Australian Standard Geographical Classification Remoteness Research Articles

Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR)

ObjectiveTo compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia.DesignObservational study using data from a multicentre national registry.SettingData...

Infective endocarditis: a Hunter New England perspective.

Infective endocarditis (IE) is a severe infection conferring significant morbidity and mortality. It is associated with geographical variation, complicating diagnosis and treatment of patients in a standardised manner. To evaluate the presentation, treatment and outcomes of patients with IE in the Hunter New England Local Health District (HNELHD). A total of 112 patients with definite IE admitted to hospitals within the HNELHD between 2011 and 2015 was retrospectively analysed. The mean age of patients was 56.8 (standard deviation 20.3) and 62.5% were male. The most common valve affected was the mitral valve, in 41% of patients, and the most common organism was Staphylococcus aureus, in 47.7% of patients. A history of IE was present in 10% of patients and 19.6% presented with prosthetic valve IE. Survival among patients treated surgically was 100% at 30 days, 92% at 1 year and 83% at 3 years, versus 82% at 30 days, 65% at 1 year and 51% at 3 years for those not operated (P = 0.004). Valve type, organism and Australian Standard Geographical Classification remoteness area did not have a statistically significant effect on mortality (P-value 0.095, 0.456 and 0.186, respectively). Factors associated with improved survival by univariate analysis included surgery and multidisciplinary team review. IE in the HNELHD affects a relatively young cohort of patients and is associated with a high mortality. Outcomes could be improved by implementation of a multidisciplinary team approach and inpatient cardiac surgery.

Twenty-five years on: outcomes of a longitudinal evaluation of the NSW Rural Resident Medical Officer Cadetship Program

The New South Wales Rural Resident Medical Officer Cadetship Program began in 1988 as a strategy to increase the numbers of junior doctors in rural hospitals. This article outlines the results of an evaluation undertaken in 2014. Specifically, it will look at where former cadets who entered the program between 1989 and 2010 were working in 2014, what training programs they chose and their attitudes toward the program. Data were collected using a semi-structured questionnaire sent to all the former cadets who entered the program from 1989 until 2010. This included self-administered questions relating to background (where the majority of the students' primary schooling was undertaken), vocational training, current role, current work location and attitudes towards the cadetship. Responses were received from 142 of the 211 cadets in the study (67%). Of the 142 former cadets who responded to the questionnaire, 90 had completed a vocational training program and were working as fully qualified medical practitioners. A further 44 were trainees, six were non-specialist hospital doctors and two were no longer practising. Overall, the most popular vocational training programs among fully qualified doctors and trainees combined were general practice, anaesthetics/intensive care and emergency medicine. Over half of the cadets included in the analysis (<i>n</i>=74, 53%) were working in rural areas (Australian Standard Geographical Classification Remoteness Areas 2-5) in 2014 and practice location was significantly (<i>p</i><0.001) influenced by career choice. Of the cadets working in rural locations, the majority (58%) were working as general practitioners while 38% had chosen other specialties and 4% were working as hospital non-specialists. An equal proportion of cadets came from urban and rural backgrounds while a small proportion grew up overseas. The cadets with rural backgrounds were more likely to choose general practice than those from urban backgrounds. A similar analysis of cadets comparing geographic background and practice location showed cadets of rural background were more likely to be working in a rural location than cadets of urban background. The cadetship is an effective link between medical school and rural practice. The success of the program relies in part on the mentoring, networking and other educational opportunities available to cadets, which serve to foster their interest and provide a structured pathway to long-term rural practice. It has been demonstrated that targeted incentive based scholarship schemes with a return-of-service component can be beneficial, particularly where they include ongoing support and reinforcement throughout the transition from undergraduate to postgraduate training.

