Australian Journal of Rural Health最新文献

Occasions of low-value care (LVC) are those that confer little or no benefit to the patient or where harm (including lost treatment opportunity and financial cost) exceeds likely benefit.¹ While it is easy to conceptualise health care as either low or high value, the reality is that ‘value’ is conferred on a continuum and within a context. Some health care activities are widely acknowledged as low value (e.g., cranial CT in patients without meeting clinical decision criteria² and MRIs for low back pain³). However, much health care is conducted in the ‘grey zone’^{4, 5} where the ‘value’ of health care is context dependent.

In regional, rural and remote Australia, the provision of health care is characterised by challenges distinct from our urban counterparts. Limited access to services, high rates of multimorbidity, and a maldistributed and inconstant workforce are some of the contextual factors in our ‘grey zone’.

From the perspectives of regional (Townsville), rural (New England) and remote (Thursday Island) health services, we describe how the contexts of our clinical environments guide our clinical decisions and challenge notions of what is, and what is not, LVC.

Townsville University Hospital is a tertiary referral centre in regional North Queensland supporting the health care needs of 700 000 people.⁶ Amidst a national context of emergency department overcrowding^{7, 8} the Townsville University Hospital Emergency Department (TUH-ED) cared for 99 748 people in 2024. The challenges of providing care in this time-, space-, staff- and information-constrained setting can lead to LVC.⁹ Similar to metropolitan settings, we have identified that approximately a third of urine cultures, coagulation studies, blood cultures and cranial CT scans conducted within the TUH-ED setting, may be seen as low value.^{10, 11} Recent semi-structured interviews with TUH-ED clinicians identified LVC is fuelled by perceptions of efficiency further compounded by clinician beliefs about consequences and capabilities of care provision (unpublished data). This array of systemic and individual factors is shaping clinician behaviour and contributing to the persistence of LVC at TUH-ED.

The New England region of NSW has a population of 160 000 spread over a wide geographic area with regional and rural towns of MM3-6 in size. Like many rural health services, there is an increasing reliance on a locum rather than a local workforce. In many locations, it is difficult to even attract a locum workforce, so emergency care is provided via telehealth support. Since telehealth specialists cannot physically examine patients, the ordering CT scans of all body parts has increased. It is likely that clinical skill variability, concern for patient outcomes and the desire for a cli

Clinical trials are essential components of health practice and are vital to developing new therapies, advancing interventions, improving service delivery and enhancing models of care.¹ For patients, participation in clinical trials improves outcomes in many disease areas and reduces variation in practice, due to strict monitoring requirements. For health practitioners, clinical trials present an opportunity to be at the cutting edge of best practice. For services, clinical trials improve standard procedures. For health systems, industry sponsored trials are an additional source of revenue that could be reinvested to build clinical trial units. Reports suggest that there is significant return on investment in this sector.²

For these and other reasons, the new National Clinical Trial Governance Framework has called for clinical trials to be included as a routine aspect of clinical practice.³ In the cancer care sector, which serves a significant number of patients with incurable diseases, international guidelines recommend clinical trials as the first option.⁴ This means, to be aligned with international best practice, every cancer service should be offering clinical trials to all cancer patients regardless of postcode, at least for patients with incurable diseases.

Australia and many Western countries have invested significant resources to build clinical trial capabilities and enable engagement in local and international trials. However, people in regional, rural and First nations communities continue to have limited access to trials close to home.^{5, 6} As a result, they must endure substantial travel, major costs and inconvenience, and often, must relocate to metropolitan centres or pass up the opportunity to participate. This is a key challenge highlighted by the accompanying commentary (Walsh et al.)⁷ and specifically emphasised in the accompanying research paper (McPhee et al.).^{7, 8} Alarmingly, an MJA study recently described particularly poor representation of First nations communities in trials (exemplified in trials of parenting programs).⁹

Many of the challenges and barriers to health services in regional, rural and First nations communities are apparent (or even more pronounced) in the case of clinical trials. Workforce shortages and turn over at all levels, limited skills and awareness among staff of the potential benefit of trials, and inadequate investment in infrastructure are common. This constrains such sites from attracting sponsors and hosting clinical trials as stand-alone sites. Beyond this, system cultural issues within rural and First nations services may stifle participation, or the economic imperatives of metropolitan trial units and their sponsors may overrule.

In the light of the above, it is not unreasonable