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Streamlining patient flow from primary to specialty care: a critical requirement for improved access to specialty care

https://policybase.cma.ca/en/permalink/policy11299
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
Text
When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing. Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports. Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country. Visit CMA's Referral and Consultation Process Toolbox1 for examples. Recognition, in the form of appropriate compensation, must also be given to the time spent preparing and analyzing referral requests as well as conducting consultations. Support for the use of information technology infrastructure, where available, will also facilitate efforts to streamline referral and consultation processes. It should be noted that, while the language of this policy statement has a focus on primary to specialty care referrals, the concepts and recommendations apply to referrals between all specialties. RECOMMENDATIONS * All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes. * There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients. * While acknowledging the referring physician's ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is "appropriate". * The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines. * Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations. Introduction When a physician decides that a patient requires the expertise of another specialist, the most appropriate next step can range from the specialist answering a question to assessing the need for a particular procedure or treatment. No matter how simple or complex the specialist's involvement may be, successful communication between all physicians is critical. Unfortunately, this does not occur as often as it should. In October 2012, a survey of physicians on the topic of referrals found that while over half of both family physicians (52%) and other specialists (69%) agree that referral communication is effective, two-thirds of family physicians noted that some kind of communication problem was a main source of frustration for them; for example not being informed about: referral receipt, the patient's appointment, a treatment plan, or that the specialist does not do the service requested. A similar proportion of specialists noted a lack of basic or supporting information (e.g., reason for referral or lab test results) as a main frustration with referral requests.2 The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region. Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist. The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. non-contributory family history). This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation. Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences. An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician. Some of the provincial Colleges of Physicians and Surgeons have guidelines or standards of practice specifically about referrals and consultations. The most comprehensive of these are the College of Physicians & Surgeons of Nova Scotia's (CPSNS) Guidelines for Physicians Regarding Referral and Consultation3 and the College of Physicians and Surgeons of Alberta's (CPSA) Standard for Practice on The Referral Consultation Process.4 In addition, the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) developed collaboratively a guide to enhancing referrals and consultations between physicians.5 While these documents do not discuss which method of communication should be used for each referral request scenario, they do provide guidance in a number of areas, including: * minimum requirements for information that should be provided with all referral requests * information that should be conveyed to patients (e.g., why they are being referred, information about the specialist appointment, etc) as well as who should be providing this information * processes that should be followed for patients requiring ongoing care from the consulting physician While standardization of the minimum information requirements that should be included in communications between referring and consulting physicians is essential for finding efficiencies with referral processes, these efficiencies will not be fully realized without proper consideration of the information technology infrastructure that is used to convey this information. The way in which the information is provided should not require additional effort for either the sender or the receiver. Electronic referral systems, where all data necessary for an informative referral can be easily obtained by the appropriate physician from the patient's electronic health record, would be the best way to ensure that this occurs. However, until this becomes a reality, a suitable compromise can be found by allowing flexibility in the format in which the information is provided. Communication from Primary Care to Specialty Care When the extent of a specialist's involvement in patient care is simply providing a second opinion or advice about appropriate next steps, standardizing the process for this kind of communication is relatively straightforward. This is because the variation that exists in this situation is primarily due to the availability of the consulting specialist and the methods of communication that each referring physician can use to contact the specialist. Certain regions of the country have established consultation services whereby specialists participating in the program must respond to consult requests within a specified time frame. Examples of effective consultation systems include the telephone advice line known as Rapid Access to Consultative Expertise (RACE)6 in BC or the secure electronic consultation system known as Building Access to Specialist Care through e-Consultation (BASE)7 in the Champlain Local Health Integration Network (LHIN) in Ontario. Such services have proven quite effective at reducing the number of unnecessary referrals8,9; thereby ensuring more appropriate use of specialty care and helping to reduce wait times for this care. Through both of these systems, specialists ensure that they are available to respond to the consult question in a timely manner and each system uses only one form of communication. At the other end of the spectrum of specialist involvement in patient care, when the patient sees the specialist, there is a much greater degree of variation in what is required of the specialist - from one-time interventions such as surgical procedures, to chronic care. The best approach for streamlining the referral process in these more complex situations varies, depending on the type of specialist care that is required. Central Intake With central intake referral systems, the referring physician sends a referral request to one location. This central location can be organized in two ways; central triage or pooled referrals. With central triage, referrals are assigned to specialists based on their level of urgency. With pooled referrals, each referral is allocated to the next available specialist, who then does the triaging. The differences in where the triaging occurs exist due to a number of factors; including the type of care the specialty provides as well as the number of specialists in the geographic region. However, for both types of central intake systems, the referring physician follows a standard process regardless of the specialist who assumes care of the patient. Regardless of the type of central intake method that is used, the option to choose a particular specialist must always be available. However, even with this option in place, a central intake system of any kind is not necessarily the most appropriate solution for all specialties. This is often the case when ongoing patient-specialist relationships are quite common. For example, a woman might prefer that the same obstetrician cares for her during all of her pregnancies, or patients with chronic conditions such as arthritis or diabetes and require continuous care throughout their lifetime. In these situations, coordinating a central intake program where a significant proportion of specialist appointments are repeat visits is difficult. Physician Directory A physician directory might be a more useful referral tool in situations where specialties do not have sufficient numbers of specialists in one geographic region or for those that have a high degree of sub-specialization. Such directories provide, at a minimum, details of the services each specialist provides and does not provide. Those that provide information regarding wait times, especially those with information on the wait for the first specialist visit, are extremely useful for referring physicians as it allows them to select a specialist with the most appropriate wait time for their patient and, where relevant, it also allows the referring physician to develop an appropriate care plan based on the time the patient must wait for specialty care. Despite the fact that the complexities with specialty referrals mean that there is no one solution that is appropriate for all types of specialties, the extreme variation in processes that currently exists is also unnecessary. Standard referral information requirements for specialty groups with similar needs, such as most surgical specialties, have been effectively established in some areas of the country. For example, in Calgary, Alberta, a major initiative known as Medical Access to Service10, has, among other things, successfully developed a standard referral form and process for central intake for multiple specialties. While most of these specialties also request additional information, each specialty has agreed on a standard set of minimum requirements. These standards were developed collaboratively with physicians and could be expanded nationwide, while taