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Otorhinolaryngology, head and neck surgery (ORL) doctors diagnose and treat disorders of the ear, nose and throat, and head and neck. ORL conditions are common, accounting for one in eight primary care encounters, and make up a large part of the clinical workload of general practitioners, rural physicians, emergency physicians and paediatricians.[[1]] Rural patients face greater barriers to healthcare compared to those in urban centres.[[2]] These include long travel distances, lack of access to transport, telecommunication, increased costs, higher levels of deprivation, and wider socio-economic factors.[[2,3]] As a result, numerous ORL presentations are managed by rural and emergency physicians in rural hospitals. To our knowledge, no study has looked at the type and volume of ORL cases of rural patients in Aotearoa, New Zealand. We aim to provide information on the diagnoses of rural patients presenting with ORL complaints and identify differences between rural and urban patients. These data may be useful in targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Methods

Design

A 6-year retrospective study was performed from 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using the ICD-10 codes (Appendix 2) relevant to ORL. Data were retrieved from the data warehouse including age, gender, ethnicity, closest hospital, domicile, decile, rural status, hospital of presentation, outcome of encounter (admitted to hospital, discharged directly from the emergency department [ED], transfer to another hospital, general practitioner [GP] follow-up, ORL outpatient clinic, did not wait in ED) and discharge diagnosis description. Patients’ electronic clinical notes including discharge summaries were reviewed to confirm inclusion in the study.

Setting

This study was conducted in Te Tai Tokerau, Northland, which spans from Cape Reinga to Te Hana. The wide geographical spread of Northland means that patients can be more than four hours from specialty services in Whangārei. There is a higher proportion of Māori people compared to the national average.[[5,6]] The whenua (land) of 12 iwi falls either partly or wholly within Te Tai Tokerau, as shown in Appendix 1.[[7]] There is an estimated population of more than 178,000 people,[[4]] and the population is older than the national average, with age brackets of 50+ being over-represented.[[5,6]] There is a very high proportion of people living in areas of high deprivation.[[5,6]] There are five hospitals, Whangārei Hospital being the largest and the only one providing secondary care services including access to 24/7 on call ORL services. Kaitaia, Bay of Islands, Dargaville and Rawene Hospitals are rural hospitals. Rural hospitals are staffed by trained generalists who diagnose and treat a diverse range of clinical presentations.[[8]] They provide variable levels of service to adapt to the needs of the rural communities that they serve.[[8]] The Royal New Zealand College of General Practitioners (RNZCGP) Division of Rural Hospital Medicine identifies three levels of rural hospital in the 2022 Training Handbook:[[8]]

1. A hospital with acute inpatient beds and daily visiting medical cover. On call cover outside of these times is provided by appropriately trained nursing and/or medical staff. There are no on-site laboratory services, and limited radiology services.[[8]]

2. A hospital with acute inpatient beds and medical care on-site during normal working hours with on-call cover outside of these hours. Point-of-care and off-site laboratory services and on-call radiography services are available.[[8]]

3. A hospital with 24-hour onsite medical cover and 24-hour access to laboratory and radiology services.[[8]]

Rural and urban

Rural and urban status was retrieved from the NDHB data warehouse. This has been classified using the Stats NZ Urban Rural indicator, based on last known patient address.[[9]] Categories include “Main Urban Centre”, “Secondary Urban Centre, “Minor Urban Area”, “Rural Centre”, and “Other Rural”. This classification system does not differentiate by access to rural or urban healthcare.[[9]] In our study, “Rural Centres", “Other Rural”, and “Minor Urban Centres” were grouped as “Rural”, and “Main Urban Centres” was grouped as “Urban”. Using the census indicator, areas such as Kaitaia and Dargaville are described as minor urban areas. However, these areas are serviced by rural hospitals as seen in Figure 1. As such, minor urban areas were included in the rural group as this better reflects their access to healthcare.

View Figure 1, Tables 1–4.

Inclusion and exclusion criteria

The study included any patient acutely presenting to Kaitaia, Bay of Islands, Dargaville or Whangārei hospitals with an ORL diagnosis. Conditions included are listed in Appendix 2. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded. Patients were also excluded if their residential address was outside of Northland. Cases were excluded if they were referred directly by their GP to the ear, nose and throat (ENT) service and were not seen by a rural medicine or ED physician.

Ethics approval

The study was deemed out-of-scope by the Health and Disability Ethics Commission on 5 January 2022. NDHB locality approval was granted on 27 October 2021. The study was reviewed and approved by the NDHB Māori Health Directorate on 27 October 2021.

Statistical analysis

Categorical data were described with the number and percentage. Normally distributed data were described with the mean and standard deviation (SD). Non-normally distributed data were described with the median and interquartile range (IQR). Dichotomous variables were analysed with a Chi-squared test or a Fisher’s exact test. A Mann–Whitney U test was used to analyse non-normally distributed data. Data were entered in IBM SPSS (Version 28.0, Armonk, NY) for analysis.

Results

Demographics

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three-hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. Demographic information is shown in Table 1.

