Health Service Implementation and Antifragile Characteristics: A Dirt Research Approach

Petrie S & PA Peters. (2023) “Health Service Implementation and Antifragile Characteristics in Rural Communities: A Dirt Research Approach.” International Journal of Environmental Research and Public Health. 20(14): 6418.

Abstract

The implementation of health and care services within rural communities requires necessary sensitivity to the unique facets of rural places. Often, rural service implementation is executed with inappropriate frameworks based on assumptions derived from urban centres. To understand the characteristics of rural communities that can facilitate successful program implementation better, ethnographic accounts of rural health and care services were compiled in rural communities within Canada, Australia, and Iceland. Ethnographic accounts are presented in the first and third person, with an accompanying reflexive analysis immediately following these accounts. Antifragility was the guiding concept of interest when investigating rural implementation environments, a concept that posits that a system can gain stability from uncertainty rather than lose integrity. These ethnographic accounts provide evidence of antifragile operators such as optionality, hybrid leadership, starting small, nonlinear evaluation, and avoiding suboptimisation. It is shown that the integration of these antifragile operators allows programs to function better in complex rural systems. Further, the presence of capable individuals with sufficient knowledge in several disciplines and with depth in a single discipline allows for innovative local thinking initiatives.

Keywords: rural health; health services; ethnography; electronic health; place-based health; antifragility

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Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review

LeBlanc M, McGaughey T, & PA Peters. (2023) “Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.” International Journal of Environmental Research and Public Health. 20(7): 5385. .

Abstract

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Keywords: health care; rural health; healthcare inequalities; public health systems research; health care costs; health services research

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A National Epidemic with Severe Local Implications: A Global to Local Review of Substance Use to Analyze the State of Addictions in Rural Eastern Ontario

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A National Epidemic with Severe Local Implications

This research (summarized below) is also presented as an interactive ArcGIS Storymap available at the following link..

Substance Use in Canada

The dramatic rise in substance-use disorder prevalence across North America has become an urgent and escalating health issue in need of rapid intervention. In 2012, Statistics Canada conducted a study concluding that 6 million Canadians met the criteria for substance-use disorder, but even this value is thought to be an underestimate (1). It is likely this statistic has increased greatly since 2012 when considering the surging overdose crisis and significant increase in opioid-use, as well as opioid-related deaths in the past three years (2). In 2017, the cost of substance use was calculated to be $46 billion, a 5.4% increase since 2015, which factored for associated healthcare, lost productivity, criminal justice, and other direct costs (3). Substance use and addictions in Canada is therefore multifactorial, involving social, health, and economic implications.

Substance use and addiction is a global public health crisis that has rapidly escalated over the last decade. Substance use disorder is one of the most prevalent causes of morbidity and mortality internationally (4), with alcohol- and opioid-related harms being of most concern. The United States of America and Canada have historically had the highest prevalence of opioid drug use mostly due to the availability of such drugs when compared to less developed countries and have both seen an even greater increase in use since the emergence of Covid-19. Of greatest concern, is the spike in opioid deaths which has also more than doubled since 2010 (5). Canada and the United States have the highest rates of prescribed opioids worldwide, and although the US sees considerably more opioid-related deaths, per capita opioid use, and alcohol-attributed health deficits, recent data shows Canada is paralleling increases in these areas which is a cause of great concern (6). Continuing health professions education programs have begun to gain a hold on prescription opioids and their potentially harmful effects, but there has been a major increase in non-pharmaceutical opioid use across Canada which accounted for 90% of apparent opioid deaths from January to June 2021 (7).

The life expectancy of Canada has levelled for the first time since World War II, with one of the main contributors being opioid-related deaths. This negative trend was first observed in British Columbia, which has been in a declared public health emergency since 2016 due to significant opioid-related deaths, but life expectancy has since begun to plateau for all of Canada. Most deaths seen in the past five years have been males between the ages of 20-49, which therefore has a significant impact on life expectancy, with alcohol and drug use identified as the most important risk factor among young adults (7).

Alcohol and opioid use are currently a major focus for substance use disorder harms, as these sectors have seen the greatest increase in associated harms and affect the most individuals, although it should be noted that an increase in stimulant use as well as polysubstance use has been observed in the past few years. Substantially less mortality is seen with these substances, and toxic supply is less of a concern, but many of the initiatives and treatment options addressing the opioid crisis can also benefit those impacted by stimulant addiction and polysubstance use. Other addiction disorders such as gambling can also have detrimental effects on overall health and wellbeing of Canadians, but this report will have a greater focus on drug addiction and substance use disorder, specifically regarding opioid use, as it is an incredibly urgent public health crisis causing the death of thousands and therefore requires immediate intervention.

