Rural general physicians: improving access and reducing costs of health care in the bush

Abstract

Objective To assess the effectiveness of the introduction of a trainee specialist physician into the workforce mix of a rural hospital in the Northern Territory. Methods A retrospective review comparing clinical and non-clinical outcomes during two corresponding 6-month periods in 2011 and 2012, before and after a FRACP Trainee in General and Acute Care Medicine commenced employment in the hospital. Results There was a significant reduction of 18% in total length of stay of admitted adult patients, with a 23% reduction of inter-hospital transfers and a 43% reduction of total aeromedical evacuations after the introduction of the trainee specialist. Although there was a 9% increase in patients presenting to the emergency department, there was a 9% reduction in total adult admissions. There was no change in the overall in-patient mortality rate; however, there was a significant change in the location of death, with an increase in patients dying in Katherine Hospital and a reciprocal decrease in death rate in those who had been transferred to Royal Darwin Hospital after the arrival of the trainee Conclusions The addition of an Advanced Trainee in General Medicine led to a significant change in the capacity of the hospital to care for unwell and complex patients. The role of the hospital in the care of dying patients was redefined and allowed many more people to pass away closer to their community and families. There were considerable savings at Katherine Hospital in terms of reduced bed pressure, reduced hospital bypass behaviour and reduced inter-hospital transfers, and these translated into significant benefits for the tertiary referral hospital in Darwin. A rural general physician can greatly value add to the capacity of a rural hospital and is a highly effective mechanism for reducing the disparities in healthcare access for rural and Indigenous patients. What is known about this topic? There is little research about the clinical and non-clinical impact of the addition of general speciality clinicians into the workforce of rural hospitals. Although there are several regional hospitals in Australia that have general specialists (i.e. emergency department physicians, general physicians and surgeons) and sub-specialists where the volume of patients is adequate to support such a workforce, there has been no published assessment of the impact of the addition of such speciality services. What does this paper add? This paper provides evidence of the cost-effectiveness of the addition of a specialist general physician to the workforce of a remote hospital servicing a large Indigenous population with very high burdens of acute and chronic illnesses in the Northern Territory. The paper demonstrates the potential to significantly add capacity to a rural or regional hospital by moving general speciality care to the hospital rather than, or in addition to, providing other methods of speciality and sub-speciality health care delivery. What are the implications for practitioners? The implications of this paper are that a significantly cost-effective means of addressing health care delivery to rural and remote populations is through the addition of appropriately trained general specialists such as emergency department physicians, general physicians and general surgeons. The implications extend to broader workforce development policies for education providers, speciality colleges and state and federal governments.