Implications of telehealth services for healthcare delivery and access in rural and remote communities: perceptions of patients and general practitioners.

BACKGROUND: Accelerated by the coronavirus disease 2019 (COVID-19) pandemic, Australia has shifted towards greater use of telehealth to deliver care for rural and remote communities. This policy direction might risk a shift away from the traditional model of informed person-centred care built around care relationships to a technology-mediated health transaction. Potential opportunity costs of widespread telehealth services on the quality of care for rural and remote communities remain understudied. METHODS: A qualitative study was conducted in three local health districts of rural New South Wales, Australia. Data were collected through in-depth interviews. A total of 13 participants was interviewed. Data were analysed using thematic analysis. RESULTS: Patient participants perceived telehealth as an alternative when specialist care was limited or absent. Both patients and clinicians perceived that the deeper caring relationship, enabled through face-to-face interactions, could not be achieved through telehealth services alone, and that telehealth services are often superficial and fragmented in nature. Patients in this study contended that virtual consultations can be distant and lacking in personal touch, and risk losing sight of social circumstances related to patients' health, thereby affecting the trust placed in healthcare systems. CONCLUSIONS: Simply replacing face-to-face interactions with telehealth services has the potential to reduce trust, continuity of care, and effectiveness of rural health services. Telehealth must be used to assist local clinicians in providing the best possible care to rural and remote patients within an integrated service delivery model across diverse rural contexts in Australia.

Do General Practitioners in a Visiting Medical Officer Arrangement Improve the Perceived Quality of Care of Rural and Remote Patients? A Qualitative Study in Australia.

Background: In rural and remote Australia, general practitioners (GPs) provide care across the continuum from primary to secondary care, often in Visiting Medical Officer (VMO) arrangements with a local hospital. However, little is known about the role of GP-VMOs in improving the perceived quality of care and health outcomes for rural and remote communities. Methods: We collected qualitative data from three GP-VMOs (all aged >55 years) and 10 patients (all aged over 65 years) in three local health districts of New South Wales, Australia. Thirteen in-depth interviews were conducted between October 2020 and February 2021. We employed thematic analysis to identify key roles of GP-VMOs in improving the perceived quality of care and health outcomes of rural and remote patients. Results: Our study advances the current understanding regarding the role of GP-VMOs in improving the perceived quality of services and health outcomes of rural and remote patients. Key roles of GP-VMOs in improving the perceived quality of care include promoting the continuity of care and integrated health services, cultivating trust from local communities, and enhancing the satisfaction of patients. Conclusions: GP-VMOs work across primary and secondary care creating better linkages and promoting the continuity of care for rural and remote communities. Employing GP-VMOs in rural hospitals enables the knowledge and sensitivity gained from their ongoing interactions with patients in primary care to be effectively utilised in the delivery of hospital care.

Effects of employing primary care doctors in hospital to improve the quality of care and health outcomes of rural patients: A systematic scoping review.

OBJECTIVE: To describe effects of employing primary care doctors in hospital care and their roles in improving the quality of care and health outcomes of rural and remote patients. DESIGN: A systematic scoping review. SETTING: Peer-reviewed publications were sourced from 3 online journal databases (PUBMED, SCOPUS and Web of Science). PARTICIPANTS: All study designs from peer-reviewed journals that discussed effects of employing primary care doctors in hospital care Interventions: employing primary care doctors in hospital care. MAIN OUTCOME MEASURES: Positive and negative consequences of employing primary care doctors in hospital care, and the roles of primary care doctors in improving the quality of care and health outcomes. RESULTS: A total of 12 articles met the inclusion and exclusion criteria. Positive outcomes included improved access to specialised treatment, improved continuity of care, reduced waiting list and admission rates, improved skills, competence and confidence of primary care doctors, and increased satisfaction from both health providers and patients/families. Negative consequences reported included increased prescriptions and poorly documented history and physical examinations. CONCLUSION: Employing primary care doctors in hospital care can fill the gaps in the delivery of acute care, emergency medicine and maternity care. Primary care doctors bring advanced clinical skills and a patient-centred approach to the hospital care. They also improve the quality of referrals leading to freed-up clinical capacity of tertiary hospitals to treat more serious conditions. The provision of acute or emergency care and secondary care in rural and remote areas should be directed towards patient-oriented not provider-oriented policies.

Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update.

BACKGROUND: Antibiotic use is the most important modifiable risk factor for healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). Previous systematic reviews cover studies published until 31 December 2012. OBJECTIVES: To update the evidence for associations between antibiotic classes and HCFA-CDI to 31 December 2020. METHODS: PubMed, Scopus, Web of Science Core Collection, WorldCat and Proquest Dissertations & Theses were searched for studies published since 1 January 2013. Eligible studies were those conducted among adult hospital inpatients, measured exposure to individual antibiotics or antibiotic classes, included a comparison group and measured the occurrence of HCFA-CDI as an outcome. The Newcastle-Ottawa Scale was used to appraise study quality. To assess the association between each antibiotic class and HCFA-CDI, a pooled random-effects meta-analysis was undertaken. Meta-regression and subgroup analysis was used to investigate study characteristics identified a priori as potential sources of heterogeneity. RESULTS: Carbapenems and third- and fourth-generation cephalosporin antibiotics remain the most strongly associated with HCFA-CDI, with cases more than twice as likely to have recent exposure to these antibiotics prior to developing HCFA-CDI. Modest associations were observed for fluoroquinolones, clindamycin and ß-lactamase inhibitor combination penicillin antibiotics. Individual study effect sizes were variable and heterogeneity was observed for most antibiotic classes. CONCLUSIONS: This review provides the most up-to-date synthesis of evidence in relation to the risk of HCFA-CDI associated with exposure to specific antibiotic classes. Studies were predominantly conducted in North America or Europe and more studies outside of these settings are needed.

Geographic variation in health system performance in rural areas of New South Wales, Australia.

OBJECTIVES: (i) To quantify geographic variation in selected health system performance indicators across local government areas of rural New South Wales and (ii) to compare relationships between sociodemographic factors and health system performance indicators across the regions. DESIGN: Ecological study. SETTING: Rural New South Wales communities. PARTICIPANTS: Eighty-nine local government areas in rural areas comprising 47 inner regional, 33 outer regional, 6 remote and 3 very remote areas. MAIN OUTCOME MEASURES: Deaths from avoidable causes, public hospital admissions for potentially preventable conditions, screening program participation, immunisation coverage. RESULTS: The largest geographic variation between rural areas of New South Wales was seen for avoidable mortality and potentially preventable hospital admissions. The average annual avoidable age-standardised mortality rate (2013-2017) ranged from 78.1 per 100 000 population to 493.7 per 100 000 population and the age-standardised rate of potentially preventable hospitalisations (2016-2017) ranged from 1491 to 5797 per 100 000 population. Approximately three quarters of local government areas had bowel and breast cancer screening participation rates equivalent to or better than the overall New South Wales rate; however, only 34% of local government areas met the New South Wales rate for cervical cancer screening. The least variation was seen for immunisation coverage; Byron had the lowest immunisation coverage for all 3 ages. The most common explanations for variation between rural local government areas in New South Wales were remoteness and socioeconomic characteristics. CONCLUSIONS: The analysis of health system performance indicators reveals differences among New South Wales rural local government areas. The results highlight specific areas that might benefit from targeted intervention to improve inequities particularly for avoidable mortality and potentially preventable hospitalisations.

Social and community networks influence dietary attitudes in regional New South Wales, Australia.

