The impacts of withdrawal and replacement of general practitioner services on aeromedical service trends: a 13-year interrupted time-series study in Tennant Creek, Northern Territory.

BACKGROUND: The Royal Flying Doctor Service (RFDS) provides aeromedical care to patients during fixed-wing transport over vast distances to healthcare unavailable in rural or remote communities. This study examined the relationship between changes in local accessibility to primary healthcare services and rates of aeromedical service use over time. METHODS: This was a 13-year interrupted time-series study (1999-2012) in Tennant Creek, Northern Territory. Quarterly aeromedical service use for primary care sensitive conditions were calculated and exposure to general practice (GP) services was characterised over time with events modelled as intervention variables: (a) GP service withdrawal (Nov-2004); and (b) GP service replacement (Dec-2006). Intervention effects were estimated using PROC ARIMA in SAS after examination of the time-series structure. RESULTS: GP withdrawal resulted in an immediate and sustained doubling in quarterly aeromedical service use (+11.8 services per quarter) and GP service replacement had no significant effect. DISCUSSION: Large and immediate increases in aeromedical service use result from the loss of local GPservices yet, in this case, replacement with a new GP service, 2-years hence, did not ameliorate that effect after six years. CONCLUSIONS: These findings demonstrate the immediate impact of GP-service loss on the rates ofaeromedical transfer of patients from this remote community and lend caution to expectations about thetimeline over which newly implemented primary health care services in such contexts can mitigate the impact of such a loss.

Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction.

OBJECTIVE: To evaluate the impact of the regionalised Integrated Cardiovascular Clinical Network (ICCNet) on 30-day mortality among patients with myocardial infarction (MI) in an Australian rural setting. DESIGN, SETTING AND PATIENTS: An integrated cardiac support network incorporating standardised risk stratification, point-of-care troponin testing and cardiologist-supported decision making was progressively implemented in non-metropolitan areas of South Australia from 2001 to 2008. Hospital administrative data and statewide death records from 1 July 2001 to 30 June 2010 were used to evaluate outcomes for patients diagnosed with MI in rural and metropolitan hospitals. MAIN OUTCOME MEASURE: Risk-adjusted 30-day mortality. RESULTS: 29 623 independent contiguous episodes of MI were identified. The mean predicted 30-day mortality was lower among rural patients compared with metropolitan patients, while actual mortality rates were higher (30-day mortality: rural, 705/5630 [12.52%] v metropolitan, 2140/23 993 [8.92%]; adjusted odds ratio [OR], 1.46; 95% CI, 1.33-1.60; P< 0.001). After adjustment for temporal improvement in MI outcome, availability of immediate cardiac support was associated with a 22% relative odds reduction in 30-day mortality (OR, 0.78; 95% CI, 0.65-0.93; P= 0.007). A strong association between network support and transfer of patients to metropolitan hospitals was observed (before ICCNet, 1102/2419 [45.56%] v after ICCNet, 2100/3211 [65.4%]; P< 0.001), with lower mortality observed among transferred patients. CONCLUSION: Cardiologist-supported remote risk stratification, management and facilitated access to tertiary hospital-based early invasive management are associated with an improvement in 30-day mortality for patients who initially present to rural hospitals and are diagnosed with MI. These interventions closed the gap in mortality between rural and metropolitan patients in South Australia.