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

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

Open access

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

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

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

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

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

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

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

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



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

Design: Retrospective cohort study.

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

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

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

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

Simplify to Unify

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

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

Simplify to unify – Commissioning Letter including invitation

Commissioning Final for External Stakeholders

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

Watch for job adverts here.


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


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

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

Short notice we know but seminar on ethics – link below


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

Presenter: Associate Professor Fiona McDonald,

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

When: Monday 4 September, 1pm – 2pm

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

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

Meeting ID: 922 351 556

Password: 595584

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


Potato Ethics: What Rural Communities Can Teach Us about Healthcare

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

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


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

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

Helen Clayson

link to open access:


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

Rural health podcast from Wales: the first RHCW Podcast

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

Launch of the first RHCW Podcast!


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


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


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


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


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


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


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


Thank you





Lansio Podlediad cyntaf IGGC!


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


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


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


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


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


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


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


Thank you





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

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.

RNZCGP Awards for 2023 – Strong Rural representation

Thursday, July 27th, 2023 | claly44p | No Comments

Congratulations to all our rural health champions receiving awards at GP23.

Dr Janine Lander – James Reid Award for her excellence in relation to education in rural health

Dr Greville Wood – Eric Elder Medal for exemplifying quality and commitment to teaching.

Dr Jo Scott Jones – Distinguished Fellowship

Dr Verne Smith – Community Service Medal

Prof Tim Stokes – President’s Service Medal



See here full list of award winners

Rural Health Strategy

Friday, July 21st, 2023 | claly44p | No Comments

The Rural Health Strategy was published by the Ministry of Health on 12 July 2023. Rural Health Strategy | Ministry of Health NZ The Rural Health Strategy has been released with the suite including the other five health strategies mandated under the Pae Ora (Healthy Futures) Act 2022: New Zealand Health Strategy, Hauora Māori Strategy, Pacific Health Strategy, Health of Disabled People Strategy, and Women’s Health Strategy.

The Rural Health Strategy was developed with support and engagement from people within the health sector and key stakeholders within rural communities.

The Rural Health Strategy sets the direction for improving the health and wellbeing of rural communities over the next 10 years, through five priorities. The strategy also provides context around the wider determinants in rural communities and an initial assessment of rural health outcomes. There are still many gaps around reporting and monitoring outcomes for rural communities for health agencies to work on further.  Any queries related to the Rural Health Strategy, or the other strategies, can be made to the Ministry of Health:

The Health and Independence Report 2022 has also been published by the Ministry of Health, as supporting material for the health strategies. Health and Independence Report 2022 | Ministry of Health NZ

The data released with this report includes data for some rural breakdowns using the Geographic Classification for Health. The user-friendly version for downloading the data appendix is published here: GitHub – minhealthnz/health-and-independence-report: Supplementary and supporting data for the Health and Independence Report

The data appendix includes some data for rural communities from the New Zealand Health Survey (from 2021/22, with some back to 2013/14), Mortality rates, percentages not enrolled in primary care, median drive times to enrolled practices and enrolment in practices within the Very Low Cost Access Scheme.

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.

Hauora Taiwhenua Rural Student Research Scholarships and BNZ Rural Development Scholarship.

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

Can you help spread the news?

Hauora Taiwhenua Rural Health Network is pleased to announce the availability of three $5,000 Rural Student Research Scholarships for the 2023/24 year.

Two of the Scholarships are open to any health students to support a 12-week elective/studentship, and/or research placement within a rural community of the student’s choice. A BNZ Rural Development scholarship is available to any year two and above Medical Student for the same period.

Previous examples of research include 2022 recipient of one of the research scholarships, Krystyna Glavinovic, a second-year medical student from the University of Auckland. Krystyna conducted a research project titled: Understandings and experiences of climate change in rural general practices in Aotearoa-New Zealand

Supervised by Dr Kyle Eggleton of the University of Auckland and A/Prof Alex Macmillan of the University of Otago, Krystyna undertook the study to determine the understandings, experiences and sense of preparedness of rural general practice staff in Aotearoa-New Zealand with respect to climate change and associated adverse weather events.

In 2023, Samantha Menzies, fourth-year medical student at Tauranga Hospital, was the recipient of the BNZ Rural Development Scholarship. She has since been conducting a research project with Dr Kyle Eggleton.

“Our project was a rapid review of the available literature about rural healthcare ethics. It is the first research paper to describe rural doctors’ unique ethical challenges compared to urban doctors. It is currently awaiting a peer review and is informing the development of a teaching resource about medical ethics for medical students.”

She continued to describe how “the scholarship has allowed me to explore my newfound interest in rural medicine. I got to ‘deep dive’ into the literature and have in-depth but causal discussions with Dr Kyle about the reality (both the highs and lows) of being a rural doctor, so thank you Hauora Taiwhenua Rural Health Network and BNZ for this opportunity”.

As both examples of previous projects indicate, the successful applicants are expected to write up the results of any research and attempt to get this published. In addition, the student is expected to provide an abstract for presentation at the National Rural Health Conference or comparable health conference.

Students wishing to apply should complete the attached application form and return to Hauora Taiwhenua by 1st August 2023.

Rural Student Research Scholarships and BNZ Rural Development Scholarship[10]


Any views or opinion represented in this site belong solely to the authors and do not necessarily represent those of the University of Otago. Any view or opinion represented in the comments are personal and are those of the respective commentator/contributor to this site.


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