Type of presentations

Rural patients were more likely to have rhinology or throat symptoms and less likely to present with an otology presentation than their urban counterparts, as seen in Table 2. The most common presentation was epistaxis with 16.8% (n=927/5,534) of total presentations. Rates were similar between rural (19%, n=462/2,430) and urban (15%, n=465/3,104) patients. The four next most common presentations were otological. Otitis media made up 13.3% of rural, 18.1% of urban and 16.0% of overall presentations. Otitis externa made up 8.3% of rural, 14.3% of urban and 11.7% of all presentations. Otalgia made up for 6.8% of rural, 4.9% of urban and 5.7% of overall presentations. Foreign bodies in ears were seen in 5.3% of rural, 5.0% of urban and 5.1% of all presentations. Following this, sinusitis was diagnosed in 5.1% of rural, 4.9% of urban and 5.0% of all presentations. Nasal fractures were diagnosed in 5.2% of rural, 4.0% of urban and 4.5% of all presentations. A full breakdown of presentations is provided in Appendix 3.

Complications

There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications shown in Table 3. One hundred and nine complications (48.7%) were in rural patients and 115 (51.3%) in urban patients. The most common complication in both rural and urban patients was a post-operative bleed making up 71/109 (65.1%) complications in rural patients and 72/115 (62.6%) complications in urban patients.

Outcome of presentations

There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the ED (p<0.001). Fifty-six rural patients were transferred to another hospital and 21 rural patients seen in Whangārei ED had been transferred from another hospital totalling 77 of 2,430 (3.2%). There was a significant difference in the rate of admission to hospital with 516 of 2,430 (21.2%) rural patients and 457 of 3,104 (14.7%) urban patients requiring admission (p<0.001).

Discussion

This retrospective review describes the numbers and types of ORL presentations seen in the emergency department acutely across Northland. The most common presenting diagnosis was epistaxis while the majority of presentations as an overall group were otological. Rural patients were more likely to present with rhinology or throat/laryngology symptoms and less likely to present with otology symptomatology compared to urban patients. Most rural and urban patients were discharged from ED; however, rural patients were more likely to be admitted to hospital than urban patients. Three point two percent of rural patients were transferred to another hospital for ORL admission.

Our results show the significant number of ORL presentations to hospital in both rural and urban patients. Rural ORL care is imperative due to the geographic spread of the region and the limitation of immediate specialty services to Whangārei Hospital. Appropriate resourcing and education opportunities need to be provided to rural health practitioners to ensure they have the knowledge and experience to manage acute ORL conditions.[[11]] This study suggests that the key areas to target are the management of epistaxis, otitis media, otitis externa, otalgia, foreign bodies in ears, nasal fractures, and post-operative bleeding. While ORL outreach services are important, educational opportunities and formal teaching sessions are crucial to provide high quality care to our rural patients.

We found that admissions to hospital were higher in rural patients compared to urban patients. This may be due to several reasons including greater severity of disease requiring admission, reduced access to primary care, lack of access to specialist review and opinion, or the need to address socio-economic determinants of health.[[2,3]] Further research is required to accurately determine the reasons for higher admissions in rural patients. The findings of this study, however, can be used to guide healthcare resources and planning.

This is the first study to explore rural health presentations in ORL in Aotearoa, New Zealand. There is a scarcity of published literature surrounding rural presentations of ORL cases both in Aotearoa and around the world. A prospective audit conducted in a tertiary Belgian hospital found that 20.5% of patients referred to the ENT emergency service over a 1-month period had a nose or sinus complaint, 36.8% an otological or vestibular complaint and 42.6% with a laryngeal or neck complaint; however, this did not focus on rural patients.[[12]] A recently published scoping review of 79 US based studies examining rural disparities in ORL found that there is low-quality evidence with large gaps in the literature in all subspecialties.[[13]] There is no consistent definition in the literature regarding rurality.[[14]] In this study rurality has been defined using the Stats NZ Urban Rural indicator, classified by patient address. This is commonly used in health research but does not consider distance from health services.[[10,14]] It is for this reason that our study grouped “Rural Centre”, “Other Rural” and “Minor Urban Areas” as rural to better reflect the distance from, and therefore access to, health services. Further study using the newly developed Geographic Classification for Health may provide greater insight into disparities between urban and rural populations.[[14]]

Several limitations exist in this study. First this is a retrospective study and is limited by misclassification bias and missing information. Participant identification relied on accurate diagnosis and clinical coding of patient events. This study did not include patients from Rawene Hospital, which is run under the rural hospital medicine scope of practice by Hauora Hokianga as data systems are not shared with NDHB. It is important to interpret the results of this study with the understanding that only patients presenting to the Hospital ED were included. Patients treated in the community, referred directly to ORL from the community or who were seen in the acute ORL clinic instead of the ED were not included.

Conclusion

This retrospective review provides a picture of acute ORL presentations in Northland, which has been analysed with respect to geography. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

View Appendices 1–3.

Summary

Abstract

Aim

Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients.

Method

A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded.

Results

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p<0.001).

Conclusion

This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Author Information

Chelsea L Heaven: Registrar, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand. Matthew James McGuinness: Training Registrar, Department of General Surgery, Te Whatu Ora Southern, Invercargill, New Zealand. Subhaschandra Shetty: Otolaryngologist and Head and Neck Surgeon, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand.

Acknowledgements

Correspondence

Chelsea L Heaven: Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Private Bag 9742, Whangārei 0148, New Zealand.

