When systems fall apart: the performance of the nursing station model in communities with populations over 2,500 peoples

Abstract

Primary healthcare (PHC) providers working in Manitoba First Nations (FNs) communities have anecdotally reported that the workload they face does not match staffing levels, leaving the care they provide comparable to a walk-in clinic, especially in communities with a population over 2,500. The purpose of this study was to evaluate the capacity of Nursing stations to deliver PHC services in FN communities with populations greater than 2,500, compared to smaller FN communities with populations less than 2,500, by analysing markers of chronic kidney disease (CKD) quality care among individuals living with CKD. We also assessed whether different models of care might reduce disparities in health outcomes. This partnership between researchers from the First Nations Health and Social Secretariat of Manitoba and the University of Manitoba used health administrative data held at the Manitoba Centre for Health Policy (2006–2019), linked to the Manitoba First Nations Research File to identify FNs. Data used included: Diagnostic Services Laboratory Data, Medical Claims, Hospital Discharge Abstracts, Drug Program Information Network Data, Public Canadian Census Files, Manitoba Health Insurance Registry and Physician Resource File. All records were de-identified. PHC visits and hospitalisation rates were higher in larger communities, suggesting a tendency to refer patients more readily to a higher level of care. In contrast, FNs living with CKD in smaller communities are more likely to receive follow up kidney function screening. Premature mortality rates for FNs living with CKD remain lower in larger communities. Our findings show that access to responsive PHC in Manitoba's rural and remote communities remains aspirational and may reflect pragmatic adaptations to workload pressures. There is an urgent need to assess the economic and health impact of these adaptations, to ensure that they result in optimal health results and progress equity for FNs, Manitobans, and those living in rural and remote communities.

Introduction

First Nations (FNs) in Canada access health care through a variety of publicly funded providers (family physicians [FPs], specialists and hospitals) and organisations (Regional Health Authorities) that are a part of every province's healthcare system [1]. The systems funded by the federal government and the provinces, including staffing levels, are planned and implemented based on historical expenditures, workforce planning, budgets, collective agreements, professional scope of practice and other factors as well. A lack of federal and provincial coordination has resulted in conflicting priorities, resulting in service gaps and inequities [2–4].

For historical reasons described in more detail elsewhere [1], the federal government took on increasing responsibilities for the provision of health services on FN reserves since the 1950s [5]. These include Nursing stations providing a limited range of PHC services. Since the early 1990s, most FN communities oversee a complement of PHC services locally (some more fully, some partially) with federal funds [6]. In Manitoba, PHC nurses working on reserve remain primarily federally employed, although one community employs its own complement of PHC nurses and three more communities rely on provincially employed nurses.

Previous work conducted in Manitoba and British Columbia have shown that communities served by Nursing stations have a lower rate of hospitalisation for Ambulatory Care Sensitive Conditions [ACSC, 7,8,9,10]. Anecdotally however, we hear that in communities with populations over 2,500 people, Nursing stations cannot deliver good PHC, and operate like walk-in clinics, with delays in referrals and follow up. This has been attributed to a disproportionate case load with overwhelming health care needs, to which is added an unwieldy administrative burden related to reporting requirements, the work associated with finding a hospital willing to admit a patient requiring emergency care, securing permission for medical transportation, consultations with the on-call FP when required and finally charting [11]. This calls into question the sustainability of the Nursing station model as currently staffed in larger FN communities. To test this proposition, this paper assesses the capacity of Nursing stations to deliver PHC services in larger FN communities with populations greater than 2,500, compared to smaller FN communities with populations less than 2,500, by analysing primary care markers among individuals living with chronic kidney disease (CKD). Acknowledging that some Nursing stations benefit from additional programming delivered by the First Nations Health and Social Secretariat of Manitoba's (FNHSSM) Diabetes Integration Project (DIP) and/or Ongomiizwin Health Services (OHS), we also assessed whether different models of care can reduce disparities in outcomes.

