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Published articles that are of interest to the rural health community

Cost savings of the rural accelerated chest pain pathway

Thursday, December 22nd, 2022 | claly44p | No Comments

The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis.

Rory Miller, Garry Nixon, Tim Stokes, Michelle Smith, John W. Pickering, Talis Liepins and Martin Than. Journal of Primary Health Care 2022 doi:10.1071/HC22117

Hot off the Press & available to all at https://www.publish.csiro.au/HC/HC22117

With a rural accelerated chest pain pathway developed and shown to be equivalent to accelerated diagnostic chest pain pathways in urban EDs for patients with low-risk cardiac events, the team has now surveyed patients to evaluate the potential cost savings to both individuals and the health system.  Despite the low response rate, it is evident that savings can be made at many levels.  This pathway will  now be evaluated across Aotearoa NZ https://www.hrc.govt.nz/resources/research-repository/evaluating-bedside-high-sensitivity-troponin-within-rural-chest-pain

 

ABSTRACT

Introduction. The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim. This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods. This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results. In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion. Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.

New chest pain test for rural hospitals and general practices

Tuesday, December 13th, 2022 | claly44p | No Comments

Congratulations to Rory and the team with their successful pilot study, supported by the Heart Foundation, evaluating the safety and effectiveness of an accelerated chest pain pathway, including a troponin test performed in rural settings.  Read more: https://www.heartfoundation.org.nz/about-us/news/stories/new-chest-pain-test-for-rural-hospitals-and-general-practices

A message from Rory:

A sincere and huge thank you to all sites that contributed to this project and made it a success. The primary findings have been published here as an open access article:  https://academic.oup.com/ehjacc/article/11/5/418/6562963?login=false and covered here in LOFP: https://blogs.otago.ac.nz/rural/a-prospective-multi-centre-study-assessing-the-safety-and-effectiveness-following-the-implementation-of-an-accelerated-chest-pain-pathway-using-point-of-care-troponin-for-use-in-new-zealand-rural-hosp/

The project is discussed here on the podcast: https://blogs.otago.ac.nz/rural/podcast-rural-accelerated-chest-pain-pathway-repost-from-the-rnzcuc/

We have subsequently been awarded a research grant to implement a high sensitivity point-of-care troponin in 30 rural health facilities across Aotearoa. If you are currently using a point-of-care troponin and are interested in being part of this project then please reach out to: rory.miller@otago.ac.nz

Doctors’ experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study

Thursday, December 8th, 2022 | claly44p | No Comments

Hedman M, Doolan-Noble F, Stokes T and Brännström M. 
BMJ Open 2022;12:e062968. doi: 10.1136/bmjopen-2022-062968

 

Back in 2018 the Department of General Practice and Rural Health hosted Dr Mante Hedman – rural GP from northern Sweden – for his PhD research on rural health care in Sweden and NZ. His NZ research has now been published and is OPEN ACCESS: https://bmjopen.bmj.com/content/12/12/e062968

Abstract

Objective To explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals. Design The study had a qualitative design, using qualitative content analysis. Setting The study was conducted in South Island, New Zealand, and included nine different rural hospitals. Respondents Semistructured interviews were conducted with 16 rural hospital doctors. Results Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience. Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context. Conclusions This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

Defining rural in Aotearoa New Zealand: a novel geographic classification for health purposes

Wednesday, October 26th, 2022 | claly44p | No Comments

OPEN ACCESS NOW AVAILABLE

Jesse Whitehead, Gabrielle Davie, Brandon de Graaf, Sue Crengle, David Fearnley, MicHelle Smith, Ross Lawrenson & Garry Nixon

NZMJ, Vol135, No 1559. Published August 5, 2022: https://journal.nzma.org.nz/journal-articles/defining-rural-in-aotearoa-new-zealand-a-novel-geographic-classification-for-health-purposes

You’ve heard about it!  Now read in detail on how the Geographic Classification for Health in Aotearoa NZ was developed. A game-changer for rural health policy and delivery.

