Concurrent Speakers

Background: Whilst the value of rural clinical exposure in attracting health students to long term rural locations is now proven, a key element which needs to be explored are the economic benefits of health education training in rural communities.

In a discrete geographic area in remote Canada the economic value of health education training was explored and found that there was significant direct and indirect multiplier effects of funding within small northern communities (1).Prior looked at remote communities in Australia and Canada and identified institutional and individual gains using economic, social and human dimensions(2).This paper reviews two Australian rural sites and considers the direct and indirect financial impacts of the Rural Health Multidisciplinary Training program (RHMT) being delivered in these sites.

Objectives: This is the first Australian exploration of the financial benefits to be gained from health professional student training and potentially raises the question of other measurable benefits that programmes of training may bring.

The building of social capital within communities, the contribution to community ‘life’ and the establishment of critical mass of health workforce should all be measurable outputs from such an exploration.

Results: The direct financial multiplier effect was calculated on the goods and services directly purchased though the grant in the postcode area of the training sites. Using the REMPLAN Economic Access program and publicly available council data, an estimation was made of the indirect multiplier effect that this would then have on employment and local business. Sector agreed benchmarks were used to calculate the multiplier effect of student spending.

Discussion: Consistent with overseas experience the economic impacts of salaries and purchase of goods and services had major direct and indirect employment and economic benefits for the two Modified Monash (MM3) locations studied. Student spending also provided a major economic stimulus.

The impact of an increasing critical mass of health clinicians and expansions in health services were also noted as major attractants for new residents to both locations. Measuring the financial impact of these indirect benefits was recognised as challenging and will be included in the next phase of this study.

Conclusion: Rural communities require ongoing economic stimulus and turnover in order to prosper. The contribution of health training and health services to economic wellbeing cannot be underestimated. Benchmarking this value is proving useful in engaging the community with health training and supporting genuine reciprocity and the welcoming of health students.

Introduction: Lung cancer is the fifth most commonly diagnosed cancer and foremost cause of cancer death in Australia¹. Current projections indicate 12,271 Australians are likely to be diagnosed with lung cancer in 2018² and that this is estimated to increase to 160,000 by 2028³. The five year relative survival of 17% for those diagnosed with lung cancer is extremely poor compared with the 65%to 95% survival rates for those diagnosed with prostate, breast, colorectal and melanoma cancer⁴. Nationally, only 11.7% of lung cancer patients are diagnosed with stage 1 disease compared with 42.8% for breast, 35.9% for prostate and 22.1% for colorectal cancer⁵. Moreover, 28% of lung cancer patients in Australia are not staged at diagnosis⁶, potentially missing out on curative treatment options. A further 20% receive no treatment, while only one in two patients has access to best practice lung Multi-Disciplinary Team (MDT) care⁷.

Delays in the delivery of lung cancer care may be influenced by a number of health system factors. Critical appraisal of the literature has identified a number of factors responsible for inopportune management, including inappropriate specialist referral, a multitude of diagnostic investigations and health services attended to attain a lung cancer diagnosis⁸.  A recent review of the factors responsible for delays in the delivery of acute care reported inadequate access to conclusive lung cancer diagnostic procedures and results as the primary cause (78%) of delays in 106 out of a 136 cases⁹. Other factors such as inequitable entry, poor communication, clerical delays and ineffective care coordination may cause further delays in the timeliness of lung cancer care^{10, 11}. Such challenges are magnified for those in regional and rural Australia where approximately half of all those diagnosed with clinical stage III and IV lung cancer reside¹².  Restricted lung cancer diagnostic services in regional compared to urban regions limit the potential of early lesion detection¹³. Moreover, ready access to treatment is more limited in rural localities with patients frequently needing to travel greater distances to receive specialist treatment¹⁴. The recognised workforce shortage of lung cancer specialists in rural regions may further exacerbate delays in care delivery¹⁵.

The Victorian Lung Cancer Service Redesign Program (VLCSRP) was established in 2016 to support development of local redesign projects to decrease delays in the diagnosis and treatment of lung cancer.  Five redesign projects were conducted at three regional and two metropolitan health services in Victoria. Each project consisted of five clearly defined phases, a set up phase, diagnostic phase, solution phase, implementation and evaluation phase and a sustainability phase. This paper distinguishes important variation in outcomes between the two regions.

