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Introduction Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles. Materials and Methods We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico's trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles. Results Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions. Conclusions In addressing rural patients' needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.
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BACKGROUND: Every year, Puerto Rico faces a hurricane season fraught with potentially catastrophic structural, emotional and health consequences. In 2017, Puerto Rico was hit by Hurricane Maria, the largest natural disaster to ever affect the island. Several studies have estimated the excess morbidity and mortality following Hurricane Maria in Puerto Rico, yet no study has comprehensively examined the underlying health system weaknesses contributing to the deleterious health outcomes. METHODS: A qualitative case study was conducted to assess the ability of the UPR health system to provide patient care in response to Hurricane Maria. An established five key resilience framework and inductive analysis was used to identify factors that affected health system resilience. Thirteen Emergency Medicine Physicians, Family Medicine Physicians, and Hospital Administrators in a University of Puerto Rico (UPR) Community Hospital were interviewed as part of our study. RESULTS: Of the five key resiliency components, three domains were notably weak with respect to UPR resiliency. Prior to the Hurricane, key personnel at the UPR hospital were unaware of the limited capacity of back-up generators at hospitals and were ill-prepared to transfer ICU patients to appropriate hospitals. Post Hurricane, the hospital faced self-regulation challenges when triaging the provision of Hurricane-related emergency services with delivering core health services, in particular for patients with chronic conditions. Finally, during and after the Hurricane, integration of patient care coordination between the UPR hospital ambulances, neighboring hospitals, and national and state government was suboptimal. The two remaining resiliency factors, addressing diverse needs and system adaptiveness in a time of crisis, were seen as strengths. CONCLUSIONS: Hurricane Maria exposed weaknesses in the Puerto Rican health system, notably the lack of awareness about the limited capacity of backup generators, poor patient care coordination, and interruption of medical care for patients with chronic conditions. As in other countries, the current COVID epidemic is taxing the capacity of the Puerto Rico health system, which could increase the likelihood of another health system collapse should another hurricane hit the island. Therefore, a resilience framework is a useful tool to help health systems identify areas of improvement in preparation for possible natural disasters.