that rural practitioners do to gain access is not necessarily a bad thing; however, the time spent in negotiating referral during an acute event may take a solitary rural practitioner away from the women requiring referral and from other rural people who require care. Although the underlying assumption in systems thinking is that streamlining the referral process is necessary, negotiation of a bed allowed practitioners to adapt to circumstances to some degree. Regulation of referral routes might not be the answer in terms of the referral system and, clearly, rural practitioners wanted a voice in any referral discussions. Study results suggest caregivers, decision makers and policy makers must broaden the referral focus beyond the management of wait lists as the key to system entry and attend to the needs of rural stakeholders in the referral process. There is a need to develop and test interventions that women and their families would find helpful at each step in the referral journey. For instance, identifying and evaluating effective supports for women during the ‘‘getting in’’ phase may be useful. Anticipating and identifying the needs of family who drive women to and from referral appointments and exploring alternative modes of transport and delivery of the referral service could ease some stress that arises from referral. Educational opportunities for tertiary centers to learn about the rural regions they service may be indicated so the ramifications of returning patients home to these communities and lifestyles is understood and incorporated into discharge teaching and planning. The need for urban caregivers to understand rural access issues and for effective communication between rural and urban practitioners has been previously noted (Bourke et al., 2004; Hollins et al., 2000). Clear avenues for follow-up with their family physician and specialist, and clarification of the roles each will play in women’s recovery, should be developed and communicated. This could be included as part of revascularization referral networks that have recently been advocated for community hospitals in Canada (Alter et al., 2003b). There is also a need to develop cardiac rehabilitation resources to which rural women can be referred. Future research should explore the referral process from the perspective of rural men, families and rural and urban practitioners involved in post-MI care. In this way a more complete
picture of both referral and the possibilities to enhance the process for those who must use it could be developed.
Conclusion The culture of referral that emerged in this study reflects an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. There are indications that the rural context of care is poorly understood by urban care providers. Clearly, rural practitioners require excellent communication and clinical skills to acquire access to post-MI care for rural women. In addition, the relationships established between rural generalists and urban specialists appear to be critical to accessing care. Systematic planning and implementation of approaches to referral that reflect valuing of rural–urban practice realities and the people that practice within those settings is required to address the needs of post-MI rural women, their families and health care professionals. The ‘‘culture of referral’’ that emerged from the rural context of this study requires further investigation and strategies are needed to provide rurally sensitive, seamless post-MI care. References Alter, D.A., Naylor, C.D., Austin, P.C., Chan, B.T.B., Tu, J., 2003a. Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction. Canadian Medical Association Journal 168 (3), 261–264. Alter, D.A., Tu, J.V., Austin, P.C., Naylor, C.D., 2003b. Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada. Journal of the American College of Cardiology 42 (3), 410–419. Bain, N.S.C., Campbell, N.C., 2000. Treating patients with colorectal cancer in rural and urban areas: a qualitative study of the patients’ perspective. Family Practice 17 (6), 475–479. Barnhart, J.M., Cohen, O., Wright, N., Wylie-Rosett, J., 2006. Can non-medical factors contribute to disparities in coronary heart disease treatment? Journal of Health Care for the Poor and Underserved 17, 559–574. Bourke, L., Sheridan, C., Russell, U., Jones, G., DeWitt, D., Liaw, S.T., 2004. Developing a conceptual understanding of rural health practice. Australian Journal of Rural Health 12, 181–186. Caldwell, P., Arthur, H.M., Rideout, E., 2005. Lives of rural women after myocardial infarction. Canadian Journal of Nursing Research 37 (1), 54–67. Chan, T.B., Austin, P.C., 2003. Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada. Medical Care 41 (4), 500–511. Chan, B., Young, W., 1999. Burden of cardiac disease. In: Naylor, C.D., Slaughter, P.M. (Eds.), Cardiovascular Health and Health Services in Ontario: An ICES Atlas. Institute for Clinical Evaluative Sciences, Toronto, Canada, pp. 1–14. Dafoe, W., Arthur, H., Stokes, H., Morrin, L., Beaton, L., for the Canadian Cardiovascular Society Access to care Working Group on Cardiac Rehabilitation, 2006. