Highlights
Healthcare disparities in neurosurgical care persist across Canada, affecting patient outcomes and population health.
Geographic, cultural and socioeconomic barriers contribute to unequal access.
Change is needed in the Canadian healthcare system to achieve timely, universal and equitable access to neurosurgical care for all.
Introduction
The Canadian healthcare system emphasizes universal and equitable access to medical services through public funding. Canada’s geographic vastness and unequal allocation of healthcare resources have led to significant challenges in the timely and equitable provision of healthcare services. Reference Sergeant, Saha and Lalwani1 Timely access to neurosurgical care is a crucial component of such healthcare provision. Many Canadians living in rural or remote regions encounter barriers in accessing neurosurgical care, as these areas often lack the necessary facilities and specialists. Reference Harding, McFarlane, Honey, McDonald and Illes2 These barriers to healthcare access hinder prompt diagnosis and timely surgical intervention, both of which are critical within neurosurgery, where delays in care result in adverse health outcomes and significantly impact patients’ quality of life or survival rates. Reference Olah, Gaisano and Hwang3–Reference Upadhyayula, Yue, Yang, Birk and Ciacci5
Canada’s largest and best-equipped neurosurgical centers are concentrated in urban areas, leaving rural and remote populations facing long and often hazardous travel for treatment. This urban–rural divide imposes considerable financial, emotional and logistical burdens on both patients and their families, delaying diagnoses and treatment and increasing the risk of preventable complications. Reference Weeks, Chang and Pagán6 Equity-deserving groups, including Indigenous, immigrant and low-income populations, face compounded and unique barriers to accessing neurosurgical care. Reference Sanford and Sheppard7 For Indigenous communities, geographic isolation and the legacy of colonialism, including mistrust in healthcare systems, create substantial barriers to seeking and receiving care. Reference Phillips-Beck, Eni, Lavoie, Kinew, Achan and Katz8,Reference Sehgal, Henderson, Murry, Crowshoe and Barnabe9 These compounded barriers highlight the need for culturally congruent care models and policies to dismantle systemic barriers across the healthcare system.
While there is a considerable breadth of research examining disparities in healthcare access in Canada, the focus on neurosurgical care remains limited. Existing studies have predominantly explored barriers to general healthcare, such as the impact of socioeconomic status, healthcare infrastructure and the availability of services. Reference Olah, Gaisano and Hwang3,10,Reference Ansell, Crispo, Simard and Bjerre11 The highly specialized nature of neurosurgery suggests that the factors influencing access to care are complex and multifaceted, warranting specific investigation. Reference Dewan, Rattani and Gupta12
We performed a scoping review to highlight the barriers and facilitators that impact access to neurosurgical care in diverse communities across Canada. The challenges to neurosurgical access across different populations are reviewed, with a focus on equity-deserving groups. By identifying key themes and gaps in the literature, this review aims to inform the development of further research and more equitable healthcare policies and practices.
Methods
This scoping review was conducted utilizing the protocol detailed by Arksey and O’Malley (2005) and further expanded upon by Levac, Colquhoun and O’Brien (2010). Reference Arksey and O’Malley13,Reference Levac, Colquhoun and O’Brien14 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was used for this review. Reference Tricco, Lillie and Zarin15 The protocol was registered on the Open Science Framework (https://osf.io/ug6wt/) on November 1, 2024. These protocols form the basis of the reporting of this article.
Eligibility criteria
This scoping review focused on the lived experiences of individuals of all ages who required neurosurgical care, with particular attention to equity-deserving groups. The eligibility criteria were designed to ensure a comprehensive examination of the multifaceted factors influencing access to neurosurgical services in Canada.
Only primary research from qualitative or mixed-methods studies was included. From mixed-methods studies, only the qualitative data were extracted. Peer-reviewed journals, along with gray literature such as government reports, non-government organization (NGO) publications, dissertations and theses, were considered for eligibility. Furthermore, the review only included studies published in English after January 2000, ensuring the inclusion of relevant evidence. For relevant studies, the study population must involve individuals requiring neurosurgical care in Canada, focusing on diverse communities. This includes, but is not limited to, socio-economic, Indigenous, geographic, racial and cultural diversity. To ensure relevance, studies were required to explicitly address barriers or facilitators to access neurosurgical care.
The exclusion criteria encompassed studies that focused solely on neurosurgical techniques, surgical outcomes or unrelated healthcare topics. Furthermore, studies without sufficient empirical data, such as theoretical papers or opinion-based research, were excluded. The eligibility criteria are provided in Table 1.
