Investigating high-risk rural regions for potentially preventable hospitalisations: a method for place-based primary healthcare planning
Susan O’Neill
A * , Steve Begg A , Evelien Spelten A Nerida Hyett A B C
A
B
C
Abstract
Inaccessibility of primary healthcare services in rural and remote communities is argued to lead to higher rates of potentially preventable hospitalisations. This research aimed to develop an explanatory method that could be applied for investigating a rural setting considered high risk for potentially preventable hospitalisations, and to describe how to improve place-based pathways to primary healthcare services that would prevent potentially preventable hospitalisations.
The method described in this paper provides a structured and detailed plan for examining regions identified as high risk for a particular potentially preventable hospitalisation condition. The method was developed and tested through a series of research studies on ear, nose and throat (ENT) conditions in the Murray Primary Health Network, that had regions identified as high-risk hotspots for ear, nose and throat potentially preventable hospitalisations.
The procedure developed for investigating hotspot regions of potentially preventable ear, nose and throat hospitalisations included six steps: (1) develop investigative questions; (2) identify and select potentially preventable hospitalisations condition and region; (3) literature review of best practice service needs and service mapping; (4) healthcare provider and consumer experiences; (5) illustrate patient journey; and (6) summarise recommendations for primary health care.
This method provides an understanding of the access pathways to primary healthcare services, and identifies where interventions and prevention strategies would support residents in obtaining equitable health care. This developed method can be further applied and tested as a mechanism for health and service needs assessment by primary healthcare planning and coordination agencies, which in Australia include Primary Health Networks, public health units and hospital networks.
Keywords: health needs assessment, hotspots, mixed methods, place-based, potentially preventable hospitalisations, Primary Health Networks, primary healthcare, rural and remote.
Introduction
Australia’s population consists of approximately 27 million people, of which 7 million live in rural and remote areas, representing 28% of the Australian population (AIHW 2024). Those living in rural and remote communities experience barriers to healthcare access due to geographic distribution, limited availability and higher costs (Thomas et al. 2015; Zurynski et al. 2021). It is more challenging for governments and service providers to sustain rural and remote health services because of workforce shortages, high staff turnover and fragmented funding streams that are not sufficient for delivering services in these contexts (Tham et al. 2011; O’Neill et al. 2021, 2024).
Inaccessibility of primary healthcare services in rural and remote communities is argued to lead to higher rates of potentially preventable hospitalisations, and subsequently poorer health outcomes than people living in metropolitan regions (AIHW 2024). Potentially preventable hospitalisations are an accepted measure of primary healthcare system performance and can geographically highlight areas of concern where rates of hospitalisation are high (Duckett and Griffiths 2016). Examining high-risk regions identified as hotspots for higher rates of potentially preventable hospitalisations provides an understanding of healthcare accessibility, and supports the development of targeted primary healthcare interventions (AIHW 2021).
In the 2016 Perils of Place report by the Grattan Institute, two communities within the Murray Primary Health Network (PHN) in Victoria, Australia were identified as hotspots for potentially preventable hospitalisations of ear, nose and throat (ENT) conditions (Duckett and Griffiths 2016;). Further research conducted within the Murray PHN region by the authors of this current paper identified additional areas considered high risk for ENT potentially preventable hospitalisations (Duckett and Griffiths 2016; O’Neill et al. 2023). The potentially preventable ENT hospitalisations conditions identified were otitis media, upper respiratory tract infections and acute tonsillitis; with the residents from postcodes with higher than expected hospitalisations for these conditions being more likely than others to be aged between 0 and 9 years, or from First Nations communities, or come from a culturally and linguistically diverse background (O’Neill et al. 2023).
The overall aim of this research was to develop an explanatory method that could be applied for investigating any rural setting considered high risk for potentially preventable hospitalisations, and to describe how to improve place-based pathways to primary healthcare. This method was developed from the mixed methods research studies that investigated ENT hotspots in the Murray PHN. This method can be further applied to high-risk settings for other vaccine-preventable, acute, and chronic conditions that are known to have high rates of potentially preventable hospitalisations (AIHW 2021), that would improve access to care close to home; this being a key objective of PHNs across Australia and of national primary healthcare reforms (Australian Government 2022; Department of Health and Aged Care 2024).