INTRODUCTION: Rural populations in Australia have a higher prevalence of obesity, cardiovascular disease, type II diabetes and some cancers. The purpose of the present study was to determine associations between socioeconomic characteristics (socioeconomic position, income, wealth, debt, occupation, social network diversity), dietary attitudes, and fruit and vegetable intake for people living rurally in Australia. METHOD: A community based cross-sectional survey between February and July 2018 of 326 adults (median age 57 years, range 20-90 years, 64.4% female) who attended rural shows in four rural towns in south-eastern New South Wales, supplemented with data from patients attending general practices in two additional towns. Participants completed a questionnaire that recorded self-reported daily consumption of fruit and vegetables, a dietary attitude score, and items measuring social and economic circumstances. RESULTS: Using multivariable regression analysis, the odds of meeting Australian fruit intake guidelines was 13% higher for each unit increase in dietary attitude score (odds ratio (OR)=1.13, 95% confidence interval (CI)=1.03-1.23). The odds of meeting vegetable intake guidelines were 19% higher for each unit increase in score (OR=1.19, 95%CI=1.09-1.31). Social and economic factors were not independently associated with fruit or vegetable intake. Dietary attitude score, in turn, increased on average by 0.07 points (95%CI=0.01-0.12) for each additional occupation type among the participants' social networks. For women who socialised regularly in small towns the score was 1.97 points higher (95%CI=0.93-3.00). Men in outer regional areas were more likely to meet vegetable intake guidelines than men in inner regional areas, whereas women in outer regional areas were more likely to meet fruit intake guidelines than women in inner regional areas. CONCLUSIONS: Greater fruit and vegetable intake was predicted by healthier dietary attitudes which in turn were related to social and community connections, rather than economic factors.

Incidence and predictors of HIV, chlamydia and gonorrhoea among men who have sex with men attending a peer-based clinic.

Introduction Despite a range of interventions, annual numbers of new diagnoses of HIV infection among men who have sex with men (MSM) in Australia have not declined in recent years. Peer-based sexual health clinics targeting MSM, such as the M Clinic in Perth (WA, Australia), have been put in place to provide safe sex counselling and to increase testing rates among MSM and who are at high risk of HIV infection. The aim of this study was to assess the incidence of HIV, chlamydia and gonorrhoea among men attending the M Clinic. METHODS: This was a historical cohort study of repeated M Clinic clients from January 2011 to June 2015 inclusive. Testing and risk factor data from M Clinic client software were used to estimate the incidence of HIV, chlamydia and gonorrhoea and associated factors. RESULTS: The incidence of HIV, chlamydia and gonorrhoea was 1.87, 13.58 and 6.48 per 100 person-years respectively. Older men had a higher incidence of HIV infection but a lower incidence of chlamydia and gonorrhoea than younger men. CONCLUSIONS: The HIV incidence was higher than found in similar studies in other Australian sexual health clinics, but the incidence of chlamydia and gonorrhoea was similar. The high HIV incidence among clients of the M Clinic points to the importance of making pre-exposure HIV prophylaxis available to clients of the M Clinic and similar services.

Cytomegalovirus viraemia and mortality in renal transplant recipients in the era of antiviral prophylaxis. Lessons from the western Australian experience.

BACKGROUND: Cytomegalovirus (CMV) establishes a lifelong infection that is efficiently controlled by the immune system; this infection can be reactivated in case of immunosuppression such as following solid organ transplantation. CMV viraemia has been associated with CMV disease, as well as increased mortality and allograft failure. Prophylactic antiviral medication is routinely given to renal transplant recipients, but reactivation during and following cessation of antiviral prophylaxis is known to occur. The aims of this study were to assess the incidence, timing and impact of CMV viraemia in renal transplant recipients and to determine the level of viraemia associated with adverse clinical outcomes. METHODS: Data from all adult (18 years and over) Western Australian renal transplant recipients transplanted between 1 January 2007 and 31 December 2012 were obtained from the Australia and New Zealand Dialysis and Transplant registry and were supplemented with data obtained from clinical records. Potential risk factors for detectable CMV viraemia (≥600 copies/ml) and all-cause mortality were assessed using univariable analysis and Cox Proportional Hazards Regression. RESULTS: There were 438 transplants performed on 435 recipients. The following factors increased the risk of CMV viraemia with viral loads ≥600 copies/ml: Donor positive/Recipient negative status; receiving a graft from a deceased donor; and receiving a graft from a donor aged 60 years and over. CMV viraemia with viral loads ≥656 copies/ml was a risk factor for death following renal transplantation, as was being aged 65 years and above at transplant, being Aboriginal and having vascular disease. Importantly 37% of the episodes of CMV viraemia with viral loads ≥656 copies/ml occurred while the patients were expected to be on CMV prophylaxis. CONCLUSIONS: CMV viraemia (≥656 copies/ml) was associated with all-cause mortality in multivariable analysis, and CMV viraemia at ≥656 copies/ml commonly occurred during the period when renal transplant recipients were expected to be on antiviral prophylaxis. A greater vigilance in monitoring CMV levels if antiviral prophylaxis is stopped prematurely or poor patient compliance is suspected could protect some renal transplant recipients from adverse outcomes such as premature mortality.

