Internal medicine in the bush: a clinical audit of a rural and remote outreach programme

The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016

BACKGROUND

Hepatitis C virus infection (HCV) is a communicable disease of increasing global importance with 1.75 million new infections and 400,000 related deaths annually. Until recently, treatment options have had low uptake and most infected people remain untreated. New Direct Acting Antiviral medications can clear the virus in around 95% of cases, with few side-effects. These medications are restricted in most countries but freely accessible in Australia, yet most people still remain untreated. This study applies a cross-sectional research design to investigate the socio-spatial distribution of HCV in South Australia, to identify vulnerable populations, and examine epidemiological factors to potentially inform future targeted strategies for improved treatment uptake.

METHOD

HCV surveillance data were sourced from South Australia's Communicable Diseases Control Branch and socio-economic population data from the Australian Bureau of Statistics from January 2010 to December 2016 inclusive. HCV cases were spatially mapped at postcode level. Multivariate logistic regression identified independent predictors of demographic risks for HCV notification and notification source.

RESULTS

HCV notifications (n = 3356) were seven times more likely to be from people residing in the poorest areas with high rates of non-employment (75%; n = 1876) and injecting drug use (74%; n = 1862) reported. Notifications among Aboriginal and Torres Strait Islander people were around six times that of non-Indigenous people. HCV notifications negatively correlated (Spearman's rho - 0.426; p < 0.001) with socio-economic status (residential postcode socio-economic resources Index). History of imprisonment independently predicted HCV diagnoses in lesser economically-resourced areas (RR1.5; p < 0.001). Independent predictors of diagnosis elsewhere than in general practices were non-employment (RR 4.6; p = 0.028), being male (RR 2.5; p < 0.001), and younger than mean age at diagnosis (RR 2.1; p = 0.006).

CONCLUSIONS

Most people diagnosed with HCV were from marginalised sub-populations. Given general practitioners are pivotal to providing effective HCV treatment for many people in Australia a most concerning finding was that non-employed people were statistically less likely to be diagnosed by general practitioners. These findings highlight a need for further action aimed at improving healthcare access and treatment uptake to help reduce the burden of HCV for marginalised people, and progress the vision of eliminating HCV as a major public health threat.

Prevalence of Hepatitis C Among Australian Aboriginal and Torres Strait Islander people: A Systematic Review and Meta-Analysis

CONTEXT

Aboriginal and Torres Strait Islanders (Aboriginal) account for approximately 3% of the Australian population. They have the poorest health, economic and social outcomes. Higher notification rates of hepatitis C antibodies (anti-HCV) have been reported among Aboriginal compared with non-Aboriginal people. The identification of Aboriginal people in national surveillance has some weaknesses, with only four of the eight jurisdictions included in national reporting. To address some of these limitations, we aim to estimate the pooled prevalence of anti-HCV among Aboriginal people in Australia.

EVIDENCE ACQUISITION

We searched the databases: Pubmed, Web of Science and Informit, and the New South Wales and Northern Territory Public Health Bulletins. A study was included if it reported the number of Aboriginal people testing positive for anti-HCV and the number tested for anti-HCV. A meta-analysis by population-group was conducted if three or more studies reported a prevalence estimate. Variables included: author, year of publication, study design, study period, gender (female, male), age, population group (Aboriginal people in prison, Aboriginal people who inject drugs), number testing anti-HCV positive, number tested for anti-HCV and prevalence (%). Due to a long time period, we separated the studies estimating the prevalence anti-HCV among Aboriginal people in prison into two time periods, 1994 - 2004 and 2005 - 2012.

RESULTS

Overall, 15 studies met our inclusion criteria. Among Aboriginal people in prison, the pooled prevalence of anti-HCV was 18.1% (95%CI: 6.6 - 29.7). The pooled prevalence among Aboriginal people in prison was 25.7% (95%CI: 4.1-47.3) in studies published between 1994 - 2004 and 14.5% (95%CI: 1.7 - 27.3) in studies published from 2005 - 2012. The pooled prevalence of anti-HCV was 58.7% (95%CI: 53.9 - 63.5) among Aboriginal people who inject drugs and 2.9% (95%CI: 0.30 - 6.1) among Aboriginal people who did not inject drugs, however there was significant heterogeneity (I(2) > 90.0%, P < 0.01). There was significant selection bias in the studies as most included individuals who inject drugs.

CONCLUSIONS

Our analysis shows that the overall prevalence of anti-HCV was significantly biased towards people who inject drugs; resulting in an over-estimation of anti-HCV prevalence among Aboriginal people. Our review highlights that unsafe injecting is the main transmission route for HCV infection among Aboriginal people in Australia.

Service distribution and models of rural outreach by specialist doctors in Australia: a national cross-sectional study

Objective This paper describes the service distribution and models of rural outreach by specialist doctors living in metropolitan or rural locations. Methods The present study was a national cross-sectional study of 902 specialist doctors providing 1401 rural outreach services in the Medicine in Australia: Balancing Employment and Life study, 2008. Five mutually exclusive models of rural outreach were studied. Results Nearly half of the outreach services (585/1401; 42%) were provided to outer regional or remote locations, most (58%) by metropolitan specialists. The most common model of outreach was drive-in, drive-out (379/902; 42%). In comparison, metropolitan-based specialists were less likely to provide hub-and-spoke models of service (odd ratio (OR) 0.31; 95% confidence interval (CI) 0.21–0.46) and more likely to provide fly-in, fly-out models of service (OR 4.15; 95% CI 2.32–7.42). The distance travelled by metropolitan specialists was not affected by working in the public or private sector. However, rural-based specialists were more likely to provide services to nearby towns if they worked privately. Conclusions Service distribution and models of outreach vary according to where specialists live as well as the practice sector of rural specialists. Multilevel policy and planning is needed to manage the risks and benefits of different service patterns by metropolitan and rural specialists so as to promote integrated and accessible services. What is known about this topic? There are numerous case studies describing outreach by specialist doctors. However, there is no systematic evidence describing the distribution of rural outreach services and models of outreach by specialists living in different locations and the broad-level factors that affect this. What does this paper add? The present study provides the first description of outreach service distribution and models of rural outreach by specialist doctors living in rural versus metropolitan areas. It shows that metropolitan and rural-based specialists have different levels of service reach and provide outreach through different models. Further, the paper highlights that practice sector has no effect on metropolitan specialists, but private rural specialists limit their travel distance. What are the implications for practitioners? The complexity of these patterns highlights the need for multilevel policy and planning approaches to promote integrated and accessible outreach in rural and remote Australia.