CKD and models of care in FN communities

Manitoba FNs have the highest documented prevalence and the second highest incidence of end-stage kidney disease (ESKD) in Canada. This is likely related to many factors including the continuing effects of colonisation, remoteness, delayed access to and discontinuities in care and poverty [4,12]. Institutional racism also likely play a role: this might include explicit instances of differential treatment based on erroneous assumptions, such as what was experienced by Brian Sinclair and Joyce Echaquan with lethal consequences, or more insidious forms which might result in result in delays or substandard care [13]. End-stage kidney disease (ESKD) is partially attributable to ineffective, unresponsive and/or inaccessible PHC [14], and continues to fundamentally impact the lives of FN individuals, their families and communities in Canada [15,16]. Despite repeated evaluations and the implementation of a range of kidney services, including the early screening in 20 FN communities through FNHSSM's DIP [17]; and time limited interventions such as the First Nations Community-Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) project [18,19, a project focused on screening 11 communities for evidence of CKD and creating referral pathways], rates of CKD/ESKD among Manitoba FN peoples are increasing.

For FNs, accessing responsive and timely care is complex, and involve navigating diverse models of care crossing multiple jurisdictions. In FN communities with seasonal or no road access, PHC is primarily provided in Nursing stations by federally-employed or in one community, FN government employed nurses working with an expanded scope of practice. In Manitoba, the staffing of Nursing stations for the provision PHC is the responsibility of the First Nations and Inuit Health Branch of Indigenous Services Canada (FNIHB), which defines staffing levels for PHC nursing services, and the provincial Department of Health (Shared Health), which allocates and funds primarily visiting FPs to FN communities. This model of care developed organically, as an adaptation of diseconomies of scale which would have prevented the deployment of a FP-centric model in a large number of small and dispersed communities [1,5].

Over the last forty years, FPs and other professionals working for OHS have provided PHC on-reserve to twelve Manitoba FN communities served by Nursing stations (a total of 22,010 FN individuals according to 2017 data). OHS is an Indigenous-centric University of Manitoba Primary Health Care (PHC) organisation led by a team of Indigenous and non-Indigenous health professionals, committed to implementing trauma-informed care (more explicitly since 2008, although the organisation existed since the 1970s). In addition, FNHSSM's DIP offers diabetes and kidney health screening and follow-up services to FN individuals in 19 communities. Regular screening and referral are provided by DIP nurses and guided by referral pathways. Table 1 summarises the information presented above for easy reference.

Table 1.

Summary of agencies involved in FN PHC delivery.

Agency	Abbrev	Level of government	Role
First Nations Health and Social Secretariat of Manitoba	FNHSSM	A subset of the Manitoba FN government organisation, the Assembly of Manitoba Chiefs	Supports 63 Manitoba First Nation communities Coordinates and facilitates policy discussions with provincial and federal governments Leads research of relevance to FNs Engage in some service delivery (DIP, described below)
Diabetes Integration Project	DIP	A program of FNHSSM	Offers diabetes and kidney health screening and follow-up services to FN individuals in 19 communities
First Nations and Inuit Health Branch of Indigenous Services Canada	FNIHB	Federal government agency	Funds FNs for health education and promotion services, Employs/funds FN to employ PHC nurses with an expanded scope of practice
Provincial Department of Health (Shared Health)	Shared Health	Provincial government	Planning and delivery of health services off-reserve Payment of family physicians and specialists, including those providing visiting services on-reserve
Kidney Health Manitoba	KHM	Program of the provincial government	Kidney health-care services Manitoba Includes kidney health clinic care for stages one to five CKD as well as in-centre (outpatient) and home dialysis
Ongomiizwin Health Services	OHS	University-based Indigenous-centric PHC delivery organisation	Provides primarily visiting family physician and specialist care to 12 FN communities

Access to dialysis in rural and remote communities still requires relocation for a majority of FN individuals, and is mostly limited to institution-based haemodialysis for a variety of factors, including community infrastructure shortcomings [20–23] and reticence to home modalities [24]. Current modalities in use include: institution-based haemodialysis (HD, 78% in MB), home haemodialysis (HHD, 3%) and peritoneal dialysis [PD, 19%, see 4,18,19,25,26]. Recent work by the Manitoba Centre for Health Policy (MCHP) systematically documented the kidney care Manitobans receive [27], but did not differentiate FN peoples in the cohort.

