Poor access to kidney disease management services in susceptible patient populations in rural Australia is associated with increased aeromedical retrievals for acute renal care.

BACKGROUND: Inequalities in access to renal services and acute care for rural and remote populations in Australia have been described but not quantified. AIM: To describe: the coverage of renal disease management services in rural and remote Australia; and the characteristics of patients who had an aeromedical retrieval for renal disease by Australia's Royal Flying Doctor Service (RFDS). METHODS: Data from the RFDS, the Australian Bureau of Statistics, and Health Direct were used to estimate provision of renal disease management services by geographic area. RFDS patient diagnostic data were prospectively collected from 2014 to 2018. RESULTS: Many rural and remote areas have limited access to regular renal disease management services. Most RFDS retrievals for renal disease are from regions without such services. The RFDS conducted 1636 aeromedical retrievals for renal disease, which represented 1.6% of all retrievals. Among retrieved patients, there was a higher proportion of men than women (54.6% vs 45.4%, P < 0.01), while indigenous patients (n = 546, 33.4%) were significantly younger than non-indigenous patients (40.9 vs 58.5, P < 0.01). There were significant differences in underlying diagnoses triggering retrievals between genders, with males being more likely than females to be transferred with acute renal failure, calculus of the kidney and ureter, renal colic, obstructive uropathy, and kidney failure (all P < 0.01). Conversely, females were more likely to have chronic kidney disease, disorders of the urinary system, acute nephritic syndrome, tubulo-interstitial nephritis, and nephrotic syndrome (all P < 0.01). CONCLUSION: Aeromedical retrievals for acute care were from rural areas without regular access to renal disease prevention or management services.

Rural and remote dental care: Patient characteristics and health care provision.

OBJECTIVE: To describe the characteristics of patients who used the Royal Flying Doctor Service dental clinics and determine Royal Flying Doctor Service and non-Royal Flying Doctor Service dental service provision in mainland Australia. DESIGN: A prospective cohort study. SETTING: All Royal Flying Doctor Service dental clinics located throughout rural and remote Australia. PARTICIPANTS: All patients who accessed an Royal Flying Doctor Service dental clinic from April 2017 to September 2018. INTERVENTIONS: Royal Flying Doctor Service mobile dental clinics. MAIN OUTCOME MEASURES: Patient demographics and dental procedures conducted (by age, sex and Indigenous status); and the dental service provision and coverage (Royal Flying Doctor Service and non-Royal Flying Doctor Service) within mainland rural and remote Australia. RESULTS: There were 8992 patient episodes comprising 3407 individual patients with 27 897 services completed. There were 920 (27%) Indigenous and 1465 (43%) non-Indigenous patients (n = 1022 missing ethnicity data). The mean (SD) age was 31.5 (24.8) years; the age groups 5-9 years and 10-14 years received 17.6% and 15.1% of the services, respectively. There were 1124 (33%) men and 1295 (38%) women (n = 988 with missing sex data). Women were more likely (all P < .05) to receive preventive services, diagnostic services, restorative services, general services, endodontics and periodontics. Men were more likely (both P < .05) to receive oral surgery and prosthodontics. There are many rural and remote people required to travel more than 60 minutes by vehicle to access dental care. CONCLUSION: Without increasing dental provision and preventive services in rural areas, it seems likely that there are and will be unnecessary oral emergencies and hospitalisations.

Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.

OBJECTIVES: To characterise the people retrieved by the Royal Flying Doctor Service (RFDS) for treatment of mental and behavioural disorders, and to assess mental health care provision in rural and remote areas. DESIGN: Prospective review of routinely collected RFDS and Health Direct data. SETTING, PARTICIPANTS: RFDS aeromedical retrievals of patients from anywhere in Australia except Tasmania during 1 July 2014 - 30 June 2017 for the treatment of mental or behavioural disorders. MAIN OUTCOME MEASURES: Retrievals by ICD-10 mental and behavioural disorder diagnoses. RESULTS: 2257 patients were retrieved by the RFDS for treatment of mental or behavioural disorders, including 1394 males (62%) and 863 females (38%); 60% of patients were under 40 years of age, 35% identified as Indigenous Australians. The most frequent mental and behavioural disorders were schizophrenia (227 retrievals, 16.5% of retrievals with ICD diagnoses), bipolar affective disorder (185, 13.5%), and depressive episodes (153, 11.2%). Psychoactive substance misuse triggered 194 retrievals (14.2%), including misuse of multiple drugs (85, 6.2%), alcohol (61, 4.5%), and cannabinoids (25, 1.8%). The mean age of patients retrieved for treatment of substance misuse (29.6 years; SD, 11.6 years) was lower than for retrieved patients overall (37.0 years; SD, 19.3 years); 38 of 194 patients retrieved after psychoactive substance misuse (19.6%) were under 19 years of age. Most retrieval sites were rural and remote communities with low levels of mental health care support. CONCLUSION: Mental and behavioural disorders are an important problem in rural and remote communities, and acute presentations trigger a considerable number of RFDS retrievals.

