Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost‐effective alternative care model: a retrospective cross‐sectional study

Wednesday, September 6th, 2023 | Rory | No Comments

Open access

Alexander M, Lan NS, Dallo MJ, Briffa TG, Sanfilippo FM, Hooper A, Bartholomew H, Hii L, Hillis GS, McQuillan BM, Dwivedi G. Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost‐effective alternative care model: a retrospective cross‐sectional study. Medical Journal of Australia. 2023 Jul 4.

This is an interesting paper kindly forwarded by Brendan Marshall. The authors devised a novel protocol where patients with chest pain (excluding STEMI) who presented to a rural hospital in Western Australia would have a CTCA before any transfer for angiography.

They then looked retrospectively to apply this novel pathway on patients that were transferred for angiography and examined the costs. Patients that were transferred for angio included those with NSTEMI, troponin ‘negative’ chest pain and “other”.

The headline by the authors was that providing a CTCA in a rural hospital before transfer for angiography would prevent 53% of patients from needing transfer (and save a bucket load of cash).

Many of these patients who were transferred for angiography had normal troponin concentrations (38.7%) or other reasons (valvular heart disease, cardiomyopathy e.t.c. (18.2%). These patients was where the majority of the savings came from

In NZ, I don’t think many of these patients would be transferred for angiography as an inpatient anyway, perhaps reflecting vastly different practice. Very few (6.2%) of the group in with NSTEMI would have been able to remain in a rural hospital after a proposed CTCA first protocol.

Not transferring NSTEMI for angiography in those that are well enough to benefit from an invasive procedure is a departure from current Australian and NZ guidelines.

CTCA requires upgraded software and 64-slice CT scanners (and training e.t.c) which is apparently prohibitive in our relatively well resourced rural hospital at Thames anyway. Although undoubtedly better diagnostic value compared to ETT!



Objectives: To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management; to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD.

Design: Retrospective cohort study.

Setting, participants: Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year.

Main outcome measures: Severity and management of CAD (medical management or revascularisation); health care costs by care model (standard care or a proposed alternative model with local CTCA assessment).

Results: The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years); 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non‐ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries (< 50% stenosis) underwent revascularisation; nine patients with moderate CAD (50–69% stenosis; 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel; 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed‐days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved.

Conclusion: Many rural and remote Western Australians transferred for ICA in Perth have non‐obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost‐effective strategy for risk stratification of people with suspected CAD.

Simplify to Unify

Monday, September 4th, 2023 | Rory | No Comments

I’m sure it’s not simple but here is some information on the new proposed structure and processes around commissioning. Not the new national and regional rural roles, including clinical advisors.

Simplify to unify – Commissioning Letter including invitation

Commissioning Final for External Stakeholders

Simplify to unify – Commissioning Decision Document Stakeholder plan on a page

Watch for job adverts here.


We will try and keep you posted as more things come through (Thanks Emma Davey for the info!


Seminar: “Is there and should there be a distinct rural health ethics?”

Friday, September 1st, 2023 | Rory | No Comments

Short notice we know but seminar on ethics – link below


Topic: “Is there and should there be a distinct rural health ethics?”

Presenter: Associate Professor Fiona McDonald,

Australian Centre for Health Law Research, Queensland University of Technology, Adjunct Associate Professor, Department of Bioethics, Dalhousie University, Canada

When: Monday 4 September, 1pm – 2pm

Where: Bioethics Seminar Room 119, 1st Floor, 71 Frederick Street, Dunedin 9016.

Attending Online: Join from PC, Mac, iOS or Android:

Meeting ID: 922 351 556

Password: 595584

To those joining online, we ask that you please mute yourselves upon arrival to avoid any accidental interruptions.


Potato Ethics: What Rural Communities Can Teach Us about Healthcare

Friday, September 1st, 2023 | Rory | No Comments

Fors, M. Potato Ethics: What Rural Communities Can Teach Us about Healthcare. Bioethical Inquiry 20, 265–277 (2023).


