Health professional and patient perspectives of factors associated with potentially avoidable hospitalisations in a rural Australian setting: a qualitative study


 Background

Potentially avoidable hospitalisations are a proxy measure of effective primary care at a population level. Hospitalisations for the chronic health conditions of diabetes, congestive cardiac failure and chronic obstructive pulmonary disease account for half of the potentially avoidable hospitalisations for chronic diseases. These hospitalisations are higher in rural areas and socioeconomically disadvantaged areas. Scarce qualitative research has focussed on the identification of factors associated with potentially avoidable hospitalisation from the perspectives of health professionals or patients. This study sought to identify factors associated with potentially avoidable hospitalisations in a rural context from the perspectives of patients and health professionals.
Methods

Patients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia, and health professionals involved in the care of patients with these conditions, were invited to participate in interviews between September and October 2019. Conversations were recorded, transcribed verbatim and analysed using thematic analysis.
Results

Nine patients and 16 health professionals participated in semi-structured interviews. Five themes were identified (representing factors associated with potentially avoidable hospitalisation); namely General Practitioner involvement, individual patient factors, the influence of the rural locality, medication awareness and health service access. Within these themes, inter-related subthemes emerged including sub-optimal disease management plans, barriers to accessing general practice, poor mental health, patients living alone, healthcare costs, sub-optimal communication and poor connectivity between patients and beneficial services.
Conclusion

Factors associated with potentially avoidable hospitalisation in this rural area were complex and inter-related. These factors encompassed health service access and disease management, as well as socioeconomic disadvantage. Results suggest that improved indicators of access to effective health services, including primary care, are necessary to address potentially avoidable hospitalisation.

Identi cation of factors may inform algorithms to identify patients at risk of potentially avoidable hospitalisation and provide identi ed patients with additional support, or to inform solutions to reduce avoidable hospitalisation. The aim of this study was to explore factors associated with potentially avoidable hospitalisations in a rural context from the perspectives of patients and health professionals.

Methods
Aim: The aim of the study was to identify factors associated with potentially avoidable hospitalisation for congestive heart failure, COPD or type 2 diabetes from the perspectives of patients and health professionals within the Benalla Local Government area.

Design
This was a qualitative study using semi-structured interviews following the Consolidated criteria for reporting qualitative research (COREQ) guidelines (13). Thematic analysis was chosen as it allowed for synthesis focused on a phenomenon of interest (14), this being the factors associated with potentially avoidable hospitalisations for congestive cardiac failure, COPD or type 2 diabetes in a rural Australian setting. Thematic analysis is also is a transparent method that actively seeks to remain close to the primary data and avoids over analysis (15).

Setting
Benalla is a medium sized rural town (Modi ed Monash Model 4 (16)), located approximately 200 km from the state capital city. The Benalla local government area (LGA) is more socio-economically disadvantaged than the state average (Index of Relative Socioeconomic disadvantage (IRSD) of 957 compared with Victorian average IRSD of 1010) (16), and has a high percentage of people aged 65+ (23% compared with 15% in Victoria) (16). The number of General Practitioners (GPs) per 1000 population (1.2) is equivalent to the state average (17), although access to bulk-billed services (no out of pocket cost is incurred by patient) is lower than state average (18). Benalla LGA experienced higher than state average potentially avoidable hospitalisations during the nancial years 2015/2016, 2016/2017 and 2017/2018 for COPD (3/3 of these nancial years), congestive cardiac failure (2/3 of these nancial years) and type 2 diabetes mellitus (1/3 of these nancial years) (19). Benalla Health employs 330 staff across acute, community and residential aged care services including a public hospital with 24 acute beds servicing a catchment of 13 800 people (19).
The hospital medical service is delivered by local GPs. The Urgent Care Centre is staffed by nurses, and patients typically incur a fee if a doctor is required to attend. There is one pharmacist on staff and no dedicated discharge coordinator. At times, patients from Benalla receive healthcare from the hospital (Northeast Health) in the neighbouring larger town of Wangaratta located approximately 50 km away.