Aeromedical retrieval for suspected appendicitis in rural and remote paediatric patients.

INTRODUCTION: The aim of this paper was to describe the characteristics of paediatric patients who underwent an aeromedical retrieval within Australia (gender and Indigenous status) for suspected appendicitis between 1 July 2014 and 30 June 2018 (4 years). By understanding these trends, we hope to further justify the need for point-of-care ultrasound training for clinicians working in rural and remote Australia. METHOD: Participants included Royal Flying Doctor Service (RFDS) patients aged 0-18 years (inclusive) who underwent an aeromedical retrieval for suspected appendicitis within Australia. Data were collected and coded on each patient's inflight working diagnosis, using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding method. A combination of descriptive statistics and chi-square analyses was used in data analysis, with significance considered at <0.05. RESULTS: There were 384 children with a working diagnosis of suspected appendicitis, including 191 (49.7%) males and 193 (50.3%) females, with 133 (34.6%) patients identifying as Aboriginal and/or Torres Strait Islander (hereafter referred to as Indigenous) Australians. The aeromedical retrievals were from rural and remote locations to inner-regional or metropolitan hospitals, with an average distance flown of 339.0 (SD = 206.4) kilometres. The RFDS most frequently retrieved for acute appendicitis (n = 159; 41.4%), acute abdominal pain (n = 127; 33.1%), and unspecified appendicitis (n = 84; 21.9%). There were non-significant (P = 0.9) diagnostic differences between genders. Non-Indigenous patients were overrepresented, compared with Indigenous patients, in relation to a transfer with a diagnosis of acute appendicitis (P = <0.01), whereas Indigenous patients were overrepresented, compared with non-Indigenous patients, in relation to transfers with diagnoses of acute abdomen pain and unspecified appendicitis (P = <0.01). CONCLUSION: A significant number of paediatric patients are aeromedically retrieved from rural and remote locations with a diagnosis of appendicitis or acute abdominal pain. Future research should consider whether training in abdominal point-of-care ultrasound reduces retrievals.

What is the importance of the referral letter in the patient journey? A pilot survey in Western Australia.

BACKGROUND: Access to specialists is mediated by general practitioners in many countries. In these settings, specialists rely on information in referral letters when deciding which cases to schedule for their clinics. METHOD: Two-hundred and seven consecutive referral letters to gastroenterologists were scored for the amount of information relayed to the specialist, using a published schedule. The 'quality' scores for these referral letters were compared for four groups of patients: patients diagnosed with histological lesion, those with no histological lesion, those who failed to attend clinic, or those who had a diagnosis unknown. Forty-two referral letters were generated with a range of quality scores. Four gastroenterologists were asked to identify which letters described patients 'likely' to have a significant or benign colorectal condition, and whether they could triage the cases for their clinic given only the information in the letters. RESULTS: It was not possible to differentiate which letters related to patients in each of the four categories (P = 0.6). Patients who failed to attend were more symptomatic than those with a histological lesion (35.4 versus 28.2, mean difference 7.14, 95% confidence interval (CI) 14.1 to 0.15, P = 0.045). Patients referred 'urgently' were not, on the basis of the referral letters, the most symptomatic group (29.7 versus 27, mean difference 2.7, 95% CI -3.4 to 8.8, P = 0.38). The specialists failed to agree on the proportion of cases that could be triaged for their clinics. The cases that could be triaged contained more information (mean 66.38 versus 49.86, mean difference 16, 95% CI 1.3-31.7, P < 0.001). CONCLUSION: There was no evidence for an association between the amount of information relayed and the diagnosis of a histological lesion. However, more information was helpful when deciding which patients to schedule first. By corollary, patients referred with lesser documentation of their clinical presentation may be denied 'urgent' access to the gastroenterology clinic.