Do people living in rural and urban locations experience differences in harm when admitted to hospital?

Wednesday, June 2nd, 2021 | Rory | No Comments

Atmore C, Dovey S, Gauld R, et al. Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study. BMJ Open 2021;11:e046207. doi:10.1136/ bmjopen-2020-046207

People living in rural communities had no difference in hospital harm compared to people living in urban communities, except when they were transferred, and then more than double the harm – maybe they were sicker or maybe the transfer process itself was part of it, this needs to be looked into further. From this GP record review, 3% of patients admitted to rural hospitals were transferred.


Objective Little is known about differences in hospital harm (injury, suffering, disability, disease or death arising from hospital care) when people from rural and urban locations require hospital care. This study aimed to assess whether hospital harm risk differed by patients’ rural or urban location using general practice data.

Design Secondary analysis of a 3-year retrospective cross-sectional general practice records review study, designed with equal numbers of rural and urban patients and patients from small, medium and large practices. Hospital admissions, interhospital transfer and hospital harm were identified.

Setting New Zealand (NZ) general practice clinical records including hospital discharge data. Participants Randomly selected patient records from randomly selected general practices across NZ. Patient enrolment at rural and urban general practices defined patient location.

Outcomes Admission and harm risk and rate ratios by rural-urban location were investigated using multivariable analyses adjusted for age, sex, ethnicity, deprivation, practice size. Preventable hospital harm, harm severity and harm associated with interhospital transfer were analysed.

Results Of 9076 patient records, 1561 patients (17%) experienced hospital admissions with no significant association between patient location and hospital admission (rural vs urban adjusted risk ratio (aRR) 0.98 (95% CI 0.83 to 1.17)). Of patients admitted to hospital, 172 (11%) experienced hospital harm. Rural location
was not associated with increased hospital harm risk
(aRR 1.01 (95% CI 0.97 to 1.05)) or rate of hospital harm per admission (adjusted incidence rate ratio 1.09 (95%
CI 0.83 to 1.43)). Nearly half (45%) of hospital harms became apparent only after discharge. No urban patients required interhospital transfer, but 3% of rural patients did. Interhospital transfer was associated with over twice the risk of hospital harm (age-adjusted aRR 2.33 (95% CI 1.37 to 3.98), p=0.003).

Conclusions Rural patient location was not associated with increased hospital harm. This provides reassurance for rural communities and health planners. The exception was patients needing interhospital transfer, where risk was more than doubled, warranting further research.

Supporting Allied Health Professionals in Rural New Zealand – presentation 1 June 12pm

Thursday, May 27th, 2021 | Rory | No Comments

Sarah is giving a presentation on her thesis:

1 June 2021 – 12pm

In-person: Room 1.02 School of Physiotherapy, University of Otago, Dunedin

Zoom: Meeting ID: 965 3790 5832 I Password: 407013


Sarah Walker (HRC Clinical Research Training Fellow)

Abstract: Sarah’s PhD aims to explore the roles of allied health professionals working in rural New Zealand. This will be done through a qualitative strand looking at the experiences of rural allied health professionals, the challenges they face and the attributes and skills needed to reach the full potential of their roles, and a quantitative strand characterising the clinical scope of practice of rural physiotherapists in comparison to their urban counterparts. This presentation will introduce Sarah as a rurally based researcher, outline the methods, and indicate preliminary findings from the qualitative strand..

Bio: Sarah began her PhD with the School of Physiotherapy in February 2020, based at the Section of Rural Health in Dunstan Hospital, Clyde. She is co-supervised by the Department of General Practice and Rural Health, and also works 0.3FTE as a Physiotherapist and Clinical Lead for Central Otago Health Services. Sarah’s research focuses on rural healthcare and the rural allied health workforce. Sarah is due to finish her PhD in May 2023

Clinical Director Rural Health – NZRGPN/Hauroa Taiwhenua

Friday, May 21st, 2021 | Rory | No Comments

Congratulations Jeremy!

