Boost: Visiting-specialist services to improve access and outcomes for isolated populations

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December 2007

The Problem: Access to specialist care in rural and remote communities

People living in rural and remote communities often have among the greatest health needs i but the most limited access to healthcare services, including specialist care. ii This is commonly referred to as the "inverse care law," where the availability of medical care is inversely related to the needs of the population. iii For example, while rural Canada makes up the majority (99.8 percent) of terrain and is home to roughly 20 percent (nine million) of Canadians, iv only about 16 percent of family physicians and two percent of specialists have practices in these areas. v

Rural family physicians often shoulder a heavy workload in these areas, vi made more difficult by lack of access to specialist services for their patients. vii One solution for increasing access to specialist services is visiting-specialist services or specialist outreach clinics. ii, viii This is when specialist physicians make planned, regular visits from their usual practice location (usually hospitals or their own private offices in urban areas) to see patients in primary care or rural hospital settings. viii These clinics can improve access to specialty care and health outcomes for patients, especially disadvantaged groups since access barriers have important health consequences, while also improving collaboration between primary caregivers and specialists. viii

Strategy for Change

Specialist outreach clinics should be well co-ordinated, adequately resourced and take place on a routine basis, viii with a specialist (or group of specialists) visiting a community anywhere from once every few weeks to once a year. ix The specialist may see patients in a primary care office where patients would go to see their primary care practitioner; alternatively, the clinics may be offered in small hospital emergency departments or outpatient clinics.

Many specialty areas can be covered during outreach, such as surgery, obstetrics/gynecology, ophthalmology and oncology. ii When clinics are conducted in primary care offices, visit schedules should be negotiated with local primary care staff. Portable equipment may be used such as slit-lamps for conducting eye examinations or colposcopes for gynecologic exams. ii When clinics are conducted in hospital settings, the equipment may be hospital-owned and case schedules are negotiated with hospital administration. Outreach clinics may last a few hours to a week depending on the service that is provided. viii For example, visiting surgical specialists will frequently spend half a day in a clinic and half a day in the operating room.

The most common model, described here, is a "shifted outpatients" model where, within limits, specialists provide the same kinds of consultations, investigations and procedures as they do in their regular settings. viii Alternatively, specialists and primary care practitioners may use outreach visits as a vehicle to allow for additional activities such as staff education and joint consultations with patients.

What the Research Says

Research evidence from a Cochrane review shows that specialist outreach can significantly improve access to specialist care for patients. viii While the highest-quality studies included in this review were conducted in major urban settings, such as inner cities, research in a disadvantaged rural setting showed greater improvements in access to specialist care. ii In particular, the investigators found that improvements in access to specialist consultations and procedures in this setting came without increased primary care referrals as well as without additional demand for hospital-based care. ii

Specialist outreach can also lead to improvements in health outcomes for patients and greater efficiency in the use of hospital-based services by reducing unnecessary referrals and investigations. viii This is particularly the case when outreach specialists work collaboratively with or provide education seminars to local primary care practitioners. viii- xiiiIncreased collaboration and consultations may improve provider-to-provider communication and lead to more positive patient experiences. viii Hosting specialist consultations in primary care settings may also offer such benefits as familiarity and reduced stigma for patients and fewer distractions for providers. viii

In terms of costs, international research on collaborative management of depression in urban settings has found that specialist outreach costs more for healthcare systems when compared with typical, hospital-based specialist care. xiv, xv However, in rural settings, other international research suggests one specialist visit can save many patients the cost and time of travel. xvi In some Canadian jurisdictions, medical travel costs are funded by the healthcare system. However, in other areas, patients must pay for these costs out-of-pocket.


There are a number of proposed solutions for increasing access to specialist services in rural and remote areas - from telemedicine (interactive video consultations) xvii to expanding the role of family physicians in providing specialist care. xviii- xx Outreach services are a well-evaluated way of enabling patients from rural and remote populations to access speciality care without incurring travel costs and the other inconveniences associated with travel. Importantly, these clinics allow patients to have their families and other loved ones accompany them to their appointments if need be.


i. World Health Organization. 1995. "World health report 1995: Bridging the gaps." Geneva: World Health Organization.

ii. Gruen RL et al. 2006. "Specialist outreach to isolated and disadvantaged communities: A population-based study." Lancet; 368: 130-138.

iii. Tudor Hart J. 1971. "The inverse care law." Lancet; 1(7696): 405-412.

iv. Beshiri R, Bollman RD and Statistics Canada. 2001. "Population structure and change in predominantly rural regions." Rural and Small Town Canada Analysis Bulletin; 2(2). Catalogue no. 21-006-XIE.

v. Canadian Institute for Health Information. 2006. Geographic distribution of physicians in Canada: Beyond how many and where.

vi. Wootton J. 2007. Who will provide secondary care in rural Canada? Canadian Journal of Rural Medicine; 12(2): 67.

vii. Telford et al. 2002. "Obstacles to effective treatment of depression: a general practice perspective." Family Practice; 19(1): 45-52.

viii. Gruen RL et al. 2004. "Specialist outreach clinics in primary care and rural hospital settings." The Cochrane Database of Systematic Reviews. Issue 1, No: CD003798 DOI: 10.1002/14651858.CD003798.pub2.

ix. Gruen RL et al. 2002. Outreach and improved access to specialist services for Indigenous people in remote Australia: The requirements for sustainability. Journal of Epidemiology Community Health; 56: 517-521.

x. Katon W et al. 1997. "Collaborative management to achieve depression treatment guidelines." The Journal of Clinical Psychiatry; 58(Supplement 1): 20-23.

xi. Katon W et al. 1999. "Stepped collaborative care for primary care patients with persistent symptoms of depression: A randomized trial." Archives of General Psychiatry; 56(12): 1109-1115.

xii. Roy-Byrne PP et al. 2001."A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care." Archives of General Psychiatry; 58(9): 203-207.

xiii. Vierhout WP et al. 1995. "Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders." Lancet; 346(8981): 990-994.

xiv. Simon GE et al. 2001. "Cost-effectiveness of a collaborative care program for primary care patients with persistent depression." American Journal of Psychiatry; 158(10): 1638-1644.

xv. Von Korff M et al. 1998."Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression." Psychosomatic Medicine; 60(2): 143-149.

xvi. Gruen, RL et al. 2001. "Improving access to specialist care for remote Aboriginal communities: Evaluation of a specialist outreach service." The Medical Journal of Australia; 174(10): 507-511.

xvii. Duplantie J. 2007. "Telehealth and the recruitment and retention of physicians in rural and remote regions: a Delphi study." Canadian Journal of Rural Medicine; 12(1): 30-36.

xviii. Society of Rural Physicians of Canada. 2006. "Federal solutions for rural health care."

xix. Glazebrook RM and Harrison SL. 2006. "Obstacles and solutions to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia." Rural and Remote Health; 6(online): 502.

xx. Working Group of the Society of Rural Physicians of Canada. 2001. "Joint position paper on training for rural family physicians in anesthesia."

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Evidence Boost is prepared by staff at the Canadian Health Services Research Foundation and published only after review by experts on the topic. The Foundation is an independent, not-for-profit corporation. Interests and views expressed by those who distribute this document may not reflect those of the Foundation.