Primary health care utilisation and delivery in remote Australian clinics during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic period (2020 to 2022) challenged and overstretched the capacity of primary health care services to deliver health care globally. The sector faced a highly uncertain and dynamic period that encompassed anticipation of a new, unknown, lethal and highly transmissible infection, the introduction of various travel restrictions, health workforce shortages, new government funding announcements and various policies to restrict the spread of the COVID-19 virus, then vaccination and treatments. This qualitative study aims to document and explore how the pandemic affected primary health care utilisation and delivery in remote and regional Aboriginal and Torres Strait Islander communities. METHODS: Semi-structured interviews were conducted with staff working in 11 Aboriginal Community-Controlled Health Services (ACCHSs) in outer regional, remote and very remote Australia. Interviews were transcribed, inductively coded and thematically analysed. RESULTS: 248 staff working in outer regional, remote and very remote primary health care clinics were interviewed between February 2020 and June 2021. Participants reported a decline in numbers of primary health care presentations in most communities during the initial COVID-19 lock down period. The reasons for the decline were attributed to community members apprehension to go to the clinics, change in work priorities of primary health care staff (e.g. more emphasis on preventing the virus entering the communities and stopping the spread) and limited outreach programs. Staff forecasted a future spike in acute presentations of various chronic diseases leading to increased medical retrieval requirements from remote communities to hospital. Information dissemination during the pre-vaccine roll-out stage was perceived to be well received by community members, while vaccine roll-out stage information was challenged by misinformation circulated through social media. CONCLUSIONS: The ability of ACCHSs to be able to adapt service delivery in response to the changing COVID-19 strategies and policies are highlighted in this study. The study signifies the need to adequately fund ACCHSs with staff, resources, space and appropriate information to enable them to connect with their communities and continue their work especially in an era where the additional challenges created by pandemics are likely to become more frequent. While the PHC seeking behaviour of community members during the COVID-19 period were aligned to the trends observed across the world, some of the reasons underlying the trends were unique to outer regional, remote and very remote populations. Policy makers will need to give due consideration to the potential effects of newly developed policies on ACCHSs operating in remote and regional contexts that already battle under resourcing issues and high numbers of chronically ill populations.

Attitudes to Short-Term Staffing and Workforce Priorities of Community Users of Remote Aboriginal Community-Controlled Health Services: A Qualitative Study.

In recent years, there has been an increasing trend of short-term staffing in remote health services, including Aboriginal Community-Controlled Health Services (ACCHSs). This paper explores the perceptions of clinic users' experiences at their local clinic and how short-term staffing impacts the quality of service, acceptability, cultural safety, and continuity of care in ACCHSs in remote communities. Using purposeful and convenience sampling, community users (aged 18+) of the eleven partnering ACCHSs were invited to provide feedback about their experiences through an interview or focus group. Between February 2020 and October 2021, 331 participants from the Northern Territory and Western Australia were recruited to participate in the study. Audio recordings were transcribed verbatim, and written notes and transcriptions were analysed deductively. Overall, community users felt that their ACCHS provided comprehensive healthcare that was responsive to their health needs and was delivered by well-trained staff. In general, community users expressed concern over the high turnover of staff. Recognising the challenges of attracting and retaining staff in remote Australia, community users were accepting of rotation and job-sharing arrangements, whereby staff return periodically to the same community, as this facilitated trusting relationships. Increased support for local employment pathways, the use of interpreters to enhance communication with healthcare services, and services for men delivered by men were priorities for clinic users.

Telehealth in remote Australia: a supplementary tool or an alternative model of care replacing face-to-face consultations?

