ANZ J. Surg.

(2001) 71, 544–547

ORIGINAL ARTICLE

COSTS OF ACCESSING SURGICAL SPECIALISTS BY RURAL AND

REMOTE RESIDENTS

SARAH L. RANKIN, WAYNE HUGHES-ANDERSON, ANTHONY K. HOUSE, DUGAL I. HEATH, ROBERT J. AITKEN
AND JILL HOUSE

University Department of Surgery, Sir Charles Gairdiner Hospital, QEII Medical Centre, Nedlands,
Western Australia, Australia

Introduction: Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is avail-
able on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred
by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting.
Methods: A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999
inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist
consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same
formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was deter-
mined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average
waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-
based service.
Results: An estimated saving of AU$1077 was made per specialist consultation when accessing a local rather than a metropolitan
service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time.
Conclusion: The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing
specialist treatment can be reduced if a visiting specialist service is available.

Key words: cost analysis, health-care access, rural health care, visiting specialist services.

INTRODUCTION The severity and discomfort of the medical condition also affect
the financial, physical and psychosocial burden. Metropolitan
Specialist services in Australia are principally located in
hospitals have little capacity to be flexible for rural patients who
regional towns. Western Australia forms one-third of the Aus-
often experience long delays and the need for recurrent visits.3
tralian land mass. It has a population of just less than 2 million, of
Distance and travel costs are a barrier to seeking and completing
whom approximately half a million (28%) live in rural areas (a
medical attention.4–6
large number of these in small towns of less than 5000 people).1
In 1996 the University Department of Surgery developed
Many rural and remote Australians do not have access to resident
the Rural Surgical Service (RSS)7 which visits small country
specialist surgeons2 because an estimated minimum population of
towns in Western Australia, typically with populations under
20 000 is required for their financial and professional viability.
5000, where there is no resident surgeon.
The ratio of specialists to patients is 1:15 000 in the capital
Few studies have taken into account the personal costs
city and environs and 1:44 000 for the rest of the State (Royal Aus-
incurred by patients transferred for medical care. In the present
tralasian College of Surgeons, WA Branch, pers. comm., 2000).
study the patients are those who have been selected by their
Patients often have little choice but to travel for specialist care,
general practitioner as suitable for care in their home location
either to their regional centre or to the metropolitan area. Resident
and of these more than 90% have completed their treatment
rural specialists, a scarce resource, are mainly in coastal towns and
without transfer. The study does not evaluate the cost of providing
by geographical location may not be in the most convenient or
a local surgical service because this is the subject of a further
logical place to which patients can relocate.
manuscript. It is hypothesized that rural patients have additional
The Patients’ Assisted Travel Scheme (PATS) of the Health
expenses and impediments in seeking specialist care. The
Department of Western Australia (HDWA) might reimburse a
present report examines their costs for consultative services.
proportion of the travel and accommodation expenses incurred by
rural patients who are referred to larger centres. Variables such as
ethnicity, patient age, family structure, occupation and lost METHODS
income contribute to hidden expenses that are non-refundable.
Seventy-two patients, who had a consultation with a visiting
specialist surgeon between the months December 1998 and
February 1999 inclusive, were eligible subjects. The names
Correspondence: Professor A. K. House, University Department of Surgery, were arranged in alphabetical order and the patients were contacted
2nd Floor, M Block, QEII Medical Centre, Nedlands, WA 6009, Australia.
Email: akhouse@cyllene.uwa.edu.au
until 50 had been surveyed. Calls were made within 8–10 weeks of
the patient’s appointment.
Accepted for publication 9 April 2001. Patients in a telephone interview completed a rural health
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COST OF RURAL PATIENT SPECIALIST ACCESS 545

survey. This was adapted from a HDWA questionnaire.8 The The estimated cost of relocating to a metropolitan centre was
study explored patient demographics, mode of transport, dis- calculated using the same criteria used for the local visit. The
tance travelled to hospital, occupation, lost income, treatment additional known distance and travel time was calculated. Given a
options and need for an accompanying person. The RSS data- mean distance of 1214 km it was assumed that patients would
base was used to calculate the waiting list time for surgical require 3 days away: 2 days travelling and 1 day for the surgical
appointments and day-case procedures performed in the consultation.
country. The Day Procedure Unit (Sir Charles Gairdiner Hospital) A comparison of additional assistance required from accompa-
provided waiting list data on the same items at a metropolitan base nying persons was made between the 50 RSS users and a subset
hospital over the same period. of 16 patients who had also used a metropolitan service in the last
Travel costs were determined using the mean return distance 12 months.
travelled in kilometres to the hospital (local or metropolitan) Participants were asked whether they preferred travelling to
and multiplying them by vehicle running costs (Royal Automobile the city, to a regional or district hospital or to a local consultation.
Club, Information Services Perth WA, pers. comm., 1999). Data analysis was performed using M I N T A B (Minitab Inc.,
The patients lost income was calculated by multiplying lost State College, CA, USA) Non-normally distributed data were
work time in hours by the mean hourly wage of the sample. It was compared using means and the Mann–Whitney U-test.
assumed that wages were based on a 40-h week. Recommended
weekly wage rates for the various occupations9 were combined and
dividing them by 40 determined the mean hourly wage. Lost
RESULTS
work time included time spent travelling to and from the spe- Fifty-five patients were invited to participate in the study. One
cialist appointment, waiting at the hospital as well as time spent patient refused and four surveys were voided due to missing
with the specialist. data. The remaining 50 surveys were included.
The mean age was 49.6 ± 18.5 years with a median age of
47.5 years. The number of couples with no children and the
Table 1. Demographics of patient sample (n = 50) compared with
state population12 median age of the sample were greater than the average for
Western Australia.10 The household structure was similar to the
Average values for Sample WA comparison State average except for the number of couples whose children no
longer live at home. Patient demographic data are summarized
Household structure (Table 1). Patients within the study faced a mean round trip of
Couples with children 48% (24) 49.7% 1215 km rather than a significantly shorter distance of 67.8 km for
Couples no children 42% (21) 34.5% a visiting service. Almost all patients (96%) travelled by private
Single family 10% (5) 13.9% motor vehicle. The additional distance was directly proportional
Employment status to the time taken to reach a central location and impacts on the
Employed 60% (30) 50%
travel, accommodation expenses and time off work. The dis-
Full time 40% (20) 66.6%
Part time 10% (5) 31.2% tance was increased by a factor of 19 and translates to a loss of
Casual 10% (5) – income by a factor of 13 for a metropolitan consultation (Table 2).
Not in work* 40% (20) 35% The personal out-of-pocket expenses are presented (Table 2).
Age A proportion of all patients (46%) required an escort, usually
Mean 49.6 ± 18.5 years – the spouse, and a metropolitan visit increased the need (75%).
Median 47.5 years 32.5 years It is shown that lost income is not confined to the patient but
Sex distribution includes one-quarter of the accompanying person’s income
Male 50% (25) 52.1% (Table 3). The average waiting list times for day surgery are
Female 50% (25) 47.9% considerably longer in the metropolitan hospital (Table 4).
*Includes retirees, mothers and individuals on sickness benefits or workers The majority (88%) of rural patients preferred a local service.
compensation. The remaining treatment options of the sample were shared
WA, Western Australia. among regional hospitals (14%), district hospitals (4%) and