Our interactive ArcGIS Storymap provides further analysis of this epidemic for rural Eastern Ontario, highlighting both the harms and the services available in this region.

Link to the complete Storymap: .

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What a Pandemic Has Taught Us ĐÓ°ÉÔ­´´ the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia

Petrie S, Carson D, Peters PA, Hurtig A-K, LeBlanc M, Simpson H, Barnabe J, Young M, Ostafichuk M, Hodge H, Glademan J, Smale M, & M Gonzalez Garcia. (2021) “What a Pandemic Has Taught Us ĐÓ°ÉÔ­´´ the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.” Frontiers in Public Health. 9: 768624 .

Abstract

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that “successful” response to the pandemic would depend on a level of local autonomy, “absorptive capacity,*” strong service-community connections, an “anti-fragile†” approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress.

*Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately.

†Antifragility is defined as an entities’ ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

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Asad Fatima, Nur Fozia, Morris Julia, & Bobiak Julia. (2021). “Report: Defining Rural.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON.

A full PDF of this report is also available.

What does it mean to be rural?

Rurality is perceived as being a social constructed phenomenon.

The concept of rural found in the literature is often explained from a sociological perspective. For instance, rural can be further explained by the idea of “rurality” itself, or more a rurality alluded to as “extractive” or “northern” (Stark, Gravel, and Robinson 2014). Although varying definitions exist, rurality is generally perceived as being a socially constructed phenomenon that extends widely to agricultural or resource-dependent regions/communities (Williams and Kulig, 2012). Rurality is also commonly relational as it refers to proximity and spatial isolation from/to other places and services (Bourke et al., 2012).

The second concept of rural can be explained through the “identity” of a community or village (Dampier et al. 2014). However, this method is often linked to a set of myths related to living in small and isolated settlements (Peters, 2018) that often describe rural regions as “declining” regions. From this perspective, rural regions are viewed as being unable to withstand economic changes, endure declining population counts, higher poverty levels as well as a pleather of social problems including lagging behind urban areas in education and health status (Markey, Halseth, and Manson 2008). From a narrowed health perspective, rural areas are viewed using the deficit discourse, which refers to rural health as deficient, classifies urban health as the standard and compares rural health to urban health, acquainting rural health for what it lacks compared to urban, as opposed to what it accomplishes in its own context (Bourke et al., 2010).

The myths of rural decline are fought by various communities within rural regions using means such as “resilience,” “capital,” or “identity” (Buikstra et al. 2010). However, communities are often seen as singularities, with shared goals, spirit, leadership, and actions (Besser 2009). As such, overlap exists in the literature between community identity and rurality in “declining” regions. Although communities are now beginning to challenge the myth of singularity from a conceptual perspective, we believe researchers should avoid defining or describing rural regions using an urban-centric lens, referring to them as “declining” regions or view them from a deficit discourse perspective (Carson, Carson, and Lundmark 2014; Storey and Hall 2018; Markey, Halseth, and Manson 2008; Bourke et al., 2010).

Rural regions and communities have been subject to numerous independent definitions of “rural,” each with their strengths and weaknesses. Due to the absence of a standardized rural definition, a combination of both quantitative and qualitative rural definitions has formed.

In Canadian literature, quantitative definitions of rural primarily utilize secondary data sources, such as census data to define “rural.” This can allow for the geographical visualization of statistical data, but potentially reinforce the notion of “decline” (O’Hagan and Cecil 2007; Smailes, Griffin, and Argent 2014). Qualitative definitions of rural have the benefit of looking for resilience and social capital in communities where present, while withdrawing from the discourse of decline perspective, linked narrowly to population growth (Stark et al. 2014). However, disadvantages exist when applying qualitative rural definitions to analyze and visualize rural data. As such, disciplines across areas of health care professionals, policymakers, and health researchers lack consensus around which definition of “rural” is used to describe rurality across Canada and in particular, Ontario (Pitblado et al., 2005). Definitions found are often used for convenience rather than validity, where the need for data to easily merge is prioritized over consistency between theory, method, and practice. We recognize these challenges and believe research should avoid defining rural areas using an urban-centric lens.