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation. Canadian Journal of Cardiology 22 (11), 905–911. Graham, M.M., Knudston, M.L., O’Neill, B.J., Ross, D.B., for the Canadian Cardiovascular Society Access to Care Working Group, 2006. Treating the right patient at the right time: access to cardiac catheterization, percutaneous coronary intervention and cardiac surgery. Canadian Journal of Cardiology 22 (8), 679–683. Health Canada. Rural Health [Cited 31 May 2001]. Available from URL: /http:// www.hc-sc.ga.ca/ruralhealthS. Hollins, J., Veitch, C., Hays, R., 2000. Interpractitioner communication: telephone consultations between rural general practitioners and specialists. Australian Journal of Rural Health 8, 227–231. Khaykin, Y., Austin, P.C., Tu, J.V., Alter, D.A., 2002. Utilisation of coronary angiography after acute myocardial infarction in Ontario over time: have referral patterns changed? Heart 88, 460–466. King, K.M., Humen, D.P., Smith, H.L., Phan, C.L., Teo, K.K., 2001. Predicting and explaining cardiac rehabilitation attendance. Canadian Journal of Cardiology 17 (3), 291–296. Knudston, M.L., Beanlands, R., Brophy, J.M., Higginson, L., Munt, B., Rottger, J., on behalf of the Canadian Cardiovascular Society Access to Care Working Group, 2006. Treating the right patient at the right time: access to specialist consultation and noninvasive testing. Canadian Journal of Cardiology 22 (11), 819–924. Kralj, B., 2000. Measuring ‘rurality’ for purposes of health-care planning: an empirical measure for Ontario. Ontario Medical Review October, 33–52. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Beverly Hills, CA.
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Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
The influence of a ‘‘culture of referral’’ on access to care in rural settings after myocardial infarction Patricia H. Caldwell , Heather M. Arthur Faculty of Health Sciences, McMaster University, 1200 Main Street West, HSC 2J20D, Hamilton, Ontario, Canada L8N 3Z5
a r t i c l e in f o
a b s t r a c t
Article history: Received 21 December 2006 Received in revised form 6 February 2008 Accepted 1 April 2008
Access to care is an issue for rural people who require tertiary care following a myocardial infarction (MI). Access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers. Using a critical ethnographic approach, rural women, their nurses and physicians were interviewed to explore how rurality affected women’s referral and access to care following a MI. Findings reflect that a previously undocumented culture of referral that was shaped by human factors influenced access to care. The culture of referral reflected an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. The findings extend conceptual understandings of access to health care in relation to rural populations. & 2008 Elsevier Ltd. All rights reserved.
Keywords: Access Rural Cardiac Referral
Introduction Access to health care is a fundamental element of national and international policies and programs intended to increase the health of populations. In relation to health care, ‘‘access’’ is a multi-dimensional concept that is contextually modulated by the place, the players and the processes within which it is examined. In Canada, which has a universal health care system that guarantees access to all, challenges still exist for persons seeking and providing rural health care. This has resulted in the identification of access to rural health services as a priority for Canadian policy makers (Romanow Commission, 2002). Factors affecting rural persons’ access to health services include distance from emergency care (Weinert and Boik, 1995); distance to the local hospital; travel time and distance to a referral center; availability of family doctors, specialists, diagnostic testing and ambulances; weather conditions (Kralj, 2000); affordability of transportation; perceptions of geographical distances; and willingness to seek out care (Porter, 1998). There are suggestions that gender and sex-based differences may also affect access to cardiovascular care for those who live in lower socioeconomic regions such as rural places (Khaykin et al., 2002). The high burden of cardiovascular disease in rural Canada has driven patients and care providers to view access issues as key to rural cardiovascular resource planning and care (Chan and Young, 1999; O’Neill et al., 2005). Recently the access discourse in
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E-mail address: [email protected] (P.H. Caldwell). 1353-8292/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2008.04.002
