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

New Zealand postgraduate medical training by distance for Pacific Island country-based general practitioners: a qualitative study

Wednesday, April 27th, 2022 | claly44p | No Comments

Blattner K et al. Journal of Primary Health Care 2022; 14(1): 74–79.

Open Access https://doi.org/10.1071/HC21090

“Enrolling at the University of Otago distance-taught Rural Postgraduate programme allowed me the flexibility to study, work, and not have to relocate my young family to NZ. The registration process was simple and the content of the papers were applicable to the Cook Islands context especially the challenges faced in rural/remote settings with very little resources. It created a career pathway for upskilling which formed an important academic component for the Cook Islands GP Fellowship Programme which I’ve been blessed as a recipient.” Dr Teariki Puni

This study explores student experiences of the now established partnership between the University of Otago rural postgraduate programme and Pacific Island country-based doctors. While successful in meeting clinical relevance and professional connections, there needs to be better access to University resources and academic support akin to those based on campus. The lead author, Kati Blattner, is a tremendous advocate and support for these students who have achieved highly. See previous posts:  https://blogs.otago.ac.nz/rural/congratulations-mafi/  and  https://blogs.otago.ac.nz/rural/new-cook-island-gps/ and https://blogs.otago.ac.nz/rural/cooks-islands-doctor-upskills-with-otago-diploma/

Abstract

Introduction. New Zealand health training institutions have an important role in supporting health workforce training programmes in the Pacific Region. Aim. To explore the experience of Pacific Island country-based doctors from the Cook Islands, Niue, and Samoa, studying in New Zealand’s University of Otago distance-taught Rural Postgraduate programme. Methods. Document analysis (16 documents) was undertaken. Eight semi-structured interviews were conducted with Pacific Island country-based students. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately, followed by a process to converge and corroborate findings. Results. For Pacific Island countries with no previous option for formal general practice training, access to a recognised academic programme represented a milestone. Immediate clinical relevance and applicability of a generalist medical curriculum with rural remote emphasis, delivered mainly at a distance, was identified as a major strength. Although technologies posed some issues, these were generally easily solved. The main challenges identified related to the provision of academic and other support. Traditional university support services and resources were campus focused and not always easily accessed by this group of students who cross educational pedagogies, health systems and national borders to study in a New Zealand programme. Study for individuals worked best when it was part of a recognised and supported Pacific in-country training pathway. Discussion. The University of Otago’s Rural Postgraduate programme is accessible, relevant and achievable for Pacific Island country-based doctors. The programme offers a partial solution for training in general practice for the Pacific region. Student experience could be improved by tailoring and strengthening support services and ensuring their effective delivery.

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 hospital and primary care settings

Wednesday, April 6th, 2022 | claly44p | No Comments

Rory Miller, Garry Nixon, John W. Pickering, Tim Stokes, Robin M. Turner, Joanna Young, Marc Gutenstein, Michelle Smith, Tim Norman, Antony Watson, Peter George, Gerald Devlin, Stephen Du Toit, Martin Than. 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 hospital and primary care settings, European Heart Journal. Acute Cardiovascular Care, 2022; 

OPEN ACCESS https://doi.org/10.1093/ehjacc/zuac037

It’s great to see a significant piece of rural clinical research from NZ published in an international journal. I know many of you contributed to this study.

This has important clinical implications. We now know that we don’t disadvantage our patients when using point of care troponins, as long as we use them as part of the Rural Accelerated Chest Pain Pathway. We also have a clearly defined group of chest pain patients we can assess without admitting to hospital. If the DHBs (or what follows them) can get the funding streams right, there is the potential to manage many of these patients in rural GP, resulting in savings to both patients and the health system.

Well done Rory. This is excellent work!

Doing without the residential component of a blended postgraduate rural medical programme during the 2020 COVID-19 pandemic in New Zealand: student perspectives

Wednesday, January 12th, 2022 | claly44p | No Comments

Katharina Blattner, Rory Miller, Mark Smith & Janine Lander (2022) 

Education for Primary Care, DOI: 10.1080/14739879.2021.2011626

To link to this article: https://doi.org/10.1080/14739879.2021.2011626  

In a post-COVID19 era we have all experienced a move into the virtual environment especially for ongoing education/professional development and will relate to this study’s findings.

ABSTRACT 

Aim: Rural-targeted postgraduate medical training is a key factor associated with entering rural practice. Rural health professionals often experience geographical and professional isolation, which can impact their training and education. In New Zealand, during the 2020 COVID-19 pandemic, an established distance postgraduate rural medical programme replaced its in-person residentials with virtual workshops. This study aimed to gain insights into the student experience of the virtual workshops, with emphasis on exploring the effects of the absence of an in-person component. 

Method: Qualitative exploratory design. All students who had completed a semester one 2020 University of Otago rural postgraduate module were invited by email to participate. Fifteen semi-structured interviews were conducted by video-conference. A thematic analysis was conducted using a general inductive approach. 

Results: Three themes captured the main issues. 1. Making sure everyone is in the same boat: the key roles of an in-person component were identified as consolidation of learning, benchmarking and connectedness. 2. Learning but not connecting: virtual workshops were well facilitated, allowed continuation of study and the convenience of staying home, however connectedness faded. 3. We’ve got to keep a human touch in a digital age: looking beyond the pandemic, opportunities for streamlining virtual content were identified, however there was concern around diminished communication and cultural aspects of learning and the absent connection with rural health services and communities. 

Conclusion: A virtual workshop is valuable in the COVID-19 environment but does not replace an in-person component of a distance postgraduate training programme for rural medicine 

If you would like the full text please contact katharina.blattner@otago.ac.nz

HINTS exam – Head Impulse, Nystagmus, Test of Skew

Tuesday, November 2nd, 2021 | claly44p | No Comments

The HINTS exam: Who to perform the HINTS exam on, how to perform it, and how to interpret the result.

https://www.youtube.com/watch?v=1q-VTKPweuk

Check out this paper:

Quimby, A.E., Kwok, E.S.H., Lelli, D. et al. Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. J of Otolaryngol – Head & Neck Surg 47, 54 (2018). https://doi.org/10.1186/s40463-018-0305-8

Abstract

Background

Dizziness is a common presenting symptom in the emergency department (ED). The HINTS exam, a battery of bedside clinical tests, has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo. The present study sought to assess practice patterns in the assessment of patients in the ED with peripherally-originating vertigo with respect to utilization of HINTS and neuroimaging.

Methods

A retrospective cohort study was performed using data pertaining to 500 randomly selected ED visits at a tertiary care centre with a final diagnostic code related to peripherally-originating vertigo between January 1, 2010 – December 31, 2014.

Results

A total of 380 patients met inclusion criteria. Of patients presenting to the ED with dizziness and vertigo and a final diagnosis of non-central vertigo, 139 (36.6%) received neuroimaging in the form of CT, CT angiography, or MRI. Of patients who did not undergo neuroimaging, 17 (7.1%) had a bedside HINTS exam performed. Almost half (44%) of documented HINTS interpretations consisted of the ambiguous usage of “HINTS negative” as opposed to the terminology suggested in the literature (“HINTS central” or “HINTS peripheral”).

Conclusions

In this single-centre retrospective review, we have demonstrated that the HINTS exam is under-utilized in the ED as compared to neuroimaging in the assessment of patients with peripheral vertigo. This finding suggests that there is room for improvement in ED physicians’ application and interpretation of the HINTS exam.

“No better or worse off”: Mycoplasma bovis, farmers and bureaucracy

Monday, October 25th, 2021 | claly44p | No Comments

Chrystal Jaye, Geoff Noller, Mark Bryan, Fiona Doolan-Noble (2021) “No better or worse off”: Mycoplasma bovis, farmers and bureaucracy. Journal of Rural Studies, Volume 88, Pages 40-49, ISSN 0743-0167,

https://doi.org/10.1016/j.jrurstud.2021.10.007.

This paper uses Habermas’ theory of lifeworld and system to dissect the collision that happened on farms during the management of the incursion between farming values of stock welfare and practical and relational forms of knowledge; and policy, regulation, compliance and technical instrumental forms of knowledge.

