Specialist outreach to isolated and disadvantaged communities: a population-based study.

BACKGROUND: Visiting-specialist clinics (specialist outreach) have the potential to overcome some of the substantial access barriers faced by disadvantaged rural, remote, and Indigenous communities, but the effectiveness of outreach clinics has not been assessed outside urban and non-disadvantaged settings. We aimed to assess the effects of outreach clinics on access, referral patterns, and care outcomes in remote communities in Australia. METHODS: We undertook a population-based observational study of regular surgical, ophthalmological, gynaecological, and ear, nose, and throat outreach visits, compared with hospital clinics alone, on access, referral practices, and outcomes for the populations of three remote Indigenous communities in northern Australia for 11 years. We assessed all new non-emergency potential specialist surgical cases who presented initially between Jan 1, 1990, and Jan 1, 2001. The effects of outreach clinics on the proportion of patients referred, the time from referral to initial specialist consultation, and the rates of community-based and hospital-based procedures were analysed using logic regression and Cox proportional hazard models. FINDINGS: 2339 new surgical problems presented in 2368 people between 1990 and 2001. Outreach improved the rate of referral completion (adjusted hazard ratio 1.41, 95% CI 1.07-1.86) and the risk of timely completion according to the urgency of referral (adjusted relative risk 1.30, 1.05-1.53). Outreach had no significant effect on initiation of elective referrals, but there were 156 opportunistic presentations on outreach clinic days. Specialist investigations and procedures in community clinics removed the need for many patients to travel to hospital, and outreach consultations were associated with a reduced rate of procedures that needed hospital admission (adjusted hazard ratio 0.67, 0.43-1.03). INTERPRETATION: Specialist outreach visits to remote disadvantaged Indigenous communities in Australia improve access to specialist consultations and procedures without increasing elective referrals or demands for hospital inpatient services.

The demand for surgery: an analysis of referrals from Australian general practitioners.

BACKGROUND: Optimal planning for surgical training and the surgical workforce requires knowledge of the need and demand for surgical care in the community. This has previously relied on indirect indicators, such as hospital throughput. We aimed to describe referrals from general practitioners (GPs) to surgeons in Australia using a classification of surgical disorders developed especially for primary care settings. METHODS: Terms in the International Classification of Primary Care Version 2-Plus were reclassified into categories delineated by specialist surgeons, resulting in the Surgical Nosology In Primary-care Settings (SNIPS). Referrals to surgeons were analysed using data on 303,000 patient encounters by a random sample of 3030 GPs involved in the Bettering the Evaluation and Care of Health (BEACH) study. RESULTS: Thirty-two per cent (143,013) of all problems were classified as potential surgical problems, of which 9.5% (13,570) were referred to surgeons at an overall rate of 44.8 referrals per 1000 GP encounters. Patients with surgical problems were significantly older than the overall general practice patient population. Women and patients with health care cards were significantly less likely than men and patients without health care cards to be referred when a surgical problem was managed by the GP. Forty-two per cent of all surgical referrals were accounted for by the following categories: skin lesions, skin infection/injury, upper gastrointestinal, breast lumps/cancer, spine, knee arthritis/pain, knee injury/instability, infective and non-infective ear disorders. Many commonly referred problems are usually managed as outpatients. CONCLUSIONS: The data from this study may have application for surgical workforce planning and ensuring trainees receive adequate exposure to commonly referred conditions. The classification system (SNIPS) may be useful for future research concerning the interface between primary care and specialist surgical practice.