Critique on an Environmental Scan

An environmental scan is a strategic research tool used to assess the current landscape of healthcare services, policies, and barriers to access; it helps identify gaps and opportunities for improvement, informing future healthcare initiatives (Wilburn et al., 2016). Environmental scans have been widely used in primary care research to evaluate system-wide healthcare accessibility and identify areas requiring intervention (Graham et al., 2008). The study - Geographic differences in availability and access to care services for asthma and COPD: Case study of Vancouver Coastal Health, British Columbia by Choy et al. (2024) examines the geographic disparities in access to asthma and COPD care within the Vancouver Coastal Health (VCH) Authority, highlighting the differences between urban and rural communities. While this environmental scan does not focus specifically on pulmonary rehabilitation (PR), its findings are highly relevant to my health promotion initiative, which aims to examine the barriers seniors with COPD face when accessing pulmonary rehabilitation and explore potential strategies to improve accessibility. Ultimately, this work will contribute to bridging the gap in healthcare services for seniors by identifying systemic obstacles and proposing practical solutions.

Summary of the Environmental Scan

Objectives:

1. Identify the availability of asthma and COPD care services in urban and rural communities within VCH.

2. Examine the implementation of past asthma and COPD quality improvement (QI) initiatives.

Methods and Procedures:

The environmental scan was conducted between October 2020 and June 2021, using multiple data sources:

• Interviews with key informants from VCH via phone, online meetings, and email.

• Review of internal VCH reports on prior environmental scans.

• Online search of VCH webpages for available asthma and COPD services.

• Literature review across academic and grey literature databases (CINAHL, Medline, Embase) to identify previous QI initiatives focused on asthma and COPD management.

Key Findings:

1. Limited and unequal service availability

• Specialty outpatient care (including general respirology and severe asthma/COPD clinics), pulmonary rehabilitation (PR), and respiratory education services were limited in urban areas and unavailable in rural VCH communities.

• Spirometry services, essential for diagnosing COPD, were severely restricted in rural regions. Rural VCH communities could only provide 0–23% of the estimated needed spirometry tests, while urban areas provided 40–75%.

• No clinical smoking cessation services were available in rural regions.

2. Lack of QI initiatives in rural regions

• Of the 16 identified QI initiatives, none were conducted at rural VCH healthcare sites.

• Some urban QI initiatives aimed to improve spirometry access but failed to address systemic issues in rural areas.

3. Long wait times and accessibility barriers

• In urban areas, wait times for asthma and COPD services ranged from 3 to 6 months, while data for rural communities were unavailable or nonexistent.

• Patients in rural communities faced significant travel-related burdens, including high costs and long distances to access essential respiratory care services.

Critique of the Environmental Scan

Strengths

• Comprehensive data collection

  • The study integrates multiple data sources, including interviews, internal VCH reports, and online searches, ensuring a robust analysis of healthcare availability (Graham, et al, 2008).

  • The use of key informant interviews provides valuable qualitative insights into system-level challenges.

• Alignment with clinical guidelines

  • The study references national and international guidelines, such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2023), to ensure its analysis is consistent with evidence-based COPD management strategies.

  • The study underscores the limited availability of pulmonary rehabilitation (PR), a key intervention recommended in COPD management guidelines, highlighting the need for improved rehabilitation services (McCarthy et al., 2015).

• Policy and system-Level relevance

  • The findings highlight critical gaps in rural respiratory care, making this study highly relevant for policymakers (Wilson et al., 2020).

  • The lack of QI initiatives in rural areas suggests a need for targeted interventions to address service disparities and healthcare inequities

  
  

Limitations

• Limited timeframe and pandemic impact

  • The scan was conducted during the COVID-19 pandemic, a significant healthcare disruption that likely altered service availability.

  • The findings may not fully represent pre- and post-pandemic healthcare realities, limiting their long-term applicability (Wilburn et al., 2016).

• Incomplete data on rural communities

  • The scan excluded some rural regions (e.g., Bella Bella, Bella Coola) due to a lack of available personnel, making it difficult to assess the full extent of healthcare disparities.

  • Patient visit data and wait times for rural services were often unavailable, limiting the ability to quantify access challenges accurately (Wilson et al., 2020).

• Lack of follow-up on QI initiatives

  • While the study identifies past urban-focused QI efforts, it does not explore why no QI initiatives have targeted rural regions or why previous projects failed to improve rural healthcare access.

  • The long-term impact of urban QI initiatives remains unknown due to a lack of follow-up research on their effectiveness.

• Missed opportunity to address telehealth expansion

  • Despite evidence supporting telehealth-based PR programs (Stickland et al., 2011), the environmental scan does not fully explore virtual PR as a potential solution.

  • Given the shortage of healthcare professionals in rural areas, telehealth and home-based rehabilitation (Holland et al., 2016) could be viable alternatives to expanding PR accessibility.

The environmental scan by Choy et al. (2024) highlights significant disparities in asthma and COPD care services between urban and rural communities within VCH, emphasizing the need for targeted interventions to improve access. These findings align with Wilson et al. (2020), who note that rural healthcare challenges persist despite ongoing efforts to enhance services in Canada. Expanding spirometry and pulmonary rehabilitation availability, implementing telehealth-based rehabilitation, and developing quality improvement initiatives focused on rural healthcare could help address these gaps. Moreover, incorporating longitudinal studies and patient-level data would provide a clearer understanding of the long-term impact of these disparities, supporting more effective and equitable healthcare planning.

References

Choy, A., Shellington, E. M., Collins-Fairclough, A., Strydom, N., & Carlsten, C. (2024). Geographic differences in availability and access to care services for asthma and COPD: Case study of Vancouver Coastal Health, British Columbia. Canadian Respiratory Journal, 2024(8019557), 1-16. https://doi.org/10.1155/2024/8019557

Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2023). Global strategy for the diagnosis, management, and prevention of COPD. https://goldcopd.org/2023-gold-report-2/

Graham, P., Evitts, T., & Thomas-MacLean, R. (2008). Environmental scans: How useful are they for primary care research? Canadian Family Physician, 54(7), 1022.

https://pmc.ncbi.nlm.nih.gov/articles/PMC2464800/

Holland, A.E., Mahal, A.S., Hill, C.J., Lee, A.L., Burge, A.T., Cox, N.S., Moore, R.P., Nicolson, C.H., O’Halloran, P.D., Lahham, A., Gillies, R., & McDonald, C.F. (2016). Home-based rehabilitation for COPD using minimal resources: A randomised, controlled equivalence trial. Thorax, 72(1), 57-65. http://doi.org/10.1136/thoraxjnl-2016-208514

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane database of systematic reviews, 2015(2), CD003793. https://doi.org/10.1002/14651858.CD003793.pub3

Stickland, M. K., Jourdain, T., Wong, E. Y., Rodgers, W. M., Jendzjowsky, N. G., & MacDonald, G. F. (2011). Using telehealth technology to deliver pulmonary rehabilitation to patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal, 18(4), 216. https://doi.org/10.1155/2011/640865

Wilburn, A., Vanderpool, R. C., & Knight, J. R. (2016). Environmental scanning as a public health tool: Kentucky’s human papillomavirus vaccination project. Preventing Chronic Disease, 13, E109. https://doi.org/10.5888/pcd13.160165

Wilson, C. R., Rourke, J., Oandasan, I. F., Bosco, C., & Map Implementation Committee, R. R. Progress made on access to rural health care in Canada. Canadian Family Physician, 66(1), 31. https://pmc.ncbi.nlm.nih.gov/articles/PMC7012120/