In a Manitoba-based screening study of 468 FN individuals, 17% of those with albuminuria (a key indicator of CKD) did not have diabetes or hypertension, suggesting that a broader aetiology needs to be included in addressing kidney disease [28]. Current Clinical Practice Guidelines (CPG) created by Kidney Health Manitoba (KHM), which recommends yearly kidney function screening for all at risk individuals, including all FN individuals over 10 years of age [29] is a Risk-Based Triage tool promoted to triage referrals using a Kidney Failure Risk Equation Reference [27]. The intent was to eliminate virtually any wait time to see a nephrologist team for patients at high risk of progression to ESKD. This approach identified all Manitoba FNs at high risk, thereby justifying the yearly screening of all FNs over 10 years of age (estimated at 52,245 FN individuals in 2017).

At the time of writing, the extent to which these CPG are implemented by PHC providers (including on-reserve, OHS and other PHC providers off-reserve) is not known. The yearly screening of 52,245 FN individuals raises issues of high sensitivity countered by a low specificity which may lead FPs to question this approach. Further, despite being cost effective in the long run [30], extending timely care to those deemed at risk may be beyond what the Manitoba healthcare system can deliver: related factors include the scarcity of providers working in FN and surrounding communities, and the high demand on their time for emergent care resulting in a demand-driven PHC system where immediate health concerns take precedence over effective chronic disease prevention and management. Based on estimates calculated with findings from the FINISHED study [18,19], implementing these CPG would result in 17,429 referrals PHC for follow-up and 367 new referrals to nephrology, raising questions as to whether alternatives CPG, developed with PHC providers, and informed by patients' experience, might be more pragmatic, and as a result, effective [31–37].

Evidence from the United States shows that once the national Indian Health Services adopted an integrated approach to the prevention and treatment of CKD, the incidence of ESKD began to decrease [31,38–42]. Translating this success to the Manitoba context will require working across jurisdictions and providers (Shared Health and the Regional Health Authorities, OHS, FN communities), thus the need for an integrated and evidence-based strategy.

Methods

The IK-Health Project is a program of research created as a partnership between FNHSSM, KHM, the University of Manitoba and Seven Oaks Hospital. It was funded by the Canadian Institutes for Health Research, #387891.

IK-Health focuses on improving the continuity of CKD care for Manitoba FN [43,44]. This retrospective cohort study is part of this program of research.

Ethics

This study received approval from the Health Information Research Governance Committee (HIRGC) of the FNHSSM, as required. The Provincial Health Research Privacy Committee (PHRPC) and the University of Manitoba Health Research Ethics Board (File number H23086) also approved this study.

Data sources

The Manitoba First Nations Research File, which is connected to the health administrative data stored at MCHP, was utilised to track FN identity: FNHSSM is in charge of maintaining the Manitoba First Nations Research File, a registration of all residents of Manitoba who meet the requirements to be classified as Status Indians (or a registered FNs) under the Indian Act [the Indian Act defines who in Canada can define themselves as a Status Indian, or Registered First Nations] [45]. The following datasets were accessed for data linkage: Manitoba Health Insurance Registry, Medical Claims, Drug Program Information Network, Hospital Discharge Abstracts, Shared Health Diagnostic Services Laboratory Data, Public Canadian Census Files and Physician Resource File. Every record was de-identified, and a scrambled personal health identification number was used to track specific persons through their care trajectory.