Participants:
A convenience sample of patients admitted to Benalla Health with a primary diagnosis of COPD, congestive cardiac failure or type 2 diabetes in the preceding twelve months (International Classi cation of Disease (ICD) codes beginning E11 (Type 2 diabetes mellitus with or without complications), I50 (Congestive cardiac failure, congestive heart failure) or J44 (Other chronic obstructive pulmonary disease) were utilised). A letter was sent to all eligible patients inviting them to participate in an interview. An email was sent to all organisations within the Benalla LGA employing health professionals involved in the care of patients with COPD, diabetes or congestive cardiac failure for distribution to their staff inviting them to participate in an interview.

Data collection
Semi-structured questions were developed in consultation with experts in the eld of chronic illness and community health care. The questions sought to explore factors associated with potentially avoidable hospitalisations in the rural context, from the perspectives of patients and health professionals and are listed as Appendix 1. Interviews were undertaken at a location chosen by the participant and included private homes, workplaces and community health facilities. The female interviewers (KG, PhD, Research Fellow and TA BPhyty, MPH, Project O cer) had training in interviewing techniques, experience in chronic disease management and health care delivery research. The interviewers had no prior or ongoing relationship with the participants. Interviews were audio-recorded and transcribed verbatim. No nonparticipants or non-researchers were present during the interviews. No repeat interviews were conducted.
One participant did not consent to audio-recording and notes were taken by the interviewer. Names of people, towns, clinics and unusual health conditions have been changed in the reporting of this study to ensure anonymity of participants.

Analysis
Thematic synthesis was completed in two stages by two authors. Free codes were organised into descriptive themes (Stage 1), with con rmation of themes through discussion (two researchers). Central emergent analytical themes were developed through group discussion (Stage 2) to provide a broader understanding and meaning to the data regarding factors associated with potentially avoidable hospitalisation in the rural Australian context (two researchers). Transparency of method, the use of independent investigators, and group discussion were used to promote the validity of ndings, rigor and trustworthiness of the synthesis process. The nal themes, are listed in Table 1.

Results
There were 32 unique patients admitted to Benalla Health in the nancial year 2018-2019 with a primary diagnosis of COPD, 35 with congestive cardiac failure and 13 with diabetes, as summarised in Table 1.
Approximately half of the admissions for these conditions were repeat admissions during the 12 month period (51 of 109 admissions). After exclusion of patients who had since passed away, 69 were eligible to participate. Nine patients consented to participate (13% response rate), along with 16 health professionals, as summarised in Tables 2 and 3. No participants dropped out of the study. Interviews were undertaken between September and October 2019, with a duration of 13 to 33 minutes for health professional interviews and 8-48 minutes for patient interviews.   Involvement of the General Practitioner: Organisation of care: Organisation of care was a key factor associated with patients being able to manage their disease and ultimately the risk of potentially avoidable hospitalisation. Participants spoke of action plans and GP management plans that could either be bene cial or of little value. Bene cial management plans were individualised, disease speci c, meaningful and patient centred.
I was in and out of that Emergency place a fair bit, early on. (Now) less frequent, because I've got everything under control, and I've got that action plan. (P2). "Yeah, the knowledge, the three steps, the action plan which they give you, which I've got up on the fridge and what to look for and everything like that. If you get to number three, perhaps you should ring the ambulance or something" (P2) Because it's not really that hard to really-to follow that care plan that they've given me, It's not very complicated at all. After this period of time, having pneumonia and having chest infections, I sort of-I'm a bit more onto it now. (P3).
The basic stuff, which is people having plans; (for) managed exacerbations and complications. There's been a big push for that for asthma and COPD…It's pushing that side of things but having similar things for heart failure and diabetes management. I suppose diabetes management, there's often-there isn't a developed plan for how you would managed that. (HP13) Conversely, management plans that were perceived to be of little value in supporting patients' selfmanagement when they were not tailored to the individual patient needs or their health conditions.
Clients have no idea where their plan is, so it's somewhere in the cupboard and when you see it, it's a generic template that's basically had the client's name put on it and it's meaningless to them, not helping them manage their chronic disease at all because it's not been personalised. It's basically, 'oh the podiatrist said I can get ve free visits in the year, doc, can you do that paperwork?' (HP3).