Abstract

Aim: Describe the first specifically designed and validated five-level rurality classification for health purposes in New Zealand that is both data-driven and incorporates heuristic understandings of rurality. Method: Our approach involved: (1) defining the purpose and parameters of a proposed five-level Geographic Classification for Health (GCH); (2) developing a quantitative framework; (3) undertaking co-design with the National Rural Health Advisory Group (NRHAG), and extensive consultation with key stakeholders; (4) testing the validity of the five-level GCH and comparing it to previous Statistics New Zealand (Stats NZ) rurality classifications; and (5) describing rural populations and identifying differences in all-cause mortality using the GCH and previous Stats NZ rurality classifications.  Results: The GCH is a technically robust and heuristically valid rurality classification for health purposes. It identifies a rural population that is different to the population defined by generic Stats NZ classifications. When applied to New Zealand’s Mortality Collection, the GCH estimates a rural mortality rate 21% higher than for residents of urban areas. These rural–urban disparities are masked by the generic Stats NZ classifications. Conclusion: The development of the five-level GCH embraces both the technical and heuristic aspects of rurality. The GCH offers the opportunity to develop a body of New Zealand rural health literature founded on a robust conceptualisation of rurality.

Equity of travel required to access first definitive surgery for liver or stomach cancer in New Zealand

Wednesday, October 5th, 2022 | claly44p | No Comments

Gurney J, Whitehead J, Kerrison C, Stanley J, Sarfati D, Koea J. Equity of travel required to access first definitive surgery for liver or stomach cancer in New Zealand. PLoS One. 2022 Aug 11;17(8):e0269593. doi: 10.1371/journal.pone.0269593. PMID: 35951652; PMCID: PMC9371338.

OPEN ACCESS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9371338/

This recent study focuses on travel required for patients to access surgery for liver or stomach cancer in New Zealand, particularly for Māori. Gurney et al. find that that Māori on average travel twice as far for cancer surgery compared to Europeans. A substantial minority of both Māori and European liver cancer patients must travel more than 200km for their first primary liver surgery, and this situation appears worse for Māori. This research has important implications for rural communities – which have a higher proportion of Māori residents than urban areas – and there are likely to be similar situations with other essential health services. To help address these inequitable travel barriers to access cancer care, it is recommended that additional support is provided to Māori patients, including financial support, and that Te Whatu Ora consider localising as much service provision as possible. (J.Whitehead)

 

Abstract

In New Zealand, there are known disparities between the Indigenous Māori and the majority non-Indigenous European populations in access to cancer treatment, with resulting disparities in cancer survival. There is international evidence of ethnic disparities in the distance travelled to access cancer treatment; and as such, the aim of this paper was to examine the distance and time travelled to access surgical care between Māori and European liver and stomach cancer patients. We used national-level data and Geographic Information Systems (GIS) analysis to describe the distance travelled by patients to receive their first primary surgery for liver or stomach cancer, as well as the estimated time to travel this distance by road, and the surgical volume of hospitals performing these procedures. All cases of liver (ICD-10-AM 3rd edition code: C22) and stomach (C16) cancer that occurred in New Zealand (2007-2019) were drawn from the New Zealand Cancer Registry (liver cancer: 866 Māori, 2,460 European; stomach cancer: 953 Māori, 3,192 European), and linked to national inpatient hospitalisation records to examine access to surgery. We found that Māori on average travel 120km for liver cancer surgery, compared to around 60km for Europeans, while a substantial minority of both Māori and European liver cancer patients must travel more than 200km for their first primary liver surgery, and this situation appears worse for Māori (36% vs 29%; adj. OR 1.48, 95% CI 1.09-2.01). No such disparities were observed for stomach cancer. This contrast between cancers is likely driven by the centralisation of liver cancer surgery relative to stomach cancer. In order to support Māori to access liver cancer care, we recommend that additional support is provided to Māori patients (including prospective financial support), and that efforts are made to remotely provide those clinical services that can be decentralised.

