Reminder: Diabetes CME – Acute problems & COVID study

Thursday, July 30th, 2020 | Rory | No Comments

Go to otago.ac.nz/cme-diabetes to register.


‘Exploring the response to the Covid-19 pandemic at the rural hospital – base hospital interface:  experiences of rural hospital doctors’ 

We are seeking rural hospital senior medical officers to undertake a short interview about their experiences working clinically during COVID-19 pandemic/lockdown. Ideally we are seeking doctors who were working clinically in NZ rural hospitals. If you are interested please click on the following link to read the information sheet and consent form.

https://otago.au1.qualtrics.com/jfe/form/SV_07J6JG4SXKiHK9T

COVID-19 pandemic response

Thursday, July 23rd, 2020 | Rory | No Comments

‘Exploring the response to the Covid-19 pandemic at the rural hospital – base hospital interface:  experiences of rural hospital doctors’ 

We are seeking rural hospital senior medical officers to undertake a short interview about their experiences working clinically during COVID-19 pandemic/lockdown. Ideally we are seeking doctors who were working clinically in NZ rural hospitals. If you are interested please click on the following link to read the information sheet and consent form.

https://otago.au1.qualtrics.com/jfe/form/SV_07J6JG4SXKiHK9T

 

 

 

Information:

There have been variations in the way in which different DHBs have managed the pandemic preparations for rural hospitals. There may be important lessons to be learnt from this. 

  We are undertaking a small qualitative study to explore, from the perspective of senior rural hospital doctors, clinical advice and arrangements for patient management put in place during the pandemic period. We are interested in identifying strategies that have and have not worked.  

To do this we are seeking one representative from each rural hospital to participate in a Zoom interviewThe participants should be senior rural doctors who take ultimate clinical responsibility for patients and organising inter-hospital transfers.  

 The total time commitment will be 30 minutes.    

We would really like to hear from a member of your frontline rural hospital medical team.  

We would be grateful if you could ask around your medical staff, and if someone is willing and able to participate, they should enrol by going to  

https://otago.au1.qualtrics.com/jfe/form/SV_07J6JG4SXKiHK9T 

If anyone has  questions prior to enrolling they should feel free to contact one of us.  

 

Garry Nixon           garry.nixon@otago.ac.nz 

Kati Blattner          katharina.blattner@otago.ac.nz 

Rory Miller            rory.miller@otago.ac.nz 

Steve Withington   stephen.withington@otago.ac.nz 

 

 

Technology-facilitated care coordination in rural areas: What is needed?

Monday, July 6th, 2020 | Rory | No Comments

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics. 2020 May;137:104102.

 

Comments by the lead author – Dr. Emily Gill from Opōtiki

Take-away

People who live in rural areas have poorer health than their urban counterparts, and for those with multiple, complex medical needs, this is impacted by health IT systems.  This research suggests US rural settings may contend with more unaffiliated electronic health records (EHRs a.k.a. PMSs), than urban settings.  The equivalent in NZ is that rural areas that border between DHBs are more likely to see patients from outside their own DHB, and this poses challenges of accessing and exchanging electronic information (e.g., electronic referrals) with unaffiliated DHBs.  Policy regulations should require that health information be exchanged between all health services, from pharmacy to private hospital to allied health providers, in a way that is ‘useable’ (e.g., user-friendly; without the need to login to multiple other platforms).  An important way to evaluate whether health IT systems are improving health is to focus on care coordination activities: for patients who see multiple health providers due to their complex, chronic needs, how easily can the patient and all the health providers involved access and know pertinent health information, especially when changes are occurring frequently? 

More details:

To provide coordinated care, health information needs to be frequently transferred across settings such as primary care clinics, acute care hospitals, and community health services. The U.S. government made a major financial investment in health information technology with the aim of improving improve care coordination and provided incentives for healthcare organizations to electronically exchange information in a more efficient and accurate process.  Given the increased health needs of the rural population, this research project sought to understand the experiences of healthcare providers in exchanging information during or in response to a transfer of care.