James Cook University's rurally orientated medical school selection process: quality graduates and positive workforce outcomes

The regionally based James Cook University (JCU) College of Medicine and Dentistry aims to meet its mission to address the health needs of the region by using a selection policy favouring rural origin applicants and providing students with early and repeated exposure to rural experiences during training. This study seeks to determine if the JCU medical school's policy of preferentially selecting rural and remote background students is associated with differing patterns of undergraduate performance or graduate practice location. Data at application to medical school and during the undergraduate years was retrieved from administrative databases held by the university and the medical school. Postgraduate location data were obtained either from personal contact via email, telephone or Facebook or electronically from the Australian Health Practitioner Regulation Authority website. Practice location was described across Australian Standard Geographical Classification Remoteness Area (ASGC-RA) categories, with 1 being a major city and 5 being a very remote location. The 856 Australian-based students accepted into the JCU medical program between 2000 and 2008 came from all geographical regions across Australia: 20% metropolitan (ASGC-RA 1), 20% inner regional (ASGC-RA 2), 56% outer regional (ASGC-RA 3), and 5% from remote or very remote locations (ASGC-RA 4 and 5). Having a rural or remote hometown at application (ASGC-RA 3-5) was significantly associated with a lower tertiary entrance score (p<0.001), a lower interview score in the medical school selection process (p<0.001), being less likely to be admitted into the Honours program (p=0.001), being an advanced standing student (p=0.025), being awarded a Medical Rural Bonded Scholarship (p=0.005), taking longer to complete the 6-year course (p=<0.009) and having a lower academic achievement across years 1 to 3 (p=0.002, p=0.005 and p=0.025, respectively). Graduates having either a rural or a remote home town at application were more likely to practise in rural (RA 3-5) towns than graduates from metropolitan/inner regional centre across all postgraduate years. For example, the prevalence odds ratios (POR) for graduates practising in a rural town at postgraduate year 1 (PGY 1) having either a rural or remote hometown were 2.6 and 1.8, respectively, times that of graduates having a metropolitan/inner regional hometown, while at PGY 9 the PORs had increased to 4.2 and 9.5, respectively. Bonded medical place students showed many similar trends to rural students in both their pre-medical school and undergraduate performance indicators but lower engagement in rural practice in the 5 years of data available. Some significant differences were noted between rural and remote origin students and metropolitan or inner regional origin students in terms of academic achievement in the first 3 years of the course and length of time taken to complete the course. However, this group of rural and remote-origin students seems to do just as well in the exams in the clinical years (years 4-6) and are much more likely to practise in rural and remote areas. These data suggest that JCU's selection process favouring rural origin applicants does not compromise academic standards, but does produce graduates whose patterns of practice accord with the mission of the school.

Measuring HPV vaccination coverage in Australia: comparing two alternative population‐based denominators

Objective:To compare the use of two alternative population‐based denominators in calculating HPV vaccine coverage in Australia by age groups, jurisdiction and remoteness areas. Method:Data from the National HPV Vaccination Program Register (NHVPR) were analysed at Local Government Area (LGA) level, by state/territory and by the Australian Standard Geographical Classification Remoteness Structure. The proportion of females vaccinated was calculated using both the ABS ERP and Medicare enrolments as the denominator. Results:HPV vaccine coverage estimates were slightly higher using Medicare enrolments than using the ABS estimated resident population nationally (70.8% compared with 70.4% for 12 to 17‐year‐old females, and 33.3% compared with 31.9% for 18 to 26‐year‐old females, respectively.) The greatest differences in coverage were found in the remote areas of Australia. Conclusion:There is minimal difference between coverage estimates made using the two denominators except in Remote and Very Remote areas where small residential populations make interpretation more difficult. Adoption of Medicare enrolments for the denominator in the ongoing program would make minimal, if any, difference to routine coverage estimates.

Assessing HPV vaccine coverage in Australia by geography and socioeconomic status: are we protecting those most at risk?

ObjectiveTo determine whether HPV vaccine coverage in 12–13‐year‐olds varies by geographical area, remoteness and ecological level indicators of socioeconomic status (SES). MethodData from the National HPV Vaccination Program Register (NHVPR) were analysed at Statistical Local Area (SLA) level, by the Index of Relative Disadvantage (IRSD) and the Australian Standard Geographical Classification Remoteness Structure. ResultsNationally, 73% of females aged 12–13 years in 2007 were fully vaccinated against HPV. Coverage in low SES areas (71.5%) was 4.1 percentage points lower than coverage in high SES areas (75.6%). Uptake of the first two doses was higher in the very remote parts of Australia (dose 1 – 88.5%, dose 2 – 81.8%) than in major cities (dose 1 – 83.4%, dose 2 – 80.2%), but not for dose 3 where coverage in major cities was 3% higher (73.6% versus 71.4%). ConclusionNotifications of HPV vaccine doses delivered to females aged 12–13 through schools suggest a high and relatively equal uptake across socioeconomic groups. Females in remote regions have the highest uptake of dose 1 but are least likely to complete the course. This may be due to particular challenges in vaccine delivery to residents of remote areas.

