Rural-urban differences in health service utilization in upper-middle and high-income countries: a scoping review.

PURPOSE: This scoping review aims to understand the extent and attributes of literature evaluating differences between rural and urban populations' utilization of health services in upper-middle and high-income countries. METHOD: The review was conducted in line with established scoping review methodology guidelines. We used the "Participants, Concept and Context" framework to guide the inclusion criteria and determination of the review's scope. Studies published over a 15-year period (2008-2022) were identified using Embase, Medine, PubMed, and Scopus databases. Study attributes, areas of focus and findings were reviewed and extracted. RESULTS: The search identified 179 studies. The number of studies published looking at rural-urban differences in health service utilization has increased over time. The focus of these studies is relatively evenly split between primary and secondary sectors. The majority of studies observed less service utilization by rural populations than urban-especially so in primary-sector services. When higher rural utilization of secondary services was observed this was frequently attributed to poor access to other services that would have had the potential to mitigate the secondary demand. Studies were not commonly grounded in principles of equity or fairness and rarely offered value judgements on observed differences in utilization. There were limited system-level studies - the vast majority being disease- or service-specific analyses. We consider this a notable gap in the literature. CONCLUSION: This scoping review identifies key parameters of studies on rural-urban variation in health service utilization. The finding that most studies observed rural populations utilized comparatively less services is concerning, in the context of general evidence about high levels of health need in rural communities. Future system-level research considering the combined variations in need and utilization appears a priority.

Rural-urban variation in the utilisation of publicly funded healthcare services: an age-stratified population-level observational study.

AIM: To compare age-stratified public health service utilisation in Aotearoa New Zealand across the rural-urban spectrum. METHODS: Routinely collected hospitalisation, allied health, emergency department and specialist outpatient data (2014-2018), along with Census denominators, were used to calculate utilisation rates for residents in the two urban and three rural categories in the Geographic Classification for Health. RESULTS: Relative to their urban peers, rural Maori and rural non-Maori had lower all-cause, cardiovascular, mental health and ambulatory sensitive (ASH) hospitalisation rates. The age-standardised ASH rate ratios (major cities as the reference, 95% CIs) across the three rural categories were for Maori 0.79 (0.78, 0.80), 0.83 (0.82, 0.85) and 0.80 (0.77, 0.83), and for non-Maori 0.87 (0.86, 0.88), 0.80 (0.78, 0.81) and 0.50 (0.47, 0.53). Residents of the most remote communities had the lowest rates of specialist outpatient and emergency department attendance, an effect that was accentuated for Maori. Allied health service utilisation by those in rural areas was higher than that seen in the major cities. CONCLUSIONS: The large rural-urban variation in health service utilisation demonstrated here is previously unrecognised and in contrast to comparable international data. New Zealand's most remote communities have the lowest rates of health service utilisation despite high amenable mortality rates. This raises questions about geographic equity in health service design and delivery and warrants further in-depth research.

Rural-urban variation in COVID-19 vaccination uptake in Aotearoa New Zealand: Examining the national roll-out.

This study aimed to understand rural-urban differences in the uptake of COVID-19 vaccinations during the peak period of the national vaccination roll-out in Aotearoa New Zealand (NZ). Using a linked national dataset of health service users aged 12+ years and COVID-19 immunization records, age-standardized rates of vaccination uptake were calculated at fortnightly intervals, between June and December 2021, by rurality, ethnicity, and region. Rate ratios were calculated for each rurality category with the most urban areas (U1) used as the reference. Overall, rural vaccination rates lagged behind urban rates, despite early rapid rural uptake. By December 2021, a rural-urban gradient developed, with age-standardized coverage for R3 areas (most rural) at 77%, R2 81%, R1 83%, U2 85%, and U1 (most urban) 89%. Age-based assessments illustrate the rural-urban vaccination uptake gap was widest for those aged 12-44 years, with older people (65+) having broadly consistent levels of uptake regardless of rurality. Variations from national trends are observable by ethnicity. Early in the roll-out, Indigenous Maori residing in R3 areas had a higher uptake than Maori in U1, and Pacific peoples in R1 had a higher uptake than those in U1. The extent of differences in rural-urban vaccine uptake also varied by region.

The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis.

Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.

Corrigendum to: The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis.

Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.