Table 1. Inclusion criteria for studies screened. Title/abstract screening criteria
Information sources
Throughout the search, reviewers met frequently to determine the ideal approach for study selection through an iterative approach, as described by Levac et al. 2010. Reference Levac, Colquhoun and O’Brien14 To comprehensively identify potentially relevant documents for this scoping review, the authors decided on the following electronic databases: MEDLINE (via Ovid interface, 2000 onward), EMBASE (via Ovid interface, 2000 onward), Cochrane Library (including the Cochrane Database of Systematic Reviews, via Wiley interface, 2005 onward), PsycINFO (via Ovid interface, 2000 onward) and Scopus (2000 onward). These databases were selected to ensure comprehensive coverage of both medical and socioeconomic literature pertinent to accessing neurosurgical care.
In addition to electronic databases, gray literature sources, including government reports, NGO publications and university repositories, were reviewed to capture data that might not be published in peer-reviewed journals. This includes searching specific sites such as ProQuest, the Canadian Institutes of Health Research and Health Canada for relevant reports and policy documents. To ensure literature saturation, the reference lists of included studies and relevant reviews identified through the search process were scanned for additional documents.
Selection of sources of evidence
After obtaining the sources from the relevant peer-reviewed databases and gray literature sources, the studies were entered into Covidence and screened for duplicates. Two independent reviewers conducted text and abstract screening for each study, adhering to the eligibility criteria for text and abstract screening (Table 1). In cases of disagreement, the research team would collectively formulate a final decision on whether each study would progress to the full-text screening stage. The same iterative process was repeated for full-text screening, along with conflict resolution as per the eligibility criteria for full-text screening (Table 2). Following the data screening process, forward and backward reference searching occurred for all included studies.
Table 2. Inclusion criteria for studies screened. Full-text screening criteria
Data charting process
A standardized charting form was developed and piloted in Excel to ensure clarity and consistency in capturing key variables. This form focused on extracting essential details related to study context, methods, population characteristics and thematic findings while leaving room to document emerging insights during analysis.
Data extraction was performed independently by two reviewers to enhance reliability, with any discrepancies resolved through consensus or consultation with a third reviewer. The process was iterative, allowing for the inclusion of new variables or adjustments to the charting form to capture unanticipated data points or patterns. This approach ensured a rigorous and adaptable method for charting, maintaining alignment with the PRISMA-ScR guidelines and the objectives of the scoping review. Reference Tricco, Lillie and Zarin15
Data items
General study information was extracted, including the names of the authors, the year of publication and the geographic location of the study. Details on study design and methods were also recorded, specifying the type of study (e.g., qualitative or mixed-methods), the data collection techniques and the duration of the study period. Population characteristics were a critical focus, capturing the target population’s demographics, sample size and the study’s considerations related to equity-deserving groups.
The thematic focus of each study was documented, highlighting specific barriers and facilitators to accessing neurosurgical care, as well as intersectional factors that reflect overlapping identities or systemic challenges when relevant. Reported outcomes included insights from patients, their families and healthcare providers regarding their experiences, as well as systemic barriers, such as institutional and policy-level challenges and geographic barriers related to distance and access. Additional information included the disclosure of any conflicts of interest and funding.
To maintain consistency, data extraction followed the pre-established framework by Gale et al. (2013). Reference Gale, Heath, Cameron, Rashid and Redwood16 Studies were assumed to reflect diverse Canadian communities if explicitly stated, and only data directly related to barriers or facilitators in neurosurgical care were included.
Thematic analysis
Thematic analysis of the extracted documents was conducted, with datasets extracted to Microsoft Excel. One author coded the documents resulting from the charting using standard methods for thematic analysis with an inductive approach, as described by Braun and Clarke (2023). Reference Braun and Clarke17 A codebook was created based upon prospective themes following line-by-line coding of all eight documents. Following an iterative coding process and utilizing an inductive approach, the finalized codes were patient experiences, patient outcomes, family member experiences, healthcare provider perspectives, identity-specific barriers, geographic barriers, socioeconomic barriers, systemic barriers and educational barriers. The authors reviewed emerging themes and their frequencies, and those that were determined to be salient were selected.
Results
The initial database search yielded 1697 studies before the preliminary search. Following the studies being uploaded to Covidence and the removal of 297 duplicates, 1400 studies remained for the title and abstract screening. Of the 1400 studies reviewed through the text and abstract screening, 1368 were discarded, and 34 were selected for full-text review. The full-text screening resulted in eight studies being included in the data extraction process. Forward and backward reference searches occurred for all eight included studies; however, this process did not result in any additional included studies. The data screening process is illustrated in the PRISMA diagram (Figure 1).