For this report, a literature search of quantitative and qualitative definitions of “rural” was conducted to identify measures of defining rural areas in Ontario, Canada that can be subsequently used for data analysis and visualization. Analyzing both quantitative and qualitative definitions of rurality ensured that both social and statistical aspects of rural definitions were evaluated before determining which rural definition(s) is/are most appropriate to utilize for our project. On the one hand, it is necessary that geographically based statistical data can be represented consistently in both table and visual format; while on the other hand there are important qualitative considerations of what constitutes a “rural region.”

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Morris Julia, Bobiak Julia, Asad Fatima, & Fozia Nur. (2021) “Report: Accessibility of Health Data in Rural Canada.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON.

A full PDF of this report is also available.

Executive Summary 

The accessibility of rural health data in Canada is constrained by multiple structural and technical challenges. Survey, administrative, and census data collected in Canada are not easily accessible to health planners, policy analysts, or local health administrators, nor does the available data correspond to rurally relevant boundaries and rural places. Additionally, those data that are available only provide rudimentary indicators of population health and social determinants, ignoring important issues such as social inequity, rural poverty, and the health conditions of concern to residents in rural regions. One solution that has been proposed is the development of a web-based, openly accessible mapping and data visualization that is informed by and specific to the needs of rural health professionals.

To inform the development of an interactive web-based rural health atlas, the Rural Atlas team within the Spatial Determinants Lab at ĐÓ°ÉÔ­´´ University, Department of Health Sciences carried out two sets of informal interviews (User Needs Assessment and Tool Development). These interviews were conducted in order to obtain insight from key stakeholders that have been involved in rural health settings, rural health policy or advocacy, or the development of health mapping tools. Interviews took place via video-conferencing software with participants in the spring of 2020. These interviews have informed the development of our mapping tool for rural regions and health care system decision makers. The input from these interviews will aid us in creating a stronger evidence base for identifying health inequities and guide potential directions for policy development.

The following report provides a brief summary of the findings of both sets of interviews. Researchers took the semi structured interview notes and further analyzed them to pull out common themes introduced throughout the interviews. Using the information identified within these common themes, the Rural Atlas team is now able to tailor the health mapping tool to best fit the needs of the communities it will aid.

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Bobiak Julia, Morris Julia, Nur Fozia, & Asad Fatima. (2021). Rural Health Infrastructure in Ontario: A Rapid Review. Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa, ON. DOI:

A full PDF of this rapid review is also available.

Public Health Topic

The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

Rural regions are composed of many unique and diverse communities where health behaviours, health literacy, perceived health, and health outcomes vary between widely. In general, rural populations in Canada are characterized as generally older, less affluent, and are faced with more health issues than their urban counterparts. While this may be the case in the aggregate, there are a diversity of communities across Canada with wide variation between and within rural places. Almost one-fifth of Canadians (18%) live in rural communities yet they are persistently faced with on-going challenges recruiting and retaining family physicians and other health-care professionals, maintaining infrastructure for health service provision, and adapting health policies developed for urban environments into rural settings. These challenges, among others, contribute to inequities in access to healthcare services for these individuals residing in rural Canada.

It is recognized that major systemic change is needed to improve health outcomes for communities in rural or remote areas, but that this cannot occur with addressing access inequities to health infrastructure such as hospitals, mental healthcare, and telehealth services.

Current Knowledge

Currently in Canada, there is a lack of systematic evidence-based rural health-care planning at national or provincial levels. The lack of this rural-focused planning proves challenging for the development of rural health infrastructure. As it is recognised that the needs of rural communities differ from their urban counterparts, rural communities need rural-based solutions. These solutions will allow rural communities to develop regional capacity to innovate, experiment, and discover what works for their needs.

Provincially, the recognizes the need for the renewal of health care infrastructure and facilitates the to address regional address renewal needs on a priority basis. However, such policies are often guided by urban health-care models which may be ill-suited or have negative impacts in rural communities.

Advocacy for the need for rural health research funding resulted in a pre-budget submission being made in August 2018 to the federal government to enable rural and remote communities to carry out rural health research through the use of infrastructure funding. In June 2019, the Canadian Institutes of Health Research (CIHR) announced that it is undertaking a strategic planning consultation with input from stakeholders across Canada. These investments are essential in order for rural health research funding to reflect the realities of rural healthcare.

