Theme 1: delays in access

Timely access to neurosurgical care is critical to achieving optimal patient outcomes. ^{Reference Pansiritanachot, Riyapan and Shin26} For many individuals in Canada, delays hinder access to specialized services and exacerbate disparities in health outcomes, especially those in rural and remote communities. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2}

Transportation

Rural and remote communities often face long travel distances to specialized centers, compounded by inadequate transportation infrastructure. ^{Reference Burns, Montelpare and Leÿenaar18,Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22} Burns et al. (2024) noted that the focus of specialty services in tertiary care centers reflected a regionalization of healthcare that often rendered limited access to rural patients and significant travel burdens. ^{Reference Burns, Montelpare and Leÿenaar18} Furthermore, Indigenous communities were found to be disproportionately affected, as many remote reserves have limited transportation alternatives and must contend with systemic inequities that limit their ability to access healthcare efficiently. ^{Reference Webster, Fehlings and Rice20} Additionally, poor road quality and limited public transport options exacerbate these barriers, in which patients’ condition has often worsened due to transport delays. ^{Reference Webster, Fehlings and Rice20} Air ambulance services, such as ORNGE, while available in some cases, remain costly and are often limited by weather conditions and resource availability. ^{Reference Sy and Ross27} For example, Webster et al. (2014) documented that “coordinating a transfer was an added stressor to care provision,” and delays due to poor coordination between local and regional transport systems frequently led to missed opportunities for timely surgical intervention, with some patients requiring re-triage to alternate facilities. ^{Reference Cheng, Noonan and Shurgold28} These transportation challenges create a cascading effect, delaying diagnosis, treatment initiation and ultimately patient recovery. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Burns, Montelpare and Leÿenaar18,Reference Webster, Fehlings and Rice20}

Wait times

Long wait times for neurosurgical intervention, driven by constrained resources, triage protocols and inefficient transfers, remain a critical barrier. Webster et al. (2014) noted that such delays are major stressors for patients and their families facing emergent spinal pathology. ^{Reference Webster, Fehlings and Rice20} The impact of these delays on patient outcomes was examined further in a national geo-mapping analysis of the Rick Hansen Spinal Cord Injury Registry. ^{Reference Cheng, Noonan and Shurgold28} This study showed that more than half of patients with traumatic spinal cord injury were not transferred to a specialized spine center within 24 hours of injury, with late transfers disproportionately affecting rural cases. ^{Reference Cheng, Noonan and Shurgold28} Moreover, these delays occur despite evidence-based guidelines that indicate that early transfer of patients with spinal cord injury and surgery within 24 hours leads to better patient outcomes. ^{Reference Badhiwala, Wilson and Witiw29,Reference Quddusi, Pedro, Alvi, Hejrati and Fehlings30} These delays are particularly pronounced for equity-deserving groups, who often lack the social and financial capital to navigate complex referral systems. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2} The consequences of prolonged wait times extend beyond stress and frustration and potentially lead to irreversible neurological damage, increased morbidity and diminished quality of life. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19,Reference Webster, Fehlings and Rice20,Reference Badhiwala, Wilson and Witiw29–Reference Cadotte, Viswanathan, Cadotte, Bernstein, Munie and Freidberg31} The lack of adequate staffing and specialized equipment in rural healthcare sites further compounds the issue, leaving many patients waiting for critical interventions. ^{Reference Burns, Montelpare and Leÿenaar18,Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19}

Tertiary healthcare centers

Tertiary healthcare centers, while offering specialized neurosurgical services, often serve as bottlenecks in the healthcare system. Their limited capacity and centralized nature impede timely access for patients from rural and remote areas. ^{Reference Burns, Montelpare and Leÿenaar18} Webster et al. (2014) described how transfer to tertiary centers often involved long delays, with patients waiting in lower-acuity facilities due to bed shortages at the receiving center. ^{Reference Webster, Fehlings and Rice20} For example, Ontario’s population is served by only 11 Level 1 trauma centers equipped to handle neurosurgical cases, leading to overcrowding and extensive delays for non-urgent but essential surgeries. ³²

Moreover, the reliance on tertiary centers for specialized care places immense pressure on these institutions, leading to triaging based on severity and prioritizing acute cases over chronic or elective ones. ^{Reference Webster, Fehlings and Rice20} Khabarov et al. (2015) highlighted the emotional and logistical strain this places on families, as elective surgeries are frequently canceled at the expense of more acute trauma cases. ^{Reference Khabarov, Dimitropoulos and McGillicuddy21} A recent multicenter study of 7734 canceled neurosurgical cases at five Canadian tertiary academic centers found that 23.9 % of cancelations occurred because “a higher-acuity case” was booked emergently, while a further 28.2 % were surgeon-related, often the surgeon being pulled to emergency duty. ^{Reference MacLean, Persad and Coote33} These challenges underscore the need for distributed care models that decentralize certain neurosurgical services to improve accessibility and reduce delays for elective and non-elective neurosurgical cases. ^{Reference Burns, Montelpare and Leÿenaar18,Reference Webster, Fehlings and Rice20}

Theme 2: alternative healthcare options

As delays and systemic barriers impede equitable access to neurosurgical care, alternative healthcare delivery methods might offer promising solutions. These approaches, such as telehealth and innovative coordination systems, aim to address geographic, socioeconomic and systemic barriers by reducing logistical burdens and improving timely access to care. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Webster, Fehlings and Rice20}

Telehealth

Telehealth, particularly virtual consultations, has emerged as a transformative tool for improving access to neurosurgical expertise. ^{Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19} By enabling remote consultations, follow-ups and even device management, telehealth reduces the need for travel and alleviates the logistical burden on patients in remote areas. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2} Harding et al. (2023) emphasized that efforts must be made toward making telemedicine more widely available due to its capacity to readily provide consultation to those who otherwise would experience significant barriers to care. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2} For example, telehealth allows specialists to remotely program neuromodulation devices, alleviating the need for patients to travel to urban centers for follow-ups and improving continuity of care.