Canadian cardiovascular care has focused on ways to have the right patient receive the right care at the right time (O’Neill et al., 2005). This focus is particularly relevant for rural women postmyocardial infarction (MI). Age-specific hospitalization rates for rural women diagnosed with MI in Ontario, Canada, are 17% higher than those for urban areas (Chan and Young, 1999). Women who have MIs tend to be older, have more co-morbidities and are less likely to be referred for and receive coronary interventions (Shin et al., 1999) and cardiac rehabilitation than men (King et al., 2001). Importantly, although MI is an acute, life-altering and potentially life-threatening event for women, medical knowledge has been guided by studies based on urban men. For a recent and comprehensive review of the sex and gender differences and associated knowledge gaps, the reader is referred to the CMAJ supplement (Pilote et al., 2007). Historically, access to cardiovascular care has been viewed as a system issue. This has led to a focus on resource availability as an answer to access challenges and subsequently resulted in efforts to increase system capacity to manage the demand for specialized cardiovascular services. However, the failure of geographic proximity and resource availability to account for differences in angiography use in urban and rural settings has pointed to the need to investigate possible human behavioral factors that may influence use of rural cardiac resources which are measured as a referral endpoint (Alter et al., 2003a). While referral patterns and factors affecting the decision to refer to a specialist have received some attention, the referral process has not been explored from the rural cardiac patient’s perspective (Chan and Austin, 2003). Essential to understanding the human element embedded in the access discourse is the
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perspective of those who are referred for care. The perspective of rural women who require referral for post-MI care may help to explain and further understand the complexities of access to post-MI care. This report focuses on the culture of referral that emerged in a study that explored the ways in which rurality influenced women’s lives after MI. This study was designed to understand issues about rurality specifically through the voice of rural women and in relation to MI. We report about the perspectives of rural women and their professional caregivers about the culture of referral following MI and offer interpretations to extend conceptual understandings of access to health care.
Methods A critical ethnographic approach was taken for this study. The purpose of critical ethnography is to foster social change through examination of the influences that give rise to the status quo (Thomas, 1993). The methodology was specifically utilized to generate knowledge about issues for women who have been marginalized from cardiovascular research in relation to their sex, gender and place of residence. The methodology has been reported in detail elsewhere (Caldwell et al., 2005) and will therefore be reported in brief. The study was approved by the research ethics board of the associated university. Participants were women living in four rural communities in southwestern Ontario, Canada. The region is characterized by small towns, villages and farmland. There is a system of paved and gravel roads that connect communities. Public transportation within the rural areas and to referral centers is non-existent. Referral centers used by study participants were approximately 50–200 km from rural sites. Participants were recruited by nurses and physicians working in the rural communities and by word of mouth. Potential participants contacted the researcher via a tollfree telephone line or gave their verbal permission to be contacted by the researcher. Women who declined to participate said they were intimidated by participating in research, were themselves feeling very unwell or they were caring for another family member who was not well and did not believe they had energy to participate. Those who participated stated they were more relaxed and shared their perspectives more freely when they were given information that the interviewer was also a rural resident and a nurse. The researcher was not employed by health institutions in which women received care, nor involved in their care or access to it. Inclusion criteria were: women diagnosed with MI, living in a rural community having a population of less than 150 people per square kilometer (Health Canada, 2001), consented to an audiotaped interview and able to speak English. Additional data were obtained from fieldwork that included participant observation and interviews with family members, five nurses and two rural physicians drawn from the study region. Data were collected by the first author using semi-structured interviews, field notes from participant observation, immersion in the communities by the first author over the 7-month study period, and examination of health and lay publications regarding the communities in general and in relation to cardiovascular issues and care. The referral process was a focus in the post-MI experience of every woman. Consistent with the ethnographic approach, the referral process was subsequently explored in greater depth. This included interview questions with women such as: Tell me about how you came to be referred for care. How did those decisions get made? What was your understanding as to how that process happened? How did being referred affect you and your family? Tell me about what the referral process was like for you.