It’s unclear exactly what kind of evidence, and exactly how and when it is used, to support the development of rural health care infrastructure. From initial research, it seems that a wide variety evidence is consulted; from personal anecdotes to in-depth and specific budget requirements. The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

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Rachpaul CC, Sendanyoye C, Mahling A, Sourial M, & Trto S. (2021). “Report: Service Provision for Children and Youth with Disabilities in Rural Canada and Australia.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON. DOI: 10.22215/sdhlab/2021.2.

A full PDF of this report is also available.

BACKGROUND

Children and youth with disabilities residing in rural and remote regions of Canada and Australia are faced with limited availability and accessibility of appropriate allied health services. As a result, children and families oftenfacing difficulties obtaining a timely diagnosis (1) and experience fewer options for support services compared to their urban counterparts (2-6). Common accessibility barriers include geographic isolation, limited transportation options, long travel distances, limited number of available health care providers, increased wait times to obtain services, and high costs for appropriate services (6,7). Health service provision that takes into consideration rural and remote contexts is required to mitigate challenges imposed by geographic location.

There is limited data available regarding the prevalence of children and youth with disabilities in rural and remote communities. A greater understanding of existing resources to support children and youth with disabilities in hard-to-reach areas warrants further investigation.  To better inform this topic, a structured scoping review and thematic analysis was conducted.

Additionally, there are challenges in adequately collecting data pertaining to children and youth with disabilities. Much of this challenge is due to the lack of consensus regarding the inclusion of disability types and classifications. The UN Convention of the Rights of Persons with Disabilities (8) and the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) developed a definition of disabilities by combining pertinent elements of the definition (1). Disability is defined as, “children and adolescents who require additional resources because of exceptional gifts and talents, physical, sensory, cognitive and learning challenges, mental health issues as well as problems due to social, cultural, linguistic or family factors” (2).

This report summarizes the complete scoping review aims to provide a clear understanding of allied health service provision for children and youth with disabilities living in rural and remote communities in both Canada and Australia. This is accomplished through a comprehensives synthesis and comparative analysis of the existing literature, including identifying gaps in the literature and recommendations for future research and policy improvement.

KEY FINDINGS

SOLUTIONS AND BARRIERS

The scoping review process resulted in 33 peer-reviewed articles met inclusion criteria. The thematic analysis identified both successes and barriers to allied health service provision in rural areas pertaining to three key service needs: 1) diagnostics and assessments, 2) service availability, and 3) service accessibility. The review identified 7 major barriers and 5 major solutions in establishing adequate health service for children and youth residing in rural and remote Canada and Australia, as outlined in the figure below.  Service modality was identified as a major finding in playing a significant role in addressing barriers, with finding supportive technology and mixed modes of service provision as a solution.

Findings suggest inadequate service availability in rural communities for children and youth with disabilities because of the following:

• Disadvantages in obtaining diagnosis;
• Limited support services due to geographic isolation, transportation, and travel barriers;
• Limited number of available health care providers; and,
• Increased time and cost associated with obtaining services (1, 2-7).

Articles reported numerous solutions to address the above domains. Telepractice and technology-based programs are presented as being the single reported solution in all three major domains (9, 13, 16-24). This potential solution addresses both in-person and telehealth programs having the potential to be effective for diagnostic and assessment purposes (15-18).  The solution of utilizing the internet and social media breaks service availability barriers in improving child communication skills, its aim to improve parent’s knowledge of their child’s diagnosis, and collaboration between families and service providers (10-12,14, 20, 25-27).

Lastly, the solution of telepractice services improves service accessibility for children with disabilities in rural communities (13).  Technological integration into rural communities can be utilized to improve access to occupational therapy and the engagement of mental health services (13, 28-30). Barriers to service accessibility can be addressed by improving training, infrastructure, education on attitude change towards technological advancements, and ensuring cultural and linguistic diversity (31).

FURTHER CONSIDERATIONS

There has been increased attention being paid to children and youth with disabilities over the past decades as evidenced from this review. The data collected for children and youth with disabilities in rural communities of Canada are sparse, making it difficult to ascertain research and policy needs.