Study population

All registered FN individuals in Manitoba over the age of 10 who received an incident diagnosis of CKD between 1 April 2006 and 31 December 2019 were included. To determine CKD diagnoses, we employed a local case definition [27]. The Medical Claims or Hospital Discharge Abstracts ICD-9 or ICD-10 diagnosis code indicative of CKD, a prescription indicative of CKD in the Drug Program Information Network Data, or two abnormal estimated glomerular filtration rate (eGFR) or urine albumin to creatinine ratio (ACR) test results >90 days apart in laboratory data were the criteria used to define a case of CKD.

We calculated the eGFR with the CKD-Epidemiology Collaboration study equation for adults and the Paediatric Schwartz formula for children, imputing 3rd percentile height [46,47]. We converted urine protein to creatine ratio test results to urine ACR values using an equation developed by Weaver and colleagues [48]. The first date where one of the conditions of the CKD case definition was met was selected as the index date. Individuals were excluded from the cohort if they had a diagnosis of CKD prior to 1 April 2006 or if they were on chronic dialysis, had a kidney transplant, or were ≤10 years of age, prior to the index date. Chronic dialysis was defined using an algorithm incorporating tariff codes and the Manitoba Renal Program's kidney health records and kidney transplants were identified using tariff codes or hospital procedure codes [27].

First Nations Communities

There are 63 FN communities (reserves) in Manitoba. Each community's health services are provided by a Nursing station, a Health Centre, or a Health Office with supplementation provided by OHS and/or DIP. In this paper, we focus on the Nursing stations exclusively. Nursing stations are health clinics operating 24/7, where nurses working with an expanded scope of practice provide PHC, and where other community-based services (primary prevention and health promotion) are provided by community-employed staff (community health nurses, community-based and defined roles such as Elders workers, Community Health Representatives, wellness workers, etc). Nurses working with an expanded scope of practice have limited authority to diagnose, request tests and treat clients according to FNIHB-defined CPG, subject to provincial regulations and local protocols [49].

We used the Manitoba Health Insurance Registry to determine what address an individual in our cohort was residing in at the time of the index date and then cross-referenced with the communities to group the individuals into receiving health services from: Nursing station alone, Nursing station+DIP, Nursing station+OHS, Nursing station+OHS+DIP.

Outcomes

We used three categories of outcomes:

• Indicators of quality PHC provisions for those living with CKD: creatinine, urine ACR, potassium, A1C (HgbA1c), cholesterol, albumin, with testing performed in an outpatient setting, and extracted from the Diagnostic Services of Manitoba laboratory database for follow-up laboratory testing.

• Access to care and referrals: PHC visits and nephrology consults were obtained from the Medical Services database. According to information in the Medical Services database, a visit to a FP or nurse practitioner was considered a PHC visit.

• Indicators of overall impact of access to care for residents living with CKD: Hospitalisations, Premature Mortality (HR 95% CI). Hospital Discharge Abstracts were used to determine hospitalisations. We examined hospitalisations for ambulatory care sensitive conditions (ACSC) and general inpatient hospitalisations [8,27].

In addition, using Anatomic Therapeutic Chemical codes from the Drug Prescription Information Network, we evaluated prescriptions for angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), statins, diuretics, β-blockers and calcium channel blockers as part of our follow-up assessment of drug prescriptions.

To distinguish between different models of care, we compared the trajectory of care for FNs living with CKD residing in communities with less or more than 2,500 residents, accessing services through a mix of, nursing station staff; nursing station staff supplemented by the DIP; nursing station staff supplemented by OHS; and all Nursing stations.