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Interviews with physicians and nurses began with the question ‘‘Tell me about how it works when you refer a woman for care after a heart attack.’’ Data were manually scrutinized by two members of the research team to identify recurring themes until no new themes were generated by interview or additional data sources. Critique and discussion about the referral process and its influences occurred among the research team until consensus was achieved and themes describing the cultural process of referral were generated. Lincoln and Guba (1985) identified the following issues as essential to establishing rigor in qualitative research: credibility, transferability, dependability and confirmability. Credibility was established by reviewing interview audiotapes with transcripts; field notes and data from observation and interviews with rural health professionals were used to triangulate data sources. Women were consulted in follow-up interviews to ensure that interpretations of their perspectives were accurate. To ensure dependability and confirmability of findings, an audit trail was established. Detailed records of the analysis process and decisions by the team were maintained.
Results Women ranged from 43 to 80 years of age and were 3 months to 4 years post first MI. Seven women lived with their spouses; five lived on their own. Rural access to tertiary care in urban centers was contingent on obtaining and getting a referral for consultative, diagnostic, interventional and rehabilitative purposes. Referral to an urban center was a cultural norm that was accepted by patients, their communities and institutions. Access issues arose at four sequential points in the post-MI trajectory and from the women’s viewpoints these were (1) ‘‘getting in’’, (2) ‘‘getting there’’, (3)’’being there’’ and (4) ‘‘coming home’’. Collectively these points reflected aspects of the culture of referral in which post-MI women, their families and practitioners gained access to specialist cardiovascular care. Referral was described by women and their professional caregivers as both a process and an outcome. The referral process involved an interplay between the rural physician referee, the woman who required referral and the tertiary referral center. When a tertiary institution or service accepted a referral, access to care was deemed to be obtained. While this would traditionally be regarded as a positive outcome, participants in this study described other important issues related to referral that have received little attention, yet point to fundamental and understudied aspects of the access/referral discourse. ‘‘Getting in’’ referred to the process by which women were accepted by a tertiary center or by a specialist following a diagnosis of MI. Depending on a woman’s state of health when the referral was attempted, this could be a very stressful time. All women, irrespective of age, who were alert and aware of their need for urgent tertiary care waited for news of a successfully negotiated referral anxiously. They described this as true for their families as well. Rural physicians were the gatekeepers who could initiate referral for tertiary cardiac services and therefore the referral process was physician dependent. Without a successfully negotiated referral to a tertiary center, access could not be obtained. The skill of the rural physician in negotiating the referral was therefore critical and was valued by women, their families and nursing staff. These ‘‘access skills’’ were learned through experience when practitioners were in the position of requesting a referral. Several women believed their physicians had ‘‘pulled strings’’ or done something out-of-the-ordinary to secure a referral, even though they were accessing what was considered
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‘‘usual’’ post-MI care. This was accompanied by a general feeling on the part of the women that successful referral was due to their good luck and not because the system was working. Access to all post-MI services was a negotiated outcome and not the result of a simple request for consultation. The women understood that the health care system was overloaded, and that their rural physician was working hard to advocate for their access to tertiary care and they were grateful. All women recognized their physicians as their valued and necessary advocates. Although it was commonly held that a referral was ‘‘made’’, the nature of that process varied depending on the service required. If a referral was not accepted within time limits that the rural physician found acceptable, more rural physician time was needed to find and negotiate alternative access. One woman described waiting a week after her MI when her family physician requested her case be accepted urgently; she eventually gained access to a referral in another city. Another who was taken by air ambulance urgently was certain that she gained access because people she knew in the hospital had advocated for her. Whether luck or preferential treatment existed or not, the perception was that successful referral could require such forces to be operational. There were different routes to ‘‘getting in’’, to accessing tertiary care. Although each rural hospital had usual referral routes for acute care, rural centers in the study region were not restricted to specific practitioners or centers. When a specialist or bed was unavailable in a specific tertiary agency, negotiation of a referral to another practitioner or institution in another city was necessary. Despite the challenge getting in sometimes presented, physicians appreciated the flexibility afforded when they were not obliged to refer to a particular place or