Enhancing Health Care Access in Rural and Remote Communities: An Environmental Scan of Virtual Health Innovations in British Columbia

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Australia's Rural Health Multidisciplinary Training program: Preparing for the rural health workforce that Australia needs.

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Addressing Inequities in Kidney Care for Indigenous People in Canada.

Rural and remote communities of Australia, particularly those including Aboriginal people, experience greater morbidity and mortality across a range of health outcomes compared to urban communities. Previous national data have demonstrated that rural and remote communities experience a disproportionate burden of communicable diseases compared to their urban counterparts. This systematic review was undertaken to describe the types of research that have explored the epidemiology of communicable diseases in rural and remote communities in Australia, with particular reference to the social determinants of health. We conducted a keyword search of several databases (EMBASE, MEDLINE/PubMed, RURAL, Aboriginal and Torres Strait Islander Health Database, Web of Science Core Collection, and Google and Google Scholar websites) for peer-reviewed and grey literature that described or analysed the epidemiology of communicable diseases in rural and/or remote communities of Australia from 2004 to 2013. Exclusion criteria were applied to keep the review focused on rural and/or remote communities and the population-level epidemiological analysis of communicable diseases. From 2287 retrieved articles, a total of 50 remained after applying exclusion criteria. The majority of included articles were descriptive studies (41/50). Seven of the total 50 articles contained analytical studies; one systematic literature review and one experimental study were also identified. Due to the diversity of approaches in measuring disease burden, we performed a narrative synthesis of the articles according to the review objectives. Most of the articles investigated the disease burden in remote (n=37/50) and Aboriginal communities only (n=21/50). The studies highlighted a high prevalence or incidence of skin, eye and respiratory infections for remote Aboriginal communities, particularly children over the past decade. There was emerging evidence to suggest that housing and social conditions play an important role in determining the risk of skin, ear, respiratory and gastrointestinal infections in children. Other health service and sociocultural factors were also discussed by authors as influencing the epidemiology of communicable diseases in rural and remote communities. This systematic review identified several communicable diseases that continue to cause considerable morbidity in remote Aboriginal communities, including skin, eye and respiratory infections, particularly for children. Overall there is a substantial amount of descriptive epidemiology published, but few analytical or experimental studies. Despite a lack of empirical investigation into the social determinants of the burden of communicable disease, there is emerging evidence that has demonstrated a significant association between housing conditions and skin, ear, respiratory and gastrointestinal infections in children. There is also growing recognition of other social and environmental factors that can influence the burden of diseases in rural and remote communities. Further investment into higher quality community-based research that addresses the social determinants of communicable diseases in remote communities is warranted. The lack of research investigating zoonoses and tropical diseases was noted.

Brazil faces significant inequities in health care access, particularly in remote communities. The Brazilian Unified Health System is struggling to deliver adequate health care to its vast population. Telehealth, regulated in Brazil starting in 2022, emerged as a solution to improve access and quality of care. Thus, the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, in partnership with the Agência Brasileira de Apoio à Gestão do Sistema Único de Saúde, created the Unidade Básica de Saúde (UBS)+Digital project, which aimed to mitigate the lack of medical care in remote areas of Brazil by providing teleconsultation in primary health units (PHUs) across the country. Through teletraining and digital health strategies, the initiative enabled health care professionals to provide remote assistance, improving access to medical care. To describe the implementation and results of the UBS+Digital project, a telehealth initiative focused on training health care professionals, providing teleconsultations, and monitoring key performance indicators among PHUs in Brazil. The study examined 15 Brazilian PHUs using a multicenter, prospective design. Data were collected through anonymous surveys of patients and physicians, which were recorded in the REDCap (Research Electronic Data Capture) database. PHUs were selected based on criteria such as the absence of an on-site physician and existing technological infrastructure. Synchronous and asynchronous training was provided, focusing on digital health and teleconsultation skills. In loco training included workshops and community events to share experiences and foster local engagement. A community of practice facilitated ongoing knowledge exchange. Teleconsultations followed the person-centered clinical method and Calgary-Cambridge methodology. Key performance indicators were monitored by a dashboard to guide continuous improvement. The transition of operations was managed based on physician availability and project duration. Microcosting analysis assessed the project's economic impact using Brazilian guidelines, with statistical analysis performed using Jamovi software. From March to November 2023, the project conducted 6312 telehealth sessions. A total of 342 professionals were trained, including participants from all three training modalities that were implemented. The Net Promoter Score for teleconsultations was 97, indicating excellent service quality. Of the teleconsultations, 65.3% (4009/6140) were prescheduled, and 34.7% (2130/6140) were on demand, depending on the family health team organization. Teleconsultations resolved 85% (5219/6140) of cases, with 15% (921/6140) requiring in-person referrals or emergency care. The average absenteeism rate was 15% (1083/7223), and consultation durations were between 15 and 20 minutes, suggesting potential adjustments in scheduling. The results highlight the effectiveness of telehealth programs in primary care settings with limited medical professionals. The UBS+Digital project demonstrated that telehealth can enhance health care access, presenting a pioneering model within the Brazilian Unified Health System for digital primary care.