Continuity:
Participants often spoke of GPs who had worked in the region for many years. They also spoke of the value in GPs working in both the community and the hospital. GPs often had long term relationships with patients and other local health professionals and this was associated with high levels of trust, respect and deep understanding. When GPs retired this was keenly felt by patients.
I think the fact that patients are seen by their GPs out in the community and then if they do have a crisis with whatever their-an exacerbation of whatever illnesses, when they come to hospital they're still looked after by their GP. So, I think there's that real continuum of care; the GPs know their patients so well. (HP8).
I usually get continuity no end. I get to see the same one (GP), same time, same bat channel, same. If I can't, and somebody else does, by gee it's in consultation with him (my GP). (P9).

Individual GP traits:
Personal traits of individual GPs were also discussed. Patients and other health professionals recognised when GPs prioritised explanation of diagnoses, signs, symptoms, the reasons for tests and medications to their patients. Patients spoke of the value of being listened to and believed by their usual, trusted GP and the consequences when these things did not occur, including hospitalisation. The diabetes educator at (x) clinic, she's bloody, she's worth her weight in gold. (She) just gives me an understanding of where my levels are at, whether I need to up it a bit or knock it off a bit, or what I'm struggling with. It keeps-especially in this last 12 months, keeps a check on my weight and how-the bene ts that she sees of me taking quite a bit more responsibility and acknowledgement about that (P9).
The younger ones (GPs) are very more in tune with the new ways of doing processes. It's-if you've got to follow a certain process with the hospital system they're happy to go along with that. Some of the more experienced (GPs) with their set ways, it's a lot more of a challenge to get them to follow what we need them to do (HP10).
Individual Patient factors: Support: Health professionals and patients alike spoke of the critical importance of support, whether it came from a patient's spouse, other family, friends or community members. Support people enabled independence, reassurance, safety, transport to appointments, care when the patient was unwell and feelings of connectedness. On occasion, individuals without support were mentioned and the detrimental impact on their health was well recognised. On other occasions it was recognised that carers may be unwell themselves or become fatigued after caring for a loved one for many years.
There's so much (support) available that it's-it's like a mine eld really, isn't it? I don't think we could ask for support when it's more deserving for other people I would think. No, we get by very well. (P4).
"We have a very high incidence of people living alone in Benalla, and I think that contributes to just not being con dent in managing your chronic illness… and when you start to go down, there is no one there to tell you to go to the doctor or whatever, and so maybe you missed that opportunity where it can be xed quickly or then, it's panic stations and I have to go to the hospital because there's no one around to certainly look after me" (HP 5).
I would have like people to follow up (after a hospital admission). You know, are you okay? A phone call. Do you need a hand? I wasn't even given an appointment. I went home to a freezing home and no food. No money. Couldn't walk. Couldn't get anywhere and no friends. No next of kin here and no friends to ask for help. (P5).
Would you believe the rst time we went down (to Melbourne for a medical appointment in the Council Community car) with (John) he pulled up in the car park and that was-the doorway was straight there next to it and that was a disabled carpark so we have our disabled sticker and there was no worries. The same last time we went. I thought that's terri c because you just walk in, get in the lift, and go upstairs. So that's goods. (P6).