Correspondence Email

Chelsea.l.heaven@gmail.com

Competing Interests

Nil

1) Sorichetti BD, Pauwels J, Jacobs TB, et al. High frequency of otolaryngology/ENT encounters in Canadian primary care despite low medical undergraduate experiences. Can Med Educ J. 2022 Mar 2;13(1):86-9. doi: 10.36834/cmej.72328.

2) World Health Organization. Delivering quality health services in rural communities. In: Delivery quality health services: A global imperative [Internet]. OECD Publishing; 2018 Jul 5 [cited 2022 Nov 26]. Available from: https://www.oecd-ilibrary.org/sites/04e76409-en/index.html?itemId=/content/component/04e76409-en.

3) Smith KB, Humphreys JS, Wilson MG. Addressing the health disadvantage of rural populations: how does epidemiological evidence inform rural health policies and research?. Aust J Rural Health. 2008 Apr;16(2):56-66. doi: 10.1111/j.1440-1584.2008.00953.x.

4) Stats NZ. Northland Region [Internet]. Wellington: New Zealand Government; 2018 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/tools/2018-census-place-summaries/northland-region.

5) Northland District Health Board. Northland District Health Board Annual Report 2020 [Internet]. Northland: Northland District Health Board; 2020 [cited 2022 Nov 26]. Available from: https://www.northlanddhb.org.nz/assets/Publications/2839-NDHB-Annual-Report-2020-WEB.PDF.

6) Yong R, Browne M, Zhao J, et al. A deprivation and demographic profile of the Northland DHB. The University of Auckland. 2017 Oct 17. Available from: https://www.fmhs.auckland.ac.nz/assets/fmhs/soph/epi/hgd/docs/dhbprofiles/Northland.pdf.

7) Northland Regional Council. State of the Envrionment Report – Tangata Whenua [Internet]. New Zealand: Northland Regional Council; 2007 [cited 2023 Jan 1]. Available from: https://www.nrc.govt.nz/media/jdtblsvy/18tangatawhenua.pdf.

8) The Royal New Zealand College of General Practitioners. Rural Hospital Medicine Training Programme Handbook 2022 [Internet]. Wellington: 2021 December. Available from: https://www.rnzcgp.org.nz/gpdocs/new-website/become_a_gp/v6_DRHM_Handbook_2022.pdf.

9) Stats NZ. Urban accessibility – methodology and classification [Internet]. Wellington: New Zealand Government; 2020 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/assets/Uploads/Methods/Urban-accessibility-methodology-and-classification/Download-document/Urban-accessibility-methodology-and-classification.pdf.

10) Fearnley D, Lawrenson R, Nixon G. 'Poorly defined': unknown unknowns in New Zealand Rural Health. N Z Med J. 2016 Aug 5;129(1439):77.

11) Curran VR, Fleet L, Kirby F. Factors influencing rural health care professionals’ access to continuing professional education. Aust J Rural Health. 2006 Apr;14(2):51-5. doi: 10.1111/j.1440-1584.2006.00763.x.

12) Atta L, Delrez S, Asimakopoulos A, et al. A prospective audit of acute ENT activity in a university teaching hospital. B-ENT. 2019 Jan 1;15(2):71-6.

13) Urban MJ, Shimomura A, Shah S, et al. Rural otolaryngology care disparities: a scoping review. Otolaryngol Head Neck Surg. 2022 Jan 11:66(6):1219-1227. doi: 10.1177/01945998211068822.

14) Whitehead J, Davie G, de Graaf B, et al. Defining rural in Aotearoa New Zealand: a novel geographic classification for health purposes. N Z Med J. 2022 Aug 5;135(1559):24-40.

For the PDF of this article,
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Otorhinolaryngology, head and neck surgery (ORL) doctors diagnose and treat disorders of the ear, nose and throat, and head and neck. ORL conditions are common, accounting for one in eight primary care encounters, and make up a large part of the clinical workload of general practitioners, rural physicians, emergency physicians and paediatricians.[[1]] Rural patients face greater barriers to healthcare compared to those in urban centres.[[2]] These include long travel distances, lack of access to transport, telecommunication, increased costs, higher levels of deprivation, and wider socio-economic factors.[[2,3]] As a result, numerous ORL presentations are managed by rural and emergency physicians in rural hospitals. To our knowledge, no study has looked at the type and volume of ORL cases of rural patients in Aotearoa, New Zealand. We aim to provide information on the diagnoses of rural patients presenting with ORL complaints and identify differences between rural and urban patients. These data may be useful in targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Methods

Design

A 6-year retrospective study was performed from 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using the ICD-10 codes (Appendix 2) relevant to ORL. Data were retrieved from the data warehouse including age, gender, ethnicity, closest hospital, domicile, decile, rural status, hospital of presentation, outcome of encounter (admitted to hospital, discharged directly from the emergency department [ED], transfer to another hospital, general practitioner [GP] follow-up, ORL outpatient clinic, did not wait in ED) and discharge diagnosis description. Patients’ electronic clinical notes including discharge summaries were reviewed to confirm inclusion in the study.

