A retrospective observational study examining interhospital transfers from six New Zealand rural hospitals in 2019

Friday, July 28th, 2023 | claly44p | No Comments

Rory MillerElizabeth RimmerKatharina BlattnerSteve WithingtonStephen RamMeg ToppingHemi KakaAnna BerginJoel PiriniMichelle SmithGarry Nixon. First published: 25 July 2023 https://doi.org/10.1111/ajr.13024

Often good research involves questioning quite basic assumptions. This one tests the assumption that including specialists in a rural hospital workforce will reduce the number of patients that need transfer to the base hospital. Something I think that many in the health system (and community) would consider axiomatic. But based on the results of this small study, the exact opposite may be the case. It has obvious health policy implications. Well done to those who did this study with minimal resource, and especially the students that were involved. (Garry Nixon)



The aim of this study was to identify the percentage of patients that were transferred from rural hospitals and who received an investigation or intervention at an urban hospital that was not readily available at the rural hospital.


A retrospective observational study.


Patients were randomly selected and clinical records were reviewed. Patient demographic and clinical information was collected, including any interventions or investigations occurring at the urban referral hospital. These were compared against the resources available at the rural hospitals.


Six New Zealand (NZ) rural hospitals were included.


Patients that were transferred from a rural hospital to an urban hospital between 1 Jan 2019 and 31 December 2019 were included.

Main Outcome Measures

The primary outcome measure was the percentage of patients who received an investigation or intervention that was not available at the rural hospital.


There were 584 patients included. Overall 73% of patients received an intervention or investigation that was not available at the rural hospital. Of the six rural hospitals, there was one outlier, where only 37% of patients transferred from that hospital received an investigation or intervention that was not available rurally. Patients were most commonly referred to general medicine (23%) and general surgery (18%). Of the investigations or interventions performed, 43% received a CT scan and 25% underwent surgery.


Most patients that are transferred to urban hospitals receive an intervention or investigation that was not available at the rural hospital.

Rural residents die at higher rates than those in urban centres

Tuesday, July 18th, 2023 | claly44p | No Comments

Hot off the Press

Nixon, Garry, Gabrielle Davie, Jesse Whitehead, Rory Miller, Brandon de Graaf, Ross Lawrenson, Michelle Smith, John Wakerman, John Humphreys, and Sue Crengle. “Comparison of urban and rural mortality rates across the lifespan in Aotearoa/New Zealand: a population-level study.” J Epidemiol Community Health (2023).


Using mortality data from the Ministry of Health and Statistics New Zealand, the awesome GCH team, led by our very own Prof Garry Nixon analysed the age, sex, ethnicity and cause of 160,179 deaths registered in New Zealand between 2014 and 2018.  Deaths were categorised into five outcomes; all-cause, amenable (those that are potentially avoidable if given effective and timely healthcare), cardiovascular, cancer and injury. The results – which contradict existing data – are the strongest evidence yet that all New Zealanders who live in rural areas have poorer health outcomes across all groups aged under 60. The largest disparities were most apparent among those aged under 30 in the most rural communities where the mortality rates were double that of the most urban centres.

The disparities are most evident for injury and amenable death.

Results have major implications for rural health policy in ensuring equitable delivery of healthcare.

Check out the 1News coverage here

Background: Previous studies undertaken in New Zealand using generic rurality classifications have concluded that life expectancy and age-standardised mortality rates are similar for urban and rural populations.
Methods: Administrative mortality (2014–2018) and census data (2013 and 2018) were used to estimate age-stratified sex-adjusted mortality rate ratios (aMRRs) for a range of mortality outcomes across the rural-urban spectrum (using major urban centres as the reference) for the total population and separately for Māori and non-Māori. Rural was defined according to the recently developed Geographic Classification for Health.
Results: Mortality rates were higher overall in rural areas. This was most pronounced in the youngest age group (<30 years) in the most remote communities (eg, all-cause, amenable and injury-related aMRRs (95% CIs) were 2.1 (1.7 to 2.6), 2.5 (1.9 to 3.2) and 3.0 (2.3 to 3.9) respectively. The rural:urban differences attenuated markedly with increasing age; for some outcomes in those aged 75 years or more, estimated aMRRs were <1.0. Similar patterns were observed for Māori and non-Māori.
Conclusion: This is the first time that a consistent pattern of higher mortality rates for rural populations has been observed in New Zealand. A purpose-built urban- rural classification and age stratification were important factors in unmasking these disparities.

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.