Taupō doctor appointed as Clinical Director Rural Health

The New Zealand Rural General Practice Network is pleased to announce the appointment of Dr Jeremy Webber to the new role of Clinical Director Rural Health.

The Clinical Director Rural Health (CDRH) will make a significant contribution to ensuring the rural voice is incorporated into the implementation phase of the Health Reforms recently announced.

Health Minister Andrew Little said, when opening the recent National Rural Health Conference in Taupō, that the opportunities for addressing the challenges rural New Zealand faces in accessing health services lie in the significant consultation that will be needed to develop the detail of the reforms.

Jeremy’s role will be critical to rural General Practice having input into these discussions.

The CDRH role is being supported by a group of PHOs who represent most rural general practices throughout New Zealand, and who are contributing significant funding to make this new position a reality.

In this position, Jeremy will bring his extensive clinical experience in rural health, systems knowledge, and expertise to support the Network’s strategic advocacy work.

Jeremy’s first task will be to set up forums with rural general practices so that ideas can be collated, developed, and tested before conveying these to the Transition Unit for consideration in the design of the new reforms.

Through involvement with rural providers and communities, Jeremy will provide rural leadership to Government’s policy developments and ensure that a rural voice is clearly heard and articulated by decision makers.

His work will include an explicit focus on the treaty commitment to Māori health as well as health equity for Māori and Pasifika. It will involve engaging with key stakeholders including rural healthcare providers, DHBs, Iwi groups, Primary Health Organisations, Alliance Leadership teams and rural communities.

Jeremy says he is looking forward to the impact he can make in this position during a period of significant change across the health sector.

“The CDRH role is an exciting appointment at an opportune time where the rural voice needs prominence and strength in the reshaping of health services in Aotearoa.”

“I am conscious of the calibre of all those involved in rural health delivery and look forward to listening and learning from their wisdom and working with them to achieve equitable health outcomes for rural communities.”

Jeremy is currently a Rural Hospital Medicine Specialist in Taupō Hospital where he has worked since 2016. His role involves working in the Emergency Department, the general inpatient unit, and in weekly rural clinics, often as a solo practitioner.

He is a passionate rural health professional, and this is reflected in his wide range of clinical experience in rural general practice, hospitals and emergency in Australia and New Zealand.

In Australia, Jeremy worked as a locum GP in Alice Springs, and as a rural GP for an Aboriginal Health Service for over three years.

Jeremy is enthusiastic about the education and training of rural medicine and is currently the Chair of the Division of Rural Hospital Medicine Board of Studies and is a Rural Clinical Educator at Auckland University.

As a member of the Royal New Zealand College of General Practitioners, Jeremy is also involved in training of Registrars and implementing rural medicine practice nationally.

Network Board Chair Dr Fiona Bolden says,

“Jeremy brings a wealth of experience with him across the spectrum of rural health services. He has been active in the rural health space in New Zealand for many years and has also shown his ability and interest in rural research and education during this time.”

“Rural general practice and rural hospitals need a champion at this time of change, someone who can communicate with those in the sector and can bring together the available research and data to help support a robust plan for rural health. I believe that with the support of all of us Jeremy will be very well placed to do that.”


Thursday, May 20th, 2021 | Rory | No Comments

Joint Clinical; Senior Lecturer in Rural Health & Senior Medical Officer Rural Hospital Medicine2100407

Contact Garry Nixon



The Otago Medical School – Dunedin Campus, in association with Clutha Health First, seeks to appoint a Senior Lecturer in Rural Health. This position provides an excellent opportunity for a clinical academic to establish themselves in one of the leading medical schools in Australasia.

The appointee will provide leadership in teaching and research in the field of Rural Health while supporting an effective and efficient service for patients in the Clutha District. There are opportunities for wide collaboration with researchers in the University’s well regarded medical and biomedical science departments.

In addition to holding the position of Senior Lecturer in Rural Health at the University of Otago, the appointee will concurrently hold a position as Rural Hospital Medicine Senior Medical Officer with Clutha Health First. This is a joint University/Hospital position and will be held as single contract with the University. The two separate roles equal the equivalent of one full-time position.