Factors driving James Cook University Bachelor of Medicine, Bachelor of Surgery graduates' choice of internship location and beyond.

To identify the main reason James Cook University (JCU) Bachelor of Medicine, Bachelor of Surgery graduates chose their internship location and first four practice relocations. This cross-sectional study invited 261 JCU medical graduates to participate in an email or telephone survey. Graduates' main reason for choosing internship location and up to four subsequent relocations, post-graduate specialty training undertaken and practice location (either metropolitan or non-metropolitan) for graduates' internship year and current practice year (2012). Respondents (n=175; response rate=67%) reported personal factors as the primary driver for choosing their internship location, with 33% returning to 'near their family/home town', and 21% staying in the town they were based in Years 5 and 6. Professional reasons dominated for subsequent relocations, particularly 'long-term career ambitions'. Fifty-nine of the 175 (34%) JCU graduates had undertaken their internship in a metropolitan location (Australian Standard Geographical Classification Remoteness Area 1), while 80 (46%) currently (in 2012) practised in a metropolitan location. Internship location was not associated with later specialty training, but current metropolitan practice was associated with Surgical or Paediatrics training (P=0.007 and P=0.063, respectively), while current non-metropolitan practice was associated with General Practice and Rural Generalist training (P=0.010 and P=0.001, respectively). Personal decisions take precedence over professional career decisions for why JCU medical graduates chose their internship location, but subsequent relocations are driven by career ambitions, usually around specialty training requirements. These findings support establishing more post-graduate training opportunities in non-metropolitan settings for Surgical and Paediatric specialties as a retention strategy for a rural medical career.

Positive impacts on rural and regional workforce from the first seven cohorts of James Cook University medical graduates

The regionally-based James Cook University (JCU) School of Medicine aims to meet its mission to address the health needs of the region by combining selection and curriculum strategies shown to increase rural career recruitment outcomes. The School has graduated 536 students in its first seven cohorts from 2005 to 2011. This paper presents the early career practice locations and the specialty training undertaken by these cohorts, and describes the association between later practice location with both hometown at application and internship location. Hometown at application' data for JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates was retrieved from administrative databases held by the university, while postgraduate location and career data were obtained either from personal contact via email, telephone, Facebook or electronically from the Australian Health Practitioner Regulation Authority website. Practice location was described across Australian Standard Geographical Classification Remoteness Area (RA) categories. Data for the primary practice location of 536 JCU MBBS graduates across postgraduate years (PGY) 1 to 7 is 99% complete. A total of 65% of JCU graduates undertook their internship in non-metropolitan locations including 20% in RA 2 and 44% in RA 3-5, a pattern of practice different to that of other Australian clinicians. For the internship year, 'non-metropolitan-origin' JCU MBBS graduates predominantly worked in RA 2-5 locations, while 'metropolitan origin' graduates were more likely to work in major cities. However, by PGY 7, the distribution of 'rural' and 'metropolitan' origin JCU graduates across RA categories was similar. The RA category of internship location - either 'metropolitan (RA 1) or 'non-metropolitan' (RA 2-5) - was associated with the location of subsequent practice across PGY 2-7. This comprehensive data set provides the first real evidence from one of Australia's new medical schools on actual postgraduate practice location, as compared to 'intent to practice'. The geographic profile by RA of JCU graduates' hometown and patterns of postgraduate practice is different to that of other Australian medical students and doctors. This early evidence supports the JCU model of distributed non-metropolitan medical education, and suggests more regionally-located internship and specialty training places would further increase the medical workforce in northern and/or rural Australia. The workforce impact of the seven cohorts of graduates in this study is starting to be felt in rural and regional Australia, and, if these trends continue, will result in significant workforce improvements over the next decade. These results support further investment in regional and rural medical education.