Influence of a rural interprofessional education placement on the rural health workforce: working in primary care, rural settings, and with Māori

Thursday, June 1st, 2023 | claly44p | No Comments

Darlow Ben, Brown Melanie, McKinlay Eileen, Gray Lesley, Purdie Gordon, Pullon Sue (2023) Influence of a rural interprofessional education placement on the rural health workforce: working in primary care, rural settings, and with Māori. Journal of Primary Health Care 15, 78-83.

OPEN ACCESS https://www-publish-csiro-au.ezproxy.otago.ac.nz/hc/HC22136

Rural workforce outcomes:

“Our study suggests that short rural immersion placements do not increase rural workforce participation during early healthcare careers.”

Although a little disheartening, the authors’ findings are not that surprising given the design of their study. By only including data to 3 years after graduation we don’t really know what influence it has had on actual workforce outcomes. If we look at doctors, it’s essentially impossible to work in a rural area within the first 2 years of graduation. However the authors’ conclusion probably does align with overseas research that short rural placements have minimal impact on workforce outcomes.

Although probably not so important given the “negative” result, an issue with this study was it used self-reported geographic location. It will be great to see any future research like this to be linked to the Geographic Classification for Health (GCH)

Working with Māori outcomes:

There wasn’t anything “measurable” here. However, the free text thematic analysis showed participant’s attitudes towards working with Māori were really positive. Some “before” data might have been useful too though for comparison and to see what changes were linked to the programme.

A new research area to explore?:
The free text comments from this study show some positive attitude shifts towards rural health. It would be really interesting to see some more research into the benefits of the “rurally attuned” urban medical professional. It might not fix our rural health workforce crisis but there would hopefully still be some benefits to our communities!

(Katelyn Costello)



Introduction: Pre-registration interprofessional rural immersion programmes provide students with first-hand insight into challenges faced in rural clinical practice and can influence future practice intentions. The impact of short rural and hauora Māori interdisciplinary placements on early healthcare careers is unknown.

Aim: Explore whether a 5-week rural interprofessional education programme influenced graduates’ choices to work in primary care, rurally, and with Māori patients.

Methods: We conducted a survey-based, non-randomised trial of graduates from eight healthcare disciplines who did (n = 132) and did not (n = 479) attend the Tairāwhiti interprofessional education rural programme with hauora Māori placements. Participants were surveyed at 1-, 2-, and 3-years’ post-registration. Self-reported practice location and vocation were analysed with mixed-model logistic regression. Free-text comments were analysed with Template Analysis.

Results: We did not identify any measurable impact on rural or community workforce participation at 3-years’ post-registration. Free-text analysis indicated that a short rural interprofessional immersion placement had long-term self-perceived impacts on desire and skills to work in rural locations, and on desire and ability to work with Māori and embrace Māori models of health.

Discussion: Our study suggests that short rural immersion placements do not increase rural workforce participation during early healthcare careers. Three-years’ post-graduation may be too early to determine whether rural placements help to address rural health workforce needs. Reports from rural placement participants of increased ability to care for people from rural backgrounds, even when encountered in a city, suggest that assessment of practice location may not adequately capture the benefits of rural placement programmes.

Telehealth in remote Australia: a supplementary tool or an alternative model of care replacing face-to-face consultations?

Friday, May 5th, 2023 | claly44p | No Comments

Mathew, S., Fitts, M.S., Liddle, Z. et al. Telehealth in remote Australia: a supplementary tool or an alternative model of care replacing face-to-face consultations?. BMC Health Serv Res 23, 341 (2023).

OPEN ACCESS: https://doi.org/10.1186/s12913-023-09265-2

Interesting paper in the context of COVID19 on telehealth in rural and remote areas in Australia.  There are opportunities in this space with the COVID19 experience normalising telehealth, yet we need to bear in mind it is not an approach that save’s time or one that suits every one.  It would be interesting to hear the perspective of patients.



Background: The COVID-19 pandemic increased the use of telehealth consultations by telephone and video around the world. While telehealth can improve access to primary health care, there are significant gaps in our understanding about how, when and to what extent telehealth should be used. This paper explores the perspectives of health care staff on the key elements relating to the effective use of telehealth for patients living in remote Australia.

Methods: Between February 2020 and October 2021, interviews and discussion groups were conducted with 248 clinic staff from 20 different remote communities across northern Australia. Interview coding followed an inductive approach. Thematic analysis was used to group codes into common themes.

