Hysteroscopy needs of indigenous communities in Northern Quebec: a retrospective cohort study

ABSTRACT

We aimed to determine the surgical output for patients from Nunavik undergoing transfer to an urban centre for hysteroscopy, and associated costs. We performed a retrospective chart review of all patients from the 14 villages of Nunavik transferred for hysteroscopic surgery from 2016 to 2021. Diagnoses, surgical intervention, and nature of the procedure were all extracted from the patient charts, and costs/length of stay obtained from logisticians and administrators servicing the Nunavik region. Over a 5-year period, 22 patients were transferred from Nunavik for hysteroscopy, of which all were elective save one. The most common diagnosis was endometrial or cervical polyp and the most common procedure was diagnostic hysteroscopy. The average cost for patient transfer and lodging to undergo hysteroscopy in Montreal ranged from $6,000 to $15,000 CDN. On average, 4–5 patient transfers occur annually for hysteroscopy, most commonly for management of endometrial polyps, at a cost of $6,000 to $15,000 CDN, suggesting the need to investigate local capacity building in Nunavik and assess cost-effectiveness.

KEYWORDS:

• Global health
• hysteroscopy
• rural health services
• indigenous health services
• cost evaluation

Introduction

Although the World Health Organization (WHO) has affirmed the universal right of timely and safe access to health services [1], achieving this goal in reality evidently proves to be more challenging for certain communities. Notable impediments can be related to many factors including financial, infrastructural, or logistical issues, among others, in addition to patient-level barriers in seeking care such as mistrust or fear [2]. Northern Quebec is home to over thirteen thousand indigenous people living predominantly in 14 villages spread over the two coasts of the province, Hudson Bay and Ungava Bay [3,4]. This area, bounded by the 55^th parallel to the South and the Hudson Strait to the North, comprises a land mass larger than that of the state of California and is known as Nunavik [5,6]. Figure 1 displays the region and the location of the 14 villages. Health services to the area have been largely overseen by the Nunavik Regional Board of Health and Social Services (NRBHSS) since the signing of the James Bay and Northern Quebec Agreement (JBNQA) in 1975 [7].

Figure 1. Villages of Nunavik, North of the 55^th parallel in Quebec.

Source: https://www.makivvik.ca/wp-content/uploads/2013/02/nunavik1.gif

Reproduced with permission of Makivvik Group

Under the purview of the JBNQA and NRBHSS, health services are concentrated in two main hospitals on either coast, established in Puvirnituq (Hudson Bay) and Kuujjuaq (Ungava Bay). Periodic specialist care is scheduled in both centres, with regularly occurring non-overlapping trips from a variety of different specialities such as ophthalmology, otorhinolaryngology, and obstetrics gynaecology, slated every 2–3 months. Unfortunately, due to the extreme weather situations, trips have frequently been delayed or cancelled – further hindering access to care. As well, limited resources and support in Nunavik results in many patients requiring transfer to tertiary-care centres (typically Montreal) for a variety of reasons including emergency care, specialist follow up, or medical/surgical interventions. These patient transfers are expensive, with numerous associated costs (flight, transport and lodging, meals) and stressors to the patient such as loneliness, unfamiliarity with the environment, and lack of social/familial support. Presence of an escort is often encouraged and budgeted for, resulting in a doubling of transfer costs for patients.

Hysteroscopy is a low-risk, minimally invasive modality which is used to both assess and treat intra-uterine pathologies such as polyps, uterine fibroids, uterine septa, intra-cavitary adhesions, as well as abnormal uterine bleeding. Using local anaesthesia injected in the cervix, with or without systemic sedation, allows for the vast majority of hysteroscopic procedures to be carried out safely and tolerably. With hysteroscopy, many uterine pathologies can be diagnosed and simultaneously treated, all in an outpatient setting [8]. Transferring patients to a different city far from their primary place of residence for hysteroscopy is an expensive and potentially avoidable endeavour. With some investment in basic instruments (such as a fluid management system, functional hysteroscopes, and operative add-ons), hysteroscopy could be provided locally in the North, when gynaecologists visit for their regularly scheduled trips. As mentioned, gynaecologists regularly visit Nunavik for medical trips lasting approximately one week (occurring every 2–3 months on average in Puvirnituq), such that there would frequently be skilled providers available locally if the equipment and setup were made available. Establishing a central outpatient hysteroscopy suite in Puvirnituq to service the 14 villages of Nunavik may be preferable for patients, rather than travelling much further from remote Northern villages to Montreal, as well as potentially having the added benefit of being cost-effective.