Mortality outcomes and inequities experienced by rural Māori in Aotearoa New Zealand

Wednesday, August 24th, 2022 | claly44p | No Comments

Sue Crengle, Gabrielle Davie, Jesse Whitehead, Brandon de Graaf, Ross Lawrenson & Garry Nixon

OPEN ACCESS: Lancet Regional Health – Western Pacific 2022;28:100570. Published August 18, 2022 DOI: https://doi.org/10.1016/j.lanwpc.2022.100570

This paper is the first to use the new Geographic Classification of Health (https://blogs.otago.ac.nz/rural-urbannz/) to examine rural:urban differences and demonstrates how the GCH will impact health policy and research going forward.  Crengle et al. confirm that Māori living rurally face greater mortality incidence rates than non-Māori or urban-based Māori whereas previous studies, using older classifications, found rural Māori mortality was comparable to that of Māori living in metropolitan areas.

Summary

Background. Previous research identified inequities in all-cause mortality between Māori and non-Māori populations. Unlike comparable jurisdictions, mortality rates in rural areas have not been shown to be higher than those in urban areas for either population. This paper uses contemporary mortality data to examine Māori and non-Māori mortality rates in rural and urban areas. Methods. A population-level observational study using deidentified routinely collected all-cause mortality, amenable mortality and census data. For each level of the Geographic Classification for Health (GCH), Māori and non-Māori age-sex standardised all-cause mortality and amenable mortality incident rates, Māori:Non-Māori standardised incident rate ratios and Māori rural:urban standardised incident rate ratios were calculated. Age and deprivation stratified rates and rate ratios were also calculated. Findings. Compared to non-Māori, Māori experience excess all-cause (SIRR 1.87 urban; 1.95 rural) and amenable mortality (SIRR 2.45 urban; 2.34 rural) and in all five levels of the GCH. Rural Māori experience greater all-cause (SIRR 1.07) and amenable (SIRR 1.13) mortality than their urban peers. Māori and non-Māori all-cause and amenable mortality rates increased as rurality increased. Interpretation. The excess Māori all-cause mortality across the rural: urban spectrum is consistent with existing literature documenting other Māori health inequities. A similar but more pronounced pattern of inequities is observed for amenable mortality that reflects ethnic differences in access to, and quality of, health care. The excess all-cause and amenable mortality experienced by rural Māori, compared to their urban counterparts, suggests that there are additional challenges associated with living rurally.

The allied health workforce of rural Aotearoa New Zealand: a scoping review

Wednesday, July 20th, 2022 | claly44p | No Comments

Walker Sarah M., Kennedy Ewan, Nixon Garry, Blattner Katharina (2022) The allied health workforce of rural Aotearoa New Zealand: a scoping review. Journal of Primary Health Care. https://doi.org/10.1071/HC22055

 Open Access https://www.publish.csiro.au/HC/HC22055

 Great to see a focus on rural allied health professionals (AHP) who are often under-appreciated when we consider optimising health outcomes in our rural communities.  The lack of published material will not be surprising to AHP living and working in rural/remote Aotearoa and I applaud Sarah and colleagues for starting this narrative and highlighting important areas for research that could address rural AHP workforce capacity, capability, recognition and career progression.

 

ABSTRACT

Introduction: The allied health workforce is a crucial, if at times poorly visible, component of modern healthcare systems. The services provided by allied health professionals may be particularly important for underserved populations, including rural and remote communities.

Aim: To determine what is currently known through research about the allied health workforce in rural Aotearoa New Zealand.

Method: A scoping review of diverse sources of literature from Aotearoa New Zealand was obtained from seven databases (July 2011–July 2021).

Results: Eighty-nine articles were identified, of which 10 met the inclusion criteria; nine empirical studies and one narrative review. The included research fell into two main categories: geographic workforce distribution (n = 8), and the role of the rural allied health workforce (n = 2).

Discussion: The paucity of research that meets the criteria for inclusion makes it difficult to draw conclusions about the allied health workforce in rural Aotearoa New Zealand. There is a focus in both the international rural allied health literature and the Aotearoa New Zealand rural medical and nursing literature on: measuring geographic workforce distribution; and rural-specific training. This suggests that these issues are important to the rural workforce. Similar research is needed in Aotearoa New Zealand to inform policy and ensure the rural allied health workforce reaches its full potential in improving health outcomes for rural New Zealanders.

