Travel-associated cost savings to patients and the health system through provision of specialist head and neck surgery outreach clinics in rural New South Wales, Australia

INTRODUCTION

Centralisation of head and neck surgical services means that patients in regional and remote Australia need to travel long distances for treatment and follow-up, imparting a significant financial burden on patients and the health system.

OBJECTIVE

To estimate costs of travel to local outreach clinics and determine potential cost savings to patients and the health system by avoiding patient travel to major cities for head and neck surgical care.

DESIGN

Retrospective audit of three head and neck surgery outreach clinics in New South Wales, Australia over 4 years (2017-2020). Direct costs of travel from a patient's residence to their local outreach clinic were estimated. Costs of travel and accommodation to Sydney for an appointment were calculated for different travel modes. Estimated reimbursements for travel through government support schemes were calculated based on published rates.

FINDINGS

Some 657 patients attended the three clinics, accounting for 1981 appointments. Depending on mode of travel, the estimated median cost of return travel (including accommodation) to Sydney was $379 to $739 per patient per trip and the median government reimbursement ranged from $182 to $279 per trip. In comparison, the cost of return travel by car to local outreach clinics ranged from $28 to $163 per appointment. Outreach clinics were estimated to save patients a median of $285 per trip and avoided government reimbursements of $215 per trip.

DISCUSSION

Despite uptake in telehealth, outreach medical services remain an important asset for people living in regional areas to address inequities in access. However, the cost benefits are likely to be underestimated as our approach did not account for indirect costs associated with travel.

CONCLUSION

Outreach head and neck surgical services located in regional areas can reduce the financial burden on both patients and the healthcare system. Greater investment in outreach clinics could ensure sustainability of services to promote equitable access to specialised surgical services.

Consulting a Victorian Aboriginal community about their oral health

BACKGROUND

The legacy of colonisation, assimilation, racism and victim blaming has created inequality in health for Aboriginal people, reflected in their oral health status. Despite the existence of community dental services, oral disease levels continue to be of concern. This study, initiated by a rural Victorian ACCHO (Aboriginal Community Controlled Health Organisation), aimed to consult their community about the barriers to and enablers of oral health and understand their lived experiences with dental services.

METHODS

Using an Aboriginal knowledge framework and collaborative approach involving an Aboriginal researcher and Community Mentor, this study consulted an ACCHO community about their oral health. Following community engagement, 21 community members participated in digitally recorded yarning circles and semi-structured interviews.

RESULTS

Themes emerging from the data included dental care history and past experiences involving pain and shame, the value of having community-centred services and engagement with patients and the community.

DISCUSSION

Experiences of dental care are often related to pain driving attendance resulting in experiences that multiply fear and anxiety. While community-based care was considered a strength, approaches to individual dental care often resulted in increasing shame and diminishing trust. Increasing cultural safety and participatory approaches to designing and delivering dental care may increase engagement and trust.

CONCLUSIONS

Important gaps in cultural and clinical understanding between the community and dental service providers have been identified. These findings will be used to inform the delivery of dental services and to develop oral health promotion programs at the ACCHO, and cultural safety preparation for student dental practitioners.

'Biggest factors in having cancer were costs and no entitlement to compensation'-The determinants of out-of-pocket costs for cancer care through the lenses of rural and outer metropolitan Western Australians

OBJECTIVE

The aim of this qualitative analysis was to determine patients' perceptions of the impact of cancer-related costs.

DESIGN

A qualitative inductive content analysis of the comment sections of surveys completed by participants in a cross-sectional study of cancer-related expenses.

SETTING

Residents of 4 regional/rural and 2 outer metropolitan areas in Western Australia.

PARTICIPANTS

Adults diagnosed with breast, prostate, colorectal or lung cancer participated in the study between 1 April 2014 and 31 April 2017.

MAIN OUTCOME MEASURES

This study identified the key factors contributing to the cost experiences reported by the participants.

RESULTS

Participant comments were organised into 4 main categories perceived to incorporate the key factors contributing to the cost experiences reported by 300 participants: 1) health care system factors (access to care in the public or private sector, availability of services close to home, gap payments, cost of travel) 2) financial factors (impact of cancer on employment, ability to work, and career; and strategies for improving financial difficulties) 3) social and community support provided by the government and not-for-profit organisations and 4) understanding of the health care system.

CONCLUSION

There is a need for cost transparency, initiatives for no- or low-fee billing providers, access to care close to home, development of financial assistance schemes and return to work programs to alleviate the financial hardship experienced by cancer patients and their families.

Theoretical analysis of policies to improve the recruitment and retention of rural physicians

The lack of success in resolving the shortage of rural physicians in Organisation for Economic Cooperation and Development countries has been attributed to the weakness of implemented policies. This research examines the theoretical plausibility of policies to improve the recruitment and retention of rural physicians, first, by modelling the policies; and then, by describing how they might achieve their intended outcome based on a theoretical analysis. A theory-driven method relying on published research and expert analysis is used. A conceptual model is created to represent the policies and their underlying assumptions. Then, the functional mechanism of the policies is defined. This research demonstrates that financial, educational and tailored interventions might improve rural physician recruitment and retention, but that regulatory interventions are unlikely to do this. The majority of the policies implemented in Organisation for Economic Cooperation and Development countries are therefore theoretically plausible.

PodCast: A rural and regional service model for podiatrist-led total contact casting

PROBLEM

Diabetes-related foot disease causes significant health system costs and is a leading cause of morbidity and disproportionately affects rural populations. Total contact casts or instant total contact casts are gold standard for management of foot ulcerations resulting from diabetes-related foot disease. The aim of this study was to evaluate the impact of a podiatrist-led casting service model within a rural and regional setting.

