Western Australia remote aeromedical substance use disorders outcomes.

INTRODUCTION: Substance use disorders (SUDs) cause significant harm to regional Australians, who are more likely to misuse alcohol and other drugs (AODs) and encounter difficulty in accessing treatment services. The primary aims of this study were to describe the demographics of patients aeromedically retrieved from regional locations and compare hospital outcomes with a metropolitan-based cohort. AIMS: Retrospective case-controlled cohort study. Participants were aeromedically retrieved within Western Australia for SUDs between 1 July 2014 and 30 June 2019. Retrieved patients were case-matched based on age and hospital discharge diagnosis. Descriptive statistics and χ2 analysis were used to summarise the findings. RESULTS: One hundred thirty-six (91.3%) aeromedical retrievals were found, with the majority being male (n = 95; 69.9%). These were case-matched to 427 metropolitan patients, the majority male (n = 321; 75.2%). Retrieved patients were more likely (all P < 0.05) Indigenous (odds ratio [OR], 9.35 [95% confidence interval (CI), 5.96-14.85]), unemployed (OR, 2.9 [95% CI, 1.41-6.80]), referred to a tertiary hospital (OR, 2.18 [95% CI, 1.24-3.86]) and to stay longer in hospital (OR, 1.08 [95% CI, 1.02-1.14]). DISCUSSION: Findings highlight that unmarried and/or unemployed males were overrepresented in the retrieval group, with over half identifying as Indigenous. Regional variation in retrievals was noted, while amphetamine-type stimulants featured prominently in the retrieval cohort, who experienced longer hospital stays and more restrictive treatment. CONCLUSIONS: Comparing clinical outcomes for retrieved regional patients experiencing SUDs, service design and delivery should focus on offering culturally safe care for Indigenous people, catering for regional health care catchment areas, while ideally adopting collaborative and integrated approaches between AODs and mental health services.

Culturally appropriate psychotherapy and its retention: An example from Far North Queensland (Australia).

BACKGROUND: Culturally appropriate mental health care is essential in remote Australia. However, while associated with the development of an effective therapeutic alliance, current literature insufficiently reports the retention and psychotherapy outcomes of Indigenous adults. We aimed to describe the characteristics and retention of clients attending the Far North Mental Health and Wellbeing Service (FNS). METHODS: We conducted a retrospective cross-sectional study on clients who received one or more psychotherapy consultations between 1st July 2019 and 31st December 2020. Population, entrance, and treatment characteristics were described, with retention compared between the major cultural groups. Entrance characteristics comprised referral pathway and reason for presentation and were investigated as alternative predictors of client retention. FINDINGS: There were 186 non-Indigenous (68.3 % female) and 174 Indigenous (62.6 % female) clients, with a median number of 3.0 consultations (IQR 2.0-5.3). Indigenous status did not significantly predict retention. Referral pathway significantly predicted the number of consultations (Wald X2(6) = 17.67, p = .0071) and immediate discontinuation (Wald X2(6) = 12.94, p = .044), with self-referred clients having the highest retention. Initial presentation reason significantly predicted the number of consultations (Wald X2(5) = 13.83, p = .017), with clients with potential health hazards related to socioeconomic and psychosocial circumstances having the lowest retention. Significantly more Indigenous clients presented for this reason (20.1 % vs 4.3 %). INTERPRETATION: Comparable retention of Indigenous clients suggests cultural appropriateness of the psychotherapy being delivered by the FNS. Services might use the described therapeutic approach as a guide for culturally appropriate care.

Air Medical Retrieval of Central Australian Women in Labor: A Retrospective Observational Study.