Clostridium difficile Infections amongst Patients with Haematological Malignancies: A Data Linkage Study.

OBJECTIVES: Identify risk factors for Clostridium difficile infection (CDI) and assess CDI outcomes among Australian patients with a haematological malignancy. METHODS: A retrospective cohort study involving all patients admitted to hospitals in Western Australia with a haematological malignancy from July 2011 to June 2012. Hospital admission data were linked with all hospital investigated CDI case data. Potential risk factors were assessed by logistic regression. The risk of death within 60 and 90 days of CDI was assessed by Cox Proportional Hazards regression. RESULTS: There were 2085 patients of whom 65 had at least one CDI. Twenty percent of CDI cases were either community-acquired, indeterminate source or had only single-day admissions in the 28 days prior to CDI. Using logistic regression, having acute lymphocytic leukaemia, neutropenia and having had bacterial pneumonia or another bacterial infection were associated with CDI. CDI was associated with an increased risk of death within 60 and 90 days post CDI, but only two deaths had CDI recorded as an antecedent factor. Ribotyping information was available for 33 of the 65 CDIs. There were 19 different ribotypes identified. CONCLUSIONS: Neutropenia was strongly associated with CDI. While having CDI is a risk factor for death, in many cases it may not be a direct contributor to death but may reflect patients having higher morbidity. A wide variety of C. difficile ribotypes were found and community-acquired infection may be under-estimated in these patients.

Association of Gestational Age at Birth with Reasons for Subsequent Hospitalisation: 18 Years of Follow-Up in a Western Australian Population Study.

BACKGROUND: Preterm infants are at a higher risk of hospitalisation following discharge from the hospital after birth. The reasons for rehospitalisation and the association with gestational age are not well understood. METHODS: This was a retrospective birth cohort study of all live, singleton infants born in Western Australia between 1st January 1980 and 31st December 2010, followed to 18 years of age. Risks of rehospitalisation following birth discharge by principal diagnoses were compared for gestational age categories (<32, 32-33, 34-36, 37-38 weeks) and term births (39-41 weeks). Causes of hospitalisations at various gestational age categories were identified using ICD-based discharge diagnostic codes. RESULTS: Risk of rehospitalisation was inversely correlated with gestational age. Growth-related concerns were the main causes for rehospitalisation in the neonatal period (<1 month of age) for all gestational ages. Infection was the most common reason for hospitalisation from 29 days to 1 year of age, and up to 5 years of age. Injury-related hospitalisations increased in prevalence from 5 years to 18 years of age. Risk of rehospitalisation was higher for all preterm infants for most causes. CONCLUSIONS: The highest risks of rehospitalisation were for infection related causes for most GA categories. Compared with full term born infants, those born at shorter GA remain vulnerable to subsequent hospitalisation for a variety of causes up until 18 years of age.

Hospital admissions and gestational age at birth: 18 years of follow up in Western Australia.