Hysteroscopy, as a low-risk and multipurpose platform, can greatly expand access to basic gynaecological care for the remote Northern population of Quebec for a range of procedures; however a thorough understanding of the needs and current costs of hysteroscopy are warranted to inform future planning. The purpose of this project is to quantify the hysteroscopic needs of the 14 Indigenous villages of Northern Quebec in order to evaluate whether investing in local capacity building merits further consideration. Evaluating the current costs and delivery framework of hysteroscopy and comparing to the costs of providing the same care at a local referral hospital (Puvirnituq) with specialist visits every 2–3 months will assist in determining the feasibility as well as the need for local access to hysteroscopy.

Materials and methods

Search strategy

At a tertiary-care academic centre, the Royal Victoria Hospital, we performed a retrospective chart review from January 2016 to January 2021. All hysteroscopic procedures performed either electively or emergently were identified for patients whose primary residence originates from the 14 villages in the Nunavik region. These villages include the following: Akulivik, Aupaluk, Inukjuak, Ivujivik, Kangiqsualujjuaq, Kangiqsujuaq, Kangirsuk, Kuujjuaq, Kuujjuarapik, Puvirnituq, Quaqtaq, Salluit, Tasiujaq, and Umiujaq. This search was carried out using the electronic operative database of the institution with criteria set for procedure codes and limitations set on place of residence by address and postal code. Hysteroscopic procedures that were included in the search were diagnostic hysteroscopy, myomectomy, septoplasty, endometrial polypectomy, intrauterine device (IUD) retrieval, and endometrial ablation. Cost estimates were obtained through discussion with logisticians and administrators who service the Nunavik area, approve expenses, and arrange bookings. Ethics approval was waived by the institutional Research Ethics Board, given the study was deemed to be primarily quality improvement, and no patient identifiers would be released through the electronic search. Given the anonymised nature of data produced through the online operative record system, no informed consent was necessary for the completion of this project, in accordance with the declaration of Helsinki [9].

Primary outcome

The primary outcome of the study was a quantitative assessment of the annual case load for hysteroscopy for patients from this region, averaged over a five-year period.

Secondary outcome

Secondary outcomes included indications for hysteroscopy, type of procedure performed (both specific hysteroscopic surgery as well as the nature of the procedure, meaning elective vs. emergent), as well as an approximation of cost per case based on three key expenses: travel costs, daily expenses relating to meals, lodging, and local travel, and lastly, presence of a patient escort. These three variables were chosen as they represent in essence all the associated costs of transporting a patient from Nunavik to Montreal in order to undergo an intervention. Costs related to the intervention directly (such as consumable equipment and OR time) were excluded, as they are virtually unchanged whether the procedure is done locally in Nunavik or in Montreal and paid through public health services (Régie de l’assurance maladie du Québec – RAMQ).

Analysis

Descriptive analyses were performed for the averaged annual case load for hysteroscopy as well as the qualitative secondary outcomes mentioned previously. Cost estimates were obtained after contacting logistical support staff who assist in the planning of medical trips for this population. Direct costs related to accessing the procedure in a tertiary referral centre in Montreal were acquired (transportation, accommodation, and meals). Procedural costs related to disposable equipment, OR time, and other surgical expenses were not included in the analysis, as they are fixed costs that would be equivalent in either setting, either in Montreal or in Puvirnituq. No statistical software was required for the completion of this descriptive analysis, and there were no necessary thresholds to define for statistical significance.

Results

Over the course of 5 years from NaN Invalid Date to NaN Invalid Date , including 10 months of the COVID-19 pandemic, a total of 22 hysteroscopic procedures were performed for patients from Nunavik, all of which were elective in nature except for one. The most common procedure performed was diagnostic hysteroscopy (n = 12), followed by hysteroscopic endometrial ablation (n = 6), retrieval of intrauterine device (n = 3), and polypectomy (n = 1). Accounting for reduced surgical volume during COVID-19, there were approximately 4–5 patient transfers that occurred annually for hysteroscopy over this 5 year period.

Indications for hysteroscopy varied widely, however the three most common indications were endometrial or cervical polyp (n = 10), abnormal uterine bleeding (n = 5) and retained IUD (n = 3). Cost estimates which were obtained from logistical specialists who arrange transportation and lodging for patients from Nunavik for medical trips were collected. The average price per round trip flight per patient varies from $3,500–$4,000 CDN. Daily food allowance, lodging, and local transport amounts to approximately $500 CDN per day. Prior to the COVID-19 pandemic, the average length of stay for patients awaiting surgical intervention was 3–5 days in Montreal, however since the added complexity of travel during the pandemic, the average length has increased to 5–7 days currently. Lastly, the majority of patients travel with an escort, effectively doubling associated expenses. In summation, a 5-day trip costs approximately $13,000 CDN for a patient accompanied by their escort. Table 1 summarises cost estimates for transfer to Montreal.

Table 1. Costs for travel and lodging for transfer from Nunavik to Montreal.