OBJECTIVE: The aim of this study was to describe the characteristics and outcomes of remote-dwelling pregnant women with threatened labor referred for air medical retrieval to a regional birthing center as well as factors associated with birth within 48 hours. METHODS: This was a retrospective observational study of all pregnant women in the remote Central Australian region referred to the Medical Retrieval Consultation and Coordination Centre for labor > 23 weeks' gestation between February 12, 2018, and February 12, 2020. Univariate and multivariate statistical analyses were performed. RESULTS: There were 116 women referred for retrieval for labor. There were no births during transport, and less than half of the cases resulted in birth within 48 hours of retrieval. Tocolysis was frequently used. Predictors of birth within 48 hours were cervical dilatation ≥ 5 cm, preterm gestational age, and ruptured membranes in the univariate analysis. Nearly one third of this cohort required intervention or had complications during birth. CONCLUSION: Birth during transport for threatened labor did not occur in this cohort, and more than half of the retrievals did not result in birth within 48 hours; however, the high risk of birth complications may offset any benefit of avoiding air medical transport from remote regions. Retrieval clinicians should consider urgent transfer in cases of ruptured membranes, cervical dilatation of 5 cm or more, or gestational age less than 37 weeks.

A novel COVID-19 program, delivering vaccines throughout rural and remote Australia.

Background: The Royal Flying Doctor Service of Australia (RFDS) established a unique SARS-CoV-2 vaccination program for vaccinating Australians that live in rural and remote areas. This paper describes the preparation and response phases of the RFDS response. Methods: This study includes vaccinations conducted by the RFDS from 01 January 2021 until 31 December 2021 when vaccines were mandatory for work and social activities. Prior to each clinic, we conducted community consultation to determine site requirements, patient characteristics, expected vaccination numbers, and community transmission rates. Findings: Ninety-five organizations requested support. The majority (n = 60; 63.2%) came from Aboriginal Community Controlled Health Organizations. Following consultation, 360 communities were approved for support. Actual vaccinations exceeded expectations (n = 70,827 vs. 49,407), with a concordance correlation coefficient of 0.88 (95% CI, 0.83, 0.93). Areas that reported healthcare workforce shortages during the preparation phase had the highest population proportion difference between expected and actual vaccinations. Areas that reported high vaccine hesitancy during the preparation phase had fewer than expected vaccines. There was a noticeable increase in vaccination rates in line with community outbreaks and positive polymerase chain reaction cases [r (41) = 0.35, p = 0.021]. Engagement with community leaders prior to clinic deployment was essential to provide a tailored response based on community expectations.

The Royal Flying Doctor Service Initiation of Helicopter Video Simulation Orientation Training for Air Medical Crews in Western Australia: A Pilot Study.

OBJECTIVE: In May 2022, the Royal Flying Doctor Service Western Operations in Western Australia pioneered the introduction of the first organizational helicopter emergency service with 2 Eurocopter EC145 helicopters. This article describes the pilot study undertaken, assessing the implementation and flight crew confidence outcomes of the supplementation of video simulation training to standard clinical training for helicopter air medical retrieval. METHODS: Survey assessments using a 5-point Likert scale provided anonymous demographic data with summarized results of the means and standard deviations. Nonparametric tests were used to compare responses between the control and experimental groups from pretraining to postintervention to postpractical. RESULTS: The findings showed an increase in confidence rates after a classroom session and further increases after a practical session in the control group. The intervention group showed a small rise in overall confidence levels after being shown video simulations following the completion of their classroom session before commencing their practical session. This study established that regardless of the airframe, clinical staff, often with significant experience in air medical retrieval and critical care medicine, do not automatically have confidence in performing critical care procedures in a new aircraft type to which they have not previously been oriented. The results display a statistically significant increase in confidence levels in procedural performance after the classroom session compared with the pretraining questionnaire, with a subtle further rise when video simulations are included in the classroom session. When a classroom session is subsequently supplemented with a practical simulation session, confidence levels continue to rise. CONCLUSION: Implementing a comprehensive educational strategy including classroom and practical elements for clinical staff in their orientation to new aircraft improves their confidence in performing critical care procedures if required in flight. The addition of in-flight prerecorded videos demonstrating these critical care procedures is a useful adjunct to simulation training for flight crew in air medical retrieval, and further analytical studies may indeed show a statistically significant improvement in staff confidence.

Remoteness and socioeconomic status reduce access to specialist mental health care across Australia.

