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.

What does it mean to be an allied health professional working in rural Aotearoa New Zealand? A qualitative study.

OBJECTIVE: Building health services and workforce that are both well supported and fit for purpose is a key consideration for improving health outcomes in rural populations. Achieving this requires an understanding of the roles and practice characteristic of each professional group, including allied health professionals. This study explores what it means to be an allied health professional practicing in rural Aotearoa New Zealand. DESIGN: A qualitative study design was used, involving individual semi-structured interviews with 13 rural allied health professionals in the Otago and Northland regions. The interviews explored participants journey into rural practice, their experiences working rurally, and their views on rural practice. FINDINGS: Four main themes were derived: Identity; Connectedness; Expectations; and Providing Care. DISCUSSION: Proud of being rural, these allied health professionals are immersed within their community, intertwining their professional and personal identities. The unique nature of this dual identity while empowering for some, can also isolate rural allied health professionals from their professional bodies and urban peers. This leads to a sense of vulnerability and feeling undervalued and invisible. In response, rural allied health professionals choose to form strong connections to their local interprofessional team and their community. The connections they forge, and the breadth of their skills cumulate to enable allied health professionals to provide dynamic and responsive health services for their rural communities. CONCLUSION: This study provides the first insight into experiences and perspectives of allied health professionals within rural Aotearoa New Zealand. Despite the challenges, a sense of pride is associated with practicing rurally for allied health professionals.

A retrospective observational study examining interhospital transfers from six New Zealand rural hospitals in 2019.

OBJECTIVE: The aim of this study was to identify the percentage of patients that were transferred from rural hospitals and who received an investigation or intervention at an urban hospital that was not readily available at the rural hospital. METHODS: A retrospective observational study. DESIGN: Patients were randomly selected and clinical records were reviewed. Patient demographic and clinical information was collected, including any interventions or investigations occurring at the urban referral hospital. These were compared against the resources available at the rural hospitals. SETTING: Six New Zealand (NZ) rural hospitals were included. PARTICIPANTS: Patients that were transferred from a rural hospital to an urban hospital between 1 Jan 2019 and 31 December 2019 were included. MAIN OUTCOME MEASURES: The primary outcome measure was the percentage of patients who received an investigation or intervention that was not available at the rural hospital. RESULTS: There were 584 patients included. Overall 73% of patients received an intervention or investigation that was not available at the rural hospital. Of the six rural hospitals, there was one outlier, where only 37% of patients transferred from that hospital received an investigation or intervention that was not available rurally. Patients were most commonly referred to general medicine (23%) and general surgery (18%). Of the investigations or interventions performed, 43% received a CT scan and 25% underwent surgery. CONCLUSIONS: Most patients that are transferred to urban hospitals receive an intervention or investigation that was not available at the rural hospital.

The place of rural hospitals in New Zealand's health system: an exploratory qualitative study.

INTRODUCTION: In Aotearoa New Zealand (NZ) there is a knowledge gap regarding the place and contribution of rural hospitals in the health system. New Zealanders residing in rural areas have poorer health outcomes than those living in urban areas, and this is accentuated for Maori, the Indigenous people of the country. There is no current description of rural hospital services, no national policies and little published research regarding their role or value. Around 15% of New Zealanders rely on rural hospitals for health care. The purpose of this exploratory study was to understand national rural hospital leadership perspectives on the place of rural hospitals in the NZ health system. METHODS: A qualitative exploratory study was undertaken. The leadership of each rural hospital and national rural stakeholder organisations were invited to participate in virtual semi-structured interviews. The interviews explored participants' views of the rural hospital context, the strengths and challenges they faced and how good rural hospital care might look. Thematic analysis was undertaken using a framework-guided rapid analysis method. RESULTS: Twenty-seven semi-structured interviews were conducted by videoconference. Two broad themes were identified, as follows. Theme 1, 'Our place and our people', reflected the local, on-the-ground situation. Across a broad variety of rural hospitals, geographical distance from specialist health services and community connectedness were the common key influencers of a rural hospital's response. Local services were provided by small, adaptable teams across broad scopes and blurred primary-secondary care boundaries, with acute and inpatient care a key component. Rural hospitals acted as a conduit between community-based care and city-based secondary or tertiary hospital care. Theme 2, 'Our positioning in the wider health system', related to the external wider environment that rural hospitals worked within. Rural hospitals operating at the margins of the health system faced multiple challenges in trying to align with the urban-centric regulatory systems and processes they were dependent on. They described their position as being 'at the end of the dripline'. In contrast to their local connectedness, in the wider health system participants felt rural hospitals were undervalued and invisible. While the study found strengths and challenges common to all NZ rural hospitals, there were also variations between them. CONCLUSION: This study furthers understanding of the place of rural hospitals in the NZ healthcare system as seen through a national rural hospital lens. Rural hospitals are well placed to provide an integrative role in locality service provision, with many already long established in performing this role. However, context-specific national policy for rural hospitals is urgently needed to ensure their sustainability. Further research should be undertaken to understand the role of NZ rural hospitals in addressing healthcare inequities for those living in rural areas, particularly for Maori.

