What is important for high quality rural health care? A qualitative study of rural community and provider views in Aotearoa New Zealand.

INTRODUCTION: While the general principles of healthcare quality are well articulated internationally, less has been written about applying these principles to rural contexts. Research exploring patient and provider views of healthcare quality in rural communities is limited. This study investigated what was important in healthcare quality particularly for hospital-level care for rural communities in Aotearoa New Zealand. METHODS: A pragmatic qualitative study was undertaken in four diverse rural communities with access to rural hospitals. Data were gathered through eight community and indigenous (Maori) focus groups (75 participants) and 34 health provider interviews, and analysed thematically. RESULTS: Two study sites had large Maori populations and high levels of socioeconomic deprivation, whereas the other two sites had much lower Maori populations and lower levels of socioeconomic deprivation, but further travel distances to urban facilities. Rural hospitals in the communities ranged from 12 to 80 beds and were both government and community trust owned. A theme of the principles of high quality rurally focused health services was developed. Nine principles were identified: (1) providing patient- and family-centred care that respected people's preferences for where treatment was provided; (2) providing services as close to home as could be done well; (3) quality was everybody's job; (4) consistent care across settings, with reduction on unwarranted variation; (5) team-based care across distance, with clear communication and processes between different facilities working together; (6) equitable health care particularly for Maori, and then for the whole rural community; (7) sustainable service models, particularly for workforce, as a counterbalance to 'closer to home'; (8) health networks to improve patient flow, and reduce waste; and (9) value was more than value for money, and including valuing respectful, timely care. Another theme around rural and urban healthcare quality was developed. While the nature of care was different in different settings, patient experience should be the underlying measure of quality, and quality measures needed to be interpreted in the context of local circumstances, with rural-specific quality measures where appropriate. CONCLUSION: The researchers developed principles of healthcare quality specific to rural communities regarding patient and family preferences for where care was received, a broader focus on value beyond value for money and a strong focus on equity for indigenous people. These principles add to the rural principles previously described. Patient experience should be the underlying focus of quality, while noting that the nature of health care provided in rural and urban settings is different. The present study's findings support the concept that quality measures should be interpreted in the context of local circumstances, with the development of rural-specific measures. The authors hope the findings, when locally contextualised, will assist health policy makers, planners, providers and community leaders as they strive to improve the quality of health services for their rural communities.

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study.

OBJECTIVES: To determine the epidemiology of healthcare harm observable in general practice records. DESIGN: Retrospective cohort records review study. SETTING: 72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by rurality and size; 44 clinics consented to participate. PARTICIPANTS: 9076 patient records were randomly selected from participating clinics. INTERVENTION: Eight general practitioners examined patient records (2011-2013) to identify harms, harm severity and preventability. Analyses were weighted to account for the stratified sampling design and generalise findings to all New Zealand patients. MAIN OUTCOME MEASURES: Healthcare harm, severity and preventability. RESULTS: Reviewers identified 2972 harms affecting 1505 patients aged 0-102 years. Most patients (82.0%, weighted) experienced no harm. The estimated incidence of harm was 123 per 1000 patient-years. Most harms (2160; 72.7%, 72.4% weighted) were minor, 661 (22.2%, 22.8% weighted) were moderate, and 135 (4.5%, 4.4% weighted) severe. Eleven patients died, five following a preventable harm. Of the non-fatal harms, 2411 (81.6%, 79.4% weighted) were considered not preventable. Increasing age and number of consultations were associated with increased odds of harm. Compared with patients aged ≤49 years, patients aged 50-69 had an OR of 1.77 (95% CI 1.61 to 1.94), ≥70 years OR 3.23 (95% CI 2.37 to 4.41). Compared with patients with ≤3 consultations, patients with 4-12 consultations had an OR of 7.14 (95% CI 5.21 to 9.79); ≥13 consultations OR 30.06 (95% CI 21.70 to 41.63). CONCLUSIONS: Strategic balancing of healthcare risks and benefits may improve patient safety but will not necessarily eliminate harms, which often arise from standard care. Reducing harms considered 'not preventable' remains a laudable challenge.

Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study.

OBJECTIVE: Little is known about differences in hospital harm (injury, suffering, disability, disease or death arising from hospital care) when people from rural and urban locations require hospital care. This study aimed to assess whether hospital harm risk differed by patients' rural or urban location using general practice data. DESIGN: Secondary analysis of a 3-year retrospective cross-sectional general practice records review study, designed with equal numbers of rural and urban patients and patients from small, medium and large practices. Hospital admissions, interhospital transfer and hospital harm were identified. SETTING: New Zealand (NZ) general practice clinical records including hospital discharge data. PARTICIPANTS: Randomly selected patient records from randomly selected general practices across NZ. Patient enrolment at rural and urban general practices defined patient location. OUTCOMES: Admission and harm risk and rate ratios by rural-urban location were investigated using multivariable analyses adjusted for age, sex, ethnicity, deprivation, practice size. Preventable hospital harm, harm severity and harm associated with interhospital transfer were analysed. RESULTS: Of 9076 patient records, 1561 patients (17%) experienced hospital admissions with no significant association between patient location and hospital admission (rural vs urban adjusted risk ratio (aRR) 0.98 (95% CI 0.83 to 1.17)). Of patients admitted to hospital, 172 (11%) experienced hospital harm. Rural location was not associated with increased hospital harm risk (aRR 1.01 (95% CI 0.97 to 1.05)) or rate of hospital harm per admission (adjusted incidence rate ratio 1.09 (95% CI 0.83 to 1.43)). Nearly half (45%) of hospital harms became apparent only after discharge. No urban patients required interhospital transfer, but 3% of rural patients did. Interhospital transfer was associated with over twice the risk of hospital harm (age-adjusted aRR 2.33 (95% CI 1.37 to 3.98), p=0.003). CONCLUSIONS: Rural patient location was not associated with increased hospital harm. This provides reassurance for rural communities and health planners. The exception was patients needing interhospital transfer, where risk was more than doubled, warranting further research.