person. However, this approach also left the rural areas in a situation where no referral center was obliged to take rural patients. As one rural family practitioner who routinely provided emergency care said, People who live near tertiary centers arrive at the Emergency Room door and they are in the system. If you’re at the periphery (rural areas) there’s no room. When you’re out far enough they (tertiary centers) can put you off—that’s the reality. Study participants believed the relationship and credibility a rural physician had with a referral center or practitioner influenced their willingness to accommodate referral requests. The necessity of urban–rural relationships to be based on mutual respect as well as the rural physician’s judgment and care was identified by women and health professionals as key for successful referral. Participants reported that new rural practitioners who did not have those relationships could be challenged to get the referrals they wanted. ‘‘Getting there’’ referred to the process by which women got to their referral destination. There was no specific protocol that was known to study participants regarding transportation to tertiary care. It was perceived that transport decisions were made on an individual basis and were dependent on the patient’s condition, family availability and weather. When hospitalized patients were deemed stable, families were asked to take the patient to and from a referral appointment. For some women this included transportation from hospital via family car to a cardiac catheterization or surgery. Women who had families able to transport them described the stress involved in getting to a referral, particularly when perceptions of weather conditions and patient acuity were severe. This was true for women of all ages and living arrangements. Depending on the family’s perceptions about the acuity of the woman’s health, getting there could be a stressful
event. One woman described how her anxious husband enlisted a nurse friend to accompany them to the cardiac catheterization. Air and land ambulance services were used for unstable patients. Nurses said that some families felt pressured into transporting women to a referral but complied with the request for fear of losing the appointment. The daughter of a hospitalized elderly woman described how the appointment time for an angiogram was made in the city but the logistics were left for the family to work out. I, of course had to take her, as it costs less for a family member to take themyand then I brought her back (to the rural hospital). The first appointment for an angiogram was 9 am, so my husband took the day off work because I don’t like to drive in the city. Another woman was driven 212 h home to await further treatment decisions 5 days after air evacuation following her MI. The 5-h round trip from home to hospital was repeated four more times in the following weeks. We went down to see the cardiologist, then another day to the surgeon, then to a (pre-op) clinic for my surgery. As we’re leaving, they said we want you back here the next day. We’re doing your surgery tomorrow. The stress of finding their way to referral centers was accepted by women as part of the referral package. Patients and families sometimes booked into overnight accommodations to ensure bad weather did not result in cancellation of the referral appointment. In many cases women understood the referral to be important to their lives and those of their families and that its outcome could shape the rest of their lives. These concerns prevailed during the journey to the referral destination, but women sometimes felt their concerns were not appreciated at the tertiary center. ‘‘Being there’’ described women’s experiences while at the referral appointment or institution. For some women, being in a referral center produced anxiety, despite the gratitude they felt for the tertiary services. Women described feeling like ‘‘outsiders’’ during some of their interactions and experiences in tertiary settings. Sometimes this occurred in response to an interaction with a health professional who made what were perceived as negative comments about rural life or who gave information that had little or no relevance to their rural context. Urban caregivers’ lack of familiarity with the rural region from which women came served to create psychological distance between some patients and their urban caregivers. One woman reported a conversation with a cardiologist that reflected his lack of understanding of the context of her recovery. She tried to tell him there was nowhere she felt she could safely start a walking program in the farming community in which she lived. Walk? Where? I was surprised when the doctor said that. They would say you get out and walk. Like they think it’s so easy to just go out there and walk down a highway. I am afraid that somebody won’t know that I am there (if I need help). Like I don’t want to lay there for a half or an hour (if I need help). The lack of knowledge about the services available in rural areas contributed to some women feeling that instructions they received in the tertiary center might not be relevant to their life contexts. Some perceived that the time spent away from home or for travel was not appreciated by caregivers in tertiary settings. For women who were referred for an appointment and who were not transferred for hospitalization, the time spent traveling to and from the referral was disproportionate to the time spent in the referral appointment. The following quote illustrates that for those with referral appointments, the time spent getting to and