DESIGN

The implementation of the service model was evaluated over a 12-month period using a quality improvement approach, informed by multiple methods. Quantitative and qualitative methods were used.

SETTING

An outpatient high-risk foot clinic and community-based podiatry services within a large regional health service. The location was central Victoria, servicing rural communities within the Loddon Mallee region.

KEY MEASURES FOR IMPROVEMENT

Patient-related data included information relating to demographics, diabetes and foot pathologies. Service-related data included occasions of service, locations and the number and type of casts applied.

STRATEGIES FOR CHANGE

Upskilling podiatrists to provide the service in a safe, supportive and sustainable manner and ensuring the podiatrist-led casting service model was sufficiently adaptable for patients to access at the rural sites.

EFFECTS OF CHANGE

Increased access to total contact casts and instant total contact casts, comparable wound healing times to other studies and the model was able to be sustained.

LESSONS LEARNT

Podiatrist-led casting resulted in increased utilisation of total contact casts and instant total contact casts. The increased use of instant total contact casts in particular may help address the lack of uptake of this treatment for people with diabetes-related foot disease, thereby improving rural health outcomes.

Quality of acute stroke care in a regional Victorian hospital, Australia

OBJECTIVE

The quality of acute stroke care in a regional Victorian hospital (study hospital) was assessed by comparing with selected standard indicators of Acute Stroke Clinical Care.

DESIGN

A retrospective review of records of patients with stroke was performed manually and by reviewing electronic database.

SETTING

The study was carried out in Goulburn Valley Health, one of the five regional referral and teaching hospitals in Victoria, Australia.

PARTICIPANTS

Patients with stroke who were discharged from the study hospital between October 2015 and March 2016.

MAIN OUTCOME MEASURES

Timeliness of brain imaging, proportion of patients thrombolysed if arrived within 4.5 hours of stroke and timeliness of thrombolysis.

RESULTS

A total of 66 patients' records was found. Brain imaging was completed for 45%, compared to 25.8% nationally, if arrived to the study hospital within 1 hour of stroke and 100% imaging completed within 24 hours of arrival, compared to 75.6% nationally. When patients arrived to the emergency department within 4.5 hours of stroke, 37.5% (23.6% nationally and 18.6% in similar- sized hospitals) of them were thrombolysed, while none was thrombolysed within 60 minutes of arrival. Door-to-thrombolysis time was 85 minutes, 7 minutes longer than national standard. Symptoms onset to thrombolysis time was 225 minutes, 55 minutes longer than national standard.

CONCLUSION

The timeliness of brain imaging and thrombolysis was comparable in the study hospital to that of the national standard, while other stroke management indicators still require improvement. Continuing efforts for improvement and revisiting possible areas of delay are warranted.

Building a sustainable workforce in a rural and remote health service: A comprehensive and innovative Rural Generalist training approach

BACKGROUND

Historically it has been challenging to recruit and retain an appropriately trained medical workforce to care for rural and remote Australians. This paper describes the Queensland North West Hospital and Health Service (NWHHS) workforce redesign, developing education strategies and pathways to practice, thereby improving service provision, recruitment and retention of staff.

CONCEPT

The Mount Isa-based Medical Education Unit sought accreditation for a Rural Generalist (RG) training pathway from Internship to Fellowship with the Australian College of Rural and Remote Medicine (ACRRM) and the Regional Training Provider (RTP). This approach enhanced the James Cook University (JCU) undergraduate pathway for rurally committed students while improving recruitment and retention of RMOs/Registrars.

ACHIEVEMENTS

Accreditation was achieved through collaboration with training providers, accreditation agencies, ACRRM and a local general practice. The whole pathway from ignore Internship to Fellowship is offered with the RG Intern intake as a primary allocation site beginning in 2016. Comprehensive supervision and excellent clinical exposure provide an interesting and rewarding experience - for staff at all levels.

RESULTS

Since 2013 RMO locum rates have been <1%. Registrars on the ACRRM pathway and Interns increased from 0 to 7 positions each in 2015, with similar achievements in SMO staffing. Three RMOs expressed interest in a Registrar position, CONCLUSIONS: Appropriate governance is needed to develop and advertise the program. This includes the NWHHS, the RG Pathway and JCU.

Are rural and remote patients, families and caregivers needs in life-limiting illness different from those of urban dwellers? A narrative synthesis of the evidence

This review aimed to assess the evidence to answer the question whether palliative end-of-life care needs of patients and caregivers in rural and remote communities differs from those of urban dwellers. Peer-reviewed studies from 1996 to the present dealing with the experience of rural and remote patients and caregivers at the end-of-life compared with that of urban people were extracted for narrative synthesis. The eight studies included showed that palliative needs of rural and remote residents are related to context. Diagnosis and treatment are less well managed in rural areas. Rural differences include: people are more accepting of death and less likely to intervene to delay death; caregivers tend to be younger and include friends as well as family and local support networks are important. Rural and remote end-of-life needs are shaped by reduced access and availability of services which has a negative influence on outcomes. This is counterbalanced by an acceptance of death and local support networks. Well-designed longitudinal studies with samples comprised of rural and urban residents for comparison are required to monitor how end-of-life need might change with the approach of death. Clinicians, health services and policy makers need a better understanding of rural attitudes and of how rural community networks mobilise to support end-of-life care in their rural and remote communities.