BACKGROUND: The COVID-19 pandemic increased the use of telehealth consultations by telephone and video around the world. While telehealth can improve access to primary health care, there are significant gaps in our understanding about how, when and to what extent telehealth should be used. This paper explores the perspectives of health care staff on the key elements relating to the effective use of telehealth for patients living in remote Australia. METHODS: Between February 2020 and October 2021, interviews and discussion groups were conducted with 248 clinic staff from 20 different remote communities across northern Australia. Interview coding followed an inductive approach. Thematic analysis was used to group codes into common themes. RESULTS: Reduced need to travel for telehealth consultations was perceived to benefit both health providers and patients. Telehealth functioned best when there was a pre-established relationship between the patient and the health care provider and with patients who had good knowledge of their personal health, spoke English and had access to and familiarity with digital technology. On the other hand, telehealth was thought to be resource intensive, increasing remote clinic staff workload as most patients needed clinic staff to facilitate the telehealth session and complete background administrative work to support the consultation and an interpreter for translation services. Clinic staff universally emphasised that telehealth is a useful supplementary tool, and not a stand-alone service model replacing face-to-face interactions. CONCLUSION: Telehealth has the potential to improve access to healthcare in remote areas if complemented with adequate face-to-face services. Careful workforce planning is required while introducing telehealth into clinics that already face high staff shortages. Digital infrastructure with reliable internet connections with sufficient speed and latency need to be available at affordable prices in remote communities to make full use of telehealth consultations. Training and employment of local Aboriginal staff as digital navigators could ensure a culturally safe clinical environment for telehealth consultations and promote the effective use of telehealth services among community members.

Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice.

Background: Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas. Objective: This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work. Methods: American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program. Results: Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics. Conclusions: There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.

Optimising medical retrieval processes and outcomes in remote areas in high-income countries: A scoping review.

OBJECTIVE: This scoping review explores the structure and process-level strategies that are associated with medical retrieval outcomes. A secondary aim is to identify the range of medical retrieval outcomes used to assess the performance of remote retrieval services. DESIGN: A scoping review of peer-reviewed literature from PubMed, CINAHL and the Web of Science was undertaken following guidelines set by the Johanna Briggs Institute manual for scoping reviews. All articles were assessed by two reviewers. Themes were derived inductively from the data extracted. SETTING: Medical retrievals in sparsely populated remote locations in high-income countries. PARTICIPANTS: Staff and clients of remote medical retrieval services. INTERVENTIONS: Structures and processes (e.g. resource availability, retrieval staff structures and governance protocols) that aimed to improve medical retrieval outcomes. OUTCOMES: Patient health outcomes and service efficiency. RESULTS: Twenty-four articles were included. Three broad themes, related to the nature of the interventions, were included: optimising prehospital management of retrievals, staffing and resourcing of retrieval services and retrieval model evaluation. Mortality was the most frequently used outcome indicator in these studies, but was not measured consistently across studies. CONCLUSIONS: This review highlights significant gaps in the literature that describes the structure and processes of retrieval models operating in remote areas and a dearth of literature evaluating specific operational strategies implemented within medical retrieval models. The available literature does not meaningfully assist with identifying key outcome indicators for developing a consistent monitoring and evaluation framework for retrieval services in geographically, culturally and demographically diverse remote contexts.

Effects of turnover and stability of health staff on quality of care in remote communities of the Northern Territory, Australia: a retrospective cohort study.

OBJECTIVES: To evaluate the relationship between markers of staff employment stability and use of short-term healthcare workers with markers of quality of care. A secondary objective was to identify clinic-specific factors which may counter hypothesised reduced quality of care associated with lower stability, higher turnover or higher use of short-term staff. DESIGN: Retrospective cohort study (Northern Territory (NT) Department of Health Primary Care Information Systems). SETTING: All 48 government primary healthcare clinics in remote communities in NT, Australia (2011-2015). PARTICIPANTS: 25 413 patients drawn from participating clinics during the study period. OUTCOME MEASURES: Associations between independent variables (resident remote area nurse and Aboriginal Health Practitioner turnover rates, stability rates and the proportional use of agency nurses) and indicators of health service quality in child and maternal health, chronic disease management and preventive health activity were tested using linear regression, adjusting for community and clinic size. Latent class modelling was used to investigate between-clinic heterogeneity. RESULTS: The proportion of resident Aboriginal clients receiving high-quality care as measured by various quality indicators varied considerably across indicators and clinics. Higher quality care was more likely to be received for management of chronic diseases such as diabetes and least likely to be received for general/preventive adult health checks. Many indicators had target goals of 0.80 which were mostly not achieved. The evidence for associations between decreased stability measures or increased use of agency nurses and reduced achievement of quality indicators was not supported as hypothesised. For the majority of associations, the overall effect sizes were small (close to zero) and failed to reach statistical significance. Where statistically significant associations were found, they were generally in the hypothesised direction. CONCLUSIONS: Overall, minimal evidence of the hypothesised negative effects of increased turnover, decreased stability and increased reliance on temporary staff on quality of care was found. Substantial variations in clinic-specific estimates of association were evident, suggesting that clinic-specific factors may counter any potential negative effects of decreased staff employment stability. Investigation of clinic-specific factors using latent class analysis failed to yield clinic characteristics that adequately explain between-clinic variation in associations. Understanding the reasons for this variation would significantly aid the provision of clinical care in remote Australia.