BACKGROUND: Infants born moderate to late preterm are twice as likely to be rehospitalised within the first few weeks following discharge from the birth admission. It is not understood how rehospitalisation risk changes with age or how risks have changed over time. METHODS: A retrospective birth cohort study of all live, singleton births in Western Australia 1 January 1980-31 December 2010, without congenital anomalies, followed to 18 years of age. Rehospitalisation rates for gestational age categories (<28, 28-31, 32-33, 34-36, 37-38 and ≥42 weeks) were compared with term births (39-41 weeks) using negative binomial regression. To assess whether rehospitalisation risk changed with age or over time, analyses were conducted for different age intervals and for 5-year birth cohorts. RESULTS: Rehospitalisation rates were higher up to 18 years for all preterm and early term categories including early term (37-38 weeks) [130.2/1000 person-years at risk (pyr); 95% confidence interval 129.1, 131.4]; late preterm (34-36 weeks) (164.2/1000 pyr; 161.1, 167.4), and post-term (≥42 weeks) (115.3/1000 pyr; 111.7, 119.0) compared with term births (109.1/1000 pyr; 108.5, 109.7). The effect of gestational age on rehospitalisation was highest during the first year of life and declined by adolescence [e.g. 34-36 weeks: rate ratio = 2.10 (2.04, 2.15) for 29 days-1 year; 1.14 (1.11, 1.18) for 12-18 years]. The risk of rehospitalisation up to 1 year of age has declined since 1980, except for those born <32 weeks. CONCLUSIONS: Rehospitalisation risk is greater for singleton children born at all gestational ages compared with those born full term. This effect of gestational age on rehospitalisation is highest in the first year post-discharge, but has almost disappeared by adolescence.

Increasing incidence of Clostridium difficile infection, Australia, 2011-2012.

OBJECTIVES: To report the quarterly incidence of hospital-identified Clostridium difficile infection (HI-CDI) in Australia, and to estimate the burden ascribed to hospital-associated (HA) and community-associated (CA) infections. DESIGN, SETTING AND PATIENTS: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics. MAIN OUTCOME MEASURES: Incidence of HI-CDI (primary outcome); proportion and incidence of HA-CDI and CA-CDI (secondary outcomes). RESULTS: The annual incidence of HI-CDI increased from 3.25/10 000 patient-days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October-December quarter. The incidence plateaued in January-March 2012 and then declined by 8% (95% CI, - 11% to - 5%) per quarter to 3.76/10 000 PD in July-September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October-December 2012. Trends were similar for HA-CDI and CA-CDI. A subgroup analysis determined that 26% of cases were CA-CDI. CONCLUSIONS: A significant increase in both HA-CDI and CA-CDI identified through hospital surveillance occurred in Australia during 2011-2012. Studies are required to further characterise the epidemiology of CDI in Australia.

Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis.

OBJECTIVES: To update the evidence for associations between antibiotic classes and hospital-acquired Clostridium difficile infection (HA-CDI). METHODS: Electronic databases of journal articles, scholarly theses and conference proceedings using subject headings and keywords related to CDI and antibiotic exposure were searched. Observational epidemiological studies measuring associations between antibiotic classes and HA-CDI were eligible for inclusion. Pooled ORs and 95% CIs were calculated using a random effects model. Study factors identified a priori were examined as sources of heterogeneity. The quality of the studies was assessed using the Newcastle-Ottawa Scale. RESULTS: Of 569 citations identified, 13 case-control and 1 cohort study (15,938 patients) were included. The strongest associations were found for third-generation cephalosporins (OR = 3.20, 95% CI = 1.80-5.71; n = 6 studies; I(2) = 79.2%), clindamycin (2.86, 2.04-4.02; n = 6; I(2) = 28.5%), second-generation cephalosporins (2.23, 1.47-3.37; n = 6; I(2)  = 48.4%), fourth-generation cephalosporins (2.14, 1.30-3.52; n = 2; I(2)  = 0.0%), carbapenems (1.84, 1.26-2.68; n = 6; I(2) = 0.0%), trimethoprim/sulphonamides (1.78, 1.04-3.05; n = 5; I(2) = 70%), fluoroquinolones (1.66, 1.17-2.35; n = 10; I(2) = 64%) and penicillin combinations (1.45, 1.05-2.02; n = 6; I(2) = 54%). The study population and the timing of measurement of antibiotic exposure were the most common sources of heterogeneity. Study quality scored high for seven studies, moderate for six studies and low for one study. CONCLUSIONS: The risk of HA-CDI remains greatest for cephalosporins and clindamycin, and their importance as inciting agents should not be minimized. The importance of fluoroquinolones should not be overemphasized, particularly if fluoroquinolone-resistant epidemic strains of C. difficile are absent.