Methods: The Victorian Lung Cancer Registry (VLCR) was engaged to support a consistent approach to data collection and project evaluation. National and local site specific ethics approval to collect the required data from participating health services was obtained. Patients with a new diagnosis of primary lung cancer were prospectively enrolled over a six-month pre-implementation period (September 2016 to February 2017) and a six-month period of progressive local intervention implementation (from March to August 2017). A total of 205 subjects from all participating health services were recruited in the pre-implementation period and 224 in the implementation period. Summary statistics and time series analysis were performed to analyse indicator performance over a six-month period of observation pre-implementation (n=205) and a six-month period of local intervention implementation (n=224).

Service redesign methodologies were used to understand baseline performance and systematically improve processes by eliminating waste^23-25, improving flow^25-27 and ensuing all processes added value for the patient²⁸. A multidisciplinary diagnostic and solution workshop was conducted at each participating health service. Local service gaps, areas of variation and barriers to timeliness of care were identified. Root cause analysis was conducted and areas of data driven variation²¹ prioritised for improvement. Clinician led, evidenced based design solutions were generated to address the identified gaps and improve the efficiency and effectiveness of services. The Principles for best practice management of lung cancer in Australia were integrated into the solution design²⁹. Pilot design solutions were tested using Plan-Do-Study-Act (PDSA) iterative cycles, to better understand contributions to performance improvement³⁰.

A series of Community of Practice forums were held over the life of the project to support collaborative learning, facilitate joint problem solving and propagate best practice improvements in the delivery of lung cancer care.

Results: Regional subjects in the implementation period were more likely to be born in Australia (89% vs 61%) than their metropolitan counterparts. In regional areas from pre-implementation to implementation, clinical staging revealed an 11% increase in those diagnosed with stage I disease and a 17% decrease in those diagnosed with stage IV disease. The proportion of subjects with clinical stage not recorded in the medical record was greater in regional compared to metropolitan Victoria in both the pre-implementation (45% vs 29%) and implementation periods (41% vs 32%).

A comparison of the data from the pre-implementation and implementation periods revealed a reduction in the median time from referral to first specialist appointment with the metropolitan interval falling from 6 (IQR 0, 14) to 2 (IQR 0, 7) days and the regional interval from 9 (IQR 3, 20) to 6 (IQR 1, 14) days. Regional subjects experienced a noteworthy reduction in the first specialist appointment to Positron Emission Tomography (PET) scan interval, with a median decrease from 16 (IQR6, 27) days to 12.0 (IQR 5, 27) days.  Both metropolitan and regional subjects experienced a slight reduction in the median interval time from diagnosis to first treatment. There was a substantial increase in the proportion with a documented Multidisciplinary Meeting (MDM) in the medical record across both metropolitan (65% vs. 72%) and regional (50% vs 60%) areas. Supportive care screening tool was poorly documented across regional and metropolitan Victoria

Conclusion: This study showed important differences in the performance of selected lung cancer indicators between metropolitan and regional Victoria.

What does it mean to have an extra chromosome? Dance artist Katie Senior and Liz Lea takes you on a journey of life, love, laughter and walks in nature—in fabulous style.

Introduction: In 2016-17, Aboriginal and Torres Strait Islander people accounted for 3.3% of Australia’s population, but 6.5% of people attending Australian emergency departments (EDs), which are often the first point of contact for Aboriginal and Torres Strait Islander people with the health system. Thus, understanding the experiences of Aboriginal and Torres Strait Islander patients in EDs and their reasons for presenting is important for ensuring they receive quality emergency care.

Methods: De-identified ED presentation data was obtained from the National Non-Admitted Patient Emergency Department Care Database for all reporting public hospitals for the 2016-17 financial year. Data on Indigenous status of ED presentations was obtained for all jurisdictions except the Australian Capital Territory and Tasmania. Remoteness area of ED locations were categorised based on the Australian Statistical Geography Standard.

