Remote Primary Care Research Articles

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

Addressing Inequities in Kidney Care for Indigenous People in Canada.

Addressing Inequities in Kidney Care for Indigenous People in Canada.

Opportunities and challenges in delivering remote primary care during the Coronavirus outbreak

BackgroundSocial distancing and lockdowns were implemented during the first period of the COVID-19 pandemic. Primary care physicians needed to adapt quickly to deliver remote care/telemedicine.MethodsA cross-sectional, 47-item online Google Survey was distributed through the Israel Association of Family Physicians (IAFP) mailing list between March 31-May 5, 2020. The questionnaire included demographics, physician characteristics, and information on usage and perceived telemedicine quality. Sampling weights by sex and age groups were applied.ResultsOne hundred fifty-nine primary care physicians (10.6% of registered IAFP members; 63.5% women; mean age 53.4 ± 10.4 years and median professional experience 21.3 years) replied to the survey. The majority (59.7%) of the participants performed a mixture of in-person along with phone counseling. About 40% had no former telemedicine experience. The majority indicated that telephone and video formats were inferior to in-person consultation (68%, 57.1% online and phone, respectively). The overall counseling quality grade (on a 1–10 scale,)median (IQR)) was 6.2 (3) for telephone and 7(2) for video. While 66.9% reported experiencing no challenges, 10% had technical problems, 10% interpersonal problems, 5.6% scheduling difficulties, and 7.5% other difficulties. Majority of 56.6% physicians indicated they prescribed more antibiotics,16.4% sent more blood tests, 24.5% referred more to experts, and 49.7% referred more to imaging in comparison to usual counseling. Higher phone quality score was significantly associated with physicians who indicated not prescribing more antibiotics during the pandemic (OR = 0.30, 95%CI 0.134–0.688, p = 0.004).Higher online quality score was associated with physicians who indicated not sending more blood tests during the pandemic (OR = 0.06 95%CI 0.008–0.378, P = 0.003).ConclusionsOur findings suggest telehealth holds considerable promise for counseling in the primary care setting. However, interpersonal challenges raised by physicians should be understood in-depth to develop tailored training and further examine it in randomized trials while integrating patient-reported outcomes. Finally, further research on utility, cost, and cost-efficiency during remote counseling with follow-ups, medical prescribing, and additional referrals is needed.

A Teleconsultation Device, Consult Station, for Remote Primary Care: Multisite Prospective Cohort Study.

BackgroundTelemedicine technology is a growing field, especially in the context of the COVID-19 pandemic. Consult Station (Health for Development) is the first telemedicine device enabling completely remote medical consultations, including the concurrent collection of clinical parameters and videos.ObjectiveOur aim was to collect data on the multisite urban and suburban implementation of the Consult Station for primary care and assess its contribution to health care pathways in areas with a low density of medical services.MethodsIn a proof-of-concept multisite prospective cohort study, 2134 consecutive patients had teleconsultations. Consultation characteristics were analyzed from both the patient and practitioner perspective.ResultsIn this study, the main users of Consult Station were younger women consulting for low-severity seasonal infections. Interestingly, hypertension, diabetes, and preventive medical consultations were almost absent, while they accounted for almost 50% of consultations with a general practitioner (GP). We showed that for all regions where the Consult Station was implemented, the number of consultations increased as GP density decreased. The study of practitioner characteristics showed GPs from metropolitan areas are motivated to work with this device remotely, with a high level of technology acceptability.ConclusionsThe multisite implementation of Consult Station booths is suitable for primary care and could also address the challenge of “medical deserts.” In addition, further studies should be performed to evaluate the possible contribution of Consult Station booths to limiting work absenteeism.

Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study.

BackgroundThe COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care.AimTo explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness.Design and settingAn action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness.MethodIndividual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach.ResultsThe move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment.ConclusionThe findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote ‘by default’ and instead take into consideration both the clinical and social factors underpinning health.