OBJECTIVE: Estimate impact of socioeconomic factors and remoteness from tertiary hospital on incidence/duration of Australian mental health admissions. METHODS: Retrospective analysis of incidence/duration of public mental health unit admissions (2018-19). Covariates included Indigenous population, potentially preventable hospitalisations (PPH) and socioeconomic disadvantage. RESULTS: Regional distance from hospital was correlated with socioeconomic disadvantage (ρ: p < 0.01). Population identifying as Aboriginal or Torres Strait Islander was associated with distance from hospital, socioeconomic disadvantage and PPH (ρ: p < 0.01). Bed days per capita was explained (R2adj: 0.48) by distance and socioeconomic disadvantage (p < 0.0001). A 1% increase in distance from hospital was associated with a 0.37% decrease in per capita bed days. Admission rate per capita across Queensland and WA was explained (R2adj: 0.36) by distance, education/occupation and state (p < 0.05). Across Queensland and WA a 1% increase in distance from hospital was associated with a 0.05% decreased incidence of admission. CONCLUSIONS: Rural Australians face high mental illness burden, socioeconomic disadvantage and limited service provision. Overcoming the additional disadvantages of reduced likelihood of admission to and reduced time in hospital with increasing distance from hospital will require increased outreach proportional to remoteness.

Medical retrieval of pregnant women in labour: A scoping review.

BACKGROUND: Remote Australian women in labour often rely on retrieval services to allow birthing in specialist obstetric centres. However, there is currently debate over when not to transfer a woman in labour, for risk of an in-transit birth, associated with worse neonatal outcomes. METHODS: A scoping review methodology was undertaken, to define the scope of published literature on the topic and identify gaps in the current knowledge. RESULTS: A total of seven full texts were deemed suitable for synthesis, which were all retrospective observational studies. Four themes from the studies' findings were identified: population features, predicting time-to-birth, use of tocolysis and birth during medical evacuation. CONCLUSION: The evidence identified in this review was of low methodological quality and heterogenous. The key findings were that births in-flight are rare, despite geographical distances and long transport times, with a knowledge gap on predictors of time-to-birth.

Aeromedical retrieval services characteristics globally: a scoping review.

BACKGROUND: Aeromedical emergency retrieval services play an important role in supporting patients with critical and often life-threatening clinical conditions. Aeromedical retrieval services help to provide fast access to definitive care for critically ill patients in under-served regions. Typically, fixed-wing aeromedical retrieval becomes the most viable transport option compared with rotary-wing aircraft when distances away from centres of definitive care extend beyond 200 kms. To our knowledge, there are no studies that have investigated fixed-wing aeromedical services in the member countries of the organisation for economic cooperation and development (OECD). A description of the global characteristics of aeromedical services will inform international collaboration to optimise clinical outcomes for patients. AIM: In this scoping review, we aimed to describe the features of government- and not-for-profit organisation-owned fixed-wing aeromedical retrieval services in some of the member countries of the OECD. METHODS: We followed scoping review methodology based on the grey literature search strategy identified in earlier studies. This mostly involved internet-based searches of the websites of fixed-wing aeromedical emergency retrieval services affiliated with the OECD member countries. RESULTS: We identified 460 potentially relevant records after searching Google Scholar (n = 24) and Google search engines (n = 436). After removing ineligible and duplicate information, this scoping review identified 86 government-and not-for-profit-operated fixed-wing aeromedical retrieval services as existing in 17 OECD countries. Concentrations of the services were greatest in the USA followed by Australia, Canada, and the UK. The most prevalent business models used across the identified OECD member countries comprised the government, not-for-profit, and hybrid models. Three-quarters of the not-for-profit and two-fifths of the hybrid business models were in the USA compared to other countries studied. The government or state-funded business model was most common in Australia (11/24, 46%), Canada (4/24, 17%), and the UK (4/24, 17%). The frequently used service delivery models adopted for patients of all ages included primary/secondary retrievals, secondary retrievals only, and service specialisation models. Of these service models, primary/secondary retrieval involving the transportation of adults and children from community clinics and primary health care facilities to centres of definitive care comprised the core tasks performed by most of the aeromedical retrieval services studied. The service specialisation model provided an extra layer of specialist health care dedicated to the transportation of neonates and paediatrics. At least eight aeromedical retrieval services catered solely for children from birth to 16 years of age. One aeromedical service, the royal flying doctor service in Australia also provided primary health care and telehealth services in addition to primary retrieval and interhospital transfer of patients. The doctor and registered nurse/paramedic (Franco-German model) and the nurse and/or paramedic (Anglo-American model) configurations were the most common staffing models used across the aeromedical services studied. CONCLUSIONS: The development and composition of fixed-wing aeromedical emergency retrieval services operated by not-for-profit organisations and governments in the OECD countries showed diversity in terms of governance arrangements, services provided, and staffing models used. We do not fully understand the impact of these differences on the quality of service provision, including equitable service access, highlighting a need for further research.

'COVID on Country': an innovative model safely supporting high-risk patients in Central Australia.

In January 2022, as the COVID pandemic reached remote communities in Central Australia, The Northern Territory Health Central Australian Regional Health Service and the Royal Flying Doctor Service (RFDS) executed 'COVID on Country', a program designed to triage cases and to implement treatment and clinical review of individuals in their community without the need to be relocated to larger centres for safe provision of care. The program assessed patient factors and community/capacity factors to triage and enact pathways. Remote living people who qualified for the program or who declined aeromedical retrieval, were provided with comprehensive clinical support, including administration of intravenous sotrovimab by daily scheduled visits to all affected communities by a doctor transported on an RFDS plane. Evaluation of the program demonstrated that it was a safe and effective way to provide complex care in a culturally safe manner.

A Cohort Comparison Study on Women in Threatened Preterm Labor Given Nifedipine or Nifedipine and Salbutamol Tocolysis in Air Medical Retrieval.

OBJECTIVE: Women with threatened preterm labor in remote Australia often require tocolysis in the prevention of in-flight birth during air medical retrieval. However, debate exists over the tocolytic choice. METHODS: A retrospective analysis was undertaken on data containing women who required air medical retrieval for threatened preterm labor within Western Australia between the years 2013 and 2018. RESULTS: A total number of 236 air medical retrievals were deemed suitable for inclusion; 141 received nifedipine, and 95 women received salbutamol + nifedipine. Tocolytic efficaciousness was reported in 151 cases, proportionally more (P < .05) from the women who received salbutamol + nifedipine (n = 68, 71.6%) compared with the women who received nifedipine only (n = 83, 58.9%). Those receiving salbutamol + nifedipine were more likely to suffer maternal tachycardia (n = 87 [91.6%] vs. n = 62 [44.0%]), fetal tachycardia (n = 26 [27.4%] vs. n = 13 [9.2%]), nausea (n = 17 [17.9] vs. n = 5 [3.55%]), and vomiting (n = 12 [12.6%] vs. n = 2 [1.4%]). Three women who received salbutamol + nifedipine had serious side effects including echocardiographic changes, chest pain, and metabolic and lactic acidosis. CONCLUSION: Salbutamol + nifedipine tocolysis was proven to be more effective than nifedipine only. Although salbutamol + nifedipine had increased temporary side effects, most were nonsevere and managed in-flight.

Cohort study comparison of Mental Health and Wellbeing Services delivered by The Royal Flying Doctor Service, across Far North and Central West Queensland.