Variables

We gathered each person's demographics, comorbidities, severity of CKD and medication prescriptions at baseline. We also gathered age and sex from the Manitoba Health Insurance Registry in addition to community of residence. In order to provide classifications if one or both test values were lacking at baseline, we modified the Kidney Disease Improving Global Outcomes eGFR and urine ACR heat map used to classify patients by CKD severity [27,50]. On or before the index date, we made use of the most current measurement. Using an algorithm developed by Quan and colleagues, we gathered all comorbidities in the Elixhauser Comorbidity Index by looking back at hospitalisations and medical claims from the databases' creation until the index date [51,52].

Using a negative binomial regression model adjusted for age, sex, eGFR heat-map category, urine ACR heat-map category and Elixhauser comorbidity index, we compared rates of laboratory follow-up tests, nephrology consults, PHC visits and hospitalisations between FN communities served by Nursing stations ≥2,500 residents vs. <2,500 residents. Every comparison's outcome was shown as an odds ratio (OR) with a 95% confidence interval (CI). We also ran the same models, comparing residents of communities served by DIP, OHS, or Nursing stations alone.

Utilising McNemar's test, we compared the percentages of prescriptions for angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), statins, or other anti-hypertensives (diuretics, β-blockers and calcium channel blockers) written in the 18 months prior to the index date with the percentages written in the 18 months following the index date. We conducted these comparisons both across the entire cohort and within each category of health service providers. SAS 9.4 was used for each analysis.

Results

Table 2 provides number of FNs living in each category of community.

Table 2.

First Nations population per category.

Variable	NS<2,500 (n = 1,921)	NS≥2,500 (n = 2,433)
NS only	424 (22.1%)	1,062 (43.6%)
NS+DIP	388 (20.2%)	319 (13.1%)
NS+OHS	1,109 (57.7%)	1,052 (43.2%)
Age (years)	48.8±17.3	49.4±17.8
Age 11–17	103 (5.1%)	135 (5.5%)
Age 18+	1,919 (94.9%)	2,298 (94.5%)
Sex (female)	1,098 (54.3%)	1,289 (53.0%)
Elixhauser comorbidities index	5.4±3.2	5.8±3.3

As discussed in the methodology section, we reviewed three categories of health care indicators:

• indicators related to quality care for those living with CKD or at risk of developing CKD;

• indicators related to access to care and referrals;

• indicators of impact of different models of care provisions.

As shown in Table 3, our results are mixed. Results show that for FNs living with CKD, those living in smaller communities are more likely to be screened for creatinine, urine ACR and potassium.

Table 3.

Comparing the performance of nursing stations in communities with more than 2,500 residents, to that of nursing stations with less than 2,500 residents for residents living with CKD.

Not statistically significant.

Communities with ≥2,500 residents had higher odds ratio than communities with <2,500 residents.

Communities with ≥2,500 residents had lower odds ratio than communities with <2,500 residents.

A striking result is that the follow up of FNs living with CKD (all Nursing stations, creatinine, urine ACR, potassium, A1C) in larger communities is generally poorer than in smaller communities. Exception includes follow up for cholesterol screening, and serum albumin in communities where Nursing station services are supplemented by OHS.

PHC visits and hospitalisation rates were higher in larger communities, suggesting a tendency to refer patients more readily to a higher level of care, or later presentation. Despite these findings, premature mortality rates for FNs living with CKD remain lower in larger communities. And so while higher rates of PHC visits and hospitalisation in larger communities might suggest late presentation, the lower mortality rate in larger communities suggests instead differences in referral patterns. Interestingly, referrals for nephrology seem constant across communities, suggesting that upon diagnostic, patients identified as having CKD are routinely referred.

Table 4 shows that both categories of Nursing stations saw significant improvements in the prescription of ARB/ACEI (p < 0.001), following a CKD diagnosis. The difference between Nursing stations in communities with less than 2,500 community members and more was however not significant. These improvements are nevertheless suboptimal.

Table 4.

Prescription of an ACEi or ARB within 18 months of a CKD diagnosis.