Setting

This study was conducted in Te Tai Tokerau, Northland, which spans from Cape Reinga to Te Hana. The wide geographical spread of Northland means that patients can be more than four hours from specialty services in Whangārei. There is a higher proportion of Māori people compared to the national average.[[5,6]] The whenua (land) of 12 iwi falls either partly or wholly within Te Tai Tokerau, as shown in Appendix 1.[[7]] There is an estimated population of more than 178,000 people,[[4]] and the population is older than the national average, with age brackets of 50+ being over-represented.[[5,6]] There is a very high proportion of people living in areas of high deprivation.[[5,6]] There are five hospitals, Whangārei Hospital being the largest and the only one providing secondary care services including access to 24/7 on call ORL services. Kaitaia, Bay of Islands, Dargaville and Rawene Hospitals are rural hospitals. Rural hospitals are staffed by trained generalists who diagnose and treat a diverse range of clinical presentations.[[8]] They provide variable levels of service to adapt to the needs of the rural communities that they serve.[[8]] The Royal New Zealand College of General Practitioners (RNZCGP) Division of Rural Hospital Medicine identifies three levels of rural hospital in the 2022 Training Handbook:[[8]]

1. A hospital with acute inpatient beds and daily visiting medical cover. On call cover outside of these times is provided by appropriately trained nursing and/or medical staff. There are no on-site laboratory services, and limited radiology services.[[8]]

2. A hospital with acute inpatient beds and medical care on-site during normal working hours with on-call cover outside of these hours. Point-of-care and off-site laboratory services and on-call radiography services are available.[[8]]

3. A hospital with 24-hour onsite medical cover and 24-hour access to laboratory and radiology services.[[8]]

Rural and urban

Rural and urban status was retrieved from the NDHB data warehouse. This has been classified using the Stats NZ Urban Rural indicator, based on last known patient address.[[9]] Categories include “Main Urban Centre”, “Secondary Urban Centre, “Minor Urban Area”, “Rural Centre”, and “Other Rural”. This classification system does not differentiate by access to rural or urban healthcare.[[9]] In our study, “Rural Centres", “Other Rural”, and “Minor Urban Centres” were grouped as “Rural”, and “Main Urban Centres” was grouped as “Urban”. Using the census indicator, areas such as Kaitaia and Dargaville are described as minor urban areas. However, these areas are serviced by rural hospitals as seen in Figure 1. As such, minor urban areas were included in the rural group as this better reflects their access to healthcare.

View Figure 1, Tables 1–4.

Inclusion and exclusion criteria

The study included any patient acutely presenting to Kaitaia, Bay of Islands, Dargaville or Whangārei hospitals with an ORL diagnosis. Conditions included are listed in Appendix 2. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded. Patients were also excluded if their residential address was outside of Northland. Cases were excluded if they were referred directly by their GP to the ear, nose and throat (ENT) service and were not seen by a rural medicine or ED physician.

Ethics approval

The study was deemed out-of-scope by the Health and Disability Ethics Commission on 5 January 2022. NDHB locality approval was granted on 27 October 2021. The study was reviewed and approved by the NDHB Māori Health Directorate on 27 October 2021.

Statistical analysis

Categorical data were described with the number and percentage. Normally distributed data were described with the mean and standard deviation (SD). Non-normally distributed data were described with the median and interquartile range (IQR). Dichotomous variables were analysed with a Chi-squared test or a Fisher’s exact test. A Mann–Whitney U test was used to analyse non-normally distributed data. Data were entered in IBM SPSS (Version 28.0, Armonk, NY) for analysis.

Results

Demographics

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three-hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. Demographic information is shown in Table 1.

Type of presentations

Rural patients were more likely to have rhinology or throat symptoms and less likely to present with an otology presentation than their urban counterparts, as seen in Table 2. The most common presentation was epistaxis with 16.8% (n=927/5,534) of total presentations. Rates were similar between rural (19%, n=462/2,430) and urban (15%, n=465/3,104) patients. The four next most common presentations were otological. Otitis media made up 13.3% of rural, 18.1% of urban and 16.0% of overall presentations. Otitis externa made up 8.3% of rural, 14.3% of urban and 11.7% of all presentations. Otalgia made up for 6.8% of rural, 4.9% of urban and 5.7% of overall presentations. Foreign bodies in ears were seen in 5.3% of rural, 5.0% of urban and 5.1% of all presentations. Following this, sinusitis was diagnosed in 5.1% of rural, 4.9% of urban and 5.0% of all presentations. Nasal fractures were diagnosed in 5.2% of rural, 4.0% of urban and 4.5% of all presentations. A full breakdown of presentations is provided in Appendix 3.

Complications

There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications shown in Table 3. One hundred and nine complications (48.7%) were in rural patients and 115 (51.3%) in urban patients. The most common complication in both rural and urban patients was a post-operative bleed making up 71/109 (65.1%) complications in rural patients and 72/115 (62.6%) complications in urban patients.

Outcome of presentations

There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the ED (p<0.001). Fifty-six rural patients were transferred to another hospital and 21 rural patients seen in Whangārei ED had been transferred from another hospital totalling 77 of 2,430 (3.2%). There was a significant difference in the rate of admission to hospital with 516 of 2,430 (21.2%) rural patients and 457 of 3,104 (14.7%) urban patients requiring admission (p<0.001).

Discussion

This retrospective review describes the numbers and types of ORL presentations seen in the emergency department acutely across Northland. The most common presenting diagnosis was epistaxis while the majority of presentations as an overall group were otological. Rural patients were more likely to present with rhinology or throat/laryngology symptoms and less likely to present with otology symptomatology compared to urban patients. Most rural and urban patients were discharged from ED; however, rural patients were more likely to be admitted to hospital than urban patients. Three point two percent of rural patients were transferred to another hospital for ORL admission.