In addition, this explanatory method is intended to support PHNs with health and service needs assessments, which is a key deliverable to the Department of Health and Aged Care, and a resource for evidence-informed local collaborative planning. State and territory governments, and other community-based organisations also routinely undergo population health needs assessments, which could be strengthened with an explanatory method where the objectives align to prevention, early intervention and primary healthcare service planning.
Methods
Study setting
The ENT research studies took place in the Murray PHN catchment in the northern region of the State of Victoria, Australia from 2019 to 2023. The catchment is a diverse area that covers almost 100,000 km2 of mountains, semi-deserts and regional cities, and services a population of 644,000 people; of which approximately 21,000 persons identify as Aboriginal and/or Torres Strait Islander, representing 28% of the total First Nations population in Victoria (Australian Bureau of Statistics 2021; Department of Health and Aged Care 2024). The majority of the Murray PHN catchment is classified as MM5 (small rural towns) on the Modified Monash Model categorisation scale; with a few communities classified as MM4 and MM3 (medium and large rural towns) (Department of Health and Aged Care 2023). In terms of the Australian Statistical Geographical Standard, this catchment covers communities ranging from inner regional, outer regional and remote, with workforce shortages in primary care and specialist services experienced throughout the region (Department of Health and Aged Care 2022).
Study design
The research studies were initiated through a partnership between La Trobe University and the Murray PHN for an industry PhD to examine the ENT hotspots in the catchment, and to develop an explanatory method that could be applied for ongoing health and service needs assessments for identified high-risk regions for other potentially preventable hospitalisations conditions (O’Neill et al. 2023, 2024). The steps of this method are explained here with reference to how they were applied in the research studies, which included a descriptive data analysis (O’Neill et al. 2023), a systematic literature review (O’Neill et al. 2024) and a case study. This paper presents an overview of a proposed method developed through these series of studies that could be applied and further developed for potentially preventable hospitalisations investigations across a range of settings to inform rural primary healthcare service planning.
Procedure
The procedure developed for investigating high-risk regions, and proposed here for further application and development, includes six steps. The steps are: (1) develop investigative questions; (2) identify and select potentially preventable hospitalisations condition and region; (3) literature review of best practice service needs and service mapping; (4) healthcare provider and consumer experiences; (5) illustrate patient journey; and (6) summarise recommendations for primary health care.
Steps one to five are further described in Table 1 below, which provides a sequenced template for investigating rural communities for potentially preventable hospitalisations. The explanatory method follows an explanatory sequential design, in which quantitative data is first collected and analysed, to inform the potentially preventable hospitalisations conditions and population demographics for a specific focus of investigation in the subsequent stages (Crowe et al. 2011; Yin 2014). The mixed methods research approach was identified as applicable to investigating potentially preventable hospitalisations, as the utilisation of quantitative and qualitative methods specifies the statistical trends and personal experiences, which provides a place-based understanding of the health and service needs in rural communities, from which interventions can be developed (Yin 2014).
| Components | Aim | Indicators | Data source | |
|---|---|---|---|---|
| 1. Develop investigative questions | ||||
| Formulate questions | To create investigative questions that will structure the study rationale and process |
| Corresponding steps 2–5 | |
| 2. Identify and select potentially preventable hospitalisations condition and region | ||||
| Identify conditions | To identify the main potentially preventable hospitalisations conditions impacting the community |
| Data analysis: hospital presentation data | |
| Identify population demographics | To identify the population demographics at higher risk of hospitalisation of the condition |
| Data analysis: Census and Australian Bureau of Statistics data | |
| 3. Literature review of best practice service needs and service mapping | ||||
| Required services | To understand the healthcare services needed for effective and efficient management |
| Literature review | |
| Available services | To identify the healthcare services available in the community |
| Audit/surveys | |
| Service delivery | To understand the provision of care available in the community |
| Audit/surveys | |
| 4. Healthcare provider and consumer experiences | ||||
| Healthcare providers | To understand the lived experience of healthcare providers, the barriers and enablers of current frameworks in providing care for the identified potentially preventable hospitalisations condition |
| Interviews and/or focus group | |
| Healthcare consumers | To understand the lived experience of accessing care and managing the identified potentially preventable hospitalisations condition in the community |
| Interviews and/or focus group | |
| 5. Illustrate patient journey | ||||
| Patient journey | To map the access pathways utilised to manage and treat the identified potentially preventable hospitalisations condition |
| Interview/focus group; audit/surveys | |
The purpose of the research studies was to understand the potentially preventable ENT hospitalisation conditions impacting high-risk rural settings, through an investigation of access pathways and care provision. The aim of the studies was supported by the development of four investigative questions:
What are the main potentially preventable hospitalisation conditions impacting the region, and the at-risk population demographics? (step 2);
What are the current best practice primary healthcare models and service provisions for detecting and treating the condition, and what are the existing access pathways for the identified potentially preventable hospitalisations conditions in the identified region? (step 3);
What are the experiences of healthcare providers and consumers in managing and treating the identified potentially preventable hospitalisations conditions in their region, and what factors influence patient outcomes? (step 4);
What are the healthcare journeys of consumers in the region? (step 5).