Abstract:

The 2017 outbreak of Mycoplasma bovis in New Zealand deeply impacted rural communities, particularly cattle farmers. In 2018, the Ministry for Primary Industries (MPI) implemented an eradication programme that involved herd testing, stock culls, restriction of stock movements, decontamination of affected farms, and compensation to farmers for losses associated with the eradication programme. New Zealand news media reported widely on the emotional trauma experienced by affected farmers and MPI was criticised for poor management of the outbreak. We interviewed nineteen farmers and farming couples affected by M. bovis in Southern New Zealand to gain insight into their experiences of the outbreak. In this paper, we present the findings pertaining to one dominant thematic: that of farmers’ interactions with the bureaucracy associated with the management of the outbreak. The farm appeared to quite literally represent a site of collision between farming values of stock welfare and practical and relational forms of knowledge; and policy, regulation, compliance and technical instrumental forms of knowledge. For these reasons, Habermas’ theory of lifeworld and system presented itself as a particularly salient framework for interpreting our data. Participants experienced the eradication programme as intrusive, impractical, and inhumane; while their situated local knowledge and pragmatism were ignored in favour of adherence to wasteful and inefficient bureaucratic processes that while compliant with policy, made no sense to the farmers. We suggest that biosecurity threats such as M. bovis might be more effectively managed when the bureaucracy is attentive to the rural lifeworld and responsive to the situated knowledge of farmers.

 

The impact of interpersonal relationships on rural doctors’ clinical courage

Thursday, October 21st, 2021 | claly44p | No Comments

Walters L, Couper I, Stewart RA, Campbell DG, Konkin J. The impact of interpersonal relationships on rural doctors’ clinical courage. Rural and Remote Health 2021; 21: 6668. https://doi.org/10.22605/RRH6668

https://www.rrh.org.au/journal/article/6668

Commentary Sarah Walker (PhD Candidate): Following on from previous work on the role of clinical courage in rural generalism, Professor Walters and her colleagues explore how the relationships rural doctors develop impact on their clinical courage. The concept of clinical courage can sit uncomfortably with some of us, however the six features of clinical courage described in previous work (Konkin et al. 2020) alleviate those concerns. Although clinical courage Is formed amongst uncertainty (2) in often under resourced (4) settings, clinicians are cautious not to conflate confidence with competence (3) when clearing the cognitive hurdle and deciding on a point of action (5) that is often intrinsically tied to a deep commitment of providing care to their community (1). Critical to this is their “collegial support to stand up again” (6) where rural doctors can share discourse and use their peer reflections to support their own self reflections – it is this feature that Walters seeks to explore further in this study.

The community of practice that rural doctors build with their communities, patients, peers, and local and national healthcare teams and leaders does affect their clinical courage. The social and geographical bond these rural doctors have sets them apart from other medical communities of practice and suggest that clinical courage is seen as a meaningful and encouraged characteristic in rural generalist practice. The relationships formed within their community of practice are not taken lightly, requiring time and effort to develop and maintain. For the healthcare team, only once these relationships are appropriately developed can trust be placed on each other’s skillset, becoming an issue in areas where workforce turnover is unsettling.

Despite not being a rural doctor, Walter’s work piques my interest as a rural health professional. Working as a physiotherapist in a small team, across a large geographical area, and in many clinical areas, the concept of clinical courage resonates well with me as I am sure It does for my other allied health and nursing colleagues. I am certain that furthering our understanding of these other disciplines in rural areas will help in understanding the complex and dependent relationships and skills required for rural generalist practice.