Creating place-based health and wellbeing networks in rural and remote communities.

[Extract] Public health initiatives aimed at promoting the negative health impacts of smoking have led to decreases in smoking among non-indigenous populations; however, higher rates of smoking continue to be the leading cause of disease burden among indigenous populations throughout the developed world. For Aboriginal and Torres Strait Islander peoples (hereafter referred to as Indigenous Australians), the situation is dire with Indigenous Australians 1.9 times more likely to die of lung cancer Rates of smoking vary within and between Indigenous communities with significantly higher rates reported for Indigenous populations (41%) compared with non-Indigenous Australians (16%). Remoteness and younger age appear to be critical risk factors for higher rates of smoking among Indigenous Australians with rates as high as 62% reported for women aged 15 to 34 years in a remote community in North Queensland and 76% among men in a community in the Northern Territory.

British Columbia has over 200 rural, remote, and Indigenous communities that have limited health care resources due to physician isolation, sparsity in clinical resources, the lack of collegial support, and provider burnout. Real-time virtual support (RTVS) peer-to-peer pathways provide support to patients and providers. Amid the COVID-19 pandemic exacerbating existing health care disparities and equitable access to timely care, RTVS presents a portable and additional opportunity to be deployed in a hospital or patient home setting in rural communities. We highlight the story of the Rural Urgent Doctor in-aid (RUDi) pathway within RTVS that successfully supported the Dawson Creek District Hospital (DCDH) emergency department (ED) in 2021. This study aims to describe the rapid implementation process and identify facilitators and barriers to successful implementation. This case study is grounded in the Quadruple Aim and Social Accountability frameworks for health systems learning. The entire study period was approximately 6 months. After 1 week of implementation, we interviewed RUDi physicians, DCDH staff, health authority leadership, and RTVS staff to gather their experiences. Content analysis was used to identify themes that emerged from the interviews. RUDi physicians covered 39 overnight shifts and were the most responsible providers (MRPs) for 245 patients who presented to the DCDH ED. A total of 17 interviews with key informants revealed important themes related to leadership and relationships as facilitators of the coverage's success, the experience of remote physician support, providing a "safety net," finding new ways of interprofessional collaboration, and the need for extensive IT support throughout. Quality improvement findings identified barriers and demonstrated tangible recommendations for how this model of support can be improved in future cases. By acting as the MRP during overnight ED shifts, RUDi prevented the closure of the DCDH ED and the diversion of patients to another rural hospital. Rapid codevelopment and implementation of digital health solutions can be leveraged with existing partnerships and mutual trust between RTVS and rural EDs to ease the pressures of a physician shortage, particularly during COVID-19. By establishing new and modified clinical workflows, RTVS provides a safety net for rural patients and providers challenged by burnout. This case study provides learnings to be implemented to serve future rural, remote, and Indigenous communities in crisis.