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from the referral center was disproportionate to the time spent ‘‘being there’’. We’d be about two and a half hours. If we leave here at 8:45 we are pretty well there by eleven, it’s a long drive. If you’re lucky you wait ten minutes and you go in and you come out. You go all day for that short time, and when you come out you have to eat, and then back 2 1/2 hours again. So it is five hours that you are wasting the whole day. In winter it’s not that great a trip sometimes. It’s hard being on a road you’re not familiar with. Concerns arose regarding the lack of positive regard women sometimes perceived from nurses in tertiary centers towards rural health care and the abilities of rural providers. Rural women were quick to defend the credentials of their nurses and physicians against any criticisms, although this created questions about the cohesiveness of the cardiac care community. Women often came directly home from the city following a cardiac procedure instead of returning to the rural hospital. The homecoming could either be filled with relief or stressful, depending on the outcome of the referral. Preparation and support for the patient and family with regard to the trip home were seen as necessary by participants who had undergone procedures. One woman described going home the day following an angioplasty that was complicated by bleeding and required additional intervention. My husband drove me home. It was winter. It was a very long, trying ride. It’s about a couple of hours and I was still having a fair bit of pain where the catheter went through and actually for almost a week after I had pain there. My husband was nervous and no one gave him information to make him feel better about being responsible for me. They just told me if I had any problems, I was just to go to emergency. They didn’t really prepare me for coming home. Women expressed concern about their preparation for the journey home and for the time that came after their return. Issues such as pain control, fears about re-infarction and the stress placed on their families because of their cardiac status were foremost on the minds of women. Sometimes women returned to their homes from a referral center to await future surgery. Being told that the key to survival was the surgical intervention and then having to wait for it at some distance and time away produced anxiety for them and their families. Following referral, most women were uncertain about their need for follow-up and with whom that should occur. They did not know what or how information was shared between practitioners. Some specialists were also unfamiliar with the resources to which they could refer women in rural communities. One woman described her concern that exercise-based cardiac rehabilitation programs were unavailable in her community upon returning home and how she came to know that. So the doctor (in the tertiary center) said to me, just where is (your rural community) anyway? And then I told him. So he asked me a few questions like, well how far is that to (City A)? How far is at to (City B)? How far to (City C)? Then he says well, I guess that won’t work then. There isn’t anything around you. Despite the lack of tertiary cardiac resources in their communities, women seldom chose to view their rural care situations as under-serviced. Instead they framed their rural contexts in terms of the capacity they and their rural health providers had to manage the challenges created by referral. For instance, some women devised their own exercise programs to meet what they understood to be the rehabilitation requirements when referral was not possible. Nurses viewed this chosen approach as a coping
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mechanism women used to decrease their anxiety about possible system gaps.
Discussion Given that access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers, interventions targeted to increase access for citizens in rural areas must consider issues related to referral. Guidelines for timely referral have been proposed for diagnostic testing, specialist consultation, surgical and electrophysiologic intervention and cardiac rehabilitation (O’Neill et al., 2005, Dafoe et al., 2006; Graham et al., 2006; Munt et al., 2006). The focus of these guidelines has largely been on establishing benchmarks for wait times for cardiac services and not specifically on human social factors affecting referral or urban–rural issues. It has been suggested that some differences in care may reflect referral disparities that may occur early in the referral chain and prior to the time specialists actually offer treatment alternatives (Shin et al., 1999). Thus it is possible that in addition to known challenges to care in rural settings, rural women’s access to postMI care may be influenced by the referral practices that exist within the care culture. While the focus of referral has traditionally been on access to referral destinations and on the outcome of the referral procedure(s), these findings focus on the patient who is moving through the referral process and the culture of referral that existed in the rural context. In comparison to traditional notions of referral, in this study referral was not a simple request for access to care, nor was it merely the transfer of care from one practitioner or institution to another. While there were system processes and structures that were vital for the referral process to work, it was apparent that human factors were both vital to the referral process and critical to generating the referral culture. According to Wellstood et al. (2006), sociocultural factors affect access to care; however, human factors that are necessary for the system structures to function most effectively have not been well explored. Accounts of the referral process in this study