Abstract
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.