Exploring preference for, and uptake of, rural medical internships, a key issue for supporting rural training pathways.

BACKGROUND: Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion. METHODS: We used administrative data of all new Victorian medical graduates' location preference and accepted location of internship positions for 2013-16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between 'domestic graduates' (Australian and New Zealand citizens or permanent residents) and 'international graduates' (temporary residents who graduated from an Australian university). RESULTS: Across 2013-16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p < 0.001). Only 20.1% (551/2737) included a rural location in their top five preferences, less than for international graduates (34.4%, p < 0.001). A greater proportion of rural compared with metropolitan interns accepted a position not in their top five preferences (36.1% versus 7.4%, p < 0.001). The proportion nominating a rural location in their preference list increased across 2013-2016. CONCLUSIONS: The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent.

Rural Work and Specialty Choices of International Students Graduating from Australian Medical Schools: Implications for Policy.

Almost 500 international students graduate from Australian medical schools annually, with around 70% commencing medical work in Australia. If these Foreign Graduates of Accredited Medical Schools (FGAMS) wish to access Medicare benefits, they must initially work in Distribution Priority Areas (mainly rural). This study describes and compares the geographic and specialty distribution of FGAMS. Participants were 18,093 doctors responding to Medicine in Australia: Balancing Employment and Life national annual surveys, 2012-2017. Multiple logistic regression models explored location and specialty outcomes for three training groups (FGAMS; other Australian-trained (domestic) medical graduates (DMGs); and overseas-trained doctors (OTDs)). Only 19% of FGAMS worked rurally, whereas 29% of Australia's population lives rurally. FGAMS had similar odds of working rurally as DMGs (OR 0.93, 0.77-1.13) and about half the odds of OTDs (OR 0.48, 0.39-0.59). FGAMS were more likely than DMGs to work as general practitioners (GPs) (OR 1.27, 1.03-1.57), but less likely than OTDs (OR 0.74, 0.59-0.92). The distribution of FGAMS, particularly geographically, is sub-optimal for improving Australia's national medical workforce goals of adequate rural and generalist distribution. Opportunities remain for policy makers to expand current policies and develop a more comprehensive set of levers to promote rural and GP distribution from this group.

Outcomes of a 1-year longitudinal integrated medical clerkship in small rural Victorian communities.

