Investigation and treatment after non-ST segment elevation acute coronary syndrome for patients presenting to rural or urban hospitals in Aotearoa New Zealand: ANZACS-QI 75.

AIMS: Compare the care patients with non-ST segment elevation acute coronary syndrome (NSTEACS) received in Aotearoa New Zealand depending on the rural-urban category of the hospital they are first admitted to. METHODS: Patients with NSTEACS investigated with invasive coronary angiogram between 1 January 2014 and 31 December 2019 were included. There were three hospital categories (routine access to percutaneous coronary intervention [urban interventional], other urban [urban non-interventional] and rural) and three ethnicity categories (Maori, Pacific and non-Maori/non-Pacific). Clinical performance measures included: angiography ≤3 days, assessment of left ventricular ejection fraction (LVEF) and prescription of secondary prevention medication. RESULTS: Of 26,779 patients, 66.2% presented to urban-interventional, 25.6% to urban non-interventional and 8.2% to rural hospitals. A smaller percentage of patients presenting to urban interventional than urban non-interventional and rural hospitals were Maori (8.1%, 17.0% and 13.0%). Patients presenting to urban interventional hospitals were more likely to receive timely angiography than urban non-interventional or rural hospitals (78.5%, 60.8% and 63.1%). They were also more likely to have a LVEF assessment (78.5%, 65.4% and 66.3%). In contrast, the use of secondary prevention medications at discharge was similar between hospital categories. Maori and Pacific patients presenting to urban interventional hospitals were less likely than non-Maori/non-Pacific to receive timely angiography but more likely to have LVEF assessed. However, LVEF assessment and timely angiography in urban non-interventional and rural hospitals were lower than in urban interventional hospitals for both Maori and non-Maori/non-Pacific. CONCLUSIONS: Patients presenting to urban hospitals without routine interventional access and rural hospitals were less likely to receive LVEF assessment or timely angiography. This disproportionately impacts Maori, who are more likely to live in these hospital catchments.

Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72.

AIM: This study's aim was to identify differences in invasive angiography performed and health outcomes for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) presenting to either i) a rural hospital, or an urban hospital ii) with or iii) without routine access to percutaneous intervention (PCI) in New Zealand. METHODS: Patients with NSTEACS between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to model each of the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding. RESULTS: There were 42,923 patients included. Compared to urban hospitals with access to PCI, the odds of a patient receiving an angiogram were reduced for rural and urban hospitals without routine access to PCI (odds ratio [OR] 0.82 and 0.75) respectively. There was a small increase in the odds of dying at 2 years (OR 1.16), but not 30 days or 1 year for patients presenting to a rural hospital. CONCLUSION: Patients who present to hospitals without PCI are less likely to receive angiography. Reassuringly there is no difference in mortality, except at 2 years, for patients that present to rural hospitals.

Doctors' experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study.

OBJECTIVE: To explore rural hospital doctors' experiences of providing care in New Zealand rural hospitals. DESIGN: The study had a qualitative design, using qualitative content analysis. SETTING: The study was conducted in South Island, New Zealand, and included nine different rural hospitals. RESPONDENTS: Semistructured interviews were conducted with 16 rural hospital doctors. RESULTS: Three themes were identified: 'Applying a holistic perspective in the care', 'striving to maintain patient safety in sparsely populated areas' and 'cooperating in different teams around the patient'. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context. CONCLUSIONS: This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

Improving continuity of care of patients with respiratory disease at hospital discharge.

Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease. In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely. EDUCATIONAL AIMS: To understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.

A scope of practice that works 'out here': exploring the effects of a changing medical regulatory environment on a rural New Zealand health service.

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand.

INTRODUCTION: Achieving effective integration of healthcare across primary, secondary and tertiary care is a key goal of the New Zealand (NZ) Health Strategy. NZ's regional District Health Board (DHB) groupings are fundamental to delivering integration, bringing the country's 20 DHBs together into four groups to collaboratively plan, fund and deliver health services within their defined geographical regions. This research aims to examine how, for whom and in what circumstances the regional DHB groupings work to improve health service integration, healthcare quality, health outcomes and health equity, particularly for Maori and Pacific peoples. METHODS AND ANALYSIS: This research uses a mixed methods realist evaluation design. It comprises three linked studies: (1) formulating initial programme theory (IPT) through developing programme logic models to describe regional DHB working; (2) empirically testing IPT through both a qualitative process evaluation of regional DHB working using a case study design; and (3) a quantitative analysis of the impact that DHB regional groupings may have on service integration, health outcomes, health equity and costs. The findings of these three studies will allow refinement of the IPT and should lead to a programme theory which will explain how, for whom and in what circumstances regional DHB groupings improve service integration, health outcomes and health equity in NZ. ETHICS AND DISSEMINATION: The University of Otago Human Ethics Committee has approved this study. The embedding of a clinician researcher within a participating regional DHB grouping has facilitated research coproduction, the research has been jointly conceived and designed and will be jointly evaluated and disseminated by researchers and practitioners. Uptake of the research findings by other key groups including policymakers, Maori providers and communities and Pacific providers and communities will be supported through key strategic relationships and dissemination activities. Academic dissemination will occur through publication and conference presentations.

HealthPathways implementation in a New Zealand health region: a qualitative study using the Consolidated Framework for Implementation Research.

OBJECTIVES: To explore the process of implementation of an online health information web-based portal and referral system (HealthPathways) using implementation science theory: the Consolidated Framework for Implementation Research (CFIR). SETTING: Southern Health Region of New Zealand (Otago and Southland). PARTICIPANTS: Key Informants (providers and planners of healthcare) (n=10) who were either involved in the process of implementing HealthPathways or who were intended end-users of HealthPathways. METHODS: Semistructured interviews were undertaken. A deductive thematic analysis using CFIR was conducted using the framework method. RESULTS: CFIR postulates that for an intervention to be implemented successfully, account must be taken of the intervention's core components and the adaptable periphery. The core component of HealthPathways-the web portal and referral system that contains a large number of localised clinical care pathways-had been addressed well by the product developers. Little attention had, however, been paid to addressing the adaptable periphery (adaptable elements, structures and systems related to HealthPathways and the organisation into which it was being implemented); it was seen as sufficient just to deliver the web portal and referral system and the set of clinical care pathways as developed to effect successful implementation. In terms of CFIR's 'inner setting' corporate and professional cultures, the implementation climate and readiness for implementation were not properly addressed during implementation. There were also multiple failures of the implementation process (eg, lack of planning and engagement with clinicians). As a consequence, implementation of HealthPathways was highly problematic. CONCLUSIONS: The use of CFIR has furthered our understanding of the factors needed for the successful implementation of a complex health intervention (HealthPathways) in the New Zealand health system. Those charged with implementing complex health interventions should always consider the local context within which they will be implemented and tailor their implementation strategy to address these.