Rural Clinical School - Research Publications
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ItemPalliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit.(Elsevier BV, 2024-05)INTRODUCTION/AIM: Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. METHODS: Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. RESULTS: Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). CONCLUSIONS: End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.
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ItemNo Preview AvailableService Level Characteristics of Rural Palliative Care for with Chronic Disease(ELSEVIER SCIENCE INC, 2023-10)CONTEXT: Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers. OBJECTIVES: This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions. METHODS: A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis. RESULTS: Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%). CONCLUSION: Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care.
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ItemInfluence of rural clinical school experience and rural origin on practising in rural communities five and eight years after graduation(WILEY, 2022-06-20)OBJECTIVE: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation. DESIGN, PARTICIPANTS: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. MAIN OUTCOME MEASURES: Practice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020). RESULTS: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8-7.1) or rural communities (RR, 4.8; 95% CI, 3.1-7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3-2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2-3.1). CONCLUSION: The distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.
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ItemGrowing the pool of rural general practitioners(COLL MEDICINE & DENTISTRY JAMES COOK UNIV TOWNSVILLE, 2020)The critical importance of primary health care in maintaining a healthy population is well established internationally. Nevertheless, general practitioner care is not always easily accessible for some patients in Australia, particularly in rural regions. This is partly due to an insufficient number of medical graduates entering and being retained in the rural general practitioner workforce. Key elements of international and national programs designed to address this shortfall are discussed and include the use of entry requirements that preferentially select for applicants from a rural residence background, and immersion of medical students for a large share, or entire duration, of their training in rural communities. In addition, other factors that can influence decisions to enter and stay in rural practice are discussed.
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ItemNo Preview AvailableCardiovascular disease in patients with chronic kidney disease(DOVE MEDICAL PRESS LTD, 2009)Patients with chronic kidney disease have a high burden of cardiovascular morbidity and mortality. The vast majority of patients with chronic kidney disease do not progress to end stage renal failure, but do have a significantly higher incidence of all cardiovascular co-morbidities. Traditional cardiovascular risk factors only partially account for this increased incidence of cardiovascular disease. In patients with kidney disease the basic biology underlying cardiovascular disease may be similar to that in patients without kidney disease, but it would seem many more risk factors are involved as a consequence of renal dysfunction. Although emphasis is placed on delaying the progression of chronic kidney disease, it must be appreciated that for many patients it is vital to address their cardiovascular risk factors at an early stage to prevent premature cardiovascular death. This review examines available epidemiological evidence, discusses common cardiovascular risk factors in patients with chronic kidney disease, and suggests possible treatment strategies. Potential areas for important research are also described.
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ItemIs social exposure to obesity associated with weight status misperception? Assessing Australians ability to identify overweight and obesity(BMC, 2019-09-04)INTRODUCTION: Overweight and obesity prevalence has increased significantly over the past two decades, currently impacting greater than 60% of Australians. It is unclear if a social perception of a healthy weight has been obscured by the increase in prevalence and thus has become inconsistent with the medical definitions. METHODS: An electronic questionnaire was distributed via email and social media using the authors' informal networks. Australian adults were eligible to participate. Participants were asked to categorise their own body size using medically accepted words and previously published silhouettes, before identifying underweight, healthy weight, overweight or obesity in a series ofsilhouettes. RESULTS: Eight hundred six questionnaires were completed, a majority of participants had attained a high level of education and were employed female health professionals. Under half the studied population had a Body Mass Index (BMI) corresponding to overweight or obese categories (n = 349, 47%). Accuracy in self-perceived weight status using medicalised words was higher among respondents with BMI corresponding to the healthy weight category (n = 311, 85%) and overweight category (n = 133, 74%) than for respondents with BMI corresponding to obesity (n = 79, 45%) or underweight (n = 5, 31%). A majority of respondents were able to accurately self-perceive their weight status using silhouettes (n = 469, 70%). Females were significantly more likely to be accurate in their self-perception than males, using both medicalised words (p = < 0.001) and silhouettes (p = 0.045). Respondents with a BMI corresponding to the obese category were significantly more likely to be accurate with weight status self-perception using silhouettes than words (87% versus 46% respectively, p = < 0.001). Less than half (41%) of respondents accurately perceived silhouettes corresponding to an overweight BMI and less than one in ten respondents (9%) accurately perceived the lower limit of the silhouettes corresponding to an obese BMI. CONCLUSIONS: Repondents were challenged to accurately perceive silhouettes corresponding to an obese BMI in themselves and others. Weight status misperception was more likely to exist among those with a BMI less than 18.5 or 30 or more (underweight BMI and obese BMI). Accuracy decreased as BMI increased. Respondents with a BMI in the obese category were significantly more likely to accurately self-perceive their weight status using silhouettes than medicalised words. Silhouettes may act as an effective visual cue in initiating weight related discussions.
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ItemRural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: a systematic integrative review(BMC, 2020-05-24)BACKGROUND: People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included. METHODS: An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom. RESULTS: Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations. CONCLUSIONS: This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.