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Objectives: Arterial catheters (ACs) are critical for haemodynamic monitoring and blood sampling but are prone to complications. We investigated the incidence and risk factors of AC failure. Methods: Secondary analysis of a multi-centre randomised controlled trial (ACTRN 12610000505000). Analysis included a subset of adult intensive care unit patients with an AC. The primary outcome was all-cause device failure. Secondary outcomes were catheter associated bloodstream infection (CABSI), suspected CABSI, occlusion, thrombosis, accidental removal, pain, and line fracture. Risk factors associated with AC failure were investigated using Cox proportional hazards and competing-risk models. Results: Of 664 patients, 173 (26%) experienced AC failure (incidence rate [IR] 37/1000 catheter days). Suspected CABSI was the most common failure type (11%; IR 15.3/1000 catheter days), followed by occlusion (8%; IR 11.9/1,000 catheter days), and accidental removal (4%; IR 5.5/1000 catheter days). CABSI occurred in 16 (2%) patients. All-cause failure and occlusion were reduced with ultrasound-assisted insertion (failure: adjusted hazard ratio [HR] 0.43, 95% CI 0.25, 0.76; occlusion: sub-HR 0.11, 95% CI 0.03, 0.43). Increased age was associated with less AC failure (60–74 years HR 0.63, 95% CI 0.44 to 0.89; 75 + years HR 0.36, 95% CI 0.20, 0.64; referent 15–59 years). Females experienced more occlusion (adjusted sub-HR 2.53, 95% CI 1.49, 4.29), while patients with diabetes had less (SHR 0.15, 95% CI 0.04, 0.63). Suspected CABSI was associated with an abnormal insertion site appearance (SHR 2.71, 95% CI 1.48, 4.99). Conclusions: AC failure is common with ultrasound-guided insertion associated with lower failure rates. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000); date registered: 18 June 2010. [ABSTRACT FROM AUTHOR]

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists' primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff's skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists' clinical work can discourage private specialists from providing services In remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers. L'Organisation mondiale de la Sante a approuve l'utilisation de services de proximite pour promouvoir: le redeploiement efficace du personnel des soins de sante; la continuite des soins au niveau local; et le support professionnel au personnel de sante local et rural. L'Australie est le seul pays qui possede, depuis l'an 2000, une politique nationale soutenue de services de proximite afin de subventionner la presence de medecins specialistes dans les zones rurales. Cet article decrit l'adoption, la mise en oeuvre et la priorisation d'une politique nationale de proximite specialisee en Australie. L'adoption de cette politique nationale a fait suite a une longue histoire de services de proximite dont la reussite est largement attribuable a l'interet professionnel et a l'engagement personnel des professionnels de sante. A l'origine, cette politique soutenait seulement les nouveaux services de proximite, mais les preoccupations concernant la durabilite des services existants ont abouti a l'extension de l'admissibilite au financement a tous les services specialises. Les couts des deplacements, des temps de deplacement, d'hebergement, du soutien professionnel, de personnel de remplacement dans les cabinets primaires des medecins specialistes et de la location d'equipement ont ete subventionnes. Au fil du temps, l'engagement politique national pour le traitement equitable des populations autochtones a entraine un soutien plus cible pour acheminer les services de medecine mobile dans les zones reculees. Les priorites actuelles sont: (i) l'etablissement de services de proximite en equipe; (ii) l'amelioration des competences des professionnels locaux; (iii) la realisation de la coordination locale; et (iv) la conduite d'une evaluation coherente des besoins a lechelle nationale. L'absence de subventions pour le travail clinique des medecins specialistes peut decourager les medecins specialistes prives de venir soigner dans les zones eloignees ou le rendement clinique est faible. Pour quelle reussisse, la politique de proximite doit s'harmoniser avec les interets des professionnels de sante et soutenir l'autonomie professionnelle. A l'echelle internationale, le developpement de politiques de proximite doit tenir compte du salaire local et des conditions d'exercice des professionnels de la sante. La Organizacion Mundial de la Salud ha aprobado el uso de la difusion con el objetivo de promover la reasignacion eficiente del personal sanitario, la continuidad de la atencion a nivel local y el apoyo profesional para el personal sanitario a nivel local y rural. Australia es el unico pais que ha mantenido, desde el ano 2000, una politica nacional continuada en materia de subvencion de la difusion de especialistas medicos en las zonas rurales. Este articulo describe la adopcion, implementacion y prioridad de la politica de difusion de especialistas en dicho pais. La adopcion de la politica nacional obedecio a un largo historial de difusion con buenos resultados, impulsado en gran parte por el interes profesional y el compromiso personal de los trabajadores. En un principio, la politica apoyaba unicamente los servicios de difusion nuevos, pero la preocupacion acerca de la sostenibilidad de los servicios existentes auspicio una ampliacion de la financiacion a la totalidad de los servicios especializados. Se subvencionaron los costes y el tiempo de viaje, el alojamiento, el apoyo profesional, la asistencia al personal en los consultorios principales de los especialistas y el alquiler de equipos. Con el tiempo, el compromiso politico nacional respecto al trato equitativo de los pueblos indigenas se tradujo en un apoyo mas especifico para la difusion en las areas mas alejadas. Las prioridades actuales son: (i) establecer servicios perifericos por equipos, (ii) mejorar las capacidades del personal local, (iii) lograr la coordinacion local y (iv) llevar a cabo una evaluacion cohesiva de las necesidades a nivel nacional. La ausencia de subsidios para el trabajo clinico de los especialistas puede disuadir a los especialistas privados de prestar servicios en zonas remotas, en las que el rendimiento clinico es bajo. Para resultar satisfactoria, la politica de difusion debe armonizar los intereses del personal y apoyar la autonomia profesional. A nivel internacional, el desarrollo de una politica de divulgacion debe tener en cuenta los salarios y las condiciones locales de los miembros del personal sanitario., Introduction The World Health Organization (WHO) recognizes the need for policies designed to overcome the chronic undersupply of health workers in rural areas in both developed and developing countries. (1) [...]

