Developing visiting surgical services for rural and remote Australian communities

Specialist outreach clinics in primary care and rural hospital settings

BACKGROUND

Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services.

OBJECTIVES

To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost.

DATA COLLECTION AND ANALYSIS

Four reviewers working in pairs independently extracted data and assessed study quality.

MAIN RESULTS

73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes.

REVIEWER'S CONCLUSIONS

This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Analysis of the outcomes of a visiting surgical service to small rural communities

BACKGROUND

A team of visiting surgeons has provided regular clinics and day surgery to rural locations in country towns away from resident surgical centres. This format has provided continuity of care for 7 years despite a constantly changing medical workforce. The aim of the present study was to review the results of the group and to compare them against national standards and to provide a model for future outreach programmes.

METHODS

All patient diagnoses, procedures and clinical outcomes were recorded prospectively. This record of activity was then collated. District hospital records and clinical notes have been rechecked for complications over a discrete 4 year period.

RESULTS

There have been 7419 items of service provided, including 2676 procedures. The diagnostic grouping and subsequent day-surgery activity are consistent with the top 30 surgical separations from all Australian hospitals. These patients have been found suitable to remain in their own home environment for treatment.

CONCLUSION

Experienced surgeons operating on selected patients with careful nursing care, in small country hospitals have outcomes similar to urban hospitals.

Open access endoscopy in rural and remote Western Australia: does it work?

BACKGROUND

Access to diagnostic endoscopy is limited in rural and remote Western Australia. Published reports suggest open access referrals may result in over-servicing, this is reduced by adherence to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The aim was to assess whether an outreach surgical service offering open access endoscopy to rural areas was being over utilized.

METHODS

Prospective data collection from all patients undergoing upper and lower endoscopy procedures between January 1996 and June 2000 were included in the present study. Indications for referral between the general practitioners and the visiting surgeons were reviewed in patient records and assessed for compliance with the ASGE guidelines. The groups were analysed for appropriateness of referrals and frequency of positive pathology investigations. Records for all patients undergoing colonoscopy were reviewed to determine the reason and number of cancelled procedures.

RESULTS

A total of 772 endoscopies were performed and 75% were booked as open access services. The referral rate for procedures was greater for general practitioners (583) compared to the visiting surgeons (189), the overall compliance rate for approved indications using the ASGE guidelines for both groups was 92%. There was no significant difference in pathology found between groups.

CONCLUSION

The present study shows that an outreach rural surgical service programme in Western Australia offering open access endoscopy conforms to international guidelines and does not induce unnecessary procedures. Rural patients benefit from a personal cost savings and convenience. There is an associated reduction in government-assisted travel costs to larger centres as well as decreased waiting lists.

Costs of accessing surgical specialists by rural and remote residents

INTRODUCTION

Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting.

METHODS

A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-based service.

RESULTS

An estimated saving of AU$1,077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time.

CONCLUSION

The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available.

Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service

OBJECTIVE

To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers.

DESIGN

Combined quantitative and qualitative study.

SETTING

Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997).

PARTICIPANTS

25 remote health practitioners, patients and SOS specialists.

MAIN OUTCOME MEASURES

Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers.

RESULTS

Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services.

CONCLUSIONS

When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.