Background: Understanding cultural differences between geographical regions is essential in delivering culturally appropriate healthcare. We aimed to describe the characteristics and outcomes of diverse clients using the Far North Mental Health and Wellbeing Service (FNS) and the Central West Health and Wellbeing Service (CWS). Methods: We conducted a cohort study within Queensland, Australia, on all clients who received a mental health therapy session at either the FNS or the CWS. Patient data was prospective data collected form July 2019 to December 2020. Findings: There were1202 clients, with a median number of individual contacts per-client of 3.0 (IQR 2.0-6.0). There was 428 (35.6% 95% CI 32.90-38.39) males and 772 (64.2% 95% CI 61.44-66.94) females with a median age across the genders of 38.0 (IQR 28.0-51.0). There was 505 (42.0% 95% CI 39.20-44.86) identifying as Indigenous and 697 (58.0% 95% CI 55.14-60.80) as non-Indigenous Australians. The FNS had a significantly higher proportion of Indigenous clients (n=484; 54.8% 95% CI 51.46-58.13) as compared to the CWS (n=21; 6.6% 95% CI 4.12-9.89). Of the 1202 clients, 946 (78.7% 95% CI 76.28-80.99) had a socio-economic classification of 'most disadvantaged', consisting of 740 (83.8%) clients from the FNS and 206 (64.6%) clients from the CWS. The majority of presentations were for neurotic, stress-related and somatoform disorders (n=568; 47.3%), followed by mood affective disorders (n=310; 25.8%). The overall number of treatments strategies employed was 10798, equalling a median of 6.0 (IQR 4.0-9.0) strategies per-client, with the leading strategies being counselling/psychosocial (n=1394; 12.9%), reflective listening (n=1191; 11.0%), and strengths based reasoning (n=1116; 10.3%). There were 511 (42.5%) clients who completed the Kessler Psychological Distress Scale (K10/K5), with 493 (41.0%) clients not offered as deemed not culturally appropriate by the treating team. The mean initial K10/K5 score was 23.7 (SD 9.4) which significantly decreased (p<0.001) to 18.0 (SD 10.0) at final consultation. Interpretation: This study highlighted client socioeconomic differences between two geographically remote mental health services. It is essential that services are regionally co-designed to ensure cultural appropriateness. Funding: No funding to declare.

Remote mental health clients prefer face-to-face consultations to telehealth during and after the COVID-19 pandemic.

OBJECTIVE: To guide the efficient and effective provision of mental health services to clients in Central West and Far North Queensland, we surveyed preferences for face-to-face or in-person contact. METHODS: A clinician-designed survey of contact preferences was offered to 248 clients of mental health services in Far North and Central West Queensland in mid-2020. With the onset of COVID-19, the survey was modified to measure the impact of the pandemic. RESULTS: Just over half of the services' clients participated in the survey (50.4%), of whom more were female (63.2%). Of the participants, 46.3% in Far North and 8.6% in Central West Queensland identified as Indigenous. Strong resistance to telehealth before the pandemic across groups (76%) was moderated during COVID-19 (42.4%), an effect that appeared likely to continue past the pandemic for Central West clients (34.5%). Far North clients indicated their telehealth reluctance would return after the pandemic (77.6%). CONCLUSIONS: Our results suggest that remote Australians strongly prefer in-person mental health care to telehealth. Although the COVID-19 pandemic increased acceptance of telehealth across regions while social distancing continued, there was evidence that Indigenous Australians were more likely to prefer in-person contact after the pandemic.

Indigenous Australians have a greater prevalence of heart, stroke, and vascular disease, are younger at death, with higher hospitalisation and more aeromedical retrievals from remote regions.