Konkin J,  Grave L, Cockburn E,  et al.   Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage):  an international phenomenological study.  BMJ Open 2020;10:e037705.  doi:10.1136/ bmjopen-2020-037705

 

Abstract:

Introduction:  Clinical courage occurs when rural doctors push themselves to the limits of their scope of practice to provide the medical care needed by patients in their community. This mental strength to venture, persevere and act out of concern for one’s patient, despite a lack of formally recognised expertise, becomes necessary for doctors who work in relative professional isolation. Previous research by the authors suggested that the clinical courage of rural doctors relies on the relationships around them. This article explores in more depth how relationships with others can impact on clinical courage. Methods:  At an international rural medicine conference in 2017, doctors who practised rural/remote medicine were invited to participate in the study. Twenty-seven semistructured interviews were conducted exploring experiences of clinical courage. Initial analysis of the material, using a hermeneutic phenomenological frame, sought to understand the meaning of clinical courage. In the original analysis, an emic question arose: ‘How do interpersonal relationships impact on clinical courage’. The material was re-analysed to explore this question, using Wenger’s community of practice as a theoretical framework. Results:  This study found that clinical courage was affected by the relationships rural doctors had with their communities and patients, with each other, with the local members of their healthcare team and with other colleagues and health leaders outside their immediate community of practice. Conclusion:  As a collective, rural doctors can learn, use and strengthen clinical courage and support its development in new members of the discipline. Relationships with rural communities, rural patients and urban colleagues can support the clinical courage of rural doctors. When detractors challenge the value of clinical courage, it requires individual rural doctors and their community of practice to champion rural doctors’ way of working.

Rural-urban and within-rural differences in COVID-19 vaccination rates

Friday, October 8th, 2021 | claly44p | No Comments

Sun, Y., & Monnat, S. M. (2021). Rural-urban and within-rural differences in COVID-19 vaccination rates. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association.

https://onlinelibrary-wiley-com.ezproxy.otago.ac.nz/doi/full/10.1111/jrh.12625

Abstract:

PURPOSE: COVID-19 mortality rates are higher in rural versus urban areas in the United States, threatening to exacerbate the existing rural mortality penalty. To save lives and facilitate economic recovery, we must achieve widespread vaccination coverage. This study compared adult COVID-19 vaccination rates across the US rural-urban continuum and across different types of rural counties. METHODS: We retrieved vaccination rates as of August 11, 2021, for adults aged 18+ for the 2,869 counties for which data were available from the CDC. We merged these with county-level data on demographic and socioeconomic composition, health care infrastructure, 2020 Trump vote share, and USDA labor market type. We then used regression models to examine predictors of COVID-19 vaccination rates across the USDA’s 9-category rural-urban continuum codes and separately within rural counties by labor market type. FINDINGS: As of August 11, 45.8% of adults in rural counties had been fully vaccinated, compared to 59.8% in urban counties. In unadjusted regression models, average rates declined monotonically with increasing rurality. Lower rural rates are explained by a combination of lower educational attainment and higher Trump vote share. Within rural counties, rates are lowest in farming and mining-dependent counties and highest in recreation-dependent counties, with differences explained by a combination of educational attainment, health care infrastructure, and Trump vote share. CONCLUSION: Lower vaccination rates in rural areas is concerning given higher rural COVID-19 mortality rates and recent surges in cases. At this point, mandates may be the most effective strategy for increasing vaccination rates.

Commentary:

The higher overall COVID mortality rates areas (and higher case fatality rates) observed in rural areas in the US, particularly in the later part of the pandemic, is not news.1 We also know rural health services have struggled to cope in the US.2  The considerably lower vaccination rates in rural vs communities (46% vs 60%) noted in this paper is therefore an obvious concern.

But at least they know there is a problem. In NZ rurality is still not a variable in the vaccination data that’s being reported. Hopefully this is not too far away. In the meantime Jesse Whitehead and Ross Lawrenson have published a paper demonstrating poorer access to vaccination in rural NZ (already posted on LOFP).3

  1.  Pro G, Hubach R, Wheeler D, et al. Differences in US COVID-19 case rates and case fatality rates across the urban-rural continuum. Rural Remote Health2020;20(3):6074. doi: 10.22605/RRH6074
  2.  Underwood A. COVID-19: A Rural US Emergency Department Perspective. Prehosp Disaster Med 2021;36(1):4-5. doi: 10.1017/S1049023X20001417
  3. Spatial inequity in distribution of COVID-19 vaccination services in Aotearoa   Whitehead J, Atatoa P, Scott N, Lawrenson R. Spatial inequity in distribution of COVID-19 vaccination services in Aotearoa. Preprint on medRxiv.            https://doi.org/10.1101/2021.08.26.21262647