Predicting and preventing avoidable hospitalisations in rural Tasmanians
Creators: name: Ridge, Andrew
Publisher: name: University of Tasmania
Year: 2024

description: The primary healthcare system in Australia consists of services patients visit first for their healthcare needs, and in many cases is the most suitable sector to deliver services which help patients avoid hospitalisation. The accessibility and relatively affordability of primary healthcare services means most Australians have the opportunity to achieve good health. Despite the notion of universal healthcare, rural patients have worse health outcomes than their urban counterparts. Opportunities to engage in their own healthcare are limited by a smaller number and range of health service options, and problems accessing the right type of healthcare service. These barriers can result in patients presenting to hospital unnecessarily. <br>A potentially preventable hospitalisation (PPH) occurs when a condition that could have been prevented, or managed, with timely and adequate primary care in the community results in hospitalisation. In Australia and overseas, PPH rates are used as an indicator of how well the primary healthcare system is performing and allow for comparisons of performance between locations. A better understanding of patterns and causes of PPHs in the study area (Huon-Bruny Island region of Tasmania) could help identify points where intervention may improve health outcomes for the population, healthcare services, and the broader healthcare system. <br>The aim of this thesis was to improve the understanding of prevalence, causes, and approaches to minimising the risk of PPHs in a rural Tasmanian population. Results from multiphase mixed methods research were used to analyse local data, and to inform the design of a community-level intervention. The thesis concludes with recommendations for preventing unnecessary hospitalisation from rural communities. <br>A literature review of thirteen papers was conducted and indicated the range of healthcare services available, limited access to specialist care, higher prevalence of chronic health conditions, and affordability of services were associated more strongly with PPHs in rural, compared to urban, populations. Many psychosocial risk factors (such as living alone, health literacy, or socioeconomic status) were as important as routinely recorded clinical factors. The link between social isolation and loneliness, health literacy, and low education level or income was a persistent theme in studies of rural populations. <br>A systematic literature review was conducted to determine if any prediction models for PPH-risk among rural community-dwelling patients exist. Of five predictive models identified, only one was suitable for use with Australian general practice data. This algorithm was applied to a real-world patient database and patients at relatively high risk of PPHs were followed longitudinally for 12 months. Of the patients identified as being at high?risk of PPH, 12.6% had a documented preventable admission to hospital. Prediction models using routine general practice data only may omit important psychosocial variables.<br>The prevalence and nature of PPHs in the Huon-Bruny Island area was explored in a statistical analysis of linked general practice and hospital data. A logistic regression model was built with being single/unmarried, a higher Charlson Comorbidity Index score, and the number of general practice visits in the preceding 12 months used as significant independent predictors of PPHs. The strong association of marital status and PPH occurrence was of particular interest and pursued in subsequent research phases. <br>Using semi-structured interviews, local patients and healthcare workers were interviewed. Thematic analysis of 10 patients’ and 14 healthcare workers’ interview transcripts was used to form themes related to local causes of PPHs. Themes of enablement, community-level support, and access to healthcare services were used to describe patients’ perceptions of their PPH. Healthcare providers believed health literacy, access to primary healthcare, and convenience of hospital care were drivers of PPH. Common to both qualitative studies was the importance of patients’ ability to engage with their own health (either based on the patient’s own health literacy and enablement, or that of others around them). These data confirmed the importance of non-clinical and psychosocial factors in causing PPHs. <br>The design of a suitable pilot intervention for the Huon Valley municipal area was informed by preceding research. Based on an ability to modify health literacy characteristics, and the possibility of reducing social isolation and loneliness, a social prescribing model was selected as the basis for a feasibility trial. Social prescribing can reduce social isolation and loneliness by increasing patients’ social interaction in the community and thereby improve access to health literacy resources in the community. Better navigation of the healthcare system, greater engagement with health-promoting activities, and fewer general practitioner (GP) attendances may be the result of greater social connectedness. Over six months, the social prescribing pathway was promoted to GPs in Huonville and Cygnet using local community organisations as referral points. Both appropriateness and feasibility assessments made by 13 GPs remained very high over the six-month study. Barriers encountered by GPs, and therefore possible reasons for lower than expected uptake of social prescribing referrals, included patient selection difficulties, a lack of time during consultations, and a problematic referral pathway (e.g. need for an identifiable link worker, electronic referral mechanism, provision for link worker to proactively contact the patient after a referral).<br>This thesis presents evidence that social determinants are important, yet under-recognised, risks for PPH. Social isolation and loneliness, health literacy problems, and barriers to accessing healthcare in the community appear to be just as important as better-recognised clinical risks, such as smoking and obesity. Psychosocial predictors of PPH are not routinely assessed in primary healthcare and, if recorded, are often incomplete and hard to access for screening purposes. Patients and healthcare worker data suggest that reducing demand for healthcare may be an alternative approach to avoiding unnecessary healthcare use. Patient’s ability to perceive a need, seek, reach, pay for, and engage with healthcare may be modifiable through emerging approaches such as social prescribing. Participants viewed social prescribing positively and believed it could help divert patients away from the health system. With an improved implementation and pathway design, social prescribing could provide an appropriate and feasible means of helping to keep rural patients out of hospital. <br>Increased resource allocation and spending on healthcare service supply has not helped reduce the gap in health and outcomes between rural and urban populations. Considering other drivers of demand for healthcare services may prove to be a cost-effective approach to reduce the rural-urban health disparity. This thesis presents the case for building the capacity of individuals, communities, and organisations to optimise the performance of the existing healthcare resources in rural populations.