Surgery in the Western Canadian Arctic: Using a Logic Model to Strengthen a Rural Surgical System

Regions: Inuvialuit Settlement Region, Gwich'in Settlement Area, North Slave Region

Tags: health care, medical

Principal Investigator: Falk, Ryan (1)
Licence Number: 16700
Organization: Beaufort Delta Health and Social Service Authority
Licensed Year(s): 2020
Issued: Feb 26, 2020

Objective(s): To develop a logic model to represent the surgical services available to the mostly indigenous population living in the Beaufort Delta Region which integrates general practitioners and specialists providing surgical services to a remote and under-serviced population in a high-income country.

Project Description: This licence has been issued for the scientific research application No.4616.

This project will develop a logic model to represent the surgical services available to the mostly indigenous population living in the Beaufort Delta Region (BDR) of the Northwest Territories, describing a model which integrates general practitioners and specialists providing surgical services to a remote and under-serviced population in a high-income country. Once developed, and in combination with a review of the literature and stakeholder values, this logic model can then be used to make recommendations to improve health outcomes for a largely remote and indigenous population.

The research questions include:
1) Using a logic model approach, what is the surgical services program provided to residents of the Beaufort Delta Region by the health authority?
2) What is the burden of surgical disease in the Beaufort Delta?
3) What surgical services are available to residents of the Beaufort Delta region, at each level of hospital, in the healthcare system?
4) What is the relative role of each site in providing surgical activities, within each specialty?
5) What is the relative role of specialist surgeons vs ESS (enhanced surgical skills) physicians in addressing the surgical needs of the BDR?
6) To what extent is Telehealth being used at each site to provide consultative services (and thereby decrease medical travel) and is there a difference in use of Telehealth by type of specialty or by patient community of origin?
7) What recommendations (or future research directions) can be made to improve upon the current system, based upon the logic model that will be developed?

Potential stakeholders will initially be contacted via email to present the project and to recruit to participate in this project. Once the group of stakeholders has been identified, an informative group discussion will be organized to discuss the nature of this research project, to address any questions or concerns, and to obtain consent to participate in the interview and focus group. Any specific program planning or evaluation questions that stakeholders would like to see addressed will also be elicited at this meeting. A semi-structured one-on-one interview will be held with each stakeholder, lasting approximately one hour each, and audio-recorded. In addition, these interviews will explore program values and assumptions which underlie and influence the entire logic model. A distinction will be made between representing the current situation (i.e.: the status quo) and what stakeholders would like to see incorporated (i.e.: their ideal). This information, as well as any documentation provided by stakeholders within the health authority, will be used to develop an initial draft logic model representing the program resources, activities, outputs, and outcomes.

A focus group discussion of the stakeholders will then be held to review a logic model representing the current surgical services program. Stakeholders will be asked to provide feedback and make any suggestions to modify the presented logic model to more accurately represent their understanding of the program. This focus group will also include a discussion of which stakeholder-identified program planning and evaluation questions the researcher will be able to address during the project. Stakeholders will be provided one week to consider any other changes or reflections they would like incorporated and can then contact the co-investigator (Ryan Falk) by phone or email to communicate those changes.

After input from the focus group, as well as the cross-sectional data, has been integrated into the logic model, a final meeting will be held with the stakeholders, again in a group discussion format. In a first part, the revised logic model representing the current state of affairs will be discussed, to ensure an accurate representation of the overall program. The results of the cross sectional data analysis will also be presented at this time. In a second part, an “idealized” logic model will be presented and discussed based on: any improvements/changes to the current system that were identified by stakeholders at any point of engagement; or any recommendations that were identified during the literature review process by the principal investigator.

In a third part, future research directions to better understand and improve the program will be proposed. Those identified by the co-investigator (Ryan Falk), as well any subsequent ones proposed by the stakeholders, will be included in the final report. A period of time following this final presentation/discussion will be given for any final comments/feedback the stakeholders may wish to contribute to this project.

The final results will be prepared into a detailed report for internal use by the NTHSSA, with 3 broad purposes: presentation of the current program of surgical services; recommendations to improve the current model; and, recommendations for future research directions.

A paper will also be prepared for publication in a major medical journal (i.e.: Canadian Journal of Surgery, World Journal Surgery), which will present the logic model as an example of how rural surgical services can be delivered, integrating ESS family physicians with specialist surgeons, in a network extending from remote communities in the Canadian Arctic to the tertiary care centres of Edmonton, and caring for a mostly indigenous population spread over a large geographic area.

The cross-sectional portion of this study is intended to more fully describe the program activities component of the logic model. It will describe the types of surgical activities, as well as where those activities are provided, for residents of the Beaufort Delta Region (BDR). Surgical activities, for current purposes, are defined as consultations and procedures performed by a surgeon.

Procedures are performed in the Inuvik Regional Hospital (IRH), the Stanton Territorial Hospital (STH), or any of the Edmonton-based hospitals. While some patients may receive surgery outside of these sites, these hospitals represent the usual referral pattern and would capture the vast majority of patients from the BDR. Using the Canadian Institute for Health Information (CIHI) database, the number and type of both in-patient and out-patient surgical procedures over a 5 year period (April 1, 2014 to March 31, 2019) will be determined, including the following data: surgical specialty providing the procedure; ranking of procedures by specialty; where procedure occurred (ie: Inuvik, Yellowknife, Edmonton); patient demographics; and D, T, H, M, or N number (just the letter designation - N indicates non indigenous, other indicate indigenous).

The final informative group discussion will present study results to all involved stakeholders.

It is intended that the logic model that results from this study will be used by the Northwest Territories Health and Social Services Authority (NTHSSA) for ongoing program planning and evaluation purposes and ultimately to improving patient care. It may also give rise to future research questions, which would then initiate a new Research Ethics Board process should that be required based on the nature of those projects.

A paper will also be prepared for publication in a major medical journal (i.e.: Canadian Journal of Surgery, World Journal Surgery), which will present the logic model as an example of how rural surgical services can be delivered, integrating ESS family physicians with specialist surgeons, in a network extending from remote communities in the Canadian Arctic to the tertiary care centres of Edmonton, and caring for a mostly indigenous population spread over a large geographic area.

The fieldwork for this study will be conducted from February 26, 2020 to August 17, 2020.