This review provides an overview of existing problems and possible resolutions in improving both research and policy for children and youth with disabilities in rural Canada and Australia. The literature on this topic primary focuses on research in Australia. Future Canadian research can learn from both the successes and ongoing challenges in Australia. In addition, research within a Canadian context should incorporate provinces and territories that are neglected in this field of study. Through building on existing research and discovering new opportunities, rural health policy can be better informed. This can be accomplished via collaboration between communities, researchers, stakeholders and policy makers. Although ongoing challenges exists within diagnostic and assessment, service availability and service accessibility; through innovative services and strengthening resources within communities, rural-centered delivery models for children and youth with disabilities in Australia and Canada can be developed.

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Hondonga T, Sendanyoye C, Mahling A, Sourial M, Trto S, & PA Peters. (2021). “Report: Potential for eHealth in rural and remote follow-up care.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON. DOI: 10.22215/sdhlab/2021.1.

A full PDF of this report is also available.

Rural and remote communities in Canada and Australia are disproportionally affected by barriers when accessing healthcare. Barriers include, but are not limited to:  lengthy travel distances, inefficient communication between healthcare teams, and client disengagement in follow-up care (1–5).  These barriers are notably evident when seeking access to more specialized health services (1). While, Canada and Australia have implemented electronic health (eHealth) technologies to mitigate issues of access to specialized healthcare services in rural and remote areas, their routine use in follow-up care has not been fully implemented (6,7).

eHealth can be described as any technology that is used to deliver health services electronically (8). It is available in several mediums such as: mobile health, telehealth, and electronic health records. Mobile health is a medium in which healthcare services are delivered via mobile technologies such as smartphones, tablets, and wearables (9,10). Additionally, telehealth involves the use of telephones or video-conferencing technologies to correspond with clients, or remote client monitoring technologies to collect data on their clients’ health (6). Lastly, electronic health records are a form of eHealth technologies whereby health care providers securely store and share health information of clients (11,12).

eHealth technologies have been promoted in rural and remote communities as they have demonstrated the potential to dissolve barriers of access to healthcare services, facilitate efficient health service delivery, improve client care, and health outcomes in hard-to-reach areas (13). However, further research into the advantages and disadvantages of eHealth services in rural and remote communities is warranted. Thus, this report aims to identify the advantages and disadvantages of eHealth services among service users in rural and remote communities in Australia and Canada; specifically, examining the role eHealth plays in follow-up care, client experiences using eHealth as an alternative to face-to-face appointments, and suggestions for future implementation.

KEY FINDINGS

ADVANTAGES AND DISADVANTAGES

This review identified five advantages and four disadvantages of eHealth services for follow-up care for service users in rural and remote communities in Canada and Australia (Figure 1). eHealth services enabled healthcare team members to share information about diagnosis, test findings, imaging results, and medications with clients in a timely matter, avoiding unnecessary referrals and long-wait times for follow-up appointments (2,3,5). Consequently, physicians found eHealth facilitated improved client education and client self-management (2–5). eHealth services removed distance as a barrier to accessing health services. However, a major disadvantage of eHealth services included the inability to complete physical assessments (20,21). Moreover, clients reported a concerns about online privacy regarding the sharing of personal health information (14,16–19). Clients also felt that in some instances there was no need for follow-up appointments (16). Lastly, physicians reported non-relevant conversations took up extra time during appointments (16).

FUTURE CONSIDERATIONS

Although e-visits have proven to be beneficial in certain medical disciplines, in other fields they were deemed challenging (e.g., post-operative care). Therefore, it is imperative that future research analyzes how eHealth follow-up care can be implemented efficiently across various medical specialties. Logistical issues related to the availability of an electronic device and internet reliability remain common limitations. This issue may be addressed by an established eHealth site in a rural community, allowing e-visits for clients to save time and money on travel. Furthermore, alleviating client and provider privacy concerns is crucial for the sustainability of eHealth interventions. Promotion of secure and protected systems can offer clients reassurance on the safety and security of their private health information. In summary, a strong evidence-base is required centering these key priority areas to better inform policy and implementation of eHealth services in rural and remote communities.

METHODS

This report is based on a structured scoping review undertaken to identify the scope of research on the role eHealth plays in follow-up care in rural and remote regions of Canada and Australia. The identification of appropriate literature for this review followed Arksey and O’Malley’s five stage process, beginning with: 1) defining the key terms used in the search engines; 2) identification of relevant studies; 3) study selection based on a set of inclusion and exclusion criterion; 4) charting the data; and, 5) collating, summarizing, synthesizing and reporting on the findings of the articles (22).  The scoping review identified 18 primary articles that met inclusion criteria. Articles focused on the role of eHealth, specifically barriers, enablers, and the utility of electronic health services in follow-up care.