Results: Reduced need to travel for telehealth consultations was perceived to benefit both health providers and patients. Telehealth functioned best when there was a pre-established relationship between the patient and the health care provider and with patients who had good knowledge of their personal health, spoke English and had access to and familiarity with digital technology. On the other hand, telehealth was thought to be resource intensive, increasing remote clinic staff workload as most patients needed clinic staff to facilitate the telehealth session and complete background administrative work to support the consultation and an interpreter for translation services. Clinic staff universally emphasised that telehealth is a useful supplementary tool, and not a stand-alone service model replacing face-to-face interactions.

Conclusion: Telehealth has the potential to improve access to healthcare in remote areas if complemented with adequate face-to-face services. Careful workforce planning is required while introducing telehealth into clinics that already face high staff shortages. Digital infrastructure with reliable internet connections with sufficient speed and latency need to be available at affordable prices in remote communities to make full use of telehealth consultations. Training and employment of local Aboriginal staff as digital navigators could ensure a culturally safe clinical environment for telehealth consultations and promote the effective use of telehealth services among community members.

The place of rural hospitals in New Zealand’s health system: an exploratory qualitative study

Thursday, May 4th, 2023 | claly44p | No Comments

Blattner K, Clay L, Nixon G, Richard L, Miller R, Crengle S, Anton R, Stokes T.  The place of rural hospitals in New Zealand’s health system: an exploratory qualitative study . Rural and Remote Health 2023; 23: 7583.

OPEN ACCESS: https://doi.org/10.22605/RRH7583

It’s great to hear non-medical perspectives on the place/role of our rural hospitals. With no clear definition of what a rural hospital is, this paper highlights the range of contexts our hospitals work across between primary and secondary care, and the strengths and challenges they face.  For local communities, rural hospitals are invaluable yet they can appear invisible to the wider health system.  We hope this work further informs the Rural Health Strategy due later this year.


Introduction:  In Aotearoa New Zealand (NZ) there is a knowledge gap regarding the place and contribution of rural hospitals in the health system. New Zealanders residing in rural areas have poorer health outcomes than those living in urban areas, and this is accentuated for Māori, the Indigenous people of the country. There is no current description of rural hospital services, no national policies and little published research regarding their role or value. Around 15% of New Zealanders rely on rural hospitals for health care. The purpose of this exploratory study was to understand national rural hospital leadership perspectives on the place of rural hospitals in the NZ health system.
Methods:  A qualitative exploratory study was undertaken. The leadership of each rural hospital and national rural stakeholder organisations were invited to participate in virtual semi-structured interviews. The interviews explored participants’ views of the rural hospital context, the strengths and challenges they faced and how good rural hospital care might look. Thematic analysis was undertaken using a framework-guided rapid analysis method.
Results:  Twenty-seven semi-structured interviews were conducted by videoconference. Two broad themes were identified, as follows. Theme 1, ‘Our place and our people’, reflected the local, on-the-ground situation. Across a broad variety of rural hospitals, geographical distance from specialist health services and community connectedness were the common key influencers of a rural hospital’s response. Local services were provided by small, adaptable teams across broad scopes and blurred primary–secondary care boundaries, with acute and inpatient care a key component. Rural hospitals acted as a conduit between community-based care and city-based secondary or tertiary hospital care. Theme 2, ‘Our positioning in the wider health system’, related to the external wider environment that rural hospitals worked within. Rural hospitals operating at the margins of the health system faced multiple challenges in trying to align with the urban-centric regulatory systems and processes they were dependent on. They described their position as being ‘at the end of the dripline’. In contrast to their local connectedness, in the wider health system participants felt rural hospitals were undervalued and invisible. While the study found strengths and challenges common to all NZ rural hospitals, there were also variations between them.
Conclusion:  This study furthers understanding of the place of rural hospitals in the NZ healthcare system as seen through a national rural hospital lens. Rural hospitals are well placed to provide an integrative role in locality service provision, with many already long established in performing this role. However, context-specific national policy for rural hospitals is urgently needed to ensure their sustainability. Further research should be undertaken to understand the role of NZ rural hospitals in addressing healthcare inequities for those living in rural areas, particularly for Māori.

Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72

Monday, April 24th, 2023 | claly44p | No Comments

Rory Miller, Garry Nixon, Robin M. Turner, Tim Stokes, Rawiri Keenan, Yannan Jiang, Corina Grey, and Andrew Kerr. “Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72.” The New Zealand Medical Journal 136, no. 1573 (2023): 27-54.

Take home messages for those of us working in rural hospitals: The NSTEACS patients we deal with have similar outcomes to those admitted to the bigger hospitals, which is something we can be really pleased about given international, and some of the old NZ, data comparing rural and urban outcomes. This is despite our patients having significantly lower rates of angiography.  It speaks to our acute management and ability to transfer the patients who will benefit from angiography. It looks like the survival curves do start to diverge after a year. This needs further exploration but raises questions about follow-up and secondary prevention for rural patients. Good job on this paper everyone in providing care for these patients.