Psychological factors:
A patient's mental health was discussed by many participants. Participants spoke of the value of a positive outlook and being assertive in managing a chronic health condition but also spoke of loneliness and isolation. The long-term impacts of trauma and homelessness on health and access to health care were discussed. When mental health care was needed, barriers to access were discussed, including long wait times, inadequate numbers of beds and di culty accessing services prior to a crisis or suicide attempt.
Nothing really prevents me (from self-managing COPD), as long as I make my appointments when I know I need to. Stand up for myself, to make sure that I get in to see somebody, and, if I feel that I've got an infection, then I have to make them believe me, that I have. Because they can listen to my chest, and they go: 'oh, no, it's not that bad'. Then I'll go home and be coughing all night. (P3).
"If they've got poor mental health they're not going to go for a walk. They're not going to take their medications. They cannot afford it because they don't actually work… so mental health would be a huge thing. Disadvantage: The socio-economic disadvantage of the town was recognised, as were the barriers to healthcare when a person was living with low income, or indeed in poverty. People spoke of the costs of attending appointments, GP services, medication, transport, attending the Urgent Care Centre, ambulance support and home modi cations. Patients spoke of having to choose between medicine and food. Some patients were unable to access a GP, or a regular GP. GP clinics that were 'closed'' to new patients were mentioned.
Patients with low income who didn't drive spoke of the compounding issues of needing to travel out of Benalla to access free Emergency department treatment and being acutely unwell but unable to afford ambulance services, and then not being able to return home when they were discharged from hospital, at times an hour or more away with no public transport, often at night. These issues were acutely felt by local health professionals who were doing their best to alleviate these impacts on people.

Complexity of health:
It was well recognised that patients were often living with multiple chronic health conditions and psychosocial challenges. The complexity of these challenges in uenced capacity for self-management and development of coping strategies.
I had this guy who did have diabetes, he was homeless, he had diabetes, osteomyelitis, probable intellectual disability and chronic mental health problems. He came to hospital with a sore toe which he said had occurred a week earlier, in fact he had chronic osteomyelitis. So, he got admitted to hospital, started on all this medication, seen by the physician and promised to attend follow-up and stuff like that and didn't. He just got discharged and was never seen again. I asked Mental Health services to see him and they did a telephone consult from Wang (Wangaratta) and said 'he's not suicidal, we don't need to see him, and that was it. (HP13).
I'm getting food vouchers to survive… (P 5).
If they can't stay physically active with their PTSD (post-traumatic stress disorder) then their actual diabetes increases. Their everything goes haywire (HP14) "I was 13 pounds born to woman with gestational diabetes… and my dad developed type II diabetes, so I was doomed from the word go. I've battled type II diabetes for probably some 35 years now and of course with poor control, infection got into the bone in my foot and I had a standard 250 (millimetre) left leg amputation" (P 9). Locality: Issues related to socioeconomic disadvantage, high prevalence of chronic disease and risk factors and their contribution to potentially avoidable hospitalisation were discussed by health professionals. However, there were many instances when the local region was spoke of in very favourable terms.
Patients spoke of loving the town and its people, and connectedness to the land and nature. Patients spoke of deliberately seeking care from a small, rural health service in preference to a larger, more urbanised health service. Participants spoke of the value of the long-term local health workforce and the proactive provision of support services by the health service or the local council.
I came up from Melbourne, but I've been here 35 (years). It's just such a lovely, sweet little place to live. You really feel safe, here. (P3).
"Yeah I know if I need a doctor, they will always see at the (z) Clinic, I'm never refused… they always see me the same morning… I've been going there for 50 years… I think here in Benalla we're very fortunate" (P 7).
He (my GP) rang me up and he just said 'go to the nearest hospital now'. I was in bloody (town a), there's nothing there. I said it will take me four hours to get back, could I drive back to Wang (Wangaratta)? He said alright, I'll let them know you're coming. (P1).
"Benalla hospital's been great, it's just a bush nursing, a non-emergency hospital, but I cannot say enough about the treatment that I've had personally in my journey with my health…" (P 9).
We'd been away travelling somewhere up in New South Wales and she (my wife) wanted me to go to hospital in Canberra and a couple of other towns we went through. I thought I wasn't too bad. Anyway, I said oh no, look, I'll wait and go when we get back to Benalla' which we did. We drove straight into Urgent Care or whatever it is. They put me straight in hospital. It was evidently-the doctor or the nurse said it was very serious too. (P4).