	Pre-CKD diagnosis	Post-CKD diagnosis
Nursing station communities <2,500	61%	68%
Nursing station >2,500	64%	70%

Discussion

The Nursing station model of care was created as a pragmatic option to deliver care in relatively small and remote communities, where diseconomies of scale limits local access to specialised services. While this model has repeatedly been shown to deliver better outcomes when compared to FNs served by Health Centres [6–10,53–55], this is a first attempt at unpacking the performance of the Nursing station model in providing optimal PHC in larger versus smaller FN communities. In this study, we focused on the performance of PHC for FNs living with CKD.

The strengths of our study include the ability to examine the whole registered FN population in the province rather than just a sample, which could introduce bias due to population-level administrative data. This gave us the opportunity to do intricate analysis and pinpoint variations in the many communities that various PHC models serve. Furthermore, a longer study duration was possible due to our retrospective approach, and follow-up loss was negligible.

Still, our study also has many limitations. First, administrative data does not offer information on variables that are likely to affect access to care, such as community-based treatment quality, diagnostic delays and transportation issues. Furthermore, we are unable to determine whether CKD patients who were given medicine and had follow-up appointments chose not to follow their treatment plans or were otherwise prevented from doing so. Nevertheless, there is no cause to believe that the distribution of these parameters among PHC models is systematically biased.

Furthermore, the data from the laboratory had limitations. Due to incomplete laboratory data at baseline, we assessed eGFR and urine ACR as categorical variables rather than continuous variables in our models. We were also unable to get data on laboratory tests performed in any private laboratories in Manitoba. However, it is expected that >70% of laboratory tests, including all urine ACR testing, are performed throughout the province by Shared Health Diagnostic Services.

It is possible that the number of PHC visits in Nursing station-served communities was underestimated since some of these services are billed to the federal government or provided by salaried employees and are only partially reflected in provincial administrative records. Finally, the relatively small number of FNs living with CKD in each community may result in differences not being detectable.

Finally, our study focused on follow-up for FNs living with CKD. Anecdotal evidence suggests that PHC physicians and nurses may be under-skilled to manage CKD patients and that this may lead to less than optimal follow up. We therefore recommend caution in generalising our findings to all chronic conditions.

Our results show some ambiguity in the performance of the Nursing station model for smaller versus larger communities: follow-up of individuals living with CKD in larger communities is generally more sporadic compared to those in smaller communities, as evidenced by their monitoring of creatinine, urine ACR, potassium and A1C. However, there are exceptions to this trend, such as the follow-up for cholesterol screening and albumin in communities where Nursing station services are complemented by OHS.

In addition, larger communities show higher rates of PHC visits and hospitalisations, indicating a greater tendency to refer patients to a higher level of care. However, despite these results, the premature mortality rates for individuals with CKD living in larger communities were lower. Therefore, while the higher rates of PHC visits and hospitalisations in larger communities may suggest late presentation, the lower mortality rate in these communities suggests differences in referral patterns and prudent management instead. These referral patterns may reflect adaptations to workloads and appear to have an impact on quality of care and premature mortality. There is an urgent need to assess the economic and health impact of these adaptations, to ensure that they result in optimal health results for FNs, Manitobans and those living in rural and remote communities.

It is worth noting that referrals for nephrology appear to be consistent across communities, indicating that once diagnosed, patients identified as having CKD are consistently referred for further care. The prescription of ACE and/or ARB improved upon CKD diagnosis but remains below expectations for both types of community.

Our results show that the Nursing station model still requires fine tuning to ensure that the existing workforce and practice align with needs. Our findings suggest that there is a need to expand access to PHC human resources in FN communities with more than 2,500 residents, to address the needs of those living with CKD, and by extension, to all FNs living with chronic conditions. These findings are consistent with previous work [7,8,10].

Our analyses span 2006–19, thus pre-pandemic. COVID-19 disrupted all systems, and we assume that weaknesses in pre-pandemic systems might have been magnified during the pandemic. While a resumption of steady state in on-reserve health services might take some time, given fundamental disruption to the health care workforce [56], we assume that the limitations to the Nursing station model identified in this study will persist and require a rethinking of workforce and a monitoring of practice.

