Editorial: Navigating low-value care in regional, rural and remote Australia

Abstract

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of efficiency further compounded by clinician beliefs about consequences and capabilities of care provision (unpublished data).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 clinical safety net have also led to increases in pathology and radiology testing. Indeed, where patient transfers are required, some tertiary regional receiving teams will not accept the patient until testing and imaging have been done, citing the need for efficiency.

In primary care, a ‘time’ and a ‘wait-and-see’ approach have always been part of the diagnostic toolkit for general practice (GP). However, due to a lack of GPs in some towns, reduced patient access, substantial travel distances for patients and difficulties in getting subsequent appointments, the ordering of a suite of pathology tests in a single visit has become more frequent. Unfortunately, these contextual experiences also give rise to LVC.

Thursday Island Hospital operates emergency, inpatient, maternity, theatre, dialysis, laboratory and imaging departments. A population of 6000 predominately First Nations people are dispersed across 16 remote islands across the Torres Strait, most with only small local health services staffed by nurses and Aboriginal and Torres Strait Islander Health Workers/Practitioners who provide primary and 24-hour emergency care. Providing timely health services to people in these communities is challenging. Unplanned presentations are assessed in the context of limited bedside diagnostics such as ECG, iStats and urine tests. Escalations in care go to the Medical Officer on Thursday Island via phone and/or videoconference. In this environment, health care decisions are made by clinicians remote from the patient, with limited diagnostic tools, and a high pre-test probability for complex conditions and critical illness.

For example, early symptoms of sepsis can be broad and difficult to diagnose even in tertiary facilities. Aboriginal and Torres Strait Islander people have a higher prevalence of sepsis than other Australians.¹² For early symptoms of sepsis in general populations, a C-reactive protein (CRP) is often considered LVC; however, in this environment, with a higher pre-test probability, it can be lifesaving. A high CRP in an otherwise objectively well patient, who is only exhibiting soft signs of illness, will direct treating clinicians towards action in line with State-wide Sepsis Pathways¹³ for possible severe illness. In these remote environments with a relatively high pre-test probability of complex or severe illness and limited diagnostic tools, tests that would otherwise be considered LVC become high value for consumers and clinicians.

These three contexts reflect something of the complexity of the issue of LVC beyond metropolitan areas. In regional, rural and remote settings, finding the ‘sweet spot’¹⁴ for diagnostic investigations that balance over-use and under-use, while seeking the best health outcomes for patients in the ‘grey zone’ for effective treatment,⁵ requires an understanding of context. Our health systems have great challenges to address growing populations, diminishing resources and the tyranny of distance. Some diagnostic tests have higher pre-test probabilities than the same tests in metropolitan areas. Our access to timely interventions can depend on realities such as access to aeromedical retrievals, the need to coordinate pathology pickup with the relevant transport facilities (ferry, courier etc.), workforce familiarity with patients, as well as the pervasive reality of under-resourced facilities. In these contexts, clinician and community engagement will be critical in identifying local instances of LVC, as well as drivers, practices and behaviours. Clinician and community engagement will also be critical in understanding priorities and opportunities for interventions to achieve effective and sustainable de-implementation of LVC.¹⁵

Rae Thomas: Conceptualization; writing – original draft; writing – review and editing. Vinay Gangathimmaiah: Conceptualization; writing – original draft; writing – review and editing. Marlow Coates: Conceptualization; writing – original draft; writing – review and editing. Michelle Guppy: Conceptualization; writing – original draft; writing – review and editing.

Prof. Michelle Guppy is an associate editor and Editorial Board Member of the Australian Journal of Rural Health. The other authors declare no conflict of interest.