Medication:
Optimal use of medication was hampered by several barriers. Health professional participants spoke of patients being admitted to hospital and not having accurate, up to date medication lists, due to GP lists being out of date or GPs not being aware that a patient had been hospitalised elsewhere. Health professionals spoke of needing to go out of their way to obtain this information, which they needed to do in addition to their core roles. Additionally, community pharmacists were not reimbursed for this type of work. Pharmacists spoke of advocating for increased numbers of medication reviews, but that they had encountered resistance from GPs and bureaucratic barriers. There were also issues that arose after discharge if patients did not understand medication changes. There was recognition of the invaluable education role that community pharmacists played in patient's understanding of their disease, signs, symptoms, medications and correct medication techniques.
We see repeatedly-say for example the dose administration packs that we make, and the person goes into hospital and the drug chart that they've written up is medication from three or four months ago with no changes being made. … You say well, they're not on this, they stopped that in January, you go through and they've made all these clinical decisions based on the wrong information from the start, so it's really poor, it's a waste of your time. (HP1).
"… the other day… I spent an hour, or two hours of my time, talking to numerous nurses and doctors at Wangaratta and then the next day the GP clinic in Benalla who was trying to sort the problem out as well, but yeah I didn't get paid any extra for doing that… in the community we don't get paid anything for chasing that up" (HP 1).
We've got pharmacists who've been here for like 20 years, so pretty much all the oldies here are very much looked after (HP2 It's the tyranny of distance. Often, as I say, the people that really need it can't afford to travel. So then… Yeah I mean there is a train (to Wangaratta) but the appointments, and then the doctor is running late and they miss the train to come home, what do they do? Pay $80 for a taxi to get home, and that has happened. (HP3).
Availability was raised in relation to health workforce issues that had persisted for many years, impacting pharmacy, discharge planning, nursing and allied health. For example, insu cient numbers of physiotherapists in the hospital may have contributed to a perception that care was being prioritised to getting patients with respiratory conditions up and walking rather than providing chest physiotherapy. In addition, it was recognised that small, rural hospital could not provide highly specialised services. There were comments related to a low threshold for admission, particularly when GPs knew patients with complex, chronic conditions very well.
There's not that push to get out (discharge patients) like I've been used to in Wangaratta. There's not that bed urgency that we used to have. (HP6).
The hospital admissions are obviously GP driven as well because they have to admit them (GPs are the admitting doctors) (HP11).
I don't go to the doctors unless I need to, and he (GP) know that. If I go to him about something, he thinks I need to go to hospital, he puts me in. (P8).
"You can only do what you've got with the resources that you have. So when they are in hospital they are usually seen by a physio but they're not always given exercises or advice on discharge" (HP 3).
They (local GPs) see it (Benalla hospital) just being as a nursing home pretty soon. Benalla hospital has shrunk. So instead of having two wards it's now really one ward. The capacity has shrunk so no doubt the resources will have shrunk too (HP3).
I'll see a COPD diagnosis and there's no referral to a physio and I go so 'could they do with physio, bit of chest exercises or something?' Ooh, they can-the response from the nurses, 'but can they walk, they're okay'. The priority from allied health is to get people up and moving and that's more their focus than chest. There's a reduction in physio services at the moment, so they're prioritising. (HP6).