Objective: To outline a new index of access to primary care services in rural areas that has been specifically designed to overcome weaknesses of using existing geographical classifications. Methods: Access was measured by four key dimensions of availability, proximity, health needs and mobility. Population data were obtained through the national census and primary care service data were obtained through the Medical Directory of Australia. All data were calculated at the smallest feasible geographical unit (collection districts). The index of access was measured using a modified two-step floating catchment area (2SFCA) method, which incorporates two necessary additional spatial functions (distance-decay and capping) and two additional non-spatial dimensions (health needs and mobility). Results: An improved index of access, specifically designed to better capture access to primary care in rural areas, is achieved. These improvements come from: 1) incorporation of actual health service data in the index; 2) methodological improvements to existing access measures, which enable both proximity to be differentiated within catchments and the use of varying catchment sizes; and 3) improved sensitivity to small-area variations. Conclusion: Despite their recognised weaknesses, the Australian government uses broad geographical classifications as proxy measures of access to underpin significant rural health funding programs. This new index of access could provide a more equitable means for resource allocation. Implications: Significant government funding, aimed at improving health service access inequities in rural areas, could be better targeted by underpinning programs with our improved access measure. Key words: Access to health care, primary care, rural health, government programs, indexes. doi: 10.1111/j.1753-6405.2009.00422.x

Background: Medical training is a long process that is not complete until doctors finish specialty training. Getting into specialty training is challenging because of strong competition for limited places, depending on doctors' chosen field. This may have a negative impact on doctor well-being and reduce the efficiency of the medical training system. This study explored the barriers of pre-registrar (junior) doctors getting into specialty training programs to inform tailored support and re-design of speciality entry systems. Methods: From March to October 2019, we conducted 32 semi-structured interviews with early-career doctors in Australia, who had chosen their specialty field, and were either seeking entry, currently undertaking or had recently completed various fields of specialty training. We sought reflections about barriers and major influences to getting into specialty training. In comparing and contrasting generated themes, different patterns emerged from doctors targeting traditionally non-competitive specialty fields like General Practice (GP) and other specialties (typically more competitive fields). As a result we explored the data in this dichotomy. Results: Doctors targeting entry to GP specialties had relatively seamless training entry and few specific barriers. In contrast, those pursuing other specialties, regardless of which ones, relayed multiple barriers of: Navigating an unpredictable and complex system with informal support/guidance; Connecting to the right people/networks for relevant experience; Pro-actively planning and differentiating skills with recurrent failure of applications. Conclusions: Our exploratory study suggests that doctors wanting to get into non-GP specialty training may experience strong barriers, potentially over multiple years, with the capacity to threaten their morale and resilience. These could be addressed by a clearinghouse of information about different speciality programs, broader selection criteria, feedback on applications and more formal guidance and professional supports. The absence of challenges identified for doctors seeking entry to GP could be used to promote increased uptake of GP careers. [ABSTRACT FROM AUTHOR]

Abstract Background The two step floating catchment area (2SFCA) method has emerged in the last decade as a key measure of spatial accessibility, particularly in its application to primary health care access. Many recent ‘improvements’ to the original 2SFCA method have been developed, which generally either account for distance-decay within a catchment or enable the usage of variable catchment sizes. This paper evaluates the effectiveness of various proposed methods within these two improvement groups. Moreover, its assessment focuses on how well these improvements operate within and between rural and metropolitan populations over large geographical regions. Results Demonstrating these improvements to the whole state of Victoria, Australia, this paper presents the first comparison between continuous and zonal (step) decay functions and specifically their effect within both rural and metropolitan populations. Especially in metropolitan populations, the application of either type of distance-decay function is shown to be problematic by itself. Its inclusion necessitates the addition of a variable catchment size function which can enable the 2SFCA method to dynamically define more appropriate catchments which align with actual health service supply and utilisation. Conclusion This study assesses recent ‘improvements’ to the 2SFCA when applied over large geographic regions of both large and small populations. Its findings demonstrate the necessary combination of both a distance-decay function and variable catchment size function in order for the 2SFCA to appropriately measure healthcare access across all geographical regions.