Point-of-care ultrasound in general practice: an exploratory study in rural South Australia.

INTRODUCTION: Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to address this gap. We aimed to examine how POCUS is utilised by doctors in contemporary Australian rural general practice. METHODS: A portable ultrasound machine and access to a training course were provided to four general practices in rural South Australia, and the type and frequency of POCUS scans were recorded, along with user information, between July 2020 and June 2021. Participating general practitioners (GPs) completed a survey at the commencement of the study regarding their previous experience and confidence in using POCUS for specific assessments and procedures. RESULTS: Of the 472 scans recorded, most (95%) were for clinical indications, 3% for teaching activities and 2% for self-learning. Overall, 69% were obstetric scans, followed by abdominal (12%), gynaecological procedures (10%), other procedural (7%) and thoracic exams (1.5%). Users reported higher confidence for lower complexity POCUS. CONCLUSION: Although POCUS has diverse potential applications in rural practice, GPs reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Further studies should examine the barriers to POCUS utilisation, with particular attention to training requirements, reimbursement for use and access to machines.

Developing the geographic classification for health, a rural-urban classification for New Zealand health research and policy: A research protocol.

INTRODUCTION: Rural-urban health inequities, exacerbated by deprivation and ethnicity, have been clearly described in the international literature. To date, the same inequities have not been as clearly demonstrated in Aotearoa New Zealand despite the lower socioeconomic status and higher proportion of Maori living in rural towns. This is ascribed by many health practitioners, academics and other informed stakeholders to be the result of the definitions of 'rural' used to produce statistics. AIMS: To outline a protocol to produce a 'fit-for-health purpose' rural-urban classification for analysing national health data. The classification will be designed to determine the magnitude of health inequities that have been obscured by use of inappropriate rural-urban taxonomies. METHODS: This protocol paper outlines our proposed mixed-methods approach to developing a novel Geographic Classification for Health. In phase 1, an agreed set of community attributes will be used to modify the new Statistics New Zealand Urban Accessibility Classification into a more appropriate classification of rurality for health contexts. The Geographic Classification for Health will then be further developed in an iterative process with stakeholders including rural health researchers and members of the National Rural Health Advisory Group, who have a comprehensive 'on the ground' understanding of Aotearoa New Zealand's rural communities and their attendant health services. This protocol also proposes validating the Geographic Classification for Health using general practice enrolment data. In phase 2, the resulting Geographic Classification for Health will be applied to routinely collected data from the Ministry of Health. This will enable current levels of rural-urban inequity in health service access and outcomes to be accurately assessed and give an indication of the extent to which older classifications were masking inequities.

How rural is rural? The relationship between rural background of medical students and their career location intentions.

OBJECTIVE: Rural background is associated with greater interest in rural practice. However, there is no universally agreed definition of 'rural' background used in medical school selection. This study explored the association between definitions of 'rural' background and students' intended career locations. DESIGN: Prospective cohort study using survey data on career intention, hometown size, rurality of background, home address, high school and intended career location. SETTING: University of Auckland, New Zealand (NZ). PARTICIPANTS: Commencing medical students 2009-2017, inclusive. MAIN OUTCOME MEASURES: Univariate associations between student background according to 7 definitions of 'rural', and 3 definitions of intended practice location based on population size: urban intention (>100 000); regional intention (25 000-100 000); rural intention (<25 000). RESULTS: The sample size was 1592 students. 27.4% had a rural background by at least one definition. All definitions of rural background were associated with a greater rural intention. Applying a restrictive definition of rural (population<25 000) was associated with a higher likelihood of rural intention, but captured a smaller number of students. There was strong agreement between the population size of a student's background and intended practice location (chi-square P < .0001). CONCLUSION: Rural intention varies by definition, but the number of students captured by each definition is important. Applying a binary or overly restrictive definition may limit interested students. Medical schools should adopt a definition of 'rural' that optimises the number of eligible students and their propensity to work rurally. Further, alternative ways of identifying students with rural intentions without a rural background should be explored.