Our results show the significant number of ORL presentations to hospital in both rural and urban patients. Rural ORL care is imperative due to the geographic spread of the region and the limitation of immediate specialty services to Whangārei Hospital. Appropriate resourcing and education opportunities need to be provided to rural health practitioners to ensure they have the knowledge and experience to manage acute ORL conditions.[[11]] This study suggests that the key areas to target are the management of epistaxis, otitis media, otitis externa, otalgia, foreign bodies in ears, nasal fractures, and post-operative bleeding. While ORL outreach services are important, educational opportunities and formal teaching sessions are crucial to provide high quality care to our rural patients.

We found that admissions to hospital were higher in rural patients compared to urban patients. This may be due to several reasons including greater severity of disease requiring admission, reduced access to primary care, lack of access to specialist review and opinion, or the need to address socio-economic determinants of health.[[2,3]] Further research is required to accurately determine the reasons for higher admissions in rural patients. The findings of this study, however, can be used to guide healthcare resources and planning.

This is the first study to explore rural health presentations in ORL in Aotearoa, New Zealand. There is a scarcity of published literature surrounding rural presentations of ORL cases both in Aotearoa and around the world. A prospective audit conducted in a tertiary Belgian hospital found that 20.5% of patients referred to the ENT emergency service over a 1-month period had a nose or sinus complaint, 36.8% an otological or vestibular complaint and 42.6% with a laryngeal or neck complaint; however, this did not focus on rural patients.[[12]] A recently published scoping review of 79 US based studies examining rural disparities in ORL found that there is low-quality evidence with large gaps in the literature in all subspecialties.[[13]] There is no consistent definition in the literature regarding rurality.[[14]] In this study rurality has been defined using the Stats NZ Urban Rural indicator, classified by patient address. This is commonly used in health research but does not consider distance from health services.[[10,14]] It is for this reason that our study grouped “Rural Centre”, “Other Rural” and “Minor Urban Areas” as rural to better reflect the distance from, and therefore access to, health services. Further study using the newly developed Geographic Classification for Health may provide greater insight into disparities between urban and rural populations.[[14]]

Several limitations exist in this study. First this is a retrospective study and is limited by misclassification bias and missing information. Participant identification relied on accurate diagnosis and clinical coding of patient events. This study did not include patients from Rawene Hospital, which is run under the rural hospital medicine scope of practice by Hauora Hokianga as data systems are not shared with NDHB. It is important to interpret the results of this study with the understanding that only patients presenting to the Hospital ED were included. Patients treated in the community, referred directly to ORL from the community or who were seen in the acute ORL clinic instead of the ED were not included.

Conclusion

This retrospective review provides a picture of acute ORL presentations in Northland, which has been analysed with respect to geography. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

View Appendices 1–3.

Summary

Abstract

Aim

Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients.

Method

A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded.

Results

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p<0.001).

Conclusion

This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Author Information

Chelsea L Heaven: Registrar, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand. Matthew James McGuinness: Training Registrar, Department of General Surgery, Te Whatu Ora Southern, Invercargill, New Zealand. Subhaschandra Shetty: Otolaryngologist and Head and Neck Surgeon, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand.

Acknowledgements

Correspondence

Chelsea L Heaven: Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Private Bag 9742, Whangārei 0148, New Zealand.

Correspondence Email

Chelsea.l.heaven@gmail.com

Competing Interests

Nil

1) Sorichetti BD, Pauwels J, Jacobs TB, et al. High frequency of otolaryngology/ENT encounters in Canadian primary care despite low medical undergraduate experiences. Can Med Educ J. 2022 Mar 2;13(1):86-9. doi: 10.36834/cmej.72328.

2) World Health Organization. Delivering quality health services in rural communities. In: Delivery quality health services: A global imperative [Internet]. OECD Publishing; 2018 Jul 5 [cited 2022 Nov 26]. Available from: https://www.oecd-ilibrary.org/sites/04e76409-en/index.html?itemId=/content/component/04e76409-en.

3) Smith KB, Humphreys JS, Wilson MG. Addressing the health disadvantage of rural populations: how does epidemiological evidence inform rural health policies and research?. Aust J Rural Health. 2008 Apr;16(2):56-66. doi: 10.1111/j.1440-1584.2008.00953.x.

4) Stats NZ. Northland Region [Internet]. Wellington: New Zealand Government; 2018 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/tools/2018-census-place-summaries/northland-region.

5) Northland District Health Board. Northland District Health Board Annual Report 2020 [Internet]. Northland: Northland District Health Board; 2020 [cited 2022 Nov 26]. Available from: https://www.northlanddhb.org.nz/assets/Publications/2839-NDHB-Annual-Report-2020-WEB.PDF.

6) Yong R, Browne M, Zhao J, et al. A deprivation and demographic profile of the Northland DHB. The University of Auckland. 2017 Oct 17. Available from: https://www.fmhs.auckland.ac.nz/assets/fmhs/soph/epi/hgd/docs/dhbprofiles/Northland.pdf.

7) Northland Regional Council. State of the Envrionment Report – Tangata Whenua [Internet]. New Zealand: Northland Regional Council; 2007 [cited 2023 Jan 1]. Available from: https://www.nrc.govt.nz/media/jdtblsvy/18tangatawhenua.pdf.