 

The interviews and surveys conducted through this research described numerous gaps between the necessary care coordination activities for patients with complex needs and the capacity for technology to facilitate the process. Healthcare professionals described low confidence in the integrity of the information they receive, and the effort required to gather needed information, including challenges with arranging real-time communication with other providers caring for the same patient.  Providers described care plans, a potentially useful tool in care coordination, as being regulated to such an extent that they are not used in routine decision making. In exchanging information between organizations using different Electronic Health Records (EHRs), most systems could not automatically incorporate the new information into the existing patient record. This lack of interoperability explains the large quantities of information the providers described faxing and scanning in.  Finally, rural healthcare professionals described the compounding impact of poverty on coordinating care for their patients. Not having transportation to specialist appointments; being geographically located between multiple larger health systems, which amplifies the number of external EHR systems in use; and the lack of access to specialty services all accentuate the challenges of information exchange during care transitions.

Both the U.S. and New Zealand should continue to focus on policy that drives the development of technology standards for how health information is exchanged.  In addition to promoting EHR systems that can receive and incorporate information automatically, standards should guide the usability of digital health data, and how it is aggregated across settings to create useful longitudinal care plans. Policy in both countries should encourage further research to define meaningful measures of how coordination technology tools impact population health.

Dealing with chest pain – a pathway protocol.

Friday, July 3rd, 2020 | Rory | No Comments

Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, et al. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. Journal of Primary Health Care. 2020;12(2):129.
open access link

The study protocol for an observational study examining the safety a novel chest pain pathway that uses point-of-care troponin.

Chest pain pathway’s are used throughout the country but largely rely on laboratory based troponin assays, which are not available for a considerable proportion of the rural population.[1] This will be the first large study that examines a rural and/or primary care population.

Enrolment has been more difficult (and slower) than anticipated, but in more than 300 low risk patients (and preliminary analysis), there have been no missed Major Adverse Cardiac Events in the first 30 days after presentation. This is in line with other chest pain pathways that use the new high-sensitivity assays.

very preliminary analysis of the primary end-point 

If you have access to point-of-care troponin and aren’t involved as a study site then please get in touch with me, and if you are already contributing – thank you!! and think of entering patients with chest pain into the data collection tool!

 


  1. Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.  ↩

Untangling statistical tests

Tuesday, June 16th, 2020 | Rory | No Comments

Turner R, Samaranayaka A, Cameron C. Parametric vs nonparametric statistical methods: which is better, and why?. New Zealand Medical Student Journal. 2020 Apr 12(30):61-2.

https://nzmsj.scholasticahq.com/article/12577-parametric-vs-nonparametric-statistical-methods-which-is-better-and-why

“Statistical decisions and interpretation are not clear cut and do not follow a series of “easy to apply in all situations” rules. There is a great deal of nuance when analysing and interpreting data and applying statistical tests.”

No kidding…

A really easy to understand article describing the difference between parametric and non-parametric tests and their assumptions.

Some highlights:

“For example, the t-test has been developed using normal distribution theory, so it has an underlying assumption that the distribution of the sample mean (which is a parameter) is normal. This does not mean that the population data or the sample data need to be normally distributed.”

 

“…this normality assumption will hold for large samples (usually 30 observations or more) regardless of the distributions of the data or underlying popu-lation. This is stated by the Central Limit Theorem. Therefore, when the sample size is large we can use this parametric procedure without worrying about the normality assumption.”

 

” In practice, if we are concerned about the assumptions, we may run the parametric test first and then run the nonparametric equivalent to see broadly if we get a similar answer. If we do get a similar answer we have some reassurance that the parametric test results are reasonable to report. If we get very different answers and we were concerned about the assumptions, then we would use the nonparametric results as we cannot trust the parametric results.”