This is part 1 of ethics based posts today. Dr. Helen Clayson kindly supplied commentary:

This engaging and well-written paper by a rural Swedish psychologist explores the disconnect between the dominant urban-centric model of healthcare ethics and the realities of practice in rural communities. The author proposes a new perspective that she names ‘potato ethics’: the term relates to the attributes of this humble vegetable as ‘plain, useful and versatile’. The concept of ‘potato ethics’ is grounded in the lived experience of rural practitioners and is a type of care ethic that is contextual, relational, pragmatic and incorporates social justice. Rural practitioners will easily relate to the examples of rural challenges that are described and to the sense of a ‘moral imperative to make oneself useful’ that often involves going beyond the strict boundaries of professional scope and specific training in the absence of other staff and facilities. The paper examines traditional healthcare ethics approaches and illustrates their limitations in the rural context. The author is well-placed to address this topic: although a former urbanite, she now lives and works in a remote Norwegian community in the Arctic Circle and recognises the adjustments she has made to move away from ‘urban narcissism’. This paper is a useful addition to rural healthcare literature and I suspect it will lead to the socialisation of some new terms in rural health discourse. ‘Honour the potato’ indeed!

Helen Clayson

link to open access:


In this paper I offer the term “potato ethics” to describe a particular professional rural health sensibility. I contrast this attitude with the sensibility behind urban professional ethics, which often focus on the narrow doctor–patient treatment relationship. The phrase appropriates a Swedish metaphor, the image of the potato as a humble side dish: plain, useful, versatile, and compatible with any main course. Potato ethics involves making oneself useful, being pragmatic, choosing to be like an invisible elf who prevents discontinuity rather than a more visible observer of formal rules and assigned tasks. It also includes actively taking part in everyday disaster-prevention and fully recognizing the rural context as a vulnerable space. This intersectional argument, which emphasizes the ongoing, holistic responsibility of those involved in rural communities, draws on work from the domains of care ethics, relational ethics, pragmatic psychology, feminist ethics of embodiment, social location theory, and reflections on geographical narcissism.

Rural health podcast from Wales: the first RHCW Podcast

Monday, August 21st, 2023 | Rory | No Comments

Launch of the first RHCW Podcast!


“Supporting the Health, Care and
Wellbeing of our rural populations – a
quick tour of the Royal Welsh 2023”


We are pleased to confirm that the first RHCW Podcast has now been broadcast and can be listened to either on Spotify or Apple – links to the Spotify episode is below and if you have an Apple device, please search on the Podcast option for “Rural health and Care Wales” where our podcasts will appear. There is also a QR code at the bottom of this message where it can be accessed.


At the moment, the Podcasts are only available in English but we hope to have Welsh versions in the future.


Supporting the health, care and wellbeing of our rural populations – a quick tour of the Royal Welsh 2023


This episode of the monthly Podcasts was recorded at the Royal Welsh show held in Builth Wells, Powys from the 24-27 July 2023. In the Podcast, I chat briefly to the following people regarding a project or initiative they are or have been involved with that impacts the health, care and wellbeing of people living in rural areas of Wales:


  • Jack Evershed, previous Chair of RHCW and now a member of Llais, recalling how RHCW was set up and outlining his new role with Llais
  • Melanie Brindle from Powys County Council talking about their “grow your own” Social Worker programme
  • Natasha Lewis from Adferiad, outlining their mental health and addiction support services
  • Hannah Edwards from Diabetes Cymru explaining how they support people in rural areas that have diabetes
  • Professor Michael Woods from Aberystwyth University explaining a new project he is taking forward with a number of partners that will collate rural data and information and set up innovation labs, working closely with rural communities
  • Gill Rundle from National Federation of Women’s Institutes who explains why they are signing up men to support the “not in my name” campaign
  • Kay Helyar from the DPJ Foundation who outlines the work that the foundation does in supporting the farming community in terms of mental health


We hope you enjoy the discussions, which last around 20 minutes.


