title: Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety.
abstract: The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review.
  
  
  
  This paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014.
  
  
  
  Two hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians.
  
  
  
  Findings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.
authors: Department of Family Practice, University of British Columbia, David Strangway Building, 3rd Floor, 5950 University Blvd., Vancouver, V6T 1Z3, BC, Canada. jude.kornelsen@familymed.ubc.ca.
authors: Jude
authors: J
authors: Kornelsen
authors: Department of Family Practice, University of British Columbia, David Strangway Building, 3rd Floor, 5950 University Blvd., Vancouver, V6T 1Z3, BC, Canada.
authors: Kevin
authors: K
authors: McCartney
authors: Perinatal Services BC, Provincial Health Services Authority, West Tower, Suite 350, West 12th Ave., Vancouver, V5Z 3X7, BC, Canada.
authors: Kim
authors: K
authors: Williams
mesh_terms: D001955:British Columbia; D002585:Cesarean Section / Q000592:standards* / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D005260:Female; D058006:General Practice / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D061214:Patient Safety; D018743:Perinatal Care / Q000191:economics / Q000458:organization & administration*; D010549:Personal Satisfaction; D011247:Pregnancy; D012017:Referral and Consultation; D012423:Rural Health / Q000191:economics / Q000592:standards; D019035:Rural Health Services / Q000191:economics / Q000458:organization & administration
keywords: GP proceduralists; GP surgeons; General practitioners with enhanced surgical skills; Realist review; Rural maternity care; Rural surgical care