Aim: This study’s aim was to identify differences in invasive angiography performed and health outcomes for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) presenting to either i) a rural hospital, or an urban hospital ii) with or iii) without routine access to percutaneous intervention (PCI) in New Zealand. 

Methods: Patients with NSTEACS between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to model each of the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding. 

Results: There were 42,923 patients included. Compared to urban hospitals with access to PCI, the odds of a patient receiving an angiogram were reduced for rural and urban hospitals without routine access to PCI (odds ratio [OR] 0.82 and 0.75) respectively. There was a small increase in the odds of dying at 2 years (OR 1.16), but not 30 days or 1 year for patients presenting to a rural hospital. 

Conclusion: Patients who present to hospitals without PCI are less likely to receive angiography. Reassuringly there is no difference in mortality, except at 2 years, for patients that present to rural hospitals. 

Unmasking hidden disparities: a comparative observational study examining the impact of different rurality classifications for health research in Aotearoa New Zealand

Tuesday, April 18th, 2023 | claly44p | No Comments

Jesse Whitehead, Gabrielle Davie, Brandon de Graaf, Sue Crengle, Ross Lawrenson, Rory Miller, and Garry Nixon. “Unmasking hidden disparities: a comparative observational study examining the impact of different rurality classifications for health research in Aotearoa New Zealand.” BMJ open 13, no. 4 (2023): e067927.

OPEN ACCESS: https://bmjopen.bmj.com/content/13/4/e067927.info

The key outcome of this paper is how rural health outcomes have been underestimated by previous rurality classifications for many years. Using the Geographic Classification for Health (GCH) in any future rural-urban health analysis is encouraged.


Objectives Examine the impact of two generic—urban–rural experimental profile (UREP) and urban accessibility (UA)—and one purposely built—geographic classification for health (GCH)—rurality classification systems on the identification of rural–urban health disparities in Aotearoa New Zealand (NZ).

Design A comparative observational study.

Setting NZ; the most recent 5 years of available data on mortality events (2013–2017), hospitalisations and non-admitted hospital patient events (both 2015–2019).

Participants Numerator data included deaths (n=156 521), hospitalisations (n=13 020 042) and selected non-admitted patient events (n=44 596 471) for the total NZ population during the study period. Annual denominators, by 5-year age group, sex, ethnicity (Māori, non-Māori) and rurality, were estimated from Census 2013 and Census 2018.

Primary and secondary outcome measures Primary measures were the unadjusted rural incidence rates for 17 health outcome and service utilisation indicators, using each rurality classification. Secondary measures were the age-sex-adjusted rural and urban incidence rate ratios (IRRs) for the same indicators and rurality classifications.

Results Total population rural rates of all indicators examined were substantially higher using the GCH compared with the UREP, and for all except paediatric hospitalisations when the UA was applied. All-cause rural mortality rates using the GCH, UA and UREP were 82, 67 and 50 per 10 000 person-years, respectively. Rural–urban all-cause mortality IRRs were higher using the GCH (1.21, 95% CI 1.19 to 1.22), compared with the UA (0.92, 95% CI 0.91 to 0.94) and UREP (0.67, 95% CI 0.66 to 0.68). Age-sex-adjusted rural and urban IRRs were also higher using the GCH than the UREP for all outcomes, and higher than the UA for 13 of the 17 outcomes. A similar pattern was observed for Māori with higher rural rates for all outcomes using the GCH compared with the UREP, and 11 of the 17 outcomes using the UA. For Māori, rural–urban all-cause mortality IRRs for Māori were higher using the GCH (1.34, 95% CI 1.29 to 1.38), compared with the UA (1.23, 95% CI 1.19 to 1.27) and UREP (1.15, 95% CI 1.10 to 1.19).

Conclusions Substantial variation in rural health outcome and service utilisation rates were identified with different classifications. Rural rates using the GCH are substantially higher than the UREP. Generic classifications substantially underestimated rural–urban mortality IRRs for the total and Māori populations.

Defining catchment boundaries and their populations for Aotearoa New Zealand’s rural hospitals

Saturday, April 1st, 2023 | claly44p | No Comments

Whitehead Jesse, Blattner Katharina, Miller Rory, Crengle Sue, Ram Stephen, Walker Xaviour, Nixon Garry (2023) Defining catchment boundaries and their populations for Aotearoa New Zealand’s rural hospitals. Journal of Primary Health Care , -.