	Montreal
Flight	$3,500–$4,000
Meal, lodging, local transport	$500 per day
Length of stay	5–7 days
Total cost:^a	$6,000–$15,000

^aUpper limit reflects highest estimated cost and inclusion of a patient escort.

Since the costs of the actual surgical procedure (consumables, operative costs) are unchanged in either setting, they have been omitted from the calculations.

Benefits not financially quantified through local provision of surgical care include increased patient comfort (remaining close to home and support system), improved access through decreased wait-times, as well as less exposure to COVID-19 dense areas such as Montreal.

Discussion

In this retrospective study, we sought to determine the volume of hysteroscopic procedures performed for a population spanning 14 remote northern Quebec villages whose primary residents are of Indigenous background. Approximately 4–5 patients annually are transferred to Montreal for this procedure, resulting in travel and associated expenses amounting to $13,000 CDN per patient per 5-day trip. The most common intervention performed was diagnostic hysteroscopy and the most common indication for hysteroscopy was endometrial or cervical polyp.

This retrospective review is the first attempt to quantify and qualify the use of this diagnostic and therapeutic modality for this patient population. However, there are numerous limitations to the data gathered. For instance, gynaecologists assessing patients in the North may be less likely to suggest or offer such a minor procedure, given the major costs and commitments involved, and may rather manage with either local pharmacological alternatives or suggest a larger, more definitive surgery such as a hysterectomy. Resorting to alternative options to hysteroscopy may be occurring unintentionally, and may represent an unfair disadvantage to the patients of remote Northern Quebec. The reduced access to hysteroscopy in the North may serve as a major deterrent to gynaecologists working in Nunavik from offering this valuable, low-risk, and effective treatment option. It may be felt as not worthwhile to spend thousands of dollars and a week’s worth of time simply to undergo hysteroscopy when the same time and transportation costs could be used towards a major intervention like a hysterectomy, thus unfairly skewing both counselling and management options for this demographic of women. This may potentially result in underestimation of the number of women who may in fact be eligible and very well treated with hysteroscopy as well as those who would choose this procedure over equivalent alternatives. Furthermore, with the COVID-19 pandemic, non-emergent procedures, specialist trips to Northern Quebec, as well as patient willingness to travel were all reduced and may represent another factor to consider in potentially underestimating the most current case volume.

Establishing a hysteroscopy suite in a key Northern referral centre such as Puvirnituq offers significant advantages such as increased accessibility, decreased travel time, distance, and expense, as well as the benefit of patients being close to home and their support network. The local hospital in Puvirnituq already has the physical operating room and clinic space to accommodate hysteroscopy, as well as a sterilisation core and biomedical department. These spaces are already being used for other procedures by obstetricians/gynaecologists (such as colposcopy, cervical conization, tubal ligation/salpingectomy, oophorectomy, and mid-urethral sling placement), as well as other specialists who perform endoscopy and other minor procedures at different times of the year. As there are already gynaecologists routinely travelling to Nunavik on a regular basis, the availability of a hysteroscopy suite would enable them to offer this procedure at recurring intervals. The providers are already in place and trained, however the equipment and consumables are not. There are other considerations however, such as managing patient transport from other villages to Puvirnituq and ensuring there is sufficient lodging in local transit homes to accommodate an influx of patients awaiting procedures. A more accurate assessment of the volume to be served would help in planning resource allocation and priorities for capacity building.

Another important consideration would be the initial costs for reusable equipment and the running cost of consumables, which must be distinguished. There are numerous providers of hysteroscopic equipment on the market as well as a range of products for various needs, however studies have consistently shown the cost-effectiveness of establishing an outpatient hysteroscopy suite which is compounded in this context when expenses such as patient transport and lodging can be foregone [10–13]. Additionally, costs for consumables are identical between locations, either Nunavik or in central areas, and include items such as irrigation fluid, tubing, resection tools and ablative tools. It is important to highlight once again that the number of patients undergoing hysteroscopy is likely underestimated, given that the known costs and logistical difficulties may bias medical counselling for patients in Nunavik. It remains to be seen whether local access would then translate to higher rates of hysteroscopy use, once the financial deterrent and coordination challenges are removed, and whether this in turn may result in reduced rates of other interventions such as hysterectomy.

Conclusion

Using the best available data based on historic use and conservative estimates, there appears to be both sufficient clinical need as well as cost incentives to investigate the establishment of an outpatient hysteroscopy suite in the North to serve northern remote communities of Quebec.

Acknowledgments

We would like to acknowledge the patients who endure significant delays and challenges in accessing appropriate medical care by virtue of the remote and harsh living conditions in Nunavik, as well as the health-care workers dedicated to travelling and providing care in these regions.

Disclosure statement

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

Additional information

Funding

This work was not funded