8) The Royal New Zealand College of General Practitioners. Rural Hospital Medicine Training Programme Handbook 2022 [Internet]. Wellington: 2021 December. Available from: https://www.rnzcgp.org.nz/gpdocs/new-website/become_a_gp/v6_DRHM_Handbook_2022.pdf.

9) Stats NZ. Urban accessibility – methodology and classification [Internet]. Wellington: New Zealand Government; 2020 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/assets/Uploads/Methods/Urban-accessibility-methodology-and-classification/Download-document/Urban-accessibility-methodology-and-classification.pdf.

10) Fearnley D, Lawrenson R, Nixon G. 'Poorly defined': unknown unknowns in New Zealand Rural Health. N Z Med J. 2016 Aug 5;129(1439):77.

11) Curran VR, Fleet L, Kirby F. Factors influencing rural health care professionals’ access to continuing professional education. Aust J Rural Health. 2006 Apr;14(2):51-5. doi: 10.1111/j.1440-1584.2006.00763.x.

12) Atta L, Delrez S, Asimakopoulos A, et al. A prospective audit of acute ENT activity in a university teaching hospital. B-ENT. 2019 Jan 1;15(2):71-6.

13) Urban MJ, Shimomura A, Shah S, et al. Rural otolaryngology care disparities: a scoping review. Otolaryngol Head Neck Surg. 2022 Jan 11:66(6):1219-1227. doi: 10.1177/01945998211068822.

14) Whitehead J, Davie G, de Graaf B, et al. Defining rural in Aotearoa New Zealand: a novel geographic classification for health purposes. N Z Med J. 2022 Aug 5;135(1559):24-40.

For the PDF of this article,
contact nzmj@nzma.org.nz

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Otorhinolaryngology, head and neck surgery (ORL) doctors diagnose and treat disorders of the ear, nose and throat, and head and neck. ORL conditions are common, accounting for one in eight primary care encounters, and make up a large part of the clinical workload of general practitioners, rural physicians, emergency physicians and paediatricians.[[1]] Rural patients face greater barriers to healthcare compared to those in urban centres.[[2]] These include long travel distances, lack of access to transport, telecommunication, increased costs, higher levels of deprivation, and wider socio-economic factors.[[2,3]] As a result, numerous ORL presentations are managed by rural and emergency physicians in rural hospitals. To our knowledge, no study has looked at the type and volume of ORL cases of rural patients in Aotearoa, New Zealand. We aim to provide information on the diagnoses of rural patients presenting with ORL complaints and identify differences between rural and urban patients. These data may be useful in targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Methods

Design

A 6-year retrospective study was performed from 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using the ICD-10 codes (Appendix 2) relevant to ORL. Data were retrieved from the data warehouse including age, gender, ethnicity, closest hospital, domicile, decile, rural status, hospital of presentation, outcome of encounter (admitted to hospital, discharged directly from the emergency department [ED], transfer to another hospital, general practitioner [GP] follow-up, ORL outpatient clinic, did not wait in ED) and discharge diagnosis description. Patients’ electronic clinical notes including discharge summaries were reviewed to confirm inclusion in the study.

Setting

This study was conducted in Te Tai Tokerau, Northland, which spans from Cape Reinga to Te Hana. The wide geographical spread of Northland means that patients can be more than four hours from specialty services in Whangārei. There is a higher proportion of Māori people compared to the national average.[[5,6]] The whenua (land) of 12 iwi falls either partly or wholly within Te Tai Tokerau, as shown in Appendix 1.[[7]] There is an estimated population of more than 178,000 people,[[4]] and the population is older than the national average, with age brackets of 50+ being over-represented.[[5,6]] There is a very high proportion of people living in areas of high deprivation.[[5,6]] There are five hospitals, Whangārei Hospital being the largest and the only one providing secondary care services including access to 24/7 on call ORL services. Kaitaia, Bay of Islands, Dargaville and Rawene Hospitals are rural hospitals. Rural hospitals are staffed by trained generalists who diagnose and treat a diverse range of clinical presentations.[[8]] They provide variable levels of service to adapt to the needs of the rural communities that they serve.[[8]] The Royal New Zealand College of General Practitioners (RNZCGP) Division of Rural Hospital Medicine identifies three levels of rural hospital in the 2022 Training Handbook:[[8]]

1. A hospital with acute inpatient beds and daily visiting medical cover. On call cover outside of these times is provided by appropriately trained nursing and/or medical staff. There are no on-site laboratory services, and limited radiology services.[[8]]

2. A hospital with acute inpatient beds and medical care on-site during normal working hours with on-call cover outside of these hours. Point-of-care and off-site laboratory services and on-call radiography services are available.[[8]]

3. A hospital with 24-hour onsite medical cover and 24-hour access to laboratory and radiology services.[[8]]

Rural and urban

Rural and urban status was retrieved from the NDHB data warehouse. This has been classified using the Stats NZ Urban Rural indicator, based on last known patient address.[[9]] Categories include “Main Urban Centre”, “Secondary Urban Centre, “Minor Urban Area”, “Rural Centre”, and “Other Rural”. This classification system does not differentiate by access to rural or urban healthcare.[[9]] In our study, “Rural Centres", “Other Rural”, and “Minor Urban Centres” were grouped as “Rural”, and “Main Urban Centres” was grouped as “Urban”. Using the census indicator, areas such as Kaitaia and Dargaville are described as minor urban areas. However, these areas are serviced by rural hospitals as seen in Figure 1. As such, minor urban areas were included in the rural group as this better reflects their access to healthcare.