Optometric practice in Australian Standard Geographical Classification—Remoteness Areas in Australia, 2010

Background: This paper assesses the distribution of the optometric workforce and population per equivalent full‐time optometrist (EFTO) across the five Australian Standard Geographical Classification—Remoteness Areas (ASGC‐RA) categories in the states and territories of Australia.Methods: Data from the database of Optometrists Association Australia on the addresses of primary, secondary and visiting practices and the number of hours worked by optometrists were used to determine the number of EFTOs in each ASGC‐RA category in the states and territories. Population to EFTO ratios were calculated for each ASGC‐RA by using population data for 2009 and 2010 from the Australian Bureau of Statistics.Results: In the major cities (RA1), the proportion of optometric practitioners was greater than the corresponding proportion of the Australian population. The numbers of optometrists in the inner and outer regional areas (RA2 and RA3, respectively) were calculated as sufficient to provide an initial consultation to the corresponding populations every four to five years, while in the remote and very remote regions (RA4 and RA5, respectively), the numbers of optometrists were calculated as sufficient to provide an initial consultation once every nine or more years.Conclusions: The number of optometrists in practice in Australia is sufficient to meet the needs of the Australian population overall. The issue of the provision of optometric care in remote and very remote regions of Australia is unlikely to be addressed by increasing the number of optometrists as the sparse populations and the large areas over which these populations are spread are unlikely to be able to sustain optometric practices. This means that new service‐delivery models could be necessary for the provision of optometric services in these regions.

Differentials in Survival for Childhood Cancer in Australia by Remoteness of Residence and Area Disadvantage

It is not known whether improvements in cancer survival over recent decades have benefited children from different geographic locations equally. This is the first study to produce national survival estimates for childhood cancer in Australia by remoteness of residence and area-based socioeconomic status. The study utilized population-based data from the Australian Paediatric Cancer Registry for children diagnosed with cancer from 1996 onward who were at risk of mortality between January 2001 and December 2006 (n = 6,289). Remoteness was specified according to the Australian Standard Geographical Classification Remoteness Areas, whereas an index of area disadvantage was obtained from census information. Five-year relative survival estimates were produced by the period method for all cancers and the most common diagnostic groups, with corresponding age-sex adjusted mortality hazard ratios calculated using Poisson regression. Overall, children with cancer from remote/very remote areas had a significantly lower survival rate than their counterparts in major cities (HR = 1.55, 95% CI = 1.08-2.23). Survival was also lower for children with leukemia living in inner regional (HR = 1.52, 95% CI = 1.11-2.08) or outer regional areas (HR = 1.53, 95% CI = 1.03-2.28). There was weak evidence (P(grad) = 0.051) of a trend toward poorer survival by greater area disadvantage for all childhood cancers. Some variation in prognosis by place of residence was present for children with cancer in Australia, particularly among leukemia patients. Treatment, clinical or area-related factors that contribute to these survival differentials need to be identified.

The urban–remote divide for Indigenous perinatal outcomes

To determine whether remoteness category of residence of Indigenous women affects the perinatal outcomes of their newborn infants. A population-based study of 35 240 mothers identified as Indigenous and their 35 658 babies included in the National Perinatal Data Collection in 2001-2004. Australian Standard Geographical Classification remoteness category, birthweight, Apgar score at 5 minutes, stillbirth, gestational age and a constructed measure of perinatal outcomes of babies called "healthy baby" (live birth, singleton, 37-41 completed weeks' gestation, 2500-4499 g birthweight, and an Apgar score at 5 minutes >or= 7). The proportion of healthy babies in remote, regional and city areas was 74.9%, 77.7% and 77.6%, respectively. After adjusting for age, parity, smoking and diabetes or hypertension, babies born to mothers in remote areas were less likely to satisfy the study criteria of being a healthy baby (adjusted odds ratio [AOR], 0.87; 95% CI, 0.81-0.93) compared with those born in cities. Babies born to mothers living in remote areas had higher odds of being of low birthweight (AOR, 1.09; 95% CI, 1.01-1.19) and being born with an Apgar score < 7 at 5 minutes (AOR, 1.63; 95% CI, 1.39-1.92). Only three in four babies born to Indigenous mothers fell into the "healthy baby" category, and those born in more remote areas were particularly disadvantaged. These findings demonstrate the continuing need for urgent and concerted action to address the persistent perinatal inequity in the Indigenous population.