BACKGROUND: We aimed to determine whether heart, stroke, and vascular disease (HSVD) prevalence and emergency primary evacuation (EPE), hospitalisation, and mortality differ by patient characteristics. METHODS: An Australian-wide incidence population based study, with prospective data collected form the 1 July 2019 to the 30 October 2020. FINDINGS: Indigenous Australians reported significantly higher prevalence of HSVD at 229.0 per-1000 as compared to 152.0 per-1000 non-Indigenous Australians: risk ratio 1.5 (95% CI 1.2-1.8). 583 remote patients received an EPE for HSVD, consisting of 388 (66.6%; 95% CI: 62.6-70.4) males and 195 (33.0%; 95% CI: 29.6-37.4) females. There were 289 (49.6%; 95% CI 45.4- 53.7) patients who identified as Indigenous, and 294 (50.4%; 95% CI 46.3- 54.6) as non-Indigenous. The mean Indigenous age during EPE was 48.0 (95% CI 45.9-50.1) years old, significantly lower than the non-Indigenous mean age of 55.6 (95% CI 53.8-57.4). Indigenous patients hospitalised for HSVD were younger, the majority younger than 65 years (n=21175; 73.7% 95% CI 73.2-74.2) as compared to non-Indigenous patients (n= 357654; 33.1% 95% CI 33.0-33.15). When adjusted for HSVD prevalence, remote Indigenous patients had a higher hospitalisation rate as compared to non-remote Indigenous patients (rate ratio: 1.6; 95% CI 1.3-2.0) and remote non-Indigenous patients (rate ratio: 1.2; 95% CI 1.0-1.5). More Indigenous patients died of HSVD before the age of 65 years (n=1875; 56.5% 95% CI 54.8-58.2) as compared to non-Indigenous patients (n= 16161; 10.6% 95% CI 10.45-10.8). INTERPRETATION: Indigenous Australians have a higher prevalence, and younger age during EPE, and hospitalisation for HSVD than non-Indigenous Australians. FUNDING: This is a self/internally-funded study, with the lead organisation being the Royal Flying Doctor Service (RFDS) of Australia. For the duration of the study period, the RFDS provided in-kind support including one full-time equivalent (FTE) and resources (office space, computer, research software, and office equipment). There was no external funding source that had a role in study design or data analysis or interpretation.

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis.

BACKGROUND: Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes. METHODS: In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 µmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495. FINDINGS: The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016). INTERPRETATION: Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment. FUNDING: Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.

Pregnancy-related aeromedical retrievals in rural and remote Australia: national evidence from the Royal Flying Doctor Service.

BACKGROUND: Inequalities in the availability of maternity health services in rural Australia have been documented, but not the impact on aeromedical retrievals. This study aims to examine the prevalence of pregnancy-related aeromedical retrievals, the most common conditions (overall and in specific age groups), and their distribution according to operation area and demographic characteristics. METHODS: Cross-sectional study using administrative data from the Royal Flying Doctors Service (RFDS) including all pregnant women aged 15-49 years retrieved by the RFDS between 2015 and 2019. All pregnancy-related aeromedical retrievals were classified according to the International Classification of Diseases, Tenth Revision (ICD-10, chapter XV). The distribution of pregnancy-related conditions was presented overall and stratified by age group (i.e. < 20 years, 20-34 years and 35+ years). Retrieval and receiving sites were geographically mapped with Tableau mapping software® based on postcode numbers of origin and destination. RESULTS: A total of 4653 pregnancy-related retrievals were identified (mean age 27.8 ± 6.1 years), representing 3.1% of all RFDS transfers between 2015 and 18 and 3.5% in 2018-19 (p-value 0.01). The highest proportion of pregnancy-related retrievals (4.8%) occurred in Western operation. There was an apparent increase in pregnancy-related retrievals in South Australia and the Northern Territory (Central Operation) in 2018-19. Preterm labour/delivery was responsible for 36.4% of all retrievals (40.7% among women aged 15-19 years) and premature rupture of membranes for 14.9% (19.4% among women aged 35-49 years). Inter-hospital transfers represented 87.9% of all retrievals, with most patients relocated from rural and remote regions to urban hospitals; most retrievals occurred during the day, with a median distance of 300 km. Adolescents and Aboriginal and Torres Strait Islander were overrepresented in the sample (four and eight times higher than their metropolitan counterparts, respectively). CONCLUSIONS: The proportion of pregnancy-related aeromedical retrievals varies geographically across Australia. Overall, one-third of retrievals were related to preterm/delivery complications, especially among adolescents. Most retrievals performed by the RFDS are susceptible to public health strategies aimed at improving antenatal care and preventing unintended pregnancies among adolescents and Aboriginal and Torres Strait Islander women. Greater capacity to manage pregnancy conditions in rural hospitals could reduce the requirement for aeromedical inter-hospital transfers.