Despite its potential, disparities in digital infrastructure present significant barriers to telehealth’s adoption. Many rural and remote communities, particularly those with Indigenous populations, lack reliable internet access, making it difficult to fully implement telehealth solutions. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2} Addressing these inequities requires targeted investments in digital infrastructure, such as broadband expansion, and culturally sensitive training for healthcare providers to ensure that telehealth services meet the needs of diverse populations. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Bell, Maxwell, McAndrews, Sadikot and Racine23}

Emergency coordination systems

Coordination systems like the Emergency Neurosurgery Image Transfer System (ENITS) enable rapid sharing of diagnostic imaging between peripheral and tertiary care centers, enhancing coordination and facilitating timely decision-making for emergent neurosurgical cases. ^{Reference Webster, Fehlings and Rice20} By supporting local decision-making and expediting transfers, such systems alleviate some of the strain on overburdened tertiary centers.

While these alternative healthcare solutions show great promise, their effectiveness depends on sustainable funding, infrastructure improvements and training programs to ensure equitable access across Canada. With the right investments, telehealth and coordination systems like ENITS – along with emerging options like mobile health clinics – could significantly reduce barriers to neurosurgical care and improve outcomes for underserved populations. ^{Reference Deighton, Chhatwal and Das34}

Theme 3: policy

Barriers stemming from governmental and institutional policies present significant obstacles to equitable access to neurosurgical care. Resource allocation disparities, prioritization protocols and the lack of targeted support for vulnerable populations often impede access.

Governmental policy

Resource allocation at the provincial and federal levels creates significant disparities in access to neurosurgical services. Bell et al. (2011) noted that resource constraints have contributed to unequal access to appropriate technology and care across the province due to the lack of national standards for service distribution. ^{Reference Bell, Maxwell, McAndrews, Sadikot and Racine23} This disparity between resource availability and population need results in delayed or inaccessible care for those outside urban centers. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Bell, Maxwell, McAndrews, Sadikot and Racine23}

Furthermore, financial constraints and inconsistent funding mechanisms hinder the establishment of decentralized care models. Harding et al. (2023) emphasized that changes in government often lead to unpredictable changes in funding, illustrating the volatility of healthcare resource allocation policies. ^{Reference Harding, McFarlane, Honey, McDonald and Illes2} Topolovec-Vranic et al. (2013) also highlighted how systemic barriers, such as jurisdictional complexity and insufficiently targeted initiatives, disproportionately impact marginalized populations, including those experiencing homelessness. ^{Reference Topolovec-Vranic, Ennis and Ouchterlony24} These barriers emphasize the need for policies that directly address the unique needs of equity-deserving groups.

Hospital policy

Hospital-level policies tend to prioritize financial sustainability over equitable care, leading to widening gaps in access to care. ^{Reference Akinleye, McNutt, Lazariu and McLaughlin35} Many institutions focus on acute and high-revenue services, which can marginalize patients with chronic or elective neurosurgical needs. ^{Reference Webster, Fehlings and Rice20,Reference Bell, Maxwell, McAndrews, Sadikot and Racine23} Webster et al. (2014) identified a distinct conflict between institutional goals and the needs of patients. Specifically, they noted how competing hospital and provincial interests created barriers to the delivery of spinal care. ^{Reference Webster, Fehlings and Rice20} Additionally, the lack of robust translation services in some hospitals poses a barrier for non-English-speaking patients, particularly pronounced in diverse urban centers and remote areas with Indigenous populations. ^{Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19,Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22,Reference Topolovec-Vranic, Ennis and Ouchterlony24}

Theme 4: communication and coordination

Effective communication and coordination are critical to ensuring timely and patient-centered neurosurgical care. Systemic barriers, including inter-hospital transfer or placement inefficiencies, inadequate communication between healthcare providers and limited family engagement, continue to hinder access to neurosurgical services in Canada.

Inter-hospital coordination often poses significant challenges during emergency transfers. Webster et al. (2014) highlighted the frustrations surrounding the time-intensive triage processes of systems like CritiCall Ontario, with the process being described as a significant barrier to effective neurosurgical care due to conflicting priorities and logistical inefficiencies. ^{Reference Webster, Fehlings and Rice20} Similarly, rural hospital staff frequently struggle to maintain clear communication with transfer teams during critical illness events, which exacerbates the stress experienced by patients and their families during these transfers. ^{Reference Burns, Montelpare and Leÿenaar18}

Within hospitals, communication gaps also persist – particularly exacerbated for marginalized communities. Wong et al. (2010) underscored the importance of structured communication between patients, caregivers and healthcare providers during recovery phases. ^{Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22} The study revealed that many patients undergoing surgery for benign brain tumors lacked access to formal support systems and consistent updates from medical staff, heightening feelings of uncertainty and isolation. ^{Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22} Similarly, Khabarov et al. (2015) emphasized the emotional toll on caregivers caused by inconsistent or conflicting information from multiple healthcare providers. ^{Reference Khabarov, Dimitropoulos and McGillicuddy21}

Improving these systems requires enhanced collaboration among healthcare teams and streamlined inter-hospital transfer processes with structured communication protocols to keep families informed. Studies advocate for integrating telecommunication tools and providing regular updates to ensure continuity of care and reduce delays. ^{Reference Burns, Montelpare and Leÿenaar18,Reference Khabarov, Dimitropoulos and McGillicuddy21,Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22}