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Barnabe J., Petrie S., & P. Peters. 2020. Virtual Triage and Teletriage in Rural Canada and Australia: A Rapid Review. Spatial Determinants of Health Lab Ottawa, ON. doi: 10.22215/sdhlab/2020.2.

A complete PDF is also available for download.

Public Health Topic

Health care services and healthcare infrastructure in rural areas is continuously adapting in to meet the needs of rural and remote populations. Rural populations are unique and diverse, where there is a diversity of individuals within communities, and an equivalent diversity between communities. There are documented differences in health behaviours, health literacy, perceived health, and health outcomes between and within rural regions and rural communities. While geographic accessibility is often considered the primary driver, differences go beyond distance and include elements of demographic change, economic restructuring, and continued reductions in health and services.

The features of rural health care delivery are further underscored in the wake of the COVID-19 global health pandemic, a rapidly evolving situation which is undoubtedly putting pressure on already strained rural emergency departments (ED). In attempts to alleviate strain on front-line health provision and ensure the safety of the public, many healthcare facilities have rapidly implemented or have scaled-up eHealth solutions such as virtual triage and urgent care systems. These are virtual (virtual triage) or telephone systems (teletriage) in which patients can contact a physician or other healthcare professional who will guide them to appropriate care. The objective of these interventions is most often to reduce the overall number of in-person visits to EDs, potentially tackling ED overcrowding and misuse.

Current Knowledge

Overcrowding, long wait times, and lack of resources is a persistent issue in countries with publicly guaranteed health systems, with EDs being disproportionately affected. This is especially prevalent in rural Canada and Australia, where rural healthcare access and resources are limited. Although it is a complex problem, one of the main contributing factors to this pressure is the growing number of patients presenting to EDs with non-urgent complaints, many of whom are seeking primary care. Although seeking non-urgent care from the emergency department is seen as inappropriate to health system planners, it is often the only choice rural patients have. Over 4.7 million Canadians do not have a primary care provider and only 25% report they have a usual place of care such as an urgent care clinic, a luxury that is hard to come by in rural areas. A similar reality is seen in Australia, where access to general practitioners in regional or remote areas is limited, with many reporting visiting ED’s because a general practitioner was not available.

Initiatives such as telehealth and virtual visits have been suggested to bridge the gaps seen in rural healthcare and are part of broader eHealth initiatives that include electronic medical records, remote health monitoring, and other electronic health technologies. Identified benefits of using eHealth services for primary care provision include reducing the burdens that come with travelling long distances, increasing access to care, and cost savings across various domains. Despite perceived benefits, implementation is often non-existent, difficult, or slow. Cost, technological issues, and slow acceptance by providers is a recurring issue for successful long-term eHealth implementation.

Teletriage and virtual triage are eHealth initiatives proposed to mitigate rural healthcare gaps. Teletriage is the use of telephone conferencing services to guide patients to appropriate care based on patient presentation, the urgency of the condition, and the policy of the organization. Virtual triage is where secure video connections are integrated with secure voice. Various telephone triage initiatives have been slowly developed and implemented across Canada, and Australia. Despite the evidence of success with teletriage, virtual and video integration with these systems has been met with resistance, with few adopting it. However, amid the COVID-19 pandemic, Canadian and Australian healthcare providers have been advised to provide virtual care where possible, resulting in the rapid creation and scaling up of exiting teletriage platforms and integration of virtual triage.

Key Evidence

• Telephone triage (teletriage) has been slow to expanded in Canada and Australia.
• Teletriage is effective, safe, with high levels of reported patient satisfaction.
• Teletriage can provide an alternative to primary acute care when not available.
• Virtual triage is recent with most new platforms implemented due to the COVID-19 pandemic.
• Integration of video creates multiple layers of care, further improving effectiveness.
• Many of the limitations of tele- and virtual triage are related to existing inequalities in rural areas.
• Tele- and virtual systems can be effective at deferring patients from emergency departments.

Policy Recommendations

• Platforms need to be flexible, responsive, and tailored to regional circumstances
• Successful platforms are locally-based
• Leadership across stakeholders is essential to success
• Platforms are partnerships and collaborations
• Advertising and messaging are important
• Platforms use and create data, which must be analysed continuously

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