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Inclusion criteria and number of citations at each stage of the review.
Study characteristics
The characteristics of the data extracted in the studies varied remarkably (Table 3). The studies included in this scoping review provided qualitative evidence exploring barriers and facilitators to accessing neurosurgical care within Canada. Many studies highlighted significant challenges in delivering timely and accessible neurosurgical services, particularly in rural and isolated regions with limited specialized facilities. Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Burns, Montelpare and Leÿenaar18–Reference Webster, Fehlings and Rice20 Key barriers included institutional prejudice, cultural misalignments, socioeconomic constraints and geographic distance. The articles also examined logistical and ethical concerns, such as resource allocation and the strain on patients and caregivers in systems often lacking sufficient resources for specialized care. Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Burns, Montelpare and Leÿenaar18,Reference Webster, Fehlings and Rice20–Reference Wong, Mendelsohn, Nyhof-Young and Bernstein22 To address these issues, the studies called for improved healthcare infrastructure, culturally sensitive treatment models and targeted policy reforms to promote equitable neurosurgical access across Canada. Reference Burns, Montelpare and Leÿenaar18,Reference Khabarov, Dimitropoulos and McGillicuddy21,Reference Bell, Maxwell, McAndrews, Sadikot and Racine23,Reference Topolovec-Vranic, Ennis and Ouchterlony24
Table 3. Factors affecting access to neurosurgical care. Overview of articles included in the study
TBI = traumatic brain injury; EMS = emergency medical services.
Qualitative or mixed-methods approaches were primarily employed to capture the complex experiences and perspectives of patients, caregivers and healthcare professionals. Among the included studies, 75% (n = 6) utilized qualitative methodologies, while 25% (n = 2) employed mixed-methods approaches integrating qualitative data with quantitative metrics, such as surveys and population data. One gray literature study was selected from the gray literature sources examined. Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19 Data collection methods varied, with 62.5% (n = 5) using semi-structured interviews, 12.5% (n = 1) employing workshops, 12.5% (n = 1) conducting focus groups and 12.5% (n = 1) using surveys. Ethical considerations were uniformly prioritized, with all studies obtaining institutional review board approvals, adhering to ethical guidelines and emphasizing voluntary participation, confidentiality and cultural sensitivity, especially when involving vulnerable or rural populations.
Within the extracted studies, 62.5% (n = 5) mentioned grounding their research in a theoretical framework or approach. The most common framework was the Social Determinants of Health theory, employed by three sources. Reference Burns, Montelpare and Leÿenaar18,Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19,Reference Kalich, Heinemann and Ghahari25 Two sources utilized intersectionality theory to highlight how overlapping identities, such as Indigenous heritage, rural residency and socioeconomic status, exacerbated barriers to neurosurgical care. Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Topolovec-Vranic, Ennis and Ouchterlony24 There was an overlap between the social determinants of health theory and intersectionality theory, as they both examine systemic inequities and emphasize the need for structural reforms. Additionally, systems theory, focusing on the interconnected elements within healthcare systems, such as resource allocation and triage protocols, was employed by two sources to analyze bottlenecks in access to neurosurgical services. Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19,Reference Webster, Fehlings and Rice20
Themes in findings
Findings from the thematic analysis revealed four major themes: delays in access, alternative healthcare options, policy and communication and coordination (Figure 2A). The largest category of findings focused on delays in access, highlighting issues such as transportation challenges, wait times and resource constraints at tertiary centers. Additional themes addressed alternative healthcare options, including virtual healthcare and emergency coordination systems, which aim to bridge gaps for rural and underserved communities. Policy-related barriers, such as inequitable resource distribution and prioritization policies, further impede access (Figure 2B). Finally, communication and coordination challenges were identified as critical factors exacerbating delays and inefficiencies. To better understand the impact of these barriers, subthemes were analyzed, and code frequencies were used to draw connections between challenges and their effects.
Figure 2. Emerging themes (A) and barriers (B) to access to neurosurgical care in diverse Canadian populations.
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
Discussion
This scoping review synthesized findings related to the barriers and facilitators affecting access to neurosurgical care for diverse communities in Canada. The findings in this review reflect the impact of geographic, systemic and socioeconomic factors on access to neurosurgical care and underscore the need to develop effective strategies to mitigate these challenges.
