CRAJ Spring 2021

Spring 2021 (Volume 31, Number 1)

Addressing Inequity in Northern Ontario: A Look to the Future

By Sahil Koppikar, MD, FRCPC

Inequity and systemic discrimination have become front page news and part of dinner-time conversations in 2020. In healthcare, we have been discussing the very same topics. Although rheumatology has made great strides in the last few decades improving the health outcomes for our patients, inequity amongst certain groups remains. If we want to address inequity in rheumatology, we need to examine in depth those who are achieving suboptimal outcomes, identify the barriers in that population, and target solutions directly at those barriers.

In Ontario, such an examination turns our eyes northward.

Northern Ontario is a region of the province where health equity is often lacking and needs to be addressed with urgency. Using a rheumatology lens, patients in the north have reduced access to rheumatology care,^1,2 are more likely to have poorer outcomes,³ experience adverse events^4,5 and are at greater risk of death⁶ compared to provincial averages.

There are many causes for these discrepancies, rooted in the broader social determinants of health, that have a large impact on health outcomes. Over the past five years, there has been a big push from government and provincial organizations to systematically study and plan initiatives to mitigate some of these barriers in the short and long term.⁷

While these top-down approaches will impact the system as a whole, as rheumatologists we can narrow the health gap with some bottom-up solutions, focused on health care delivery.

In the CRAJ Winter 2020 issue, Dr. Laurence Rubin eloquently described one such solution. The Timmins Arthritis Clinic, in its current format, has been running since the late 1980s. The success of this clinic was built on decades of commitment from Dr. Rubin, Dr. Carette, and the Arthritis Society Advanced Clinical Practitioners in Arthritis Care, known as ACPACs (Mary Ellen Marcon and Lynn Richards). Importantly, they created a sustainable model of care (MOC) that was not dependent on only one physician. Over the last year, we have added weekly “direct-to-home” virtual visits that have helped to shorten the waitlist, allow for urgent consults, and increase the number of patients who can be assessed. Despite the success of this model in Timmins, similar siloed programs will be increasingly difficult to create and maintain. Instead, we need a holistic and collaborative approach to address gaps and leverage our voice towards creating lasting systemic improvement.

To this end, in the summer of 2020, the Ontario Rheumatology Association (ORA) created a Northern Ontario Committee that comprises rheumatologists, ACPACs and leaders from the Arthritis Society who are involved in northern care. This has been instrumental in bringing people with similar goals and vision together to generate innovative ideas.

In January 2021, the committee hosted two workshops to educate ORA members on the “current state of the north” and to recruit members who are interested in providing virtual care to northern patients in an ACPAC-physician model. This MOC already exists, with the ACPACs based in Sudbury and Thunder Bay. However, with increasing patient needs and upcoming retirements, it is important that we sustain the care that is already provided. We are hoping to leverage new virtual care skills that have been developed over the pandemic and find members who will be willing to offer care to patients in northern Ontario.

In recognition of the higher prevalence of Indigenous populations in northern Ontario, we will be asking all new “recruits” to complete Indigenous Cultural Safety Training. 8 Indigenous populations have faced various discriminatory policies that have created inequalities that continue to affect their health. It is the least we can do to recognize this, enhance self-awareness, and strengthen the skills of those who work with Indigenous people.

Over the last few years, we have also seen increased interest in new graduates setting up practice or travelling to the North. Two early career rheumatologists, Drs. Saara Rawn and Matthew Piche, have established permanent practices in Sault Ste. Marie. Dr. Maysam Khalfan has set up regional clinics in Kapuskasing and Hearst and plans on travelling up four times a year to provide care in these regions. Drs. Elishka Pek and Lauren King are looking to set up a similar visiting model in Thunder Bay. In Timmins, we have recruited Dr. Medha Soowamber, who is fluent in French – a critical requirement in an area where 20% of people are francophone. This interest, and action, by early career rheumatologists is encouraging and I hope it is something that sustains and expands over the coming years.

The long-term vision is to establish a multidisciplinary model that relies on training local ACPAC/extended-role practitioners (ERPs) at each major northern hub who can work alongside rheumatologists that are local, visiting, or using telemedicine. This model could potentially allow for central triaging in the north to optimize wait times and provide an expert local resource to the communities. This will require creative solutions and new MOCs that do not currently exist. Earlier in 2020,
Drs. Stephanie Tom (previous chair) and Rachel Shupak met with the Ministry of Health to discuss these issues. The Ministry was engaged and receptive and asked for a proposed business case that outlines what we envision as the ideal MOC. The ORA Northern Ontario Committee has been working on the business plan and is aiming to present it to the Ministry in the spring/summer of 2021. While we are being pragmatic, we will aim for the stars and see where that gets us!

At the end of the day, a strategy to address health equity will require engagement and commitment of stakeholders and leaders in the North. As Dr. Jennifer Walker (Canada Research Chair in Indigenous Health at Laurentian University) put it, “Solutions cannot simply be imported from the southern part of the province. The landscape – social and cultural as well as geographic – is totally different.” But we can all contribute in different ways to narrow the health equity gap and ensure patients get the care they need, no matter where they live, who they are, or what they have.

The ORA Northern Ontario committee workshop on northern virtual care. There was a great amount of interest from both new and experienced rheumatologists.

Dr. Medha Soowamber (left) and Lynn Richards (right) during our December 2020 trip to Timmins, in classic 2020 style with masks!

Sahil Koppikar, MD, FRCPC
Rheumatologist,
Women’s College Hospital, Toronto
Director, Timmins Arthritis Program
Chair, Northern Ontario Committee (ORA)

References:

1. Widdifield J, Paterson JM, Bernatsky S, et al. Access to rheumatologists among patients with newly diagnosed rheumatoid arthritis in a Canadian universal public healthcare system. BMJ Open. 2014; 4(1):e003888.

2. Badley E, Veinot P, Ansari H, et al. 2007 Survey of Rheumatologists in Ontario. University Health Network; 2008.

3. Nagaraj S, Barnabe C, Schieir O, et al. Early rheumatoid arthritis presentation, treatment, and outcomes in Aboriginal patients in Canada: A Canadian early arthritis cohort study analysis. Arthritis Care Res (Hoboken). 2018; 70(8):1245-50.

4. Widdifield J, Bernatsky S, Paterson JM, et al. Serious infections in a population-based cohort of 86,039 seniors with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2013; 65(3):353-61.

5. Ravi B, Croxford R, Hollands S, et al. Increased risk of complications following total joint arthroplasty in patients with rheumatoid arthritis. Arthritis Rheumatol. 2014; 66(2):254-63.

6. Widdifield J, Bernatsky S, Paterson JM, et al. Trends in excess mortality among patients with rheumatoid arthritis in Ontario, Canada. Arthritis Care Res (Hoboken). 2015; 67(8):1047-53.

7. Health Quality Ontario. Northern Ontario Health Equity Strategy 2020. Available at: https://www.hqontario.ca/What-is-Health-Quality/Health-Equity-and-Quality/Our-Work/Northern-Ontario-Health-Equity-Strategy. Accessed February 2021.

8. Provincial Health Services Authority Indigineous Health Program. San’yas Indigenous Cultural Safety Training 2020. Available at: https://www.sanyas.ca/about-us. Accessed February 2021.