suggested that practice divisions existed within the cardiac care culture, that referral attempted to bridge urban and rural cardiac care subcultures and that a cultural gradient existed between urban and rural practice contexts. This gradient was evident in the communication patterns between urban–rural practitioners as well as urban practitioners and rural patients. It is possible these complexities influenced (a) the access rural patients had to tertiary cardiac care, (b) that once in, perceptions of such gradients interfered with patient’s experiences of care and (c) that once home, inconsistencies (perceived or real) in the flow of information from urban to rural settings affected women’s follow-up. While the complex dynamics of patient–physician interactions may explain some differences in access to care (Barnhart et al., 2006), the dynamics of the urban–rural referral process have not been scrutinized. Knudston et al. (2006) have identified the need for improved communication between referring physicians and specialists so that timely access to care can be gained. They suggested that effective communication at the time of the referral was necessary for appropriate patientcentered cardiac resource allocation, particularly between referring physicians and specialists. While hegemony may exist in physician practice regarding generalists and specialists, it is possible this may be compounded when the generalist is from a rural setting. Future discussions need to further examine how communication between physicians with different levels of expertise and in urban and rural practice settings affects accessibility to tertiary cardiac care. Rural Canadian women have
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also identified that access to tertiary care often results in significant financial, social and emotional costs to them and their families when care is accessed in geographically distant locations (Sutherns et al., 2004). At all post-MI referral points, women’s experiences were affected by the referral culture. Issues were consistent with those reported by rural women across Canada about accessing general and specialty health care (Sutherns et al., 2004). Women’s gratitude for having any access to care and their beliefs that they could be self-sufficient upon return home contributed to their acceptance of the referral process. This phenomenon has been seen in other rural populations and attributed to rural resident’s lower expectations about how the system should meet their needs (Bain and Campbell, 2000). This makes it unlikely that those who view themselves in this way will advocate for system change or challenge the aspects of the process that were difficult for them. Changes in the referral culture would therefore be left to those in the culture who were perceived to have greater power such as physicians and health care institutions. There are indications that the referral journey could be more ‘‘rural friendly’’. The perception that rural people, rural practitioners and institutions are outside of the system and that significant effort must be made to ‘‘get in’’ and access the continuum of cardiac care required post-MI requires change. The negotiating that rural practitioners do to gain access is not necessarily a bad thing; however, the time spent in negotiating referral during an acute event may take a solitary rural practitioner away from the women requiring referral and from other rural people who require care. Although the underlying assumption in systems thinking is that streamlining the referral process is necessary, negotiation of a bed allowed practitioners to adapt to circumstances to some degree. Regulation of referral routes might not be the answer in terms of the referral system and, clearly, rural practitioners wanted a voice in any referral discussions. Study results suggest caregivers, decision makers and policy makers must broaden the referral focus beyond the management of wait lists as the key to system entry and attend to the needs of rural stakeholders in the referral process. There is a need to develop and test interventions that women and their families would find helpful at each step in the referral journey. For instance, identifying and evaluating effective supports for women during the ‘‘getting in’’ phase may be useful. Anticipating and identifying the needs of family who drive women to and from referral appointments and exploring alternative modes of transport and delivery of the referral service could ease some stress that arises from referral. Educational opportunities for tertiary centers to learn about the rural regions they service may be indicated so the ramifications of returning patients home to these communities and lifestyles is understood and incorporated into discharge teaching and planning. The need for urban caregivers to understand rural access issues and for effective communication between rural and urban practitioners has been previously noted (Bourke et al., 2004; Hollins et al., 2000). Clear avenues for follow-up with their family physician and specialist, and clarification of the roles each will play in women’s recovery, should be developed and communicated. This could be included as part of revascularization referral networks that have recently been advocated for community hospitals in Canada (Alter et al., 2003b). There is also a need to develop cardiac rehabilitation resources to which rural women can be referred. Future research should explore the referral process from the perspective of rural men, families and rural and urban practitioners involved in post-MI care. In this way a more complete
picture of both referral and the possibilities to enhance the process for those who must use it could be developed.