The studies consistently highlighted systemic inequities that disproportionately affect rural, Indigenous and socioeconomically disadvantaged populations. Barriers such as transportation, long wait times, hospital policy and communication inefficiencies were prominent, underscoring how delays in accessing specialized care result in worsened outcomes for vulnerable groups. Inadequate coordination within transfers between emergency medical services and tertiary trauma centers was frequently cited as a critical point of delay, reflecting structural inefficiencies. Reference Burns, Montelpare and Leÿenaar18,Reference Webster, Fehlings and Rice20
Although the studies primarily highlighted systemic inequities, it is important to note that equal emphasis should be placed on individual issues known to contribute to referral delays. These have been emphasized in several recent studies and include individual unconscious bias, epistemic injustices and discrimination against patients based on sex, race and socioeconomic status. Reference Furlan, Craven and Fehlings36–Reference Rubinger, Chan and Andrade39 Moreover, such factors also tend to affect patients with established diagnoses who often face unique challenges that hinder access to neurosurgical care and lead to disparate treatment. These vulnerable patient groups include those with epilepsy, functional and pain disorders and spinal cord injury. Reference Furlan, Craven and Fehlings36–Reference Rubinger, Chan and Andrade39 To effectively address these disparities, healthcare provider education and awareness need to be incorporated into teaching and continuing education curriculums to minimize individual inherent bias. This would not only serve as a framework to inform policy development but also help to mitigate such discriminatory factors, ensuring full accountability.
Facilitators like telehealth and inter-hospital coordination systems emerged as promising approaches for addressing geographic barriers. These implemented systems have enabled remote consultations, improved transfer coordination and reduced travel requirements. Reference Harding, McFarlane, Honey, McDonald and Illes2 The efficacy of such methods, however, is limited by gaps in digital infrastructure and accessibility, particularly in underserved regions. Reference Harding, McFarlane, Honey, McDonald and Illes2 Other innovative approaches, such as improved inter-hospital coordination systems, demonstrated the potential to streamline patient transfers and reduce delays, offering actionable pathways for improving care delivery. Reference Harding, McFarlane, Honey, McDonald and Illes2
Taken together, the findings emphasize the complex and multifaceted barriers to neurosurgical care in Canada, particularly for equity-deserving groups. For policymakers, healthcare providers and community organizations, these findings underscore the need for targeted reforms that prioritize equitable and efficient access. Expanding digital infrastructure, addressing systemic inefficiencies and fostering culturally sensitive care practices are essential to reducing the disparities outlined in this review. Importantly, these actions must be informed by the voices of affected communities, ensuring that interventions are both practical and inclusive.
Implications
The findings of this scoping review highlight several implications for neurosurgical healthcare access in Canada. Foremost, there is an urgent need for systemic efforts to address the geographic, socioeconomic and systemic barriers that disproportionately affect rural, Indigenous and equity-deserving populations. Expanding investments in telehealth infrastructure and mobile healthcare solutions could bridge significant gaps, especially for communities located far from tertiary care centers. Reference Jong, Mendez and Jong40 However, these interventions must be coupled with policy reforms that prioritize equitable resource distribution and address the unique challenges of underserved populations. Reference Harding, McFarlane, Honey, McDonald and Illes2
The results also suggest that enhanced coordination across healthcare systems is critical to improving access to care. Improved communication protocols between emergency medical services, rural hospitals and tertiary centers would streamline patient transfers and reduce delays. Reference Freimuth and Quinn41 This coordination effort must include culturally sensitive approaches, ensuring that Indigenous and marginalized communities receive care that respects their unique needs and experiences. Moreover, additional research funding is necessary to explore innovative care delivery models, including telemedicine and distributed neurosurgical networks, to address inequities systematically.
While these strategies could alleviate many barriers, they alone may be insufficient without targeted measures to address systemic inequities. Future initiatives should focus on training healthcare providers in culturally congruent care and on ensuring that policies explicitly account for marginalized populations, including pediatric groups with distinct needs. Policymakers must collaborate with communities to co-develop solutions that are locally relevant and sustainable. The findings of this review underscore the importance of embedding equity into all levels of neurosurgical care planning and delivery to ensure no group is left behind.
Future research directions
While existing research identifies barriers and facilitators, future studies must delve deeper into the ways systemic, geographic, socioeconomic and cultural factors intersect to compound inequities. Reference Harding, McFarlane, Honey, McDonald and Illes2,Reference Sharma, Gomez, Demestral, Hsiao, Rutka and Nathens19 For instance, the overlapping experiences of Indigenous patients in rural settings, who simultaneously face geographic isolation, systemic discrimination and financial constraints, remain underexplored. Reference Harding, McFarlane, Honey, McDonald and Illes2 Such intersectional analyses are crucial for understanding how different identities and systemic forces interact to shape health outcomes and access.