Wellbeing and health in a small New Zealand rural community

Friday, May 27th, 2022 | claly44p | No Comments

Chrystal Jaye, Judith McHugh, Fiona Doolan-Noble, Lincoln Wood,
Wellbeing and health in a small New Zealand rural community: Assets, capabilities and being rural-fit. Journal of Rural Studies, Volume 92, 2022, Pages 284-293, ISSN 0743-0167

https://doi.org/10.1016/j.jrurstud.2022.04.005

A nice paper that’s well worth reading,  A ‘healthy’ reminder about what actually matters.  Healthcare doesn’t figure that highly when rural dwellers consider health. Place is much more important, both the geographic and the social. There are no prizes for guessing the community!

Abstract

Rural dwellers in New Zealand often have fewer locally available health services. Health inequities are particularly salient for rural dwellers who are older and/ or Māori, yet the focus on these inequities has resulted in a deficit view of rural. There has been little attention to considering health and wellbeing through positive frameworks such as the Assets and Capabilities approaches. This project aimed to explore what can be learned from one small rural community about wellbeing and health; including sources of wellbeing and health. A combination of qualitative methods was used to collect data from 17 adults living in a small South Island rural community. All participants were interviewed and given the option of taking photographs to illustrate what wellbeing and health meant to them. Most participants reported that they were satisfied with their access to primary healthcare services, while acknowledging service gaps, particularly in mental health and emergency services. Health was described primarily in terms of wellbeing, and participants referenced concepts of wellbeing and health against local assets (place, community support networks, livestock, rural lifestyle and values), and a suite of capabilities adapted to the demands of the place in which they lived. The high value that rural dwellers place on the assets of their rural community and the contribution of these to their wellbeing and health may mitigate the disadvantages of distance to health services. This balance is mediated by capabilities that may be rural specific, particularly mobility and physical functioning.

COVID-19 impact on New Zealand general practice: rural–urban differences

Monday, May 23rd, 2022 | claly44p | No Comments

Eggleton K, Bui N, Goodyear-Smith F. COVID-19 impact on New Zealand general practice: rural–urban differences. Rural and Remote Health 2022; 22: 7185. https://doi.org/10.22605/RRH7185

This paper performed serial surveys in general practices across 4 countries and demonstrates something that many of us intuitively know – rural general practice is different: adaptable and resilient – in response to COVID-19 anyway. We agree with Kyle and his team that further efforts are required to define and understand NZ rural general practice – and would extend that to include all rural health providers.  

ABSTRACT

Introduction

In countries such as New Zealand, where there has been little community spread of COVID-19, psychological distress has been experienced by the population and by health workers. COVID-19 has caused changes in the model of care that is delivered in New Zealand general practice. It is unknown, however, whether the changes wrought by COVID-19 have resulted in different levels of strain between rural and urban general practices. This study aims to explore these differences from the impact of COVID-19.

Methods

This study is part of a four-country collaboration (Australia, New Zealand, Canada and the USA) involving repeated cross-sectional surveys of primary care practices in each respective country. Surveys were undertaken at regular intervals throughout 2020 of urban and rural general practices throughout New Zealand. Five core questions were asked at each survey, relating to experiences of strain, capacity for testing, stressors experienced, types of consultations being carried out and numbers of patients seen. Simple descriptive statistics were used to analyse the data.

Results

A total of 1516 responses were received with 20% from rural practices. A moderate degree of strain was experienced by general practices, although rural practices appeared to experience less strain compared to urban ones. Rural practices had fewer staff absent from work, were less likely to use alternative forms of consultations such as video consultations and telephone consultations, and had possibly lower reductions in patient volumes. These variations might be related to personal characteristics of rural as compared to urban practices or different models of care.