The models of care developed to serve Manitobans favour urban populations. Access to care in rural and remote communities remain limited [53,57]. Further, access to tertiary care in Manitoba is available in Winnipeg only: this is unique when comparing to other provinces. As a result, Manitobans living in rural and remote communities, which include more than two thirds of the FN population, are required to travel long distances by car or plane (and for some, by car to a small boat to a plane) to access specialised care. Canada could be a world leader in the design of models of rural and remote PHC. Further, FNIHB should be a world leader in evidence-based models of PHC delivered on First Nation reserves. Yet, most research conducted to bring evidence to on-reserve PHC has been conducted by Lavoie in partnership with FNHSSM [7–10,14,54,58]. Finally, Manitoba needs to become a leader in access to PHC, for FN and for all residents of rural and remote communities. A study documented that in 2016, FNs (then 15% of the population) consumed 30% of all health care resources [59]. Barriers to innovating in this space have historically been [5], and remains associated with the lack of coordination across provincial and federal jurisdiction [60]: indeed, in this space, federal investment in healthcare on reserve could result in a reduction in hospitalisation and emergency care, saving costs for the province. However, to date, systems remain confined to silo thinking [1,4,61].

Conclusions

The models of care developed to serve Manitobans and Canadians favour urban populations. Aside from Australia, where remote care has received more specific attention [62–64], we assume that the Canadian context is not unique: equity in access to responsive PHC in rural, remote and FN communities remain aspirational. Our findings show that existing models developed to serve FN individuals living with CKD are insufficient to protect kidney function, resulting in premature ESKD and dialysis, at tremendous costs to the individual, the family and the health care system.

In the Manitoba context, the provincial response has been to build more haemodialysis units in rural and remote communities, resulting in staffing challenges: this trend is unsustainable. Long-term investments in PHC are required. While the DIP, which remains funded as a “project”, is able to mitigate PHC shortcomings, the DIP operates in only 19 out of 63 Manitoba FN communities. There is an urgent need to bring together Shared Health, FNIHB, FNHSSM and PHC providers to develop a comprehensive approach.

Our study highlights what happens when existing models of care evolve organically, with little monitoring of performance. Research to date has favoured urban-centric evidence in the creation of models of care. Rural and remote models of care have been extrapolated from urban contexts, and remain ill-fitting, and under-monitored for quality. This is a field of inquiry that requires increased attention.

Funding Statement

This study was funded by the Canadian Institutes of Health Research, #387891.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The source data used in this study were originally collected during the routine administration of the health system in Manitoba, and were provided to the Manitoba Centre for Health Policy (MCHP) for secondary use in research under specific data sharing agreements between the data trustees and MCHP. The data are approved for use at MCHP only (Manitoba's Personal Health Information Act and Personal Health Information Protection Act, 2004). They are not owned by the researchers or by MCHP and cannot be deposited in a public repository. To review source data specific to this project, interested parties should contact the Repository Access & Use team at MCHP (access@umanitoba.ca), who will facilitate data access by seeking the consent of the original data holders and the required privacy and ethics review bodies on behalf of the party requesting access.

Research studies using FN data require ethics approval from the Health Information Research Governance Committee (https://www.fnhssm.com/hirgc), and we comply with their policies for data access, linkage and sharing. For inquiries about accessing Manitoba First Nations data, please contact info@fnhssm.com.

Consent for publication

Not applicable.

Ethics approval statement

This study received approval from the Health Information Research Governance Committee (HIRGC) of the FNHSSM, as required. The Provincial Health Research Privacy Committee (PHRPC) and the University of Manitoba Health Research Ethics Board (File number H23086) also approved this study. The First Nations Health and Social Secretariat of Manitoba for providing approval to link the Manitoba First Nations Research File.