Rural general practitioners (GPs) have insufficient diagnostic information to deal with complex clinical scenarios due to the inequality in medical imaging resources in rural and remote communities. The objective of this study is to explore the value of a tele-mentored handheld ultrasound (tele-HHUS) system, allowing GPs to provide ultrasound (US) services in rural and remote communities. Overall, 708 patients underwent tele-HHUS examination between March and October 2021 and March and April 2022 across thirteen primary hospitals and two tertiary-care general hospitals. All US examinations were guided and supervised remotely in real time by US experts more than 300 km away using the tele-HHUS system. The following details were recorded: location of tele-HHUS scanning, primary complaints, clinical diagnosis, and US findings. The recommendations (referral or follow-up) based on clinical experience alone were compared with those based on clinical experience with tele-HHUS information. Tele-HHUS examinations were performed both in hospital settings (90.6%, 642/708) and out of hospital settings (9.4%, 66/708). Leaving aside routine physical examinations, flank pain (14.2%, 91/642) was the most common complaint in inpatients, while chest distress (12.1%, 8/66) and flank discomfort (12.1%, 8/66) were the most common complaints in out-of-hospital settings. Additionally, the referral rate increased from 5.9% to 8.3% (kappa = 0.202; p = 0.000). The tele-HHUS system can help rural GPs perform HHUS successfully in remote and rural communities. This novel mobile telemedicine model is valuable in resource-limited areas.

The review aims to synthesize the most recent innovative models of palliative care being delivered in rural and remote locations. Worldwide, as the ageing population grows, more people will require palliative care. However, equal availability of high-quality palliative care services remains a significant challenge, particularly in rural and remote communities. Innovative models of palliative care have been developed to address the projected need of people in rural and remote areas. Models that leverage the use of digital healthcare (such as telecare and Artificial Intelligence), the non-specialized palliative care workforce (such as GPs, pharmacists, and family carers), and community driven approaches have demonstrated success in achieving positive palliative care outcomes, such as reduced physical and emotional distress, and family carers feeling more supported. There is a need to support people to remain within their rural and remote communities towards the end-of-life (EOL). While some models of care have been identified to help with this, there continues to be significant difficulties in access to health and social care in rural and remote areas. It is important we build on this research to understand more broadly the models of support for those living in remote and rural communities at the EOL.

Addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the Canadian federal response to the COVID-19 crisis. Rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic. Similarly, there has been little to no research on rural communities’ pandemic preparedness in the context of homelessness. There are large numbers of homeless individuals in rural and remote Canada, including Indigenous peoples who are over-represented in homeless populations. Rural communities, including rural and remote Indigenous communities, are often isolated and more limited than urban areas in their capacity to respond to pandemics. They are particularly vulnerable due to fewer healthcare and social service resources—the lack of which has been particularly evident during the COVID-19 pandemic. In this commentary, we suggest that policy-makers need to take seriously the situation of rural homelessness in Canada, its implications for individual and community health, and consequences in the context of pandemics. Policy- and decision-makers can address these concerns through increased homelessness funding and support for rural and remote communities, policy change to recognize the unique challenges associated with rural pandemic planning and homelessness, and more research that can be translated into policy, programs, and supports for rural homelessness and pandemic planning response.

Background: Almost twenty percent of BC population live in rural settings; yet accessing healthcare, particularly emergency health services (EHSs), is challenging for rural and remote populations as they continue to experience systemic inequities, higher incidence of chronic illnesses, and lower access to healthcare services. Access to EHSs is essential for integrated health services for these populations. Despite the challenges, healthcare providers have demonstrated resiliency in delivering EHSs in rural and remote communities through innovative approaches such as Real-time Virtual Support (RTVS). Additionally, the BC government has made significant efforts to improve EHSs by increasing the budget for innovation (e.g., virtual care and broadband technology) and emergency transport services, however, there is limited information on these innovations in the literature. This study aims to explore and understand how current innovations emerged and evolved in rural and remote EHSs to identify what works, for whom, and in which contexts, and to develop recommendations for policymakers and decision-makers to leverage innovation in rural and remote EHSs. Approach: The case study methodology, with a focus on narrative inquiry, was employed to study three rural and remote cases: two in northern BC and one in interior BC. Mixed methods were used to collect data over two phases. Phase I involved descriptive data collection and community visits. Phase II involved: semi-structured interviews with policymakers, decision-makers, managers, health providers, and administrative staff (n=3); focus groups with patients and community members (n=4); and aggregate administrative data collection from various relevant organizations (e.g., health authorities). Thematic analysis was conducted to identify common themes in the qualitative data. Quantitative data analysis, using descriptive statistics, is in process. A preliminary report was developed and shared with each case study participants through an in-person follow-up dialogue (n=20) to discuss the results and co-create actions moving EHSs innovations forward. Final individual case study reports and cross-case reports will be shared with the communities. Results: Qualitative data showed that various innovations such as Real Time Virtual Support ( pathways, virtual care, emergency physician online support, mechanical CPR devices, translation apps, and electronic triage and transfer systems were being used to provide EHSs. These innovations, particularly RTVS, equipped health providers with additional support, increased community membersaccess to EHSs, and reduced unnecessary transfer of patients out of the community. However, barriers to innovations such as limited resources (e.g., funding, digital health inequities, innovations for mental health services and support), cross-jurisdictional policies, and staff shortages were highlighted. Recommendations to enhance innovations in EHSs such as increasing funding for rural infrastructures, expanding RTVS services, exploring the alignment of policies, planning proactively, and collaborating with the local government were identified. Quantitative data analysis is currently in progress and will be included in the presentation. Implications: Recent innovations in EHSs have improved access to integrated care in rural and remote communities. Results of this study will guide policymakers and decision-makers to advance, adapt, and scale innovation and facilitate equitable access to EHSs for rural, remote, and Indigenous communities.