Conclusion

New Zealand rural general practice appeared to have a different response to the COVID-19 pandemic compared to urban general practice, illustrating the significant strengths and resilience of rural practices. While different experiences from COVID-19 might reflect differences in the demographics of the rural and urban general practice workforce, another proposition is that this difference indicates a rural model of care that is more adaptive compared to the urban one. This is consistent with the literature that rural general practice has the capacity to manage conditions in a different way to urban. While other comparable countries have demonstrated a unique rural model of care, less is known about this in New Zealand, adding weight to an argument to further define New Zealand rural general practice.

Hydroxyurea Interference in Point-of-Care Creatinine and Glucose Measurements

Tuesday, May 17th, 2022 | claly44p | No Comments

Shane A. Betman, Eldad A. Hod, Alexander Kratz, 57: Hydroxyurea Interference in Point-of-Care Creatinine and Glucose Measurements, American Journal of Clinical Pathology, Volume 143, Issue suppl_1, 1 May 2015, Page A030, https://doi.org/10.1093/ajcp/143.suppl1.031

Spurious iSTAT POC creatinine (and glucose) results with hydroxyurea

Many of us rely on iSTAT POC bloods some, or all of the time. We had a recent experience of an elderly patient who had a iSTAT POC creatinine of > 200 micromol/L and who we managed as AKI overnight. The next day his creatinine done in the main lab was 70 micromol/L.  Repeated tests  done on both the iStat and in the main lab using the same samples kept returning a similar  large disparity in creatinine levels. The problem in the end turned out to be the hyroxyurea that patient was on – which falsely elevates iSTAT POC creatinine levels. The manufacturers advice when an patient is on hydroxyurea is ‘use another method’ to test the creatinine. And it looks like the hyroxyurea has the same effect on the iSTAT glucose reading and parcetamol (not at therapeutic levels but potentially in an overdose) might have the same effect of falsely elevating the iSTAT creatinine. Might be worth keeping this in mind.

 

ABSTRACT

Background: Measurements of creatinine and glucose on the i-STAT point-of-care testing (POCT) device are known to be elevated in the presence of hydroxyurea. This interference can lead to differences between creatinine and glucose results reported from the i-STAT and samples analyzed with other methods. We sought to characterize the extent of this interference and to compare results with the epoc, a POCT device similar to the i-STAT.

Methods: Patient serum samples with known creatinine levels were pooled to create three standards – normal range (NR), high (H), and very high (VH) creatinine. Serial dilutions of hydroxyurea were added to aliquots of each standard, resulting in final hydroxyurea concentrations between 0 and 2,000 μmol/L. Each aliquot was tested with the i-STAT, epoc, and Olympus platforms.

Results: Creatinine and glucose measurements on the iSTAT showed a dose-response relationship with the concentration of hydroxyurea in the sample. Disregarding data points outside the reportable range (output from i-STAT “>20.0” or “***”), the creatinine data fit linear regression models with slopes of 0.0138 (R2 = 0.994), 0.0127 (R2 = 0.995), and 0.0163 (R2 = 0.978) for the NR, H, and VH standards, respectively. The glucose data fit linear regression models with slopes of 0.104 (R2 = 0.999), 0.102 (R2 = 0.999), 0.111 (R2 = 0.998) for the NR, H, and VH standards, respectively. Creatinine and glucose showed no correlation with hydroxyurea levels when tested with the epoc or Olympus. All other analytes tested were unaffected by hydroxyurea levels.

Conclusions: Hydroxyurea causes linear dose-dependent elevations of creatinine and glucose results from the i-STAT POCT device. Based on our linear model and pharmacokinetic data, using the i-STAT following a typical dose of hydroxyurea could result in a creatinine level that is falsely elevated by 6.15 mg/dL on average and a glucose level that is falsely elevated by 46.09 mg/dL on average. Other platforms tested did not show interference by hydroxyurea. As the operators of POCT devices are unlikely to be familiar with the limitations of the testing methodology, it is important for laboratory professionals to keep them informed of appropriate practices.

© American Society for Clinical Pathology

NOTE: 6.15mg/dL (from the conclusion) = 543 umol/L and 46.09mg/dL glucose = 2.5mmol/L