Table 2. Comparison of personal costs between visiting and metropolitan-based specialist services as estimated by patients

Factors contributing to personal costs Visiting Metropolitan Difference

service service
n = 50

Return distance (km)*‡ 67.8 1214.8 1147

(Median values) (1.0–300) (200–3400)
Cost of travel ($)† 28.25 506.21 477.96
(Median values) (0.41–123) (81–1394)
Estimated time off work (h) 5.4 72 66.6
Estimated lost income ($) 49.60 648.00 599.00
Total estimated costs per visit ($) 76.85 1154.21 1077.36
*Significant difference P > 0.001.
†Royal Automobile Club recommended $0.41/km.
‡Distance increased by a factor of 19 when comparing a metropolitan with a local service.
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546 RANKIN ET AL.

Table 3. Need for accompanying persons for patients and costs In an investigation of paediatric telemedicine consultations
involved. (TMC) in Ontario, Dick et al. included an estimate of significant
personal costs spared when using the locally accessible TMC
Visiting Metropolitan service.15 An estimated average saving of CAN$1318 ± $677
service service in travel and associated costs per consultation was made when
(n = 50) (n = 16)
a local specialist service was available. A remote Australian
% (n) % (n)
telepyschiatric service has also delivered considerable cost
Accompanying person required 46 (20) 75 (12) savings. It was not intended to replace existing services but to
Income lost 0 (0) 38 (6) augment service delivery. Both mental health professionals and
Additional travel costs 0 (0) 25 (4) consumers preferred face-to-face consultations.16 A surgical
Additional family costs 6 (3) 12 (2) procedure initiated from a consultation and clinical examination
requires a personal contact.
It is of concern that 10% of the patients would not have
Table 4. Average waiting list times for common procedures of a vis- sought a surgical opinion in the absence of a local service. This
iting and metropolitan service is consistent with the findings of Veitch et al.3 Similar findings
of rural patients delaying seeking specialist care in Europe and
Visiting service Metropolitan service USA have been reported.6,7,17 Hence the need to differentiate
Consultation 3.5 weeks 5 weeks between those services that can be provided with safety in the local
Endoscopy 15 days 84 days area to allow sufficient funds to be directed to those with serious
Varicose veins 28 days 1 year problems and the need for recurrent travel. International studies
Carpal tunnel 5 weeks 1.5 years show that there are significant delays in diagnosis and therefore
Skin excisions 14 days 30 days treatment options for cancer patients from rural areas.18,19 Desch
Vasectomy 8.3 days 1 year et al. have shown that a rural outreach cancer programme to
medically under-served rural patients lowers the cost and brings
state-of-the-art care to rural centres.20
general practitioner (GP) management (2%), on the assumption The present study demonstrates that a local service causes
that these services actually existed in these smaller institutions. Ten fewer disruptions to rural and remote patients and their family.
per cent of the sample stated that they would not have continued A visiting specialist service reduces the cost and inconvenience
with their treatment had a local service not been available. incurred by rural residents who would otherwise travel to metro-
politan hospitals for specialist care. Patients saved on average
AU$1077 in personal costs per specialist consultation. Recur-
DISCUSSION
rent visits to the specialist were avoided because some patients
This analysis focuses on the personal costs to rural patients, were consulted and treated on the same day. The shorter waiting
which have been previously overlooked. It is in line with the lists benefited patients without increasing the teaching hospital lists.
current emphasis on community concerns and aspirations for
equity of access to medical care. Travel and the lost wages resulting ACKNOWLEDGEMENTS
from time off work are the most obvious and most easily quantified.
There are numerous other expenses to consider when The present study was made possible by a pilot programme
analysing the cost of accessing specialist care regardless of developed by the Commonwealth Department of Health and
place of residency. Costs can be divided into several categories Aged Care, Rural Health Support Education and Training
including medical, personal and social and may or may not be allo- (RHSET) funding and a subsequent contract with the Health
cated a dollar value. The value of non-waged activities such as Department of Western Australia.
household duties, childcare and voluntary work have not been
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