Step two is to identify and select the potentially preventable hospitalisations conditions and impacted communities for further examination. We did this through a descriptive data analysis of all potentially preventable ENT hospitalisations in the Murray PHN, to identify the main presenting conditions within the potentially preventable hospitalisations ENT categories, the postcodes with higher than expected potentially preventable hospitalisations ENT conditions and the population demographics at risk of hospitalisations. Unit record hospital separation data was obtained from the Victorian Admitted Episodes Dataset. Postcodes in the Murray PHN were classified as having higher than expected numbers of potentially preventable hospitalisations across three subgroups of ENT conditions using indirect standardisation techniques. Differences between patients from ‘higher than expected’ postcodes and ‘other’ postcodes with respect to the distribution of demographic and other patient characteristics were determined using chi-squared tests for each ENT subgroup. The results were confirmed by logistic regression analyses using resident of a postcode with higher than expected hospitalisations as the outcome variable (for further detail on the statistical analysis and supporting documents, see O’Neill et al. 2023 publication).
The descriptive data analysis framed the parameters for the remainder of the investigation, as it provided the potentially preventable hospitalisations condition, communities with higher than expected hospitalisations, and population demographics. In the explanatory method steps, this information should be disseminated when formulating stages three to five through the following;
Building relationships: Identify relevant stakeholders in the region and present with the study findings, to obtain signed letters of support for collaboration on the study design, and assistance with participant recruitment.
Data sharing and strategising: Where resources are available within the timeframe, consult with local data sources to avoid unnecessary duplication of the investigation.
Design approach: Consider context in the timing of the investigation; as to what is appropriate and acceptable for the community’s needs.
A literature review helps identify best practice exemplar models for understanding what is effective in improving access to timely and effective preventative care for the particular potentially preventable hospitalisations condition and region. The literature review choice might be influenced by timing, resources and staff capacity. We analysed current literature (including published articles, reports and government frameworks) from six databases (MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, and Cochrane). The inclusion and exclusion search criteria was informed by the findings of step two the ‘descriptive data analysis’ (search protocol available through the O’Neill et al. 2024 publication). The systematic literature review provided the context for what was required in the mapping of healthcare services.
In mapping the healthcare services of primary care, allied health and other community services in the major towns of the identified region, a list of these services and their locations were obtained from websites in the public domain including social media. Current healthcare pathways were obtained from the Australian Government website, Healthdirect, and the Murray HealthPathways website (which is available for all health professionals to access). Key service details were retrieved and charted in Microsoft Excel, and then validated by researchers and healthcare providers with local knowledge. The services identified as required for ENT care were categorised into community services, allied health, primary care, specialist care and urgent/emergency care. This included health promotion, audiologists, speech pathologists, pharmacists, general practitioners, ENT practitioners, nurses and emergency departments. The services were presented in a table, as to describe the provision of health care in the major towns of the region; this included the operating hours, whether the services were FT – full standard operating hours including weekends and/or afters hours access, PT – partial standard operating hours, usually excluding weekends and after hours, VI – virtual only including telehealth and phone services, VS – visiting service or X – no service.
Lived experiences are essential for a place-based understanding of a community’s needs (Wakerman et al. 2009). We collected and analysed the lived experiences through interviews with healthcare consumers, healthcare providers and healthcare consumers/providers. Given the smaller population sizes within rural communities, residents may speak from experience as both a provider and consumer. The semi-structured interviews ranged from 30 to 45 min per participant. The interviews were conducted via telephone, videocall or in-person. The semi-structured interviews included open and closed questions relating to managing and treating ENT conditions in their community, the barriers encountered in ENT care, and access pathways available. Thematic analysis of the interview transcripts was used to create themes that addressed the research question (Holloway and Wheeler 2010; Yin 2014). The data coding development was supported by the use of NVivo 12 (Lumivero 2017). The data analysis involved reading and re-reading transcripts, coding and creating coding categories, grouping, and mapping the relevant codes and categories to create descriptive themes (Saldaña 2013).
