Improving Access to Diagnostic Testing for Rural Communities in Aotearoa/New Zealand

Abstract

Aim To improve access to computed tomography (CT), point-of-care laboratory testing (POC testing), point-of-care ultrasound (POCUS) and cardiac exercise testing (ETT) for rural populations. Methods 1. Utilisation rates were used to quantify improvements in access to services for rural populations. 2. Impact on diagnostic certainty and patient disposition was evaluated with a pre- and post-test questionnaire. 3. A specialist panel assessed the quality, safety and clinical impact of POCUS. 4. Qualitative interviews highlighted the benefits and challenges of the rural diagnostic services. 5. Economic evaluations of the rural diagnostic services were undertaken using cost minimisation analyses. Findings Geographic disparities in access to CT were overcome when a rural service was established. POC testing and POCUS increased diagnostic certainty, reduced admissions and inter-hospital transfers (POCUS by 8%). For some patients (4% POC testing, 5% POCUS) the test prompted urgent inter-hospital transfer. POCUS benefited 71% of patients, 22% significantly. Despite the overall benefits, significant error rates were identified. The quality of 17% of the images was inadequate and 7% were incorrectly interpreted. Ten percent of times, the POCUS findings were different to those obtained by formal imaging or the final diagnosis. The error rates were mitigated by incorporating POCUS into a full clinical assessment. Savings in the form of reduced inter-hospital transfers and hospital admissions (POC testing) outweighed the costs of the service. In the ETT study, the costs of rural ETT compared favourably to the costs of an urban service. Qualitative findings highlighted the impact of travelling large distances to access health care for elderly Māori in particular, and the improved job satisfaction for rural health professionals as a result of greater diagnostic certainty. Conclusions The wider adoption of rural CT, POC testing, POCUS and ETT, are cost effective ways of improving diagnostic certainty, reducing inter-hospital transfers and supporting rural practice. Learning and maintaining POCUS skills is challenging and demands recognised scopes of practice and standards for training, credentialing and quality assurance. Rural Māori may be particularly vulnerable to the impacts of having to travel to access healthcare, and may have the most to gain from the provision of as many health services (including diagnostic tests) as possible in their local communities.