Evaluation of an online medicines’ safety course for remote area nurses

Background: Providing healthcare in a remote or rural setting can be complex and difficult, with many Remote Area Nurses not receiving sufficient orientation or preparation. This is particularly important for the management of medicines. Aim: This analysis evaluates an online medicines safety course called Pharmacotherapeutics for Remote Area Nurses. Study Design and Methods: Eight cohorts of students (n=629), between 2016–2020, were included in the evaluation. A mixed methods approach was used to evaluate the impact of the online pharmacotherapeutics course. At the end of each module and at the end of the course participants were asked to complete an online questionnaire. In-depth semi-structured interviews with key stakeholders (n=9) were also conducted, and data thematically analysed. Results: The online pharmacotherapeutics course was well received (average of 4.3 on a 5-point Likert scale). It was easy to navigate (2.6 on a 3-point Likert scale), the flow was logical (2.8 on a 3-point Likert scale) and it was clear how to achieve learning outcomes (2.8 on a 3-point Likert scale). The learning content in each of the modules were well received (4.1-4.5 on a 5-point Likert scale) and deemed appropriate for nurses practicing in the remote areas (2.7-2.9 on a 3-point Likert scale). Thematic analysis of the stakeholder interviews and participant surveys revealed the pharmacotherapeutics course improved knowledge, confidence, and competence of nurses in relation to medicines management and results in better preparedness of the remote health workforce. Key stakeholder feedback highlighted that the pharmacotherapeutics course was seen as an important part of preparing and upskilling the remote health workforce. Discussion: Overall, the pharmacotherapeutics course was well received by nurses and key informants. It improved self-reported knowledge, confidence, competence, and preparedness for nursing practice in remote locations. Conclusion: The continued support of professional development and education for the remote health workforce is vital to ensure optimum patient care. What is already known about this topic? People in remote Australia generally experience poorer health and face increased challenges in accessing care compared with major city counterparts. In remote regions, access to healthcare services is reliant on the availability of a competent workforce with nurses forming the backbone of rural and remote primary care. The use of medications is the most common intervention in healthcare and improvements in the quality use of medicines can have significant benefits to a person’s wellbeing. What this paper adds: Professional development and education for the remote health workforce is vital to ensure optimum patient care. Education that is appropriate, relevant, and accessible can increase self-assessed knowledge, competence, and confidence in relation to medicines management. Online education that is developed in collaboration with stakeholders and addresses an identified need is an acceptable and accessible method of providing professional development to the remote health workforce.

Associations with sight-threatening diabetic macular oedema among Indigenous adults with type 2 diabetes attending an Indigenous primary care clinic in remote Australia: a Centre of Research Excellence in Diabetic Retinopathy and Telehealth Eye and Associated Medical Services Network study

ObjectiveTo identify factors associated with sight-threatening diabetic macular oedema (STDM) in Indigenous Australians attending an Indigenous primary care clinic in remote Australia.Methods and analysisA cross-sectional study design of retinopathy screening...

PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK

BackgroundThe implementation of lockdowns in the UK during the COVID-19 pandemic resulted in a system switch to remote primary care consulting at the same time as the incidence of domestic violence and abuse (DVA) increased. Lockdown-specific barriers to disclosure of DVA reduced the opportunity for DVA detection and referral.The PRECODE (PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic) study will comprise quantitative analysis of the impact of the pandemic on referrals from IRIS (Identification and Referral to Improve Safety) trained general practices to DVA agencies in the UK and qualitative analysis of the experiences of clinicians responding to patients affected by DVA and adaptations they have made transitioning to remote DVA training and patient support.Methods/DesignUsing a rapid mixed method design, PRECODE will explore and explain the dynamics of DVA referrals and support before and during the pandemic on a national scale using qualitative data and over four years of referrals time series data.We will undertake interrupted-time series and non-linear regression analysis, including sensitivity analyses, on time series of referrals to DVA services from routinely collected data to evaluate the impact of the pandemic and associated lockdowns on referrals to the IRIS Programme, and analyse key determinants associated with changes in referrals.We will also conduct an interview- and observation-based qualitative study to understand the variation, relevance and feasibility of primary care responses to DVA before and during the pandemic and its aftermath.The triangulation of quantitative and qualitative findings using rapid analysis and synthesis will enable the articulation of multiscale trends in primary care responses to DVA and complex mechanisms by which these responses have changed during the pandemic.DiscussionOur findings will inform the implementation of remote primary care and DVA service responses as services re-configure. Understanding the adaptation of clinical and service responses to DVA during the pandemic is crucial for the development of evidence-based, effective remote support and referral beyond the pandemic.Trial registrationPRECODE is an observational epidemiologic study, not an intervention evaluation or trial. We will not be reporting results of an intervention on human participants.

