Can frequent medical evacuations be reduced by managing chronic disease better in the bush?

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Dear Editor

We read the research paper 'More is more in remote Central Australia'¹ with great interest as it addresses the issue of providing acute and chronic disease management (CDM) in a remote setting. The authors found that patients who had higher numbers of GP consultations had more frequent medical evacuations. They suggested that this might be partly due to busy doctors not being able to manage the sick patients on site and not being able to provide effective management of their patients' chronic diseases. They concluded that the association of 'more is more' needs to be studied in other sites to see if 'contemporary wisdom' had really been challenged.

Our view, developed from clinical and research experience in remote far western New South Wales, is that it is not surprising that sick patients seek more acute consultations and require more evacuations. Evacuations would only be reduced if consultations included at least some effective elements of CDM or prevention. CDM can be challenging where health services are overburdened by acute presentations, as is so often the case in remote locations. GPs and nurses need to opportunistically combine all of the elements of CDM. A possible contributing factor in the association between increased primary healthcare consultations and increased evacuations is the lack of post-evacuation follow up in the community². Not all evacuations are preventable but it has been demonstrated elsewhere that CDM can reduce acute presentations and hospitalisations³. The provision of integrated acute and chronic care to manage chronic disease requires excellent systems of clinical records and recalls and the active involvement of practice nurses and health workers in implementing CDM plans.

We are researching this question in the Royal Flying Doctor Service health clinics in far west New South Wales. The research is making an assessment of the quality of CDM that frequent evacuees are receiving and exploring the potential for reducing the number of evacuations. We hope that this will help build the case for better resourced and more collaborative care in remote populations suffering from a disproportionately high burden of disease. It is not only the number of consultations that is important. It is likely to be the nature of those consultations and the systems that support them that will make a difference.

Malcolm Moore, MBBS(Hons), FRACGP, MSc International Health
Broken Hill University Department of Rural Health,
Broken Hill, New South Wales, Australia

Sue Kirby, PhD
Broken Hill University Department of Rural Health,
Broken Hill, New South Wales, Australia

References

1. Hussain J, Robinson A, Stebbing M, McGrail M. More is more in remote Central Australia: more provision of primary healthcare services is associated with more acute medical evacuations and more remote telephone consultations. Rural and Remote Health 14: 2796. (Online) 2014. Available: www.rrh.org.au (Accessed 17 November 2014).

2. Bennett K, Probst J, Vyavaharkar M, Glover S. Missing the handoff: post-hospitalization follow-up care among rural Medicare beneficiaries with diabetes. Rural and Remote Health 12: 2097. (Online) 2012. Available: www.rrh.org.au (Accessed 10 December 2014).

3. Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization a randomized trial. Medical Care 1999; 37(1): 5-14.