The next step is to construct an illustration of the patient journey or journeys to understand current pathways to care and where there are gaps or barriers. Patient journey maps aid stakeholders to assess the healthcare consumer experience from multiple perspectives (Joseph et al. 2020). Journey maps provide a way to visualise the internal and external factors affecting the different paths patients must take to meet their healthcare needs (Ly et al. 2021). We did this through the healthcare provider and consumer interviews, where one patient journey was selected based on the multiple points of contact with the available healthcare services in the region to treat an ENT condition. The journey map detailed the onset and progression of the condition, the healthcare services that were available and accessed, the healthcare professionals encountered at each stage of contact with the services, the distance and time to obtain healthcare, the need for a dependant in accessing care, the cost of healthcare services, and the distance and time required for subsequent follow ups. This was summarised to illustrate the complexity of healthcare access in rural regions (journal publication is currently in press, titled ‘A case study of rural healthcare accessibility for Ear, Nose, and Throat conditions’).
There were six recommendations summarised from the explanatory research studies that aim to improve access to ENT primary health care in rural and remote regions that is affordable, available and appropriate. These recommendations included, ongoing education and continuing professional development training in primary care and allied health care for management and treatment of ENT conditions; expanded scopes of practice for the allied healthcare workforce, and use of multidisciplinary teams in primary care to fill the gap in service delivery; continuity in care from external visiting services; tailored healthcare pathways for the unique needs of the community, addressing gaps in after hours and preventative primary care; review of the patient transport scheme in rural and remote areas; and the equitable dissemination of information in communities of visiting services and alternative appropriate virtual healthcare programs.
Key considerations
Collaborative planning
Relationships and partnerships are integral to collaborative planning; this ensures the research aim and objectives meet the needs of the affected service providers and consumers, and is informed by their experience and local knowledge. Investing in local relationships and partnerships makes best use of local knowledge, where healthcare providers are experienced innovators, resourceful and hold a broad skillset to meet the unique challenges for their community. In addition, collaborative planning brings together fragmented services, workforces, and available funding that supports the sustainable delivery of healthcare service initiatives (Hyett et al. 2024).
Data governance and ethics
As the research studies were supported by a university, ethics approvals were granted by the university’s Human Ethics Committee (ethics approval numbers REMOVED). These ethics applications detailed the data governance protocols that would be applied throughout the stages of the research. In addressing the data governance and ethics of the explanatory method template, recruitment, informed consent and confidentiality, and risk management are described here.
Purposeful sampling was used to recruit healthcare providers in the region for individual interviews. In recruiting healthcare consumers, advertisements were placed in the identified mapped organisations, circulated through contacts and networks, newsletters, and social media platforms; additionally, staff of the mapped services were encouraged to inform their patients/consumers of the study, following snowball sampling techniques (Nutbeam and Bauman 2011).
A participant informed consent form (PICF) that provided a clear understanding of the research activities and expectations was developed. The PICF was verbally discussed and signed prior to the interviews. Participants were advised that their participation in the study was voluntary, and they had the right to withdraw from the research project at any time. Participants wanting to withdraw were required to complete a signed withdrawal of consent form (provided in the PICF). Strategies to ensure ethical adherence to participant confidentiality included removing identifying information. Hospital presentation information for the descriptive data analysis was already de-identified, aggregate data. In presenting the findings of the research studies, information pertaining to the names of communities and service providers in the region were removed.
Discomfort of participants in the interviews was gauged by the interviewer, and reaffirmed by asking the participants their level of comfort in discussing their experiences. Participants were also made aware they could stop or withdraw from the interview at any time. Reputational risk was minimised by adhering to the organisations codes of conduct when representing these entities (La Trobe University and the Murray PHN).