Referrals to Urgent Dental Centres During the COVID-19 Pandemic: A Multi-Site Analysis Research Project.

The COVID-19 pandemic enforced the cessation of routine dentistry and the creation of local urgent dental care systems in the UK. General dental practices are obligated by NHS guidance to remain open and provide remote consultation and referral where appropriate to patients having pain or problems. To compare two urgent dental centres with different triage and referral systems with regard to quality and appropriateness of referrals, and patient management outcomes. 110 consecutive referrals received by a primary care urgent dental centre and a secondary care urgent dental centre were assessed. It was considered whether the patients referred had access to remote primary care dental services, fulfilled the criteria required to be deemed a dental emergency as mandated by NHS guidance, and what the outcomes of referrals were. At the primary care centre, 100% of patients were referred by general dental practitioners and had access to remote primary care dental services. 95.5% of referrals were deemed appropriate and were seen for treatment. At the secondary care site, 94.5% of referrals were direct from the patient by contacting NHS 111. 40% had received triaging to include 'advice, analgesia and antimicrobial' from a general dental practitioner, and 25.5% were deemed appropriate and resulted in treatment. Urgent dental centres face many issues, and it would seem that easy access to primary care services, collaboration between primary care clinicians and urgent dental centres, and training of triaging staff are important in operating a successful system.

Remote primary care consultations for people living with dementia during the COVID-19 pandemic: experiences of people living with dementia and their carers.

BackgroundCOVID-19 has accelerated remote healthcare provision in primary care, with changes potentially permanent. The implementation of remote provision of health care needs to be informed by vulnerable populations, such as people living with dementia.AimTo understand the remote healthcare experiences of patients living with dementia and their family carers during the COVID-19 pandemic.Design and settingQualitative interviews with community-based patients living with dementia and their carers were carried out between May–August 2020, while the COVID-19 pandemic was ongoing in England.MethodSemi-structured interviews were conducted remotely by telephone or video call with 30 patients living with dementia and 31 carers. Data were analysed using thematic analysis.ResultsThree main themes were derived relating to: proactive care at the onset of COVID-19 restrictions; avoidance of healthcare settings and services; and difficulties with remote healthcare encounters. People living with dementia and their carers felt check-up calls were reassuring but limited in scope and content. Some avoided healthcare services, wishing to minimise COVID-19 risk or reduce NHS burden, or encountering technological barriers. Difficulties in remote consultations included lack of prompts to remember problems, dealing with new emerging difficulties, rescheduling/missed calls, and inclusion of the voice of the person with dementia.ConclusionWhile remote consultations could be effective, proactive calls could be more structured around needs. Consideration should be given to replace non-verbal prompts to describe problems, particularly for new health concerns. In continuing remote consultations, it is important to facilitate engagement with patients living with dementia and their carers to ensure good practice.

The Benefits and Challenges of Point-of-Care Testing in Rural and Remote Primary Care Settings in Australia

Point-of-care (POC) testing has significant potential application in rural and remote Australian communities where access to laboratory-based pathology testing is often poor and the burden of chronic, acute, and infectious disease is high. To explore the clinical, operational, cultural, and cost benefits of POC testing in the Australian rural and remote health sector and describe some of the current challenges and limitations of this technology. Evidence-based research from established POC testing networks for chronic, acute, and infectious disease currently managed by the International Centre for Point-of-Care Testing at Flinders University are used to highlight the experience gained and the lessons learned from these networks and, where possible, describe innovative solutions to address the current barriers to the uptake of POC testing, which include governance, staff turnover, maintaining training and competency, connectivity, quality testing, sustainable funding mechanisms, and accreditation. Point-of-care testing can provide practical and inventive opportunities to revolutionize the delivery of pathology services in rural and remote sectors where clinical need for this technology is greatest. However, many barriers to POC testing still exist in these settings, and the full potential of POC testing cannot be realized until these limitations are addressed and resolved.

Antimicrobial stewardship in remote primary healthcare across northern Australia.

BackgroundThe high burden of infectious disease and associated antimicrobial use likely contribute to the emergence of antimicrobial resistance in remote Australian Aboriginal communities. We aimed to develop and apply context-specific tools to audit antimicrobial use in the remote primary healthcare setting.MethodsWe adapted the General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool to audit antimicrobial use over 2–3 weeks in 15 remote primary healthcare clinics across the Kimberley region of Western Australia (03/2018–06/2018), Top End of the Northern Territory (08/2017–09/2017) and far north Queensland (05/2018–06/2018). At each clinic we reviewed consecutive clinic presentations until 30 presentations where antimicrobials had been used were included in the audit. Data recorded included the antimicrobials used, indications and treating health professional. We assessed the appropriateness of antimicrobial use and functionality of the tool.ResultsWe audited the use of 668 antimicrobials. Skin and soft tissue infections were the dominant treatment indications (WA: 35%; NT: 29%; QLD: 40%). Compared with other settings in Australia, narrow spectrum antimicrobials like benzathine benzylpenicillin were commonly given and the appropriateness of use was high (WA: 91%; NT: 82%; QLD: 65%). While the audit was informative, non-integration with practice software made the process manually intensive.ConclusionsPatterns of antimicrobial use in remote primary care are different from other settings in Australia. The adapted GP NAPS tool functioned well in this pilot study and has the potential for integration into clinical care. Regular stewardship audits would be facilitated by improved data extraction systems.

Collaborative Video Consultations from Tertiary Care Based Telepsychiatrist to a Remote Primary Care Doctor to Manage Opioid Substitution Therapy Clinic.

Opioid use is a major problem in India and has high morbidity and mortality with a prevalence of 2.06%. There is a huge treatment gap for opioid use disorders (OUDs). Due to limited mental health resources and limited psychiatric training of medical practitioners in OUDs, a significant proportion of patients do not receive appropriate medical intervention. This article demonstrates how a primary care doctor working in a remote opioid substitution therapy (OST) clinic received assistance from the optional opioid module of clinical schedule for primary care psychiatry (CSP) and collaborative video consultation (CVC) module to address specific difficulties of patients already on Buprenorphine OST and improve the quality of care, thereby reducing chances of relapses. CVC module is a part of one-year digitally driven primary care psychiatry program designed by National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The opioid module was designed by NIMHANS, Bengaluru in collaboration with the All India Institute of Medical Sciences (AIIMS), New Delhi These observations warrant replication of this approach across diverse settings and at a larger scale to explore and evaluate its impact and effectiveness.

Synchronous Teledermoscopy in Military Treatment Facilities.

Sustained demand for dermatologic care throughout military medicine, in conjunction with increasing dermatologic provider shortages, has led to increase use of teledermatology in military treatment facilities (MTFs). Initially used to aid in the differentiation of suspicious melanocytic lesions, dermoscopy has found increasing clinical utility in an expanding realm of general dermatologic conditions. We demonstrate the use of synchronous teledermoscopy within a remote MTF by repurposing webcam technology already available at most MTFs. Two patients were seen in clinic at a remote naval primary care clinic with limited subspecialties. Once written consent was retrieved, an on-site dermatologist evaluated each patient and performed a history and skin exam with dermoscopy. Synchronous consultations were conducted with the Global Med Cart (GlobalMed(R) Clinical Access Station with TotalExam(R) 3 HDUSB camera), and Cisco webcam video jabber (Cisco TelePresence PrecisionHD USB Camera part number TTC8-03). The patients then underwent individual synchronous teledermatology consultations with an off-site U.S. Navy dermatologist located in the continental United States. The methodology for the consultation involved the use of a standard dermatoscope and jabber webcam. Two synchronous teledermatology consultations were completed successfully on patients in MTFs with limited subspecialty capabilities. Both cases, with two lesions of concern per case, had 100% concordance between the on-site and teleconsulted dermatologist. Through observing inter-rater agreements between the on-site and remote dermatologists, this small study demonstrates a novel application of technology readily available at most MTFs.

The effectiveness of a proven chronic disease prevention and screening intervention in diverse and remote primary care settings: an implementation study on the BETTER 2 Program.

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics.AimTo evaluate outcomes from implementation of BETTER in diverse clinical settings.Design & settingAn implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40–65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada.MethodAt baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported.ResultsA total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts.ConclusionClinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project.

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes. We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs. At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P<0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P=0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10min or more at a time 6.0 days a week and spent 4.8h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms. Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

Costs and effects of higher turnover of nurses and Aboriginal health practitioners and higher use of short-term nurses in remote Australian primary care services: an observational cohort study

ObjectivesTo compare the costs and effects of higher turnover of resident nurses and Aboriginal health practitioners and higher use of agency-employed nurses in remote primary care (PC) services and quantify...