Medication-related harm in New Zealand general practice: a retrospective records review.

BACKGROUND: The extent of medication-related harm in general practice is unknown. AIM: To identify and describe all medication-related harm in electronic general practice records. The secondary aim was to investigate factors potentially associated with medication-related harm. DESIGN AND SETTING: Retrospective cohort records review study in 44 randomly selected New Zealand general practices for the 3 years 2011-2013. METHOD: Eight GPs reviewed 9076 randomly selected patient records. Medication-related harms were identified when the causal agent was prescribed in general practice. Harms were coded by type, preventability, and severity. The number and proportion of patients who experienced medication-related harm was calculated. Weighted logistic regression was used to identify factors associated with harm. RESULTS: In total, 976 of 9076 patients (10.8%) experienced 1762 medication-related harms over 3 years. After weighting, the incidence rate of all medication-related harms was 73.9 harms per 1000 patient-years, and the incidence of preventable, or potentially preventable, medication-related harms was 15.6 per 1000 patient-years. Most harms were minor (n = 1385/1762, 78.6%), but around one in five harms were moderate or severe (n = 373/1762, 21.2%); three patients died. Eighteen study patients were hospitalised; after weighting this correlates to a hospitalisation rate of 1.1 per 1000 patient-years. Increased age, number of consultations, and number of medications were associated with increased risk of medication-related harm. Cardiovascular medications, antineoplastic and immunomodulatory agents, and anticoagulants caused most harm by frequency and severity. CONCLUSION: Medication-related harm in general practice is common. This study adds to the evidence about the risk posed by medication in the real world. Findings can be used to inform decision making in general practice.

Advancing bibliometric assessment of research productivity: an analysis of US Departments of Family Medicine.

INTRODUCTION Measurement of family medicine research productivity has lacked the replicable methodology needed to document progress. AIM In this study, we compared three methods: (1) faculty-to-publications; (2) publications-to-faculty; and (3) department-reported publications. METHODS In this cross-sectional analysis, publications in peer-reviewed, indexed journals for faculty in 13 US family medicine departments in 2015 were assessed. In the faculty-to-publications method, department websites to identify faculty and Web of Science to identify publications were used. For the publications-to-faculty method, PubMed's author affiliation field were used to identify publications, which were linked to faculty members. In the department-reported method, chairs provided lists of faculty and their publications. For each method, descriptive statistics to compare faculty and publication counts were calculated. RESULTS Overall, 750 faculty members with 1052 unique publications, using all three methods combined as the reference standard, were identified. The department-reported method revealed 878 publications (84%), compared to 616 (59%) for the faculty-to-publications method and 412 (39%) for the publication-to-faculty method. Across all departments, 32% of faculty had any publications, and the mean number of publications per faculty was 1.4 (mean of 4.4 per faculty among those who had published). Assistant Professors, Associate Professors, Professors and Chairs accounted for 92% of all publications. DISCUSSION Online searches capture a fraction of publications, but also capture publications missed through self-report. The ideal methodology includes all three. Tracking publications is important for quantifying the return on our discipline's research investment.

Good care close to home: local health professional perspectives on how a rural hospital can contribute to the healthcare of its community.

AIM: Hokianga Health in New Zealand's far north is an established health service with a small rural hospital, serving a largely Maori community. The aim of this study was to gain insights into the wider roles of one rural hospital from the perspective of its staff. METHOD: Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health, eight with past and current medical practitioners, three with senior non-medical staff. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the Framework Method. RESULTS: Four main themes were identified: 'Our Context', emphasising geographical isolation; 'Continuity of Care', illustrating the role of the hospital across the primary-secondary interface; 'Navigation' of health services within and beyond Hokianga; and the concept of hospital as 'Home'. CONCLUSION: Findings highlight the importance of geographically appropriate, as well as culturally appropriate, health services. A hospital as part of a rural health service can enhance comprehensive and continuous care for a rural community. Study findings suggest rural hospitals should be viewed and valued as their own distinct entity rather than small-scale versions of larger urban hospitals.

Waiting for a miracle or best medical practice? End-of-life medical ethical dilemmas in Bahrain.

BACKGROUND AND OBJECTIVES: In Bahrain, maintaining life support at all costs is a cultural value considered to be embedded in the Islamic religion. We explore end-of-life decision making for brain dead patients in an Arab country where medical cultures are dominated by Western ideas and the lay culture is Eastern. METHODS: In-depth interviews were conducted from February to April 2018 with 12 Western-educated Bahraini doctors whose medical practice often included end-of-life decision making. Discussions were about who should make withdrawal of life support decisions, how decisions are made and the context for decision making. To develop results, we used the inductive method of thematic analysis. RESULTS: Informants considered it difficult to engage non-medical people in end-of-life decisions because of people's reluctance to talk about death and no legal clarity about medical responsibilities. There was disagreement about doctors' roles with some saying that end-of-life decisions were purely medical or purely religious but most maintaining that such decisions need to be collectively owned by medicine, patients, families, religious advisors and society. Informants practised in a legal vacuum that made their ethics interpretations and clinical decision making idiosyncratic regarding end-of-life care for brain dead patients. Participants referred to contrasts between their current practice and previous work in other countries, recognising the influences of religious and cultural dimensions on their practice in Bahrain. CONCLUSIONS: End-of-life decisions challenge Western-trained doctors in Bahrain as they grapple with aligning respect for local culture with their training in the ethical practice of Western medicine.