The quality of procedural rural medical practice in Australia.
BACKGROUND
While rural Australians receive much of their procedural medical care from local health professionals in local hospitals, the current workforce shortages, rural economic decline and poor rural health care status all pose challenges to the quality of care they receive. Rural doctors struggle to receive appropriate procedural skills training, rural hospitals struggle to maintain experienced procedurally skilled nurses and other health professionals, and medical equipment, and patients are increasingly referred by clinical protocols to larger urban hospitals. On the other hand, many rural communities value highly their local rural hospital, and advocate the maintenance of hospital services close to home, even though they will have to travel for more specialised services. This article reports an exploration of the quality of a range of clinical cases gathered from rural procedural medical practice.


METHODS
The Australian College of Rural and Remote Medicine (ACRRM) approached all trained and procedurally practising rural doctors among their membership. A total of 49 agreed to participate, but only 24 were successful in the prospective recruitment of patients and contribution of patient material (operating theatre notes, anaesthetic records etc) from cases involving general surgery, anaesthetics and obstetrics, the three commonest procedural disciplines in rural medical practice. One of the researchers interviewed patients before and after their procedures and, where available, a family member and a nurse at the hospital. Thus a series of 91 detailed patient case studies was available for analysis These case studies were reviewed from up to four different perspectives: (i) rural doctor peers; (ii) regionalist specialists in the respective discipline; (iii) a medical administrator; and (iv) a rural consumer representative. A thematic analysis of transcribed interviews was conducted.


RESULTS
The collected cases represented a range of procedures commonly provided in rural hospitals, although there were relatively few surgical procedures and there was a bias in all three specialty areas towards relatively simple procedures. No adverse outcomes were reported, although some comments, particularly from the rural doctor peers, were made about the need for further information and, in a small number of cases, possible variance from accepted practice. The views of the reviewers substantially agreed that the cases were of average to high quality, although the specialist reviewers were less likely to rate care as 'excellent' than other reviewers. While the comments of the medical reviewers were more technical in nature, the comments of patients and their families, and of the rural consumer reviewer, focussed more on issues such as accessibility, cost and interpersonal communication. Many patients and some nursing staff expressed concern about the sustainability of friendly and accessible local services in the face of workforce shortages and pressure to downgrade rural hospitals.


CONCLUSIONS
This study shows that, where staff and facilities in rural hospitals are accredited for procedural care, there is little evidence of any difference in the quality of that care provided when compared with care expected in urban hospitals.
Hays
Richard B
RB
School of Medicine, James Cook University, Townsville, Queensland, Australia. richard.hays@jcu.edu.au
Evans
Rebecca J
RJ
Veitch
Craig
C
D001315:Australia; D005194:Family Practice / Q000592:standards*; D006302:Health Services Research; D006780:Hospitals, Rural / Q000592:standards*; D006801:Humans; D017060:Patient Satisfaction; D011787:Quality of Health Care; D012423:Rural Health; D019035:Rural Health Services / Q000592:standards*; D000078329:Workforce