INTRODUCTION: Access to medical services for rural communities is poorer than for metropolitan communities in many parts of the world. One of the strategies to improve rural medical workforce has been rural clinical placements for undergraduate medical students. This study explores the workforce outcomes of one model of such placements - the longitudinal integrated clerkship (LIC) - delivered in year 4, the penultimate year of the medical course, as part of the rural programs delivered by a medical school in Victoria, Australia. The LIC involved student supervision under a parallel consulting model with experienced rural generalist doctors for a whole year in small community rural general practices. METHODS: This study aimed to compare the work locations (regional or more rural), following registration as a medical practitioner, of medical students who had completed 1 year of the LIC, with, first, students who had other types of rural training of comparable duration elsewhere, and second, students who had no rural training. Study participants commenced their medical degree after 2004 and had graduated between 2008 and 2016 and thus were in postgraduate year 1-9 in 2017 when evaluated. Information about the student training location(s), and duration, type and timing of training, was prospectively collected from university administrative systems. The outcome of interest was the main work location in 2017, obtained from the Australian Health Practitioner Regulation Agency's public website. RESULTS: Students who had undertaken the year 4 LIC along with additional rural training in years 3 and/or 5 were more likely than all other groups to be working in smaller regional or rural towns, where workforce need is greatest (relative risk ratio (RRR) 5.62, 95% confidence interval (CI) 2.81-11.20, compared with those having metropolitan training only). Non-LIC training of similar duration in rural areas was also significantly associated, but more weakly, with smaller regional work location (RRR 2.99, 95%CI 1.87-4.77). Students whose only rural training was the year 4 LIC were not significantly associated with smaller regional work location (RRR 1.72, 95%CI 0.59-5.04). Overall, after accounting for both LIC and non-LIC rural training exposure, rural work after graduation was also consistently positively associated with rural background, being an international student and having a return of service obligation under a bonded program as a student. CONCLUSION: This study demonstrates the value of rural LICs, coupled with additional rural training, in contributing to improving Australia's medical workforce distribution. Whilst other evidence has already demonstrated positive educational outcomes for doctors who participate in rural LIC placements, this is the first known study of work location outcomes. The study provides evidence that expanding this model of rural undergraduate education may lead to a better geographically distributed medical workforce.

Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence.

BACKGROUND: The capacity for high-income countries to supply enough locally trained doctors to minimise their reliance on overseas-trained doctors (OTDs) is important for equitable global workforce distribution. However, the ability to achieve self-sufficiency of individual countries is poorly evaluated. This review draws on a decade of research evidence and applies additional stratified analyses from a unique longitudinal medical workforce research program (the Medicine in Australia: Balancing Employment and Life survey (MABEL)) to explore Australia's rural medical workforce self-sufficiency and inform rural workforce planning. Australia is a country with a strong medical education system and extensive rural workforce policies, including a requirement that newly arrived OTDs work up to 10 years in underserved, mostly rural, communities to access reimbursement for clinical services through Australia's universal health insurance scheme, called Medicare. FINDINGS: Despite increases in the number of Australian-trained doctors, more than doubling since the late 1990s, recent locally trained graduates are less likely to work either as general practitioners (GPs) or in rural communities compared to local graduates of the 1970s-1980s. The proportion of OTDs among rural GPs and other medical specialists increases for each cohort of doctors entering the medical workforce since the 1970, peaking for entrants in 2005-2009. Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs substantially continue to underpin Australia's rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia's rural medical workforce. CONCLUSION: It is essential for Australia to monitor its ongoing reliance on OTDs in rural areas and be considerate of the potential impact on global workforce distribution.

Cost impact of high staff turnover on primary care in remote Australia.