Engagement and knowledge translation
Healthcare provider and consumer engagement, and relevant stakeholder participation are essential to every stage of quality research, and in co-creating interventions and prevention strategies that take into account the lived experiences and understanding of those who are affected (Hyett et al. 2024). The research team of the studies offered transcripts of the audio recorded interviews for participants to review prior to the data analysis. In addition, the manuscripts and reports developed from the study findings were offered to participants who identified in the PICF that they would like to review them prior to being submitted to a journal for consideration of publication (of which there were two requests). Presentations of the study findings and recommendations were also delivered at conferences, and were disseminated to a wider audience through the Murray PHN multimedia platforms (including online, print and radio). Incorporating knowledge translation as a key consideration in the explanatory method procedure acknowledges the time and effort from participants involved, and supports research to practice translation by the involved departments and organisations to address equitable health care in their region.
Discussion
The explanatory method has outlined an approach for investigating a high-risk region for potentially preventable ENT hospitalisations, to identify the health and service needs in a rural region of Victoria. The method described in this paper aims to provide a structured and detailed plan for examining regions identified as high risk for a particular potentially preventable hospitalisations condition. By utilising an explanatory mixed methods research design, this method provides an understanding of the access pathways to primary healthcare services, and identifies where interventions and prevention strategies would support residents in obtaining equitable health care.
Identifying health and service needs
The explanatory method integrated quantitative and qualitative methods, making it robust for exploring the multifaceted issue of health and service needs. The explanatory sequential design, where quantitative data was first collected and analysed, steered the direction for the following lines of enquiry, which provided a comprehensive understanding of the healthcare access barriers and challenges (Yin 2014). This mixed methods methodology was appropriate, given the complexity of healthcare issues in rural settings, and ensured a data-driven approach that incorporated both numerical trends and lived experiences (Crowe et al. 2011).
The inclusion of local healthcare providers and consumers as key stakeholder informants in the explanatory methods investigation enriched our understanding of the real-world barriers to healthcare access. A community-based research approach ensures that the investigation outcomes will be informed by the lived experiences of both healthcare providers and consumers, which is vital for creating interventions that are practical, culturally, and contextually relevant (Hyett et al. 2024).
When an area is identified as high risk for a potentially preventable hospitalisation condition, it is necessary to systematically investigate the area to understand the gaps in access and service delivery. High rates of potentially preventable hospitalisations do not indicate the quality of primary healthcare services, there are factors that are unknown that warrant further investigation to identify what interventions would be effective. It may be that one region with high potentially preventable hospitalisations has available primary care general practice services, but lacks bulk billing, whereas another region may have bulk billing, but experiences workforce shortages that limits the operational hours provided (Duckett and Griffiths 2016).
Application of the explanatory method
Priority places need tailored place-based solutions, having an understanding of the dimensions of an issue is key to determining what further investigation is required. Although the analysis for potentially preventable hospitalisations provides a broad grouping of health conditions that may be avoidable through timely access to appropriate primary health care, further investigation is required to identify the at-risk population demographics, and healthcare service provision, for effective and efficient program development applicable to the unique needs of the community (Broemeling et al. 2006; O’Neill et al. 2023).
There has been an expansion in the range of healthcare service models being applied in rural and remote areas to address inequitable access. These include urgent care centres, priority primary care centres, telehealth and telemedicine services, and multidisciplinary care teams (Department of Health and Aged Care 2022, 2024; Murray PHN 2024). These alternative models of health care need to be measured at the community base level against other indicators from available data sources (such as Medicare Benefits Schedule and Pharmaceutical Benefits Schedule data) to determine the effectiveness for the identified community needs (Duckett and Griffiths 2016).
This explanatory method is intended to support place-based solutions, building on the existing assets and strengths identified in the community. Ongoing development of this novel method is required for testing and implementation. Furthermore, the method could be expanded to include incremental standardised data-collection from healthcare services to support the precise monitoring of potentially preventable hospitalisations trends and resource allocation.
Conclusion
This explanatory method was developed for investigating high-risk rural regions for potentially preventable hospitalisations to inform place-based planning of primary healthcare services, and to identify population health needs and preventative interventions. The method was developed and tested through the research study of ENT conditions in the Murray PHN, that had regions identified as high-risk hotspots for ENT potentially preventable hospitalisations (O’Neill et al. 2023). The developed method can be further applied and tested as a mechanism for health and service needs assessment by primary healthcare planning and coordination agencies, which in Australia include PHNs, public health units and hospital networks. Further development is recommended for optimising cost-effectiveness of the explanatory method, and for evaluation of the interventions that are applied as a result of the investigation.
Declaration of funding
This research was a part of a PhD study that received an industry funded scholarship from the Murray Primary Health Network and La Trobe University.
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