Thank you





Lansio Podlediad cyntaf IGGC!


“Cefnogi’r Iechyd, Gofal a Lles ein poblogaethau gwledig – taith cyflym o amgylch y Sioe Frenhinol 2023”


Rydym yn falch o gadarnhau bod podlediad cyntaf IGGC bellach wedi cael ei ddarlledu a gellir gwrando arno naill ai ar Spotify neu Apple – mae dolenni i’r bennod Spotify isod ac os oes gennych ddyfais Apple, chwiliwch ar yr opsiwn Podlediad ar gyfer “Rural Health and Care Wales” lle bydd ein podlediadau yn ymddangos. Mae yna hefyd god QR ar waelod y neges hon lle gellir cael mynediad ato.


Ar hyn o bryd, dim ond yn Saesneg mae’r podlediadau ar gael ond gobeithiwn gael fersiynau Cymraeg yn y dyfodol.


Supporting the health, care and wellbeing of our rural populations – a quick tour of the Royal Welsh 2023


Recordiwyd y bennod hon o’r Podlediadau misol yn y Sioe Frenhinol a gynhaliwyd yn Llanfair-ym-Muallt, Powys rhwng 24-27 Gorffennaf 2023. Yn y Podlediad, rwy’n sgwrsio’n fyr â’r bobl ganlynol ynghylch prosiect neu fenter y maent neu wedi bod yn ymwneud â hi sy’n effeithio ar iechyd, gofal a lles pobl sy’n byw mewn ardaloedd gwledig yng Nghymru:


  • Jack Evershed, cyn Gadeirydd IGGC sydd bellach yn Aelod o Llais, yn son am sut y sefydlwyd IGGC ac amlinellu ei rol newydd gyda Llais
  • Melanie Brindle o Gyngor Sir Powys  yn siarad am eu rhaglen Gweithwyr Cymdeithasol “tyfu eich hun”
  • Natasha Lewis o Adferiad, yn amlinellu eu Gwasanaethau cymorth iechyd meddwl a dibyniaeth
  • Hannah Edwards o Diabetes Cymru yn esbonio sut maen nhw’n cefnogi pobl mewn ardaloedd gwledig sydd â diabetes
  • Yr Athro Michael Woods o Brifysgol Aberystwyth yn esbonio prosiect newydd y mae’n rhedeg gyda nifer o bartneriaid a fydd yn coladu data a gwybodaeth wledig ac yn sefydlu labordai arloesi, gan weithio’n agos gyda chymunedau gwledig
  • Gill Rundle o Ffederasiwn Cenedlaethol Sefydliadau Merched sy’n esbonio pam eu bod yn cofrestru dynion i gefnogi’r ymgyrch “nid yn fy enw i”
  • Kay Helyar o Sefydliad DPJ sy’n amlinellu’r gwaith y mae’r sylfaen yn ei wneud i gefnogi’r gymuned ffermio o ran iechyd meddwl


Gobeithio y byddwch yn mwynhau’r trafodaethau sy’n para tua 20 munud.


Thank you





Acute otolaryngological presentations in Northland

Monday, June 26th, 2023 | Rory | No Comments

Heaven CL, McGuinness MJ, Shetty S. Acute otolaryngological presentations in Northland, New Zealand: analysed with respect to geography and rurality. New Zealand Medical Journal. 2023;136(1575).

This study shows that a large percentage of ED/hospital presentations with otolarngeal diagnoses in Northland are dealt with by rural hospitals. Few patients were transferred to an urban hospital (Whangarei) but there were a higher percentage of patients ‘admitted’. I suspect these findings might reflect the after-hours care provided by rural hospitals rather than urgent care facilities and the geography of the region and that patients live at a distance to the rural hospital. 



Aim: Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients.
Methods: A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded.
Results: Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p<0.001).
Conclusion: This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.