Objectives The aim of this study was to estimate the costs of providing primary care and quantify the cost impact of high staff turnover in Northern Territory (NT) remote communities. Methods This cost impact assessment used administrative data from NT Department of Health datasets, including the government accounting system and personnel information and payroll systems between 2004 and 2015, and the primary care information system from 2007 to 2015. Data related to 54 government-managed clinics providing primary care for approximately 27200 Aboriginal and non-Aboriginal people. Main outcome measures were average costs per consultation and per capita, cost differentials by clinic, year and levels of staff turnover. Linear regression and dominance analysis were used to assess the effect of staff turnover on primary care costs, after adjusting for remoteness and weighting analysis by service population. Both current and constant prices were used. Results On average, in constant prices, there was a nearly 10% annual increase in remote clinic expenditure between 2004 and 2015 and an almost 15% annual increase in consultation numbers since 2007. In real terms, the average costs per consultation decreased markedly from A$273 in 2007 to A$197 in 2015, a figure still well above the Medicare bulk-billing rate. The cost differentials between clinics were proportional to staff turnover and remoteness (both P<0.001). A 10% higher annual turnover rate pertains to an A$6.12 increase in costs per consultation. Conclusions High staff turnover exacerbates the already high costs of providing primary care in remote areas, costing approximately A$50 extra per consultation. This equates to an extra A$400000 per clinic per year on average, or A$21million annually for the NT government. Over time, sustained investments in developing a more stable primary care workforce should not only improve primary care in remote areas, but also reduce the costs of excessive turnover and overall service delivery costs. What is known about the topic? Population size and geographical remoteness are important cost drivers in remote clinics, whereas elsewhere in Australia the high use of short-term staff to fill positions has been identified as a major contributor to higher nurse turnover costs and to overall health service costs. Nursing staff expenditure accounts for a large proportion (46%) of total expenditure in NT remote health services, whereas expenditure on Aboriginal Health Practitioners (AHPs) comprises only 6%. Annual nurse turnover rates in remote NT clinics average approximately 150%, whereas levels of 40% in other contexts are considered high. What does this paper add? Annual expenditure for NT remote clinics has increased, on average, by 10% per annum between 2004 and 2015, but small declines in real expenditure have been observed from a maximum in 2012. Expenditure on nursing staff comprises 40% of overall expenditure in remote clinics, whereas expenditure on AHPs comprises less than 5%. The cost impact of every 10% increase in remote nurse and AHP annual turnover has been quantified as an extra A$6.12 per primary care consultation, which equates, on average, to an extra A$400000 per remote clinic, and an extra A$21million overall for the NT Department of Health each year. The average real expenditure per primary care consultation has decreased from A$273 in 2007 to A$197 in 2015, representing a statistically significant linear trend reduction of A$7.71 per consultation annually. What are the implications for practitioners (and other decision-makers)? Adjusting policy settings away from the high use of short-term staff to investment in appropriate training 'pipelines' for the remote primary care workforce may, in the medium and longer term, result in reduced turnover of resident staff and associated cost savings. Targeted recruitment and retention strategies that ensure individual primary care workers are an optimal fit with the remote communities in which they work, together with improved professional and personal support for staff residing in remote communities, may also help reduce turnover, improve workforce stability and lead to stronger therapeutic relationships and better health outcomes.

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland.

BACKGROUND: Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. METHODS: An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access -spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. RESULTS: 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. CONCLUSIONS: Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

Rural training pathways: the return rate of doctors to work in the same region as their basic medical training.

BACKGROUND: Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18-24 months) and for those completing both schooling and training in the same rural region. METHODS: The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1-9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained. RESULTS: Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18-24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89-5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14-9.36) were associated with returning to practice in the same rural region after training. CONCLUSIONS: Medical graduates practising rurally in their early career (1-9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training.

Comparing visual acuity, range of vision and spectacle independence in the extended range of vision and monofocal intraocular lens.

IMPORTANCE: This study is the first to compare the extended range of vision (ERV) intraocular lens (IOL) targeted at micro-monovision to a monofocal targeted at binocular emmetropia. BACKGROUND: Compares visual acuity, range of vision and spectacle independence in monofocal and ERV IOLs. DESIGN: Assessor-blinded retrospective cohort study. PARTICIPANTS: Eighty-eight participants (176 eyes) with bilateral IOL implants at 5+ month postoperative review. METHODS: Regression analyses (general estimating equations and multiple linear regression) tested associations between IOL type (ZA9002 Tecnis 3-piece or Tecnis ZCT monofocal; and Tecnis Symfony ERV IOL) and visual acuity, adjusting for key confounders including residual astigmatism. MAIN OUTCOME MEASURES: Monocular and binocular visual acuity measured with and without distance refractive correction at distance (3.00 m), intermediate (1.00 and 0.63 m) and near (0.40 m) (logMAR units); near vision reading test used British 'N' notation; self-reported spectacle independence. RESULTS: There was no significant difference between ERV and monofocal groups in uncorrected binocular visual acuity at distance (P = 0.595). Binocular uncorrected visual acuity at intermediate (0.63 m: monofocal 0.24, ERV 0.09, P < 0.001) and near (0.40 m: monofocal 0.42, ERV 0.18, P < 0.001) were significantly better in the ERV group. Binocular uncorrected near vision: all the ERV group read N8 or better, compared to 36% in the monofocal group (P < 0.001); 93% of the ERV group reported spectacle independence at near compared to 33% in the monofocal group (P < 0.001). CONCLUSIONS AND RELEVANCE: The ERV IOL, targeted to achieve micro-monovision, demonstrated superior range of visual acuity and spectacle independence compared to the monofocal targeted to achieve emmetropia.

Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia.

BACKGROUND: International evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding. METHODS: Descriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004-2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. MAIN OUTCOME MEASURES: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates. RESULTS: Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position. Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a "fading" of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels. CONCLUSIONS: Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.

Intrinsic and extrinsic factors drive ontogeny of early-life at-sea behaviour in a marine top predator.

Young animals must learn to forage effectively to survive the transition from parental provisioning to independent feeding. Rapid development of successful foraging strategies is particularly important for capital breeders that do not receive parental guidance after weaning. The intrinsic and extrinsic drivers of variation in ontogeny of foraging are poorly understood for many species. Grey seals (Halichoerus grypus) are typical capital breeders; pups are abandoned on the natal site after a brief suckling phase, and must develop foraging skills without external input. We collected location and dive data from recently-weaned grey seal pups from two regions of the United Kingdom (the North Sea and the Celtic and Irish Seas) using animal-borne telemetry devices during their first months of independence at sea. Dive duration, depth, bottom time, and benthic diving increased over the first 40 days. The shape and magnitude of changes differed between regions. Females consistently had longer bottom times, and in the Celtic and Irish Seas they used shallower water than males. Regional sex differences suggest that extrinsic factors, such as water depth, contribute to behavioural sexual segregation. We recommend that conservation strategies consider movements of young naïve animals in addition to those of adults to account for developmental behavioural changes.

Family effects on the rurality of GP's work location: a longitudinal panel study.

BACKGROUND: Reduced opportunities for children's schooling and spouse's/partner's employment are identified internationally as key barriers to general practitioners (GPs) working rurally. This paper aims to measure longitudinal associations between the rurality of GP work location and having (i) school-aged children and (ii) a spouse/partner in the workforce. METHODS: Participants included 4377 GPs responding to at least two consecutive annual surveys of the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal study between 2008 and 2014. The main outcome, GP work location, was categorised by remoteness and population size. Five sequential binary school-age groupings were defined according to whether a GP had no children, only preschool children (aged 0-4 years), at least one primary-school child (aged 5-11 years), at least one child in secondary school (aged 12-18 years), and all children older than secondary school (aged ≥ 19). Partner in the workforce was defined by whether a GP had a partner who was either currently working or looking for work, or not. Separate generalised estimating equation models, which aggregated consecutive annual observations per GP, tested associations between work location and (i) educational stages and (ii) partner employment, after adjusting for key covariates. RESULTS: Male GPs with children in secondary school were significantly less likely to work rurally (inclusive of > 50 000 regional centres through to the smallest rural towns of < 5000) compared to male GPs with children in primary school. In contrast, female GPs' locations were not significantly associated with the educational stage of their children. Having a partner in the workforce was not associated with work location for male GPs, whereas female GPs with a partner in the workforce were significantly less likely to work in smaller rural/remote communities (< 15 000 population). CONCLUSIONS: This is the first systematic, national-level longitudinal study showing that GP work location is related to key family needs which differ according to GP gender and educational stages of children. Such non-professional factors are likely to be dynamic across the GP's lifespan and should be regularly reviewed as part of GP retention planning. This research supports investment in regional development for strong local secondary school and partner employment opportunities.

Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015.

BACKGROUND: The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics. METHODS: This study used the NT Department of Health 2013-2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival. RESULTS: At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics. CONCLUSIONS: NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision-and therefore may compromise long-term sustainability-but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.