'I'm still here, that's probably the best part'. Lives of those living rurally with an implantable cardioverter defibrillator: a qualitative study.

INTRODUCTION: The use of implantable cardioverter defibrillators (ICDs) is increasing in both New Zealand and Australia. Also, both countries are experiencing an ageing of their rural populations. Much of the ICD literature focuses on the experience of those living in urban environments, with little known about the experiences of those living in rural contexts. This study aimed to answer the following questions: 'Does living rurally impact the ICD recipient experience and that of their partners?' and 'Can understanding their experiences inform best practice care for those living rurally with an ICD?' METHODS: This qualitative study employed purposive sampling and semi-structured interviews to produce rich narrative data. A general inductive approach was then used to analyse data, producing a series of coded themes through an iterative strategy, to generate an understanding of the rural lived experience after ICD implantation. Interpretations and conclusions were tested with participants at a debriefing meeting at the conclusion of the study. RESULTS: In total 14 ICD recipients and nine partners/carers/whānau (family) were interviewed. One recipient was Māori (indigenous New Zealander) and one female, and overall age range was 57-89 years. The length of time from ICD insertion varied from less than 1 year to 12 years. The final analysis highlighted the substantial role played by partners/carers of recipients. How this recipient-partner/carer dyad managed the post-ICD insertion experience was a major theme in this study. The perennial challenges of advance care planning and ICD deactivation conversation, unmet need for peer support and gaps in the provision of health-related information were all highlighted as challenges to these rural participants. The rural locale, however, posed limited challenges. Loss of a driving licence following receipt of shock therapy was irksome due to the unavailability of public transport but the impediment posed by the device on the practicalities of rural living, such as the need to use power tools and move electric fences, was, for some, more of an issue. CONCLUSION: This is one of the few studies that has considered the influence of rural location on the post-ICD insertion experience of patients and their partners/carers. ICD insertion did not appear to substantially negatively impact on the lives or experiences of rural recipients and their partners/carers. While this study did not set out to explore the role of informal carers who live rurally, the study findings suggest that female partners of rural ICD recipients undertake a significant role in terms of shouldering varying responsibilities including medication management, emotional support and transportation. As the age of ICD recipients increases, so does the age of their partners, therefore, they are also likely to be living with one or more long term conditions. Health professionals need to be aware of this additional burden as research suggests rural informal caregivers are less likely to report associated issues.

New Zealand general practice registrars' views on their academic learning needs during vocational training: online survey.

Most doctors working in New Zealand general practice undertake vocational training through the Royal New Zealand College of General Practitioners. We aimed to explore general practice registrar views on their academic learning needs during and following vocational training. An online survey of all current NZ GP trainees in 2019 was completed by 314 registrars (54% response rate). The majority (88%, 275/314) were completing RNZCGP Fellowship only, and of these half (55%, 152/275) were planning a further postgraduate qualification. A minority (12%, 33/275) indicated a desire to undertake a masters or PhD degree. Almost all (99%, 310/314) intended to work in general practice; 9% (8/314) intending to also work as rural hospital doctors. The five most common areas of interest for further training were clinical skills (68%), practice-based teaching (66%), specific clinical conditions (63%), age or life-stage specific (47%) and non-clinical areas (41%). There is a considerable gap between completing RNZCGP Fellowship, intending to undertake further (formal postgraduate) education and actually enrolling. This is concerning given the need for lifelong learning and critical evaluation of practice and health service delivery. The future New Zealand general practice workforce needs GPs to be diverse and highly skilled members or leaders of expert teams.

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.

Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care.