Characteristics and in-hospital outcomes of patients requiring aeromedical retrieval for pregnancy, compared to non-retrieved metropolitan cohorts.

BACKGROUND: Limited access to obstetrics and gynaecology (O&G) services in rural and remote Australia is believed to contribute to suboptimal birth outcomes. AIMS: To describe the characteristics of pregnancy aeromedical transfers, in-hospital outcomes, and patient access to O&G services, as compared to whole of Australia data. MATERIALS AND METHODS: We conducted a cohort study of women who required aeromedical retrieval for pregnancy-related issues between the 1 January 2015 and 31 December 2017. RESULTS: Hospital outcome data were collected on 2171 (65.2%) mothers and 2438 (100.0%) babies. The leading retrieval reason was threatened preterm labour and delivery (n = 883; 40.7%). Most patients were retrieved from rural and remote areas (n = 2224; 93.0%). Retrieved patients were significantly younger (28.0 vs 30.0 years, 95% CI 27.7-28.3), more likely to be overweight or obese (52.2% vs 45.1%, 95% CI 47.5-56.9) and to have smoked during their pregnancy (14.0% vs 9.9%, 95% CI 12.5-15.5) compared to Australian pregnant women overall. Over one-third of transferred women gave birth by Caesarean section (n = 812; 37.4%); the median gestational age at birth was 33.0 (95% CI 32.7-33.3) weeks. Early gestation is associated with low birth weights (median = 2579.5 g; 95% CI 2536.1-2622.9), neonatal resuscitation (35.4%, 95% CI 33.5-37.3), and special care nursery admission (41.2%, 95% CI 39.3-43.2). There were 42 (1.7%, 95% CI 1.2-2.2) stillbirths, which was significantly higher than seen Australia-wide (n = 6441; 0.7%). CONCLUSION: This study found that pregnant women retrieved by the Royal Flying Doctor Service were younger, with higher rates of obesity and smoking.

Mental Health Care for Rural and Remote Australians During the Coronavirus Disease 2019 Pandemic.

The aims of this article are to comment on pre-coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.

Mental Health Crises in Rural and Remote Australia: An Assessment of Direct Medical Costs of Air Medical Retrievals and the Implications for the Societal Burden.

OBJECTIVE: Adequate mental health service provision in rural and remote Australian communities is problematic because of the tyranny of distance. The Royal Flying Doctor Service provides air medical retrieval for people in rural and remote areas. The economic impact on both the Royal Flying Doctor Service and the public hospital system for mental health-related air medical retrievals is unknown. We aimed to estimate the direct medical costs associated with air medical retrievals and subsequent hospitalizations for mental and behavioral disorders for the 2017 calendar year. METHODS: All patients with a primary working diagnosis of International Statistical Classification of Diseases and Related Health Problems, 10th Version, Australian Modification F00 to F99 (mental and behavioral disorders) who underwent an air medical retrieval were included in this cost analysis. International Statistical Classification of Diseases and Related Health Problems, 10th Edition, Australian Modification codes were mapped to Australian Refined Diagnosis Related Group codes, with hospital costs applied from the National Hospital Cost Data Collection (2016/2017). All costs are reported in 2017 Australian dollars (AUDs). RESULTS: One hundred twenty-two primary evacuations and 926 interhospital transfers occurred with an in-flight diagnosis of F00 to F99, most commonly psychotic disorders, including schizophrenia and schizotypal disorders. The total direct medical costs were estimated to be AUD $20,070,527. Costs for primary evacuations accounted for 13% (AUD $2,611,260), with the majority of this associated with the subsequent hospital admission (AUD $1,770,139). Similarly, the majority of the costs associated with interhospital transfers (total costs = AUD $17,459,267) were also related to hospital costs (AUD $13,569,187). CONCLUSION: Direct medical costs associated with air medical retrievals for people experiencing a mental health crisis are substantial. The majority of costs are associated with hospital admission and treatment; however, the indirect (loss of productivity) and intangible (quality of life) costs are likely to be far greater.