BACKGROUND: (one sentence)The purpose of the SPIRO Project is to increase access to and use of spirometry (the gold standard to diagnose and manage chronic obstructive pulmonary disease), with a specific focus on improving the health outcomes of people in remote, rural, and First Nations communities in the Northern Health (NH) and Vancouver Coastal Health (VCH) authorities in British Columbia (BC), Canada. APPROACH: The goal of SPIRO is to utilize an integrated, equity-focused, learning health system (LHS) approach to provide spirometry and associated respiratory care services to remote, rural, and Indigenous communities in BC, specifically in the health care jurisdictions of NH and VCH. Our focus is on improving health outcomes of people with COPD. The LHS approach has four key steps: ) Formation of Learning Community; 2) Practice to Data; 3) Data to Knowledge; and 4) Knowledge to Practice. The SPIRO Team supports the health authorities with each step, with specific attention to identifying questions for the Practice to Data step, and designing and evaluating implementation projects to improve access to and use of spirometry. Within each of these steps, we employ a mixed-methods approach, which includes embedded case studies, electronic medical record (EMR) synthesis, qualitative interviews, social network analysis, and administrative health data modelling. We follow the principles of community-based research and Indigenous health research including OCAP (Ownership, Control, Access, Possession) principles. RESULTS: Formation of Learning Community: We have formed a 40+ member team, comprised of patients, clinicians, researchers, First Nation health organizations, community members, industry partners, and health care decision-makers. Patients were identified from the VCH Legacy for Airway Health, through social media, and through clinicians. Patient partners have an approved Patient Engagement Plan, attend team meetings, and also have separate meetings to discuss process and results. Clinician members include family physicians, respirologists, and respiratory therapists. Researchers have expertise in COPD, LHS, implementation science, health equity, economic modelling, administrative health data analysis, team science, and First Nations research methods. Decision-makers represent NH and VCH at high levels of authority, and First Nations health delivery organizations. Practice to Data: Our team has confirmed the priority questions to complete the Practice to Data step. We completed an initial study which estimated the prevalence of COPD in remote, rural, and First Nations communities, based on administrative health records and random-sampled clinical studies. This enabled us to estimate the need for spirometry in these locations. We have also identified several care gaps, including: ) the lack of EMR data related to spirometry; 2) the fragmentation and health inequities of respiratory care services in the province, and 3) the barriers to accessing spirometry at the individual, practitioner and health system levels. IMPLICATIONS: By exploring the current state of spirometry services in remote, rural, and First Nations communities, SPIRO will generate evidence-based, integrated interventions to increase accessibility of testing, appropriate education during testing, continuous education for physicians in rural practice, and culturally safe care for First Nation communities. Our next step will be the Data to Knowledge Phase, where evidence-based and data-driven solutions will be identified and tested in real world settings in rural, remote, and First Nations communities. Our learnings will be applicable to the provinces and territories in Canada and globally where access to and use of spirometry are limited.