Medical Rural Inter-professional Simulation Course

Thursday, June 4th, 2020 | Rory | 1 Comment

Medical RiSC is a course run by the University of Otago Rural Postgraduate Programme. Designed specifically for interprofessional rural hospital teams in New Zealand, it is an immersive three-day course that focuses on emergency medical care using highly realistic skills simulations and workshops.
We are inviting rural hospital doctors, nurses, paramedics and rural GPs to attend and extend their clinical knowledge and skills for medical emergency management.

Is looking to be a great course!

Sign up your team or attend as an individual!

People falling over in the South.

Tuesday, May 26th, 2020 | Rory | No Comments

Merrett A, Keys J, Crane C, Gwynne-Jones D. Non-resident orthopaedic admissions to Dunedin Hospital 1997 to 2017 and Southland Hospital 2011 to 2017. The New Zealand Medical Journal (Online). 2020 May 8;133(1514):41-5.

An interesting audit of orthopaedic injuries in the far South published in a recent NZMJ. One of the authors is the current Chair of the Division of Rural Hospital Medicine (Jennifer Keys). The authors found that overseas visitors cost the DHB a lot of extra money when they fall off or over things. It would be interesting to examine the extra workload these injuries have on the rural health services closer to the ‘action’.

Suspect on balance the tourist dollars in far outweigh any extra health costs incurred – as I think we are finding out!

Abstract

Aim

The purpose of this study is to audit the numbers of non-residents requiring orthopaedic admission to Dunedin and Southland Hospitals and determine the effects of increasing tourist numbers on healthcare resources.

Method

All non-resident orthopaedic admissions to Dunedin Hospital from January 2005 to December 2017 and Invercargill Hospital from January 2011 to December 2017 were analysed with respect to country of residence, mechanism of injury, primary diagnosis and case weights consumed. The results were combined with figures from 1997–2004 to give a 21-year series for Dunedin Hospital.

Results

There has been a significant increase in the number of admissions and case weights (CW) over the past 21 years at Dunedin Hospital (p<0.001). The most common mechanisms of injury were snow sports at Dunedin Hospital and falls for Southland Hospital. Between 2011 and 2017 there were on average 50 non-resident admissions per year (92.9 CW/year) to Dunedin Hospital and 74 admissions (120.7 CW/year) in Southland.

Conclusion

Increasing tourist numbers have resulted in an increase number of orthopaedic admissions to Dunedin Hospital over the last two decades although it remains a small proportion of the total workload. Southland Hospital is relatively more affected. These patients represent an annual cost in excess of $1,000,000 to Southern DHB.

 

Rider unknown. Too much hair for Garry…

image credit: http://www.pinkbike.com/news/Fails-for-Your-Friday-July20-2012.html

Postcard from the edge #10

Wednesday, May 20th, 2020 | Rory | 1 Comment

This postcard comes from Sara Gordon, who is a GP and Rural Hospital Registrar who is currently completing this programme at Taranaki Base Hospital.


Suddenly the apprenticeship is shifting gear; business as usual comes to a full stop. At the pointy end of training, fellowship is a blink away. My intention to do a bit more cardiology and respiratory medicine is now an irony. Our new negative pressure rooms feel as far away from anywhere, and patients cannot have their usual plethora of tests. I’m more ok with this than my colleagues.

Generalist rural training turns out to be excellent preparation for this community response

Introspection: COVID–19 is the disaster that follows you home. In most disasters there is a safe haven, there’s a safe place to retreat. The disaster is a usually a tragic tale to tell friends and family about, not one they are characters in.

Once upon a time is still now, adventure has exited the stage, leaving an uncertain future, as we build the plane we are flying it. The invisible particle that has taken the breath from our nation is dubbed the ‘Ebola of the rich’ and will be the COVID–19 of everyone; even those who hide their faces in the sand like hypoxic orange flamingos. Like the disease itself, the ramifications of a pandemic pervade every organ of our carefully structured, safe system.

COVID–19 is kicking down the sandcastle we have just built.

Developed nations are acting like newborns. Narratives prompt pragmatic action with inspiring commonsensical speed. Connections are light speed and real. This train left the station months, years ago and we woke up on it.

If there is a station, would you get off?

 

 
 
 

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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