Relevance: Rural and remote ED presentations, Aboriginal and Torres Strait Islander health

Results: A total of 281 reporting EDs provided the Indigenous status of their presentations, accounting for 7.4 million presentations. Of these, 490,220 or 6.5% were Indigenous presentations, with 68% occurring in regional, rural and remote EDs. Indigenous peoples accounted for a higher proportion of presentations in very remote (59%) and remote areas (45%), exceeding their proportion in the general population. Nationally, similar proportions (25%) of Indigenous and non-Indigenous patients arrived by ambulance, however this varied significantly by remoteness, with 19% of Indigenous compared to 7% of non-Indigenous patients arriving by ambulance to EDs in remote/very remote areas. Indigenous patients were more likely to arrive by police/correctional service vehicles across EDs in all remoteness areas (2.4% compared with 0.6%). A smaller proportion of Indigenous (30%) than non-Indigenous patients (35%) were admitted to hospital from EDs in major cities, however were more likely to be admitted in remote EDs (27% and 14% respectively). Indigenous patients were also more likely to leave the ED without being seen (10% to 6%). Respiratory system illness, illness of the skin/subcutaneous tissue and mental/behavioural disorders were more prevalent among Indigenous than non-Indigenous patients.

Conclusions: Differences exist in Indigenous ED experiences and reasons for presenting, and these highlight the need for improving access and utilisation of appropriate primary care services for Indigenous Australians. This study also suggests that improving emergency medicine staff knowledge of Aboriginal and Torres Strait Islander health issues, outcomes and cultural needs, could improve the quality and appropriateness of emergency care provided to them.

Background: Rural young people generally experience an excess burden of disease and have greater difficulties accessing services. The digital technology revolution has meant that the use of technology to support health through information seeking or online service access is increasingly common among young people. While the potential of these technologies for rural communities is profound, little is known about whether or how rural young people use them.

Methods: The Access 3 study explored how young people aged 12-24 years accessed healthcare and used technology to seek information on health and health service access. Young people were recruited via both online and offline methods, and ‘marginalised’ young people were purposively sampled including rural, at risk or currently homeless, sexuality and/or gender diverse, of refugee background and/or Aboriginal and/or Torres Strait Islander background. This analysis used data from the cross-sectional survey component of Access 3 to explore differences by age, location of residence and need for healthcare.

Findings: During 2016-17 1,416 young people completed questionnaires, of whom 478 (34%) lived in regional or remote areas. Despite similar physical and mental health profiles between ‘city’ and ‘country’ respondents, including rates of self-reported chronic health conditions (53% vs 49%), ‘city’ respondents were significantly more likely to have recently visited a doctor or GP (83% vs 79%). ‘Country’ respondents were significantly less likely to have Internet access (93% vs 98%) or own a mobile phone with internet access (81% vs 90%). While the use of technology to source health information was consistently less common among young people from the ‘country’, those with a self-reported chronic condition were significantly more likely than those without to use the internet to get information about health problems they had experienced (57% v 35%) and to use internet based programs or apps to manage health issues themselves (34% vs 18%).

Discussion/conclusion: Health-related internet use has the potential to enhance access to information and health services for young people who experience barriers, such as those who live rurally. While use of technology to access health information and services was higher among those young ‘country’ respondents with a need for healthcare, rates remained lower than for their ‘city’ counterparts. Internet access should be viewed as an issue of health equity and discussions and policy decisions around digital health considered in the context of the availability and quality of technological infrastructure as well as current usage.

Background and aim: Adolescence is a time of both risks and opportunities for current and future health and wellbeing. While Aboriginal adolescents (10-24 years) comprise almost a third of the Aboriginal community in Orange NSW, their access to the Orange Aboriginal Medical Service (OAMS) does not reflect this population structure. OAMS identified a service gap for adolescents and the OAMS Youth Access Project was established to provide an evidence base to inform the development of a youth health and engagement program.

Methods: Clinical data from OAMS (2011-12 and 2015-17) and the NSW Health Emergency Department and the Admitted Patients Data Collections for the Orange Local Government Area (2011 -14) were obtained to explore health profiles and healthcare utilisation of young people (Aboriginal and non-Aboriginal) in the region. In addition, 22 semi-structured interviews were conducted with staff employed by OAMS to determine enablers and barriers to service access and delivery for young people.

Results: Data suggest that Aboriginal adolescents in Orange are relatively underserviced in comparison to other age groups in the OAMS primary care setting and overrepresented in the acute hospital setting, both in Emergency Department (ED) presentations and hospital admissions. Aboriginal adolescents presented to an ED almost one-third more often compared to non-Aboriginal young people and were hospitalised more than twice as often. Significant health issues identified for all adolescents included smoking, mental health, overweight and obesity and injury. Staff interviews highlighted barriers and enablers at all stages of healthcare access, from perceiving the need for healthcare through to healthcare reaching and utilisation. Service strengths included free services such as transport, and areas for improvement included service literacy and youth engagement capability.