Acceptability. Participants mentioned the need for disease speci c rehabilitation programmes and for extended rehabilitation or exercise programmes to support patients longer term. Participants also spoke of in exible programmes or in exible eligibility that meant that patients may not have been able to access individualised, patient centred care. Some GP clinics were providing alternate models of care (walk-in clinics with triage, after hours service) to overcome waiting times and to ensure the patients with greatest acute needs were seen.
(a patient with chronic, complex physical, mental health and social concerns) is repeatedly admitted to hospital with (a chronic health condition), and then when she's discharged, she doesn't attend any followup. I tried to, and then I thought a bit more broadly about that, and she's got a chronic mental health issue as well, and she may also have, as many of these people, an underlying development issue. It clearly doesn't work to send her home with an appointment to see the drug and alcohol worker the next week. Can we arrange someone to go to her home and check that she's going okay and that sort of thing, and then the alcohol and drug worker to go home? No, that couldn't be done because nobody provides that service. So, if the district nurses go to her home and check that she's working okay? No, we can go and do her dressing; we don't do welfare checks. Can MIND (Community mental health service) be involved? No, MIND can't, because she hasn't got an NDIS (National Disability Insurance Scheme). A total lack of exibility. (HP13).
Everyone's an individual with individual needs (HP10). Well, everyone learns differently, regardless of their age (HP11). That's what care is about, it's called person centred care (HP12).
...when I lost my leg. To go home I needed a wheelchair. If I applied for a rebate through the scheme, they would give me $1000 but because I needed a wheelchair before I could be released from hospital, I'd have to hire it. The application may take up to 12 months. Now, at $25 a week for that wheelchair, I'd blow my bloody $1000 on chair hire. So, I might as well have bought the thing myself. (P9).
Affordability. Costs were a barrier mentioned in relation to Urgent Care, ambulance, specialist appointments, transport and GP services. These costs were compounded for patients with low income (at times because their health meant that they could no longer work) and particularly for patients living in poverty (at times linked to trauma, poor mental health, abuse or homelessness).
So our main three GP clinics in town, they're not bulk billing. So I think maybe dealing with chronic illnesses, there'd certainly be a cost involved with that especially for a lot of older people that need regular appointments as well. The other GPs can bulk bill at their own discretion. But otherwise they might be looking at $80 for a 15 minutes appointment and they only get 35 of it back. So if you're expected to go and see that GP every week or every fortnight, well you can see how people slip through the cracks that way. (HP8).
We can't even give patients a ball-park gure on the (out of pocket) costs associated (with Urgent Care). (HP8).
So, considering we have quite a, we do have a very high low socioeconomic group in Benalla. Financially to pay for GP services I'd be concerned that they would be limiting their access to medical care. Also having paid Urgent Care (Centre) here as well (HP16).
Adequacy. Discharge planning and referrals were key issues raised by health professionals. There were many examples of initiatives to improve organisation of care, communication and sharing of information including shared care folders and multi-disciplinary 'scrums', but these were not systematically applied. Other solutions including consistent guidelines for chronic disease management and clinical pathways were suggested by health professionals.
But the theme, sadly, probably for the last six to twelve months for us in community (Community Health services), and I have had to follow up with patients in the clinic (GP clinic), is poor discharge planning, or no discharge planning from hospital. That impacts on client outcomes when they get home. It can be anything from not understanding what their medications are for, or just not taking them because they don't know. Or they don't know how important they are. Certainly with the respiratory conditions with all the new inhalers and things that they are about; they're (patients) quite confused about what they should be taking and should they stop this one and start that one. (HP3).