This study provides for the first time in NZ, a standardised description of each rural hospital’s catchment boundary and the socio-demographic characteristics of the population living within it. Confirms that NZ’s rural hospitals serve very different communities.

Included on page 1 is a very helpful box explaining in fairly simple terms, geographic units so that those of us who aren’t familiar them can at least start to understand! (K. Blattner)


Introduction: There is considerable variation in the structure and resources of New Zealand (NZ) rural hospitals; however, these have not been recently quantified and their effects on healthcare outcomes are poorly understood. Importantly, there is no standardised description of each rural hospital’s catchment boundary and the characteristics of the population living within this area.

Aim: To define and describe a catchment population for each of New Zealand’s rural hospitals.

Methods: An exploratory approach to developing catchments was employed. Geographic Information Systems were used to develop drive-time-based geographic catchments, and administrative health data (National Minimum Data Set and Primary Health Organisation Data Set) informed service utilisation-based catchments. Catchments were defined at both the Statistical Area 2 (SA2) and domicile levels, and linked to census-based population data, the Geographic Classification for Health, and the area-level New Zealand Index of Socioeconomic Deprivation (NZDep2018).

Results: Our results highlight considerable heterogeneity in the size (max: 57 564, min: 5226) and characteristics of populations served by rural hospitals. Substantial differences in the age structure, ethnic composition, socio-economic profile, ‘remoteness’ and projected future populations, are noted.

Discussion: In providing a standardised description of each rural hospital’s catchment boundary and its population characteristics, the considerable heterogeneity of the communities served by rural hospitals, both in size, rurality and socio-demographic characteristics, is highlighted. The findings provide a platform on which to build further research regarding NZ’s rural hospitals and inform the delivery of high-quality, cost-effective and equitable health care for people living in rural NZ.

Keywords: catchment populations, Geographic classification for health, geography, health services, rural communities, rural health, rural health inequities, rural hospitals.

What is important for high quality rural health care?

Tuesday, March 28th, 2023 | claly44p | No Comments

Atmore C, Dovey S, Gauld R, Stokes T. What is important for high quality rural health care? A qualitative study of rural community and provider views in Aotearoa New Zealand. Rural and Remote Health. 2023 Mar 2;23(1):7635-.

Open Access https://www.rrh.org.au/journal/article/7635

This qualitative study, recently published in Rural Remote Health journal, was conducted across four NZ rural communities (each with access to a rural hospital) and adds to the growing literature supporting the rural-proofing of health policy



While the general principles of healthcare quality are well articulated internationally, less has been written about applying these principles to rural contexts. Research exploring patient and provider views of healthcare quality in rural communities is limited. This study investigated what was important in healthcare quality particularly for hospital-level care for rural communities in Aotearoa New Zealand.


A pragmatic qualitative study was undertaken in four diverse rural communities with access to rural hospitals. Data were gathered through eight community and indigenous (Māori) focus groups (75 participants) and 34 health provider interviews, and analysed thematically.


Two study sites had large Māori populations and high levels of socioeconomic deprivation, whereas the other two sites had much lower Māori populations and lower levels of socioeconomic deprivation, but further travel distances to urban facilities. Rural hospitals in the communities ranged from 12 to 80 beds and were both government and community trust owned. A theme of the principles of high quality rurally focused health services was developed. Nine principles were identified: (1) providing patient- and family-centred care that respected people’s preferences for where treatment was provided; (2) providing services as close to home as could be done well; (3) quality was everybody’s job; (4) consistent care across settings, with reduction on unwarranted variation; (5) team-based care across distance, with clear communication and processes between different facilities working together; (6) equitable health care particularly for Māori, and then for the whole rural community; (7) sustainable service models, particularly for workforce, as a counterbalance to ‘closer to home’; (8) health networks to improve patient flow, and reduce waste; and (9) value was more than value for money, and including valuing respectful, timely care. Another theme around rural and urban healthcare quality was developed. While the nature of care was different in different settings, patient experience should be the underlying measure of quality, and quality measures needed to be interpreted in the context of local circumstances, with rural-specific quality measures where appropriate.


The researchers developed principles of healthcare quality specific to rural communities regarding patient and family preferences for where care was received, a broader focus on value beyond value for money and a strong focus on equity for indigenous people. These principles add to the rural principles previously described. Patient experience should be the underlying focus of quality, while noting that the nature of health care provided in rural and urban settings is different. The present study’s findings support the concept that quality measures should be interpreted in the context of local circumstances, with the development of rural-specific measures. The authors hope the findings, when locally contextualised, will assist health policy makers, planners, providers and community leaders as they strive to improve the quality of health services for their rural communities.