Conclusions: The OAMS Youth Access Project highlighted the need for OAMS and other relevant rural health services to take a coordinated approach to adolescent health that focuses on preventative health, service approachability and acceptability as well as engagement with young people to improve youth health and wellbeing access in the community. As a result of the project the Orange Youth Health and Wellbeing Strategy was developed. The Strategy outlines recommendations for governance and resourcing; partnerships and engagement; programs, services and practice; training and development; and monitoring and evaluation. Improving youth access to OAMS and other health services will ultimately contribute to improving the health and wellbeing outcomes of young people and set up a platform to ensure the best start for future generations.

Evidence has accumulated that blood lead levels <10 µg/dL have measurable health impacts and that there may be no safe level of lead exposure. With a historical focus on reducing elevated blood lead levels in Broken Hill, little attention has been given to what factors are associated with children’s blood lead levels remaining <5 µg/ dL. Currently it is not known how many children can live in Broken Hill without developing blood lead levels ≥ 5 µg/dL. This descriptive study reports on patterns of blood lead levels among 1-4 year old children and implications for the Broken Hill Environmental Lead Management Program.

We studied all children born between 2009 and 2015 who had at least one blood lead test recorded on the Lead Management Program Database and were resident in Broken Hill at the time of the test. Routine testing is offered at 12, 18, 24, 36 and 48 months, and capillary blood lead results were classified (< 5, 5-9, 10-14, ≥15 µg/dL).

Almost half of all children at each scheduled testing point (including at 12 months) had blood lead levels <5 µg/dL, around one-third had a blood lead level 5-9 µg/dL, and less than one in five ≥10 µg/dL. One-quarter of children had tests at 12, 24 and 36 months providing longitudinal data : one-third of these children remained <5 µg/dL at each test and one-third had at least one test result ≥10 µg/dL. The remainder did not exceed 5-9 µg/dL at any of the test point with individual lead risk varying by locality. Furthermore 60% of children in the highest soil lead hazard zones had at least one test result at ≥10 µg/dL during the first three years. However, most children (70%) experiencing these levels lived elsewhere in the community.

Implications for Broken Hill lead management program: The introduction of testing at 6 months could be used to monitor trends in early lead exposure and as a trigger for early intervention (primary prevention). Zonal abatement would be an effective strategy for reducing blood lead levels in children from areas with high soil lead concentrations, based on the high individual risk to children residing there. However, for greatest effect, abatement efforts would need to be extended to other localities where most (70%) of the children with high blood lead levels live.

Contextualisation of health care across Australia’s diverse rural and remote communities is critical in ensuring service alignment to community needs, the design and delivery of effective and sustainable services, responsive professional practice and enhanced health outcomes. Health care that seeks to improve the health of these populations needs to be more than evidence-based, care providers must also engage with local organisations and agencies in the identification of their health needs and solutions design, implementation and evaluation if services are to be impactful and sustainable. However, rural community perspectives of their unmet needs, experiences and expectations of health care can be marginalised with the control of health services being centralised and firmly entrenched within health systems. Enabling rural and remote community voices to be heard, and the effective interpretation of these voices, is critical if we are to address inequities and disadvantages that contribute to the poorer health and life outcomes of some of Australia’s most marginalised populations. This presentation describes the co-design, implementation and evaluation of a community informed health service and associated model of nursing practice in far west New South Wales, Australia. The Primary Health Care Registered Nurse: Schools Based Program is underpinned by a collaboration between school education, a local health district and a university department of rural health. The program and model of nursing practice have been informed by community perspectives of unmet health needs (child and adolescent mental health and wellbeing, limited support of families with children already experiencing complex and chronic conditions, and social concerns associated with student exposure to traumatic life events), previous community experiences of healthcare (illness orientated approaches, service provision focused on service needs in preference to community needs and pre-packaged care) and community expectations of health care (care that is focused on illness prevention, health promotion, the early identification of needs and service activation, integrated and coordinated care centred on the needs of service recipients and families). These findings informed the exploration of theories and principles to guide service provision and nursing practice. Identified theories included family-centred care, trauma-informed care, primary health care and integrated care. This new service and model of practice challenge illness orientated, hospital-centric, de-contextualised service and practice and have the potential to transform the lives of some of Australia’s most marginalised children, adolescents and families and the practice of registered nurses in these contexts.