Academic Component – 0.5 FTE

The successful applicant will be based in Balclutha and be a member of the Department of General Practice and Rural Health, Otago Medical School – Dunedin Campus. The appointee will have appropriate experience in teaching and research. The incumbent will be responsible for teaching at both undergraduate and postgraduate levels. There will be significant opportunity for clinically based research, including undertaking a research based higher degree.

Clinical Component – 0.6 FTE

Clutha Health First provides primary, secondary and community-based services to a population of approximately 17,500. The Rural Hospital Medicine Senior Medical Officer (RHM SMO) is based within the 15 bed Inpatient Medical ward. The successful applicant will be responsible for all admitted patients being the sole rostered doctor on duty. Approximately 70% of all admitted patients are acute medical with the remaining 30% comprised of rehabilitation (e.g. post CVA, large joint replacement) and palliative care.

CHF is a Rural Teaching Centre for the University of Otago Rural Medical Immersion Programme hosting 5th year medical students for their full academic year. Other disciplines undertaking training include Rural Hospital Medicine registrar, GP registrars, nursing midwifery, occupational therapy, and social work students.

Further details

Collaboration and collegiality are important values in the Department, and we seek a colleague who will both enjoy and enhance our cooperative work environment. We are committed to equity and we value the benefits that diversity brings to our work and our community.

If you are looking for an exciting new opportunity and would like to learn more about joining our team, then please contact us for a confidential discussion via the contact details below:

Academic Component: Associate Professor Garry Nixon, Head of Section of Rural Health, Department of General Practice and Rural Health, Otago Medical School – Dunedin Campus.

Clinical Component: Gary Reed, Clinical Director, Clutha Health First.


To submit your application (including CV and cover letter) please click on the apply button below. There is no formal closing date and applications will be considered individually on receipt. The University reserves the right to close this vacancy at any time.

Additional Information

Contact: Associate Professor Garry Nixon    Tel: 021 1782662

Contact: Gary Reed    Tel: 027 228 5778

Webinar # 6: Wahine and Pepi – Obstetric emergencies in rural places

Sunday, May 16th, 2021 | Rory | No Comments

Webinar now up on YouTube if you want to watch (and didn’t make it to the session.)

Celia’s Slides

Brendan’s Slides


Audio only version is also available on podcast player of your choice.

Available on iTunes or any other podcast apps


There was an additional question that has been subsequently been answered:

Can you ask Celia/Brendan for advice about navigating responsibilities with midwives in acute situations? Who’s responsible for what?

From Brendan:

It’s a very good question and I suspect trickier in the acute situation in rural areas.

In larger units the team is called and in essence a ‘referrla of care’ has happened at that point and thus the obstetric team has ‘taken responsibility and lead the team.

I think this is how to interpret s88 and the specific NZ legislation (which has some very specific provisions that guide when care is handed over to an ‘obstetrician’). I know this provision fairly well as we’ve sort clarity (and with Celia’s help) have this extended to include Extended scope docs like Alan and myself.

What is less clear to me is exactly the scenario described where there isn’t an obs doctor. I’d have thought therefore that the primary responsibility remains with the LMC.

BUT this is a slightly different question to “who’s responsible for what” – and a bit like a trauma I suspect that the colleges would advocate for good communication and team based care. I think it’s a tricky as we’re used to being the point of referral and normally if we’re asked to be involved we’ve assumed that we are the team lead. I guess the problem becomes if the outcome is sub-optimal then how will the HDC view it??

Reality of introducing a new point-of-care test!

Thursday, May 13th, 2021 | Rory | No Comments

Beazley Catherine, Blattner Katharina, Herd Geoffrey (2021) Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective. Journal of Primary Health Care 13, 84-90.

An open access paper that is full of wisdom from the Hokianga. While we can reduce inequalities with near to patient technology, it is important not to neglect safety – QA! – and consider how that looks for your place: what is the resource? 



BACKGROUND AND CONTEXT: Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand’s far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme.

ASSESSMENT OF PROBLEM: Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements.