INTRODUCTION: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations - focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) - in the rural context. METHODS: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. RESULTS: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. CONCLUSIONS: In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

INTRODUCTION: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. METHODS: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. RESULTS: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. CONCLUSIONS: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Point-of-care ultrasound in rural New Zealand: Safety, quality and impact on patient management.

OBJECTIVE: To evaluate the safety, quality and impact of point-of-care ultrasound on patient management when performed by rural generalist doctors. DESIGN: Cross-sectional descriptive study. SETTING: Six rural small hospitals serving a range of communities in rural New Zealand. PARTICIPANTS: All generalist doctors practising ultrasound in the study hospitals. MAIN OUTCOME MEASURES: Technical quality, accuracy, impact on diagnostic certainty, patient disposition and overall patient care. RESULT: Participants correctly interpreted 90% of images and a similar percentage of point-of-care ultrasound findings when compared with the results of formal imaging or the final diagnosis. In total, 87% of scans contributed to the diagnostic process, changing the diagnostic probability. There was a 4% overall reduction in the number of patients needing hospital admission or transfer to an urban base hospital. The overall impact on patient care was positive for 71% of point-of-care ultrasound scans. Three percent of scans had the potential for patient harm. CONCLUSION: Rural generalists' practise a broad scope of point-of-care ultrasound that, when used as a part of the full clinical assessment, has a positive impact on patient care, improving diagnostic certainty and reducing the need for hospital admission and inter-hospital transfer. There are challenges in learning and maintaining the skills needed to practise a high standard of point-of-care ultrasound in this context. Further consideration needs to be given to the development safe scopes of practice, training, credentialing and quality assurance.

A targeted rural postgraduate education programme - linking rural doctors across New Zealand and into the Pacific.

This article describes the University of Otago Rural Postgraduate medical programme, established in 2002 to provide a targeted rural education option for medical practitioners working in rural and remote areas of New Zealand. With both faculty and participants dispersed throughout New Zealand and the Cook Islands embedded in day to day rural clinical practice, this programme uniquely reflects the national and international clinical networks it has been developed to support. It now provides the academic component of two vocational training programmes: the New Zealand Rural Hospital Medicine Training Programme and The Cook Islands General Practice Training Programme. We describe the journey the Rural Postgraduate programme has taken over the last decade: the opportunities, learnings and challenges. The programme is continuing to expand and is creating a growing community of rural and remote practitioners throughout New Zealand and the Pacific.

Training generalist doctors for rural practice in New Zealand.

Targeted postgraduate training increases the likelihood young doctors will take up careers in rural generalist medicine. This article describes the postgraduate pathways that have evolved for these doctors in New Zealand. The Cairns consensus statement 2014 defined rural medical generalism as a scope of practice that encompasses primary care, hospital or secondary care, emergency care, advanced skill sets and a population-based approach to the health needs of rural communities. Even as work goes on to define this role different jurisdictions have developed their own training pathways for these important members of the rural healthcare workforce. In 2002 the University of Otago developed a distance-taught postgraduate diploma aimed at the extended practice of rural general practitioners (GPs) and rural hospital medical officers. This qualification has evolved into a 4-year vocational training program in rural hospital medicine, with the university diploma retained as the academic component. The intentionally flexible and modular nature of the rural hospital training program and university diploma allow for a range of training options. The majority of trainees are taking advantage of this by combining general practice and rural hospital training. Although structured quite differently the components of this combined pathway looks similar to the Australian rural generalist pathways. There is evidence that the program has had a positive impact on the New Zealand rural hospital medical workforce.

The impact of a rural scanner in overcoming urban versus rural disparities in the utilisation of computed tomography.