View Figure 1, Tables 1–4.

Inclusion and exclusion criteria

The study included any patient acutely presenting to Kaitaia, Bay of Islands, Dargaville or Whangārei hospitals with an ORL diagnosis. Conditions included are listed in Appendix 2. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded. Patients were also excluded if their residential address was outside of Northland. Cases were excluded if they were referred directly by their GP to the ear, nose and throat (ENT) service and were not seen by a rural medicine or ED physician.

Ethics approval

The study was deemed out-of-scope by the Health and Disability Ethics Commission on 5 January 2022. NDHB locality approval was granted on 27 October 2021. The study was reviewed and approved by the NDHB Māori Health Directorate on 27 October 2021.

Statistical analysis

Categorical data were described with the number and percentage. Normally distributed data were described with the mean and standard deviation (SD). Non-normally distributed data were described with the median and interquartile range (IQR). Dichotomous variables were analysed with a Chi-squared test or a Fisher’s exact test. A Mann–Whitney U test was used to analyse non-normally distributed data. Data were entered in IBM SPSS (Version 28.0, Armonk, NY) for analysis.

Results

Demographics

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three-hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. Demographic information is shown in Table 1.

Type of presentations

Rural patients were more likely to have rhinology or throat symptoms and less likely to present with an otology presentation than their urban counterparts, as seen in Table 2. The most common presentation was epistaxis with 16.8% (n=927/5,534) of total presentations. Rates were similar between rural (19%, n=462/2,430) and urban (15%, n=465/3,104) patients. The four next most common presentations were otological. Otitis media made up 13.3% of rural, 18.1% of urban and 16.0% of overall presentations. Otitis externa made up 8.3% of rural, 14.3% of urban and 11.7% of all presentations. Otalgia made up for 6.8% of rural, 4.9% of urban and 5.7% of overall presentations. Foreign bodies in ears were seen in 5.3% of rural, 5.0% of urban and 5.1% of all presentations. Following this, sinusitis was diagnosed in 5.1% of rural, 4.9% of urban and 5.0% of all presentations. Nasal fractures were diagnosed in 5.2% of rural, 4.0% of urban and 4.5% of all presentations. A full breakdown of presentations is provided in Appendix 3.

Complications

There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications shown in Table 3. One hundred and nine complications (48.7%) were in rural patients and 115 (51.3%) in urban patients. The most common complication in both rural and urban patients was a post-operative bleed making up 71/109 (65.1%) complications in rural patients and 72/115 (62.6%) complications in urban patients.

Outcome of presentations

There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the ED (p<0.001). Fifty-six rural patients were transferred to another hospital and 21 rural patients seen in Whangārei ED had been transferred from another hospital totalling 77 of 2,430 (3.2%). There was a significant difference in the rate of admission to hospital with 516 of 2,430 (21.2%) rural patients and 457 of 3,104 (14.7%) urban patients requiring admission (p<0.001).

Discussion

This retrospective review describes the numbers and types of ORL presentations seen in the emergency department acutely across Northland. The most common presenting diagnosis was epistaxis while the majority of presentations as an overall group were otological. Rural patients were more likely to present with rhinology or throat/laryngology symptoms and less likely to present with otology symptomatology compared to urban patients. Most rural and urban patients were discharged from ED; however, rural patients were more likely to be admitted to hospital than urban patients. Three point two percent of rural patients were transferred to another hospital for ORL admission.

Our results show the significant number of ORL presentations to hospital in both rural and urban patients. Rural ORL care is imperative due to the geographic spread of the region and the limitation of immediate specialty services to Whangārei Hospital. Appropriate resourcing and education opportunities need to be provided to rural health practitioners to ensure they have the knowledge and experience to manage acute ORL conditions.[[11]] This study suggests that the key areas to target are the management of epistaxis, otitis media, otitis externa, otalgia, foreign bodies in ears, nasal fractures, and post-operative bleeding. While ORL outreach services are important, educational opportunities and formal teaching sessions are crucial to provide high quality care to our rural patients.

We found that admissions to hospital were higher in rural patients compared to urban patients. This may be due to several reasons including greater severity of disease requiring admission, reduced access to primary care, lack of access to specialist review and opinion, or the need to address socio-economic determinants of health.[[2,3]] Further research is required to accurately determine the reasons for higher admissions in rural patients. The findings of this study, however, can be used to guide healthcare resources and planning.