Further research should prioritize qualitative and mixed-methods approaches to capture the nuanced experiences of multiply marginalized groups, such as Indigenous women or immigrants with low socioeconomic status, as they navigate the healthcare system. Studies should also investigate how policies and interventions affect these intersecting identities differently, ensuring that equity-focused solutions address the unique needs of diverse populations. Incorporating community-based participatory research methodologies could foster collaboration with affected communities, ensuring research designs and outcomes are reflective of lived experiences and community priorities. Reference O’Brien and Whitaker42
Additionally, the role of intersectionality in the development and evaluation of interventions warrants further study. Telehealth, for example, holds promise in addressing geographic barriers but may fail to reach its full potential if digital infrastructure improvements are not paired with culturally sensitive training and policy reforms. Reference Jong, Mendez and Jong40 Research should assess the feasibility, acceptability and outcomes of such interventions across diverse demographic and geographic groups to identify best practices. These studies will not only help refine current interventions but also inform the design of new, scalable models that can bridge existing gaps in healthcare access.
Limitations
This scoping review has several limitations that should be acknowledged. First, only studies published in English were included, potentially excluding relevant research published in French and other languages that could provide insights into access barriers and facilitators in linguistically diverse populations. Second, despite a comprehensive search strategy, only eight studies met the inclusion criteria, reflecting a limited pool of relevant literature on neurosurgical care access in Canada, likely also hindering the degree of thematic analysis. It is possible that additional relevant articles were inadvertently excluded due to variations in indexing terms or reporting practices, highlighting the inherent challenges of relying solely on predefined search parameters and reference searching.
A lack of consistency in how access-related barriers and facilitators were reported across studies further constrained the synthesis. The included articles varied in their methodological approaches, populations and focal points, complicating direct comparisons. Additionally, while most studies focused on adult populations, some included pediatric cohorts, which often face distinct access challenges due to differences in healthcare pathways and resource allocation. Reference Harding, McFarlane, Honey, McDonald and Illes2 This heterogeneity in study populations may limit the generalizability of the findings to specific groups. Finally, the small number of studies analyzed underscores the need for more robust research on neurosurgical care access to fully capture the multifaceted barriers and potential interventions relevant to equity-deserving populations.
Conclusion
The reality of inequities facing diverse communities in Canada within the context of neurosurgical care remains understudied. The aim of this scoping review was to identify gaps in the current research within this field. We examined qualitative research in an attempt to illuminate the lived experiences of Canadians, especially marginalized, historically disadvantaged and equity-deserving groups. Through an iterative coding approach and thematic analysis, both barriers and facilitators to accessing neurosurgery were identified.
Most barriers identified were present at a systemic level, such as inadequate transportation infrastructure, inequitable governmental policy and geographic and monetary barriers, reflecting the entrenched nature of systemic marginalization within the Canadian context. These systemic barriers often intersect, conflating challenges for vulnerable populations and highlighting the need for comprehensive, multifaceted solutions. A few individual barriers, such as ineffective communication between healthcare providers and patients or caregivers, further emphasized the importance of patient-centered approaches to care delivery.
Notwithstanding these challenges, this review identified innovative facilitators, such as telehealth technologies and emergency coordination systems, which show potential for mitigating some of the most pressing access issues. These solutions are not without limitations, as their success depends heavily on equitable infrastructure development and tailored policy reforms. Addressing these gaps requires not only structural changes but also the inclusion of diverse voices in the development of solutions to ensure they meet the needs of all Canadians.
Although Canada’s healthcare system was built on the premise of being universal, significant challenges in access to care for diverse communities with respect to neurosurgery still exist. The results of this review demonstrate the need for change to the current structure of the Canadian healthcare system to achieve equitable access for all its citizens. Research that addresses these needs, barriers and protective factors will be crucial in addressing the ongoing gaps in care. It will also serve as a broad framework for the implementation of interventions to alleviate this disparity in healthcare delivery.
Acknowledgments
We would like to give thanks to Amanda Ross-White, the librarian who assisted the authors through pre-review tasks, search strategy and screening.
Author contributions
All authors contributed to the design of the study. JAB contributed to all parts of the manuscript, editing and project coordination. PCR contributed to all parts of the manuscript and editing and led the data screening process. TNP contributed to all parts of the manuscript and editing and led the coding and thematic analysis. JOE is the principal investigator.
Funding statement
The authors declare that there were no sources of funding that contributed to the production of this scoping review.
Competing interests
The authors have no conflict of interest or disclosures relevant to this study.
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