We do have daily meetings on the ward with the different disciplines, that's including acute staff as well as the supportive services like allied health, physios, OTs (Occupational Therapists). We do have the dieticians, diabetic educators, district nursing, post-acute care services. Sometimes the people from the shire come up and we discuss the patient's discharge needs (HP7).
The model's there (Key Worker model in which a nurse or allied health professional acts as the contact to the health service and sets goal with the patient). The model's there, but it's not staffed, so it's broken, I suppose, because of that, so we've lost leadership within that team. We've lost skills within that team. We've lost a lot of expertise within that team. (HP5).
Some people aren't referred onto Pulmonary Rehab that I think should be. For instance, if people present to Urgent Care-we don't get any referrals from them so, if a person comes in with a-you know, a respiratory problem and they get discharged back home again through, we don't get a referral, and I think that would help. (HP4).
We didn't even have the forms in Urgent Care Centre on how to refer people onto any allied health services, so we had no idea of what the process was, so I actually found the forms and we've got them now in urgent care so staff know how to make that referral (HP8).
"it's not uncommon to have patients lob up to be seen by us having been in Northeast Health as an inpatient or in emergency, with no information… We don't know what they're here for. We don't know what they've had done. We don't know what the expectations of what they want done. We're relying on the patients to tell us" (HP13).
…it does happen that we do have people admitted for discharge planning (HP9).
Awareness. There was widespread recognition of the bene t of cardiac and pulmonary rehabilitation, HIP, HARP and support services at home or in the community, but there was lack of awareness of whether these programmes were available locally, how to refer to them and eligibility criteria. Patient awareness was dependent on patients being ready and able to understand their condition, how to manage their health, ability to ask questions and seek information. There were examples of mis-conceptions regarding access to GP services, for example if patients rang early in the morning or explained that they had been discharged from hospital, appointments would be made available to them. Similarly, bulk-billed GP services would be provided for eligible patients with complex, chronic conditions if they had GP management plans in place.
With nursing staff in the hospitals or the acute settings, I don't think they understand what services are around the whole area and I think it's a really important part of being in a small community where we can send, where we can suggest to educate and encourage patients to participate. (HP14).
A lot of clients will-say for example, with heart failure, which is, they don't even know they've got heart failure. They've been in hospital, they've been managed on uid restriction and may not necessarily know that they're supposed to be on it when they get home and what it's for. (HP16).
Well, this is what annoys me, for the last 10 years I've been borderline (diabetes) and have I got it or haven't I? Or you're on the edge, and do I try to cut down (on food that may increase risk of diabetes). But I try to watch my diet. (P1).
We used to have a really good relationship with the Community Health, and we had someone from their chronic disease program come in here (GP clinic) and we'd have case conferences regularly, once a month… What worked well was the integration of information. There were complex patients that we shared, so it was about talking about the issues were and how we could manage them in an integrated fashion. What services they require and the urgency of that, and that sort of thing. Yeah. (HP13).
I think it's just frustration for me wishing they (patients) bloody understood (their condition) so they didn't end up in these predicaments (HP15).
Being inside the hospital is a bit tricky to gure out what would be the needs (of the patient) on the outside (HP9).