This is the first study to explore rural health presentations in ORL in Aotearoa, New Zealand. There is a scarcity of published literature surrounding rural presentations of ORL cases both in Aotearoa and around the world. A prospective audit conducted in a tertiary Belgian hospital found that 20.5% of patients referred to the ENT emergency service over a 1-month period had a nose or sinus complaint, 36.8% an otological or vestibular complaint and 42.6% with a laryngeal or neck complaint; however, this did not focus on rural patients.[[12]] A recently published scoping review of 79 US based studies examining rural disparities in ORL found that there is low-quality evidence with large gaps in the literature in all subspecialties.[[13]] There is no consistent definition in the literature regarding rurality.[[14]] In this study rurality has been defined using the Stats NZ Urban Rural indicator, classified by patient address. This is commonly used in health research but does not consider distance from health services.[[10,14]] It is for this reason that our study grouped “Rural Centre”, “Other Rural” and “Minor Urban Areas” as rural to better reflect the distance from, and therefore access to, health services. Further study using the newly developed Geographic Classification for Health may provide greater insight into disparities between urban and rural populations.[[14]]

Several limitations exist in this study. First this is a retrospective study and is limited by misclassification bias and missing information. Participant identification relied on accurate diagnosis and clinical coding of patient events. This study did not include patients from Rawene Hospital, which is run under the rural hospital medicine scope of practice by Hauora Hokianga as data systems are not shared with NDHB. It is important to interpret the results of this study with the understanding that only patients presenting to the Hospital ED were included. Patients treated in the community, referred directly to ORL from the community or who were seen in the acute ORL clinic instead of the ED were not included.

Conclusion

This retrospective review provides a picture of acute ORL presentations in Northland, which has been analysed with respect to geography. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

View Appendices 1–3.

Summary

Abstract

Aim

Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients.

Method

A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded.

Results

Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p<0.001).

Conclusion

This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Author Information

Chelsea L Heaven: Registrar, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand. Matthew James McGuinness: Training Registrar, Department of General Surgery, Te Whatu Ora Southern, Invercargill, New Zealand. Subhaschandra Shetty: Otolaryngologist and Head and Neck Surgeon, Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand.

Acknowledgements

Correspondence

Chelsea L Heaven: Department of Otolaryngology, Head and Neck Surgery, Te Whatu Ora Te Tai Tokerau, Private Bag 9742, Whangārei 0148, New Zealand.

Correspondence Email

Chelsea.l.heaven@gmail.com

Competing Interests

Nil

1) Sorichetti BD, Pauwels J, Jacobs TB, et al. High frequency of otolaryngology/ENT encounters in Canadian primary care despite low medical undergraduate experiences. Can Med Educ J. 2022 Mar 2;13(1):86-9. doi: 10.36834/cmej.72328.

2) World Health Organization. Delivering quality health services in rural communities. In: Delivery quality health services: A global imperative [Internet]. OECD Publishing; 2018 Jul 5 [cited 2022 Nov 26]. Available from: https://www.oecd-ilibrary.org/sites/04e76409-en/index.html?itemId=/content/component/04e76409-en.

3) Smith KB, Humphreys JS, Wilson MG. Addressing the health disadvantage of rural populations: how does epidemiological evidence inform rural health policies and research?. Aust J Rural Health. 2008 Apr;16(2):56-66. doi: 10.1111/j.1440-1584.2008.00953.x.

4) Stats NZ. Northland Region [Internet]. Wellington: New Zealand Government; 2018 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/tools/2018-census-place-summaries/northland-region.

5) Northland District Health Board. Northland District Health Board Annual Report 2020 [Internet]. Northland: Northland District Health Board; 2020 [cited 2022 Nov 26]. Available from: https://www.northlanddhb.org.nz/assets/Publications/2839-NDHB-Annual-Report-2020-WEB.PDF.

6) Yong R, Browne M, Zhao J, et al. A deprivation and demographic profile of the Northland DHB. The University of Auckland. 2017 Oct 17. Available from: https://www.fmhs.auckland.ac.nz/assets/fmhs/soph/epi/hgd/docs/dhbprofiles/Northland.pdf.

7) Northland Regional Council. State of the Envrionment Report – Tangata Whenua [Internet]. New Zealand: Northland Regional Council; 2007 [cited 2023 Jan 1]. Available from: https://www.nrc.govt.nz/media/jdtblsvy/18tangatawhenua.pdf.

8) The Royal New Zealand College of General Practitioners. Rural Hospital Medicine Training Programme Handbook 2022 [Internet]. Wellington: 2021 December. Available from: https://www.rnzcgp.org.nz/gpdocs/new-website/become_a_gp/v6_DRHM_Handbook_2022.pdf.

9) Stats NZ. Urban accessibility – methodology and classification [Internet]. Wellington: New Zealand Government; 2020 [cited 2022 Nov 26]. Available from: https://www.stats.govt.nz/assets/Uploads/Methods/Urban-accessibility-methodology-and-classification/Download-document/Urban-accessibility-methodology-and-classification.pdf.

10) Fearnley D, Lawrenson R, Nixon G. 'Poorly defined': unknown unknowns in New Zealand Rural Health. N Z Med J. 2016 Aug 5;129(1439):77.

11) Curran VR, Fleet L, Kirby F. Factors influencing rural health care professionals’ access to continuing professional education. Aust J Rural Health. 2006 Apr;14(2):51-5. doi: 10.1111/j.1440-1584.2006.00763.x.

12) Atta L, Delrez S, Asimakopoulos A, et al. A prospective audit of acute ENT activity in a university teaching hospital. B-ENT. 2019 Jan 1;15(2):71-6.

13) Urban MJ, Shimomura A, Shah S, et al. Rural otolaryngology care disparities: a scoping review. Otolaryngol Head Neck Surg. 2022 Jan 11:66(6):1219-1227. doi: 10.1177/01945998211068822.

14) Whitehead J, Davie G, de Graaf B, et al. Defining rural in Aotearoa New Zealand: a novel geographic classification for health purposes. N Z Med J. 2022 Aug 5;135(1559):24-40.

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