RESULTS: Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing.

STRATEGIES FOR IMPROVEMENT: Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance.

LESSONS: Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.

Improving access to medical education in regional/rural locations

Wednesday, May 12th, 2021 | Rory | No Comments

Kiuru, SP, Webster, CS. How might access to postgraduate medical education in regional and rural locations be best improved? A scoping review. Aust J Rural Health. 2021; 00: 19.

This scoping review from Sampsa is a good read. For me, the takeaway is the following quote:

“This study suggests that recognising the rural context is paramount. Context matters for learning and by linking learning to a professional environment provides meaning to the learner.”



Rural medical education is known as one of the most effective strategies in improving rural recruitment and retention. The aim was to identify modes of delivery to improve access to rural postgraduate medical education. Arksey and O’Malley’s methodological framework was used for conducting scoping reviews. CINAHL, Google Scholar, ERIC, PsycINFO, Medline and PubMed were searched to identify peer‐reviewed English‐language literature published between 2000 and 2019 focusing on postgraduate rural and regional medical education. A total of 102 articles were identified, with 51 included in the final analysis after applying inclusion and exclusion criteria. Outcome measures included: article type; research methodology; date of publication; country of origin; and study population. Through iterative reading, common themes were identified. A typology of 6 content themes emerged as follows: rural curriculum; procedural skills; rurally based learning; service delivery; workforce; and distance learning. The majority of articles focused on rural curriculum, and rurally based learning, with half originating from Australia or New Zealand. Although results strongly emphasised context and curriculum in rural environments, lack of specific and pragmatic approaches was noted. Surprisingly, few articles focused on rural distance learning utilising information and communication technology. Pathways to improve rural education access include recognition of the unique rural context in curriculums; development of rural educational faculty; and creation of opportunities for rural specialist training. Emphasis should be given for education provided through rural centres rather than urban facilities. Use of information technology could be increased, for example in remote trainee supervision programs.

Why we need better rural and remote health, now more than ever

Tuesday, May 11th, 2021 | Rory | No Comments

Worley P. Why we need better rural and remote health, now more than ever. Rural and Remote Health 2020; 20:5976. /10.22605/RRH5976

Open access

“services can now develop care protocols relevant to their own context and based on their own epidemiology rather than estimating how to adapt protocols developed in urban high-technology contexts.”

An editorial written in the context of COVID-19 lockdown last year that Garry revisited. Open access and really well written.

? How is it resourced ?

edit: link fixed 11/5/21 11:59

Congratulations Mafi!!

Wednesday, April 14th, 2021 | Rory | No Comments

Graduating in absentia,  Cook Islands May 2021

Among the many students graduating from Otago University this year is Dr Vakaola Mafi who is being awarded (in absentia, in the Cook Islands) the Postgraduate Diploma in Rural and Provincial Hospital Medicine

Mafi, as he is known to friends and colleagues is the first Pacific Island Country-based doctor to complete the largely distance-taught diploma. His study was facilitated under an MOU between the Cook Islands Ministry of Health and the University of Otago.

Mafi grew up in Tonga and completed his medical degree at Fiji National University. He moved to the Cook Islands with his wife (who is also a doctor) seven years ago, working as a general medical practitioner both in Aitutaki and Rarotonga.

In 2016, with limited postgraduate clinical training options open to him , he began to study in the Otago Postgraduate Rural programme by distance. Determined to reach his goal, he worked steadily at completing individual papers one at a time, studying in his own time alongside his full time clinical commitments.

Mafi’s achievement is all the more significant in that his final paper was completed entirely virtually due to the Covid pandemic: when he was unable to travel to the 5-day residential in Taranaki, a virtual link-in was created by the rural postgraduate faculty. While far from optimal, the virtual connection ensured his continued access to study.

For Mafi the best aspects of his study have been gaining connections and friendships with rural and GP colleagues in New Zealand and others in the Pacific, gaining a peer group. The biggest gain has been learning relevant evidence-based practice to a NZ standard which he can apply in his daily practice. His thanks go to his family who have supported him throughout .