Conclusion The culture of referral that emerged in this study reflects an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. There are indications that the rural context of care is poorly understood by urban care providers. Clearly, rural practitioners require excellent communication and clinical skills to acquire access to post-MI care for rural women. In addition, the relationships established between rural generalists and urban specialists appear to be critical to accessing care. Systematic planning and implementation of approaches to referral that reflect valuing of rural–urban practice realities and the people that practice within those settings is required to address the needs of post-MI rural women, their families and health care professionals. The ‘‘culture of referral’’ that emerged from the rural context of this study requires further investigation and strategies are needed to provide rurally sensitive, seamless post-MI care. References Alter, D.A., Naylor, C.D., Austin, P.C., Chan, B.T.B., Tu, J., 2003a. Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction. Canadian Medical Association Journal 168 (3), 261–264. Alter, D.A., Tu, J.V., Austin, P.C., Naylor, C.D., 2003b. Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada. Journal of the American College of Cardiology 42 (3), 410–419. Bain, N.S.C., Campbell, N.C., 2000. Treating patients with colorectal cancer in rural and urban areas: a qualitative study of the patients’ perspective. Family Practice 17 (6), 475–479. Barnhart, J.M., Cohen, O., Wright, N., Wylie-Rosett, J., 2006. Can non-medical factors contribute to disparities in coronary heart disease treatment? Journal of Health Care for the Poor and Underserved 17, 559–574. Bourke, L., Sheridan, C., Russell, U., Jones, G., DeWitt, D., Liaw, S.T., 2004. Developing a conceptual understanding of rural health practice. Australian Journal of Rural Health 12, 181–186. Caldwell, P., Arthur, H.M., Rideout, E., 2005. Lives of rural women after myocardial infarction. Canadian Journal of Nursing Research 37 (1), 54–67. Chan, T.B., Austin, P.C., 2003. Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada. Medical Care 41 (4), 500–511. Chan, B., Young, W., 1999. Burden of cardiac disease. In: Naylor, C.D., Slaughter, P.M. (Eds.), Cardiovascular Health and Health Services in Ontario: An ICES Atlas. Institute for Clinical Evaluative Sciences, Toronto, Canada, pp. 1–14. Dafoe, W., Arthur, H., Stokes, H., Morrin, L., Beaton, L., for the Canadian Cardiovascular Society Access to care Working Group on Cardiac Rehabilitation, 2006. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation. Canadian Journal of Cardiology 22 (11), 905–911. Graham, M.M., Knudston, M.L., O’Neill, B.J., Ross, D.B., for the Canadian Cardiovascular Society Access to Care Working Group, 2006. Treating the right patient at the right time: access to cardiac catheterization, percutaneous coronary intervention and cardiac surgery. Canadian Journal of Cardiology 22 (8), 679–683. Health Canada. Rural Health [Cited 31 May 2001]. Available from URL: /http:// www.hc-sc.ga.ca/ruralhealthS. Hollins, J., Veitch, C., Hays, R., 2000. Interpractitioner communication: telephone consultations between rural general practitioners and specialists. Australian Journal of Rural Health 8, 227–231. Khaykin, Y., Austin, P.C., Tu, J.V., Alter, D.A., 2002. Utilisation of coronary angiography after acute myocardial infarction in Ontario over time: have referral patterns changed? Heart 88, 460–466. King, K.M., Humen, D.P., Smith, H.L., Phan, C.L., Teo, K.K., 2001. Predicting and explaining cardiac rehabilitation attendance. Canadian Journal of Cardiology 17 (3), 291–296. Knudston, M.L., Beanlands, R., Brophy, J.M., Higginson, L., Munt, B., Rottger, J., on behalf of the Canadian Cardiovascular Society Access to Care Working Group, 2006. Treating the right patient at the right time: access to specialist consultation and noninvasive testing. Canadian Journal of Cardiology 22 (11), 819–924. Kralj, B., 2000. Measuring ‘rurality’ for purposes of health-care planning: an empirical measure for Ontario. Ontario Medical Review October, 33–52. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Beverly Hills, CA.
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