Abstract Background Rural and remote areas are characterised by a shortage of medical practitioners. Rural background has been shown to be a significant factor associated with medical graduates' intentions and decisions to practise within a rural area, though most studies have only used simple definitions of rural background and not previously looked at specialists. This paper aims to investigate in detail the nature of the association between rural background and practice location of Australian general practitioners (GPs) and specialists Methods Data for 3156 GPs and 2425 specialists were obtained from the Medicine in Australia: Balancing Employment and Life (MABEL) study. Data on the number of childhood years resident in a rural location and population size of their rural childhood location were matched against current practice location. Logistic regression modelling was used to calculate adjusted associations between doctors in rural practice and rural background, sex and age. Results GPs with at least 6 years of their childhood spent in a rural area were significantly more likely than those with 0-5 years in a rural area to be practising in a rural location (OR 2.28, 95% CI 1.69-3.08), whilst only specialists with at least 11 years rural background were significantly more likely to be practising in a rural location (OR 2.27, 95% CI 1.77-2.91). However, for doctors with a rural background, the size of the community that they grew up in was not significantly associated with the size of the community in which they currently practise. Both female GPs and female specialists are similarly much less likely to be practising in a rural location compared with males (GPs: OR 0.53, 95% CI 0.45-0.62). Conclusions This study elucidates the association between rural background and rural practice for both GPs and specialists. It follows that increased take-up of rural practice by new graduates requires an increased selection of students with strong rural backgrounds. However, given the considerable under-representation of rural background students in medical schools and the reluctance of females to practise in rural areas, the selection of rural background students is only part of the solution to increasing the supply of rural doctors.

Abstract Background Peripheral intravenous device (IVD) complications were traditionally thought to be reduced by limiting dwell time. Current recommendations are to resite IVDs by 96 hours with the exception of children and patients with poor veins. Recent evidence suggests routine resite is unnecessary, at least if devices are inserted by a specialised IV team. The aim of this study was to compare the impact of peripheral IVD 'routine resite' with 'removal on clinical indication' on IVD complications in a general hospital without an IV team. Methods A randomised, controlled trial was conducted in a regional teaching hospital. After ethics approval, 362 patients (603 IVDs) were randomised to have IVDs replaced on clinical indication (185 patients) or routine change every 3 days (177 patients). IVDs were inserted and managed by the general hospital medical and nursing staff; there was no IV team. The primary endpoint was a composite of IVD complications: phlebitis, infiltration, occlusion, accidental removal, local infection, and device-related bloodstream infection. Results IVD complication rates were 68 per 1,000 IVD days (clinically indicated) and 66 per 1,000 IVD days (routine replacement) (P = 0.86; HR 1.03; 95% CI, 0.74-1.43). Time to first complication per patient did not differ between groups (KM with log rank, P = 0.53). There were no local infections or IVD-related bloodstream infections in either group. IV therapy duration did not differ between groups (P = 0.22), but more (P = 0.004) IVDs were placed per patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly higher hospital costs per patient (P < 0.001). Conclusions Resite on clinical indication would allow one in two patients to have a single cannula per course of IV treatment, as opposed to one in five patients managed with routine resite; overall complication rates appear similar. Clinically indicated resite would achieve savings in equipment, staff time and patient discomfort. There is growing evidence to support the extended use of peripheral IVDs with removal only on clinical indication. Registration number Australian New Zealand Clinical Trials Registry (ANZCTR) Number ACTRN12608000421336.

Abstract Background The problem of access to health care is of growing concern for rural and remote populations. Many Australian rural health funding programs currently use simplistic rurality or remoteness classifications as proxy measures of access. This paper outlines the development of an alternative method for the measurement of access to primary care, based on combining the three key access elements of spatial accessibility (availability and proximity), population health needs and mobility. Methods The recently developed two-step floating catchment area (2SFCA) method provides a basis for measuring primary care access in rural populations. In this paper, a number of improvements are added to the 2SFCA method in order to overcome limitations associated with its current restriction to a single catchment size and the omission of any distance decay function. Additionally, small-area measures for the two additional elements, health needs and mobility are developed. By utilising this improved 2SFCA method, the three access elements are integrated into a single measure of access. This index has been developed within the state of Victoria, Australia. Results The resultant index, the Index of Rural Access, provides a more sensitive and appropriate measure of access compared to existing classifications which currently underpin policy measures designed to overcome problems of limited access to health services. The most powerful aspect of this new index is its ability to identify access differences within rural populations at a much finer geographical scale. This index highlights that many rural areas of Victoria have been incorrectly classified by existing measures as homogenous in regards to their access. Conclusion The Index of Rural Access provides the first truly integrated index of access to primary care. This new index can be used to better target the distribution of limited government health care funding allocated to address problems of poor access to primary health care services in rural areas.