OBJECTIVE: In 2008, Oamaru Hospital became the second rural hospital in New Zealand to install a computed tomography (CT) scanner. This article assesses the impact of this on local CT scanning rates. DESIGN: Observational: review of radiology department data. SETTING: Rural hospital imaging services. PARTICIPANTS: CT scanning patients residing in Otago region during the study period. INTERVENTIONS: There is no intervention in this observational study. MAIN OUTCOME MEASURES: CT scanning rates and waiting times before and after the introduction of the rural scanner. RESULTS: Prior to the scanner being commissioned, there was a significant urban versus rural disparity in CT utilisation. Residents in the neighbouring urban centre were 1.4 times more likely to access CT (33.2 (95% confidence interval (CI) 32.2-34.2) versus 23.0 (95% CI 21.0-25.1) scans per 1000 residents per annum). Twenty months after the scanner was commissioned, the rate for the rural community had almost doubled to 45.6 (95% CI 43.0-48.2) and was 1.2 times greater than for the urban community. This difference was not sustained, and rural and urban communities had similar CT scanning rates in 2011 and 2012. Mean waiting time for residents in the rural community fell from 21.1 (95% CI 17.1-25.2) days prior to the scanner to 6.7 (95% CI 5.6-7.8) days after the scanner was commissioned. CONCLUSIONS: On-site CT increased the rural scanning rate, corrected the rural-urban disparity and reduced waiting times without apparent over servicing.

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.

He Aroka Uruta. Rural health provider perspectives of the COVID-19 vaccination rollout in rural Aotearoa New Zealand with a focus on Maori and Pasifika communities: a qualitative study.

Introduction From a coronavirus disease (COVID-19) pandemic perspective, Aotearoa New Zealand (NZ) rural residents formed an at-risk population, and disparities between rural and urban COVID-19 vaccination coverage have been found. Aim To gain insight into factors contributing to the urban-rural COVID-19 vaccination disparity by exploring NZ rural health providers' experiences of the vaccine rollout and pandemic response in rural Maori and Pasifika communities. Methods Rural health providers at four sites participated in individual or focus group semi-structured interviews exploring their views of the COVID-19 vaccine rollout. Thematic analysis was undertaken using a framework-guided rapid analysis method. Results Twenty interviews with 42 participants were conducted. Five themes were identified: Pre COVID-19 rural situation, fragile yet resilient; Centrally imposed structures, policies and solutions - urban-centric and Pakeha focused; Multiple logistical challenges - poor/no consideration of rural context in planning stages resulting in wasted resource and time; Taking ownership - rural providers found geographically tailored, culturally anchored and locally driven solutions; Future directions - sustained investment in rural health services, including funding long-term integrated (rather than 'by activity') health services, would ensure success in future vaccine rollouts and other health initiatives for rural communities. Discussion In providing rural health provider perspectives from rural areas serving Maori and Pasifika communities during the NZ COVID-19 vaccine rollout, the importance of the rural context is highlighted. Findings provide a platform on which to build further research regarding models of rural health care to ensure services are designed for rural NZ contexts and capable of meeting the needs of diverse rural communities.

Avoiding double counting: the effect of bundling hospital events in administrative datasets for the interpretation of rural-urban differences in Aotearoa New Zealand.

BACKGROUND AND OBJECTIVES: All publicly funded hospital discharges in Aotearoa New Zealand are recorded in the National Minimum Dataset (NMDS). Movement of patients between hospitals (and occasionally within the same hospital) results in separate records (discharge events) within the NMDS and if these consecutive health records are not accounted for hospitalization (encounters) rates might be overestimated. The aim of this study was to determine the impact of four different methods to bundle multiple discharge events in the NMDS into encounters on the relative comparison of rural and urban Ambulatory Sensitive Hospitalization (ASH) rates. METHODS: NMDS discharge events with an admission date between July 1, 2015, and December 31, 2019, were bundled into encounters using either using a) no method, b) an "admission flag", c) a "discharge flag", or d) a date-based method. ASH incidence rate ratios (IRRs), the mean total length of stay and the percentage of interhospital transfers were estimated for each bundling method. These outcomes were compared across 4 categories of the Geographic Classification for Health. RESULTS: Compared with no bundling, using the date-based method resulted in an 8.3% reduction (150 less hospitalizations per 100,000 person years) in the estimated incidence rate for ASH in the most rural (R2-3) regions. There was no difference in the interpretation of the rural-urban IRR for any bundling methodology. Length of stay was longer for all bundling methods used. For patients that live in the most rural regions, using a date-based method identified up to twice as many interhospital transfers (5.7% vs 12.4%) compared to using admission flags. CONCLUSION: Consecutive events within hospital discharge datasets should be bundled into encounters to estimate incidence. This reduces the overestimation of incidence rates and the undercounting of interhospital transfers and total length of stay.