Timeliness
Participants noted that at times extended waiting times were experienced for a range of services, often due to insu cient workforce. At times these delays resulted in patients becoming more unwell before they could access health services or bene cial programmes.
Overall, the wait times for some allied health and other services are quite long, so particularly dieticians and dietetics. Access to pulmonary rehab and cardiac rehab can take a long time, so not uncommonly by the time people get into those programs it's a month/couple of months down the track from when they've, whatever their key episode was. So, they're either better or they're not going to get any better at that point. (HP13).
Well, one of the issues at the moment is, is probably, for our patients, is access to medical care. We're relatively short of practitioners, GP's, even though we're better off than many other rural and regional places, it's still quite hard to get a routine appointment. So, a routine appointment to see me at the moment is January sometime (interview conducted in October) (HP13).
We've started to use Royal Flying Doctors Telehealth to try and get people in because of the six months waiting lists (for mental health services). What's the point of seeing someone six months after they've tried to commit suicide? We often send people to (in patient mental health service in another town), they're back the next day. We send them back to (service) or to the triage, to be triaged and they're back and it's just this ping-pong. (HP14).

Discussion
This study aimed to identify factors associated with potentially avoidable hospitalisation to a rural hospital in Victoria, Australia from the perspectives of both patients and health professionals. There was value in exploring both the health professional and patient perspective in this study, and whilst the importance of giving patients a voice has been recognised (8), few studies have included the patient perspective (9).
The themes identi ed (individual GP factors, personal patient factors, locality, medication and health service access) are highly inter-related. For example, socioeconomic disadvantage combined with out-ofpocket healthcare costs in uence the degree to which cost is a healthcare access barrier. Similarly, distance to health services was a barrier, but this became more so if a patient was socioeconomically disadvantaged, socially isolated or unable to drive. Factors that appeared protective against unnecessary hospitalisation were provided by participants, while other participants described situations where these factors were absent and could associated with increased risk of hospitalisation. For example, family, friends or community groups provided care for patients and supported connectedness and independence. When a patient did not have these support networks they were more vulnerable when they became unwell.
Two similar studies in rural New South Wales, Australia identi ed factors associated with PAH from the perspectives of patients (lack of support, medication issues, poor mental health, poor understanding of disease) (9), and service providers (lack of services, lack of awareness of local services, poverty and transport issues) (8). Continuity of care has been found to be associated with PAH previously (23), as have managed care plans (24). Increased access to primary care physicians in the United States has been reported to be associated with reduced avoidable hospitalisation (20). The frequency of medical contacts has been reported to correlate with PAH (4). One of the key factors identi ed in our study related to the value of connecting patients to bene cial services, particularly upon discharge. This is in agreeance with a Canadian report that estimated that 27-76% of readmissions would be preventable if best practice discharge preparation and enactment were followed (21). Following, Provencher's recent Australian study involving at risk older adults showed than an intervention to optimise discharge preparation and post discharge support in the community across ve sites signi cantly reduced unplanned admissions (22).
Patient participants typically did not consider their hospitalisations to have been avoidable, commenting that their condition had deteriorated to the point that hospitalisation was necessary, or that their doctor had told them to present to hospital. On two occasions patient participants identi ed that not being able to see their usual GP who listened to them and took their concerns seriously may have contributed to their hospitalisation. Conversely, some health professional participants mentioned that a low threshold for admission existed, potentially related to doctors being very aware of complex social issues of some patients, a lack of bed urgency or a lack of alternate accommodation. Previous research has reported an association between higher referral rates to secondary care by doctors who are more psychosocially oriented (23).
Many patients could not easily identify the reason for their admission, or readily list their health conditions. This appeared particularly so for patients with heart conditions, and although the researchers did not have access to their primary presenting diagnosis, no participants identi ed 'heart failure' as one of their health conditions. Patient lack of awareness of heart failure has been identi ed previously (24) and it is thought that the term may be being avoided by health professionals as anxiety provoking (25).
Alternatively, heart failure has been recognised to be di cult to diagnose and differentiate from comorbid conditions (26).
Identi ed in this study were a mixture of factors that could be readily modi ed and other factors that are far less modi able. For example, the socioeconomic status of a town is complex and unable to be readily in uenced, at least in the short term, and particularly from within the health system. However, embedding individualised, meaningful exercise and rehabilitation programmes, action plans and GP management plans may be far more readily in uenced, within the health system. The in uence of socioeconomic disadvantage and psycho-social factors on potentially avoidable hospitalisations was recognised by health professional and patient participants alike, and health professionals were exploring innovative ways to address these issues. However, there was a level of frustration associated with the in exibility of services to respond to these needs. Participants appreciated the value of the long term, local health professional workforce and pro-active local council in provision of services. Patients spoke of actively choosing care at the local hospital in preference to larger, more urbanised health services. Patients also spoke of their connection to the town and the region, often decades long. The role of 'place' in health and well-being has been well recognised (27).

Conclusion
Factors associated with potentially avoidable hospitalisation were complex and inter-related. These factors encompassed factors related to access to, and disease management within, primary care and socioeconomic disadvantage. These results suggest that there is a need for improved, contextualised, subtle indicators of access to primary care and quality healthcare to monitor and ultimately address reduce unnecessary hospitalisations.

Consent for publication
Each author has provided their consent for publication.

Availability of data and materials
All data relevant to the study are included in the article or uploaded as supplementary information.

Competing interests
None to declare.

Authors' contributions
Author contributions: KG and TA designed the study, collected, analysed and interpreted data. RD acted as the independent third person during analysis. KG, TA and RD drafted the article and revised it critically for important intellectual content. SW and DK contributed to subsequent drafts. All authors read and approved the nal draft.