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.

https://www.mja.com.au/journal/2023/219/4/clinical-outcomes-and-health-care-costs-transferring-rural-western-australians

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!

Abstract

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.

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.

https://jobs.tewhatuora.govt.nz/jobtools/jncustomsearch.searchResults?in_organid=19739&in_jobDate=All

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

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, 1^st Floor, 71 Frederick Street, Dunedin 9016.

Attending Online: Join from PC, Mac, iOS or Android: https://otago.zoom.us/j/922351556?pwd=NGZIZEFJendvcTdNVHVzbHlMY1JPQT09

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.

Fors, M. Potato Ethics: What Rural Communities Can Teach Us about Healthcare. Bioethical Inquiry 20, 265–277 (2023). https://doi.org/10.1007/s11673-023-10242-x

 

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: https://link.springer.com/article/10.1007/s11673-023-10242-x

Abstract

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.