The Swansea RRHiME track: a new curriculum model for embedding rural and remote healthcare into undergraduate medicine programmes.

This article was migrated. The article was marked as recommended. Many medical programmes around the world seek to provide experiences for their students in rural and remote health, community and primary care, with a view to encouraging future doctors to practice in under resourced and under-doctored areas of the world. New schools (and satellites of existing schools) have been established in rural and remote areas with a view to recruiting students from those areas who will go on to practice there. In these new schools, and in more traditional programmes, the primary curriculum models in use are either short placements in selected areas (including overseas electives) or immersive longitudinal clerkships, typically in a primary/community setting. A wealth of evidence exists of the success of these approaches, however, for many schools, the curriculum is more fixed and there are limited opportunities for introducing what can be seen as more radical change. In this paper, we describe a new approach to curriculum design offered by the Graduate Entry Medicine (GEM) programme at Swansea University Medical School which provides a selected group of students within the cohort with a range of opportunities in rural and remote health embedded within the existing curriculum. The Rural and Remote Health in Medical Education (RRHiME) track has been positively evaluated for 7 years and is transferable to a range of curricula and contexts. The longitudinal evaluation has demonstrated that students experience a prolonged engagement in rural health environments and/or focused on rural and remote health issues, not in terms of spending time in one context but in obtaining a variety of perspectives about, and deepening their understanding of, the issues, challenges and opportunities encountered in rural and remote settings.

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.

Minimally Invasive Dentistry Based on Atraumatic Restorative Treatment to Manage Early Childhood Caries in Rural and Remote Aboriginal Communities: Protocol for a Randomized Controlled Trial.

BackgroundThe caries experience of Aboriginal children in Western Australia (WA) and elsewhere in Australia is more than twice that of non-Aboriginal children. Early childhood caries (caries among children <6 years) has a significant impact on the quality of life of children and their caregivers, and its management is demanding and commonly undertaken under general anesthesia. A randomized controlled trial using a minimally invasive dentistry approach based on Atraumatic Restorative Treatment (ART) in metropolitan Perth, WA, has demonstrated a significant reduction in the rate of referral to a dental specialist for dental care among children with early childhood caries, potentially reducing the need for treatment under general anesthesia. The tested approach was clinically successful and was without adverse effects on child dental anxiety. The model of ART-based primary care requires further testing and development if similar outcomes for Aboriginal children in remote and rural settings are to be achieved.ObjectiveThe study aims to develop, implement, and evaluate a remote primary care model to deliver effective primary dental services, encompassing treatment and preventive services, to Aboriginal preschool children (based on minimally invasive approaches including ART).MethodsThis is a two-arm parallel cluster randomized controlled study in which a test group will be provided with the intervention treatment at the start of the study and a control group will be provided with the intervention treatment 12 months after study commencement (delayed intervention). Participating communities, stratified by size of community (ie, number of children in the sample frame) and baseline caries experience, will be randomly assigned using a computer-generated block randomized list into immediate (test group) or delayed intervention (control group; provided with standard care). Informed consent will be obtained from all participants. Aboriginal research assistants will explain the study to the parents and assist the parents in completing the questionnaires. Participants in the randomized study will be examined at baseline and at 12 months follow-up by a calibrated examiner. Test group participants will subsequently be contacted and appropriate appointments coordinated for treatment. Control group participants will be provided with standard preventive care by the Aboriginal Health Workers and managed for treatment as per standard procedures.ResultsCommunity consultations have been undertaken and 26 communities have agreed to participate. Fieldwork is in progress to recruit study participants.ConclusionsThe significance of the study lies in its holistic approach to testing the model of care. Clinical evaluations as well as oral health‒related quality of life evaluations will be undertaken. Cost-effectiveness and cost-utility evaluations will assist in the development of policy options for oral health services for rural and remote communities. The elicitation of caregiver perspectives through focus group interviews will supplement the clinical, psychosocial, and cost-utility evaluations and provide a richer evaluation of the intervention.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12616001537448; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371735 (Archived by WebCite at http://www.webcitation.org/70UMxndFZ)Registered Report IdentifierRR1-10.2196/10322