Exploring and improving hospital care quality for New Zealand rural communities

Providing sustainable high quality hospital care to people in small towns and rural areas in New Zealand (NZ) is challenging. Little NZ research has explored hospital health care quality in rural communities. Little hospital patient safety literature has investigated patient location rather than hospital location. This thesis aimed to understand what influences the quality of health care received by people from rural communities requiring hospital level care, and identify ways to improve the quality of rurally focused health care services, particularly hospital-level care. A mixed methods approach was taken. The Interview Study (IS) collected views of 109 participants through eight community and Māori focus groups and 34 health provider interviews from four diverse NZ rural communities, which were thematically analysed. Although focused on hospital care, participants contributed views on the wider health system. The Hospital Harms Study (HHS) investigated hospital harm through secondary analysis of a retrospective general practice records review study of 9076 patients, where all harms had been identified. Patients’ rurality was defined by general practice address in Stats NZ defined rural centres or independent urban areas. Hospital admissions and harm from admissions were identified. Admission and hospital harm risk differences by urban-rural location were investigated using multivariable analyses, with five alternative rurality definitions tested. The component study results were combined to develop overall findings. The IS participants questioned the fairness of rural communities’ experience of higher costs to access health services. Eight themes were developed. ‘The Rural Triple Aim’ described the principles of high quality rurally focused health services, including hospital services. The remaining seven themes described the key characteristics that influence the quality of health care that rural communities experience, and relevant focus areas for improvement. These themes were access, ‘one service, many sites’ health service networks, capable workforce, Māori focused service design, greater community participation, rural-appropriate quality measures, and whole system planning and resourcing. The HHS study group was evenly distributed across rural and urban general practices, and small, medium and large practices and by sex. Of the 9076 patients, 1561 patients (17.2%) had at least one hospital admission identified during the three-year study period, and 172 patients with admissions (11.0%) experienced hospital harm. There was no association evident between rurality and hospital admission risk (adjusted risk ratio 0.98 [0.83-1.17] p=0.844), hospital harm risk (aRR 1.01 [0.97-1.05] p=0.587) or rates of hospital harm per admission (adjusted incidence rate ratio 1.09 [0.83-1.43] p=0.524). One alternative rurality definition, of greater distance to the nearest hospital, showed an increased risk of hospital harm per admission for those living far away (p<0.001). Only rural patients required inter-hospital transfer. Significant association between inter-hospital transfer and risk of hospital harm was found (rural, age adjusted RR 2.33 [1.37-3.98] p=0.003). Unmeasured differences in patient health status may confound findings. Combining component study findings, a framework for improving health care quality for rural communities is proposed. This framework, including the Rural Triple Aim and improvement areas incorporating the themes identified above, is relevant to NZ rural communities and likely transferable to other countries

Methods of a national colorectal cancer cohort study: the PIPER Project

A national study looking at bowel cancer in New Zealand has previously been completed (the PIPER Project). The study included 5,610 patients and collected medical information about how each person was found to have bowel cancer and the treatment they received. This paper reports how the study was carried out. The information collected in the study will be used to look at the quality of care being provided to New Zealand patients with bowel cancer, and to find out if differences in care occur based on where people live, their ethnicity and their socioeconomic status

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

How did New Zealand’s regional District Health Board groupings work to improve service integration and health outcomes: a realist evaluation

Objectives In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country’s 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity.Design We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work ‘worked’ across NZ while noting important regional differences.Setting NZ’s four regional DHB groupings.Participants Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Māori and Pasifika leadership and lead clinicians for regional work streams.Results Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of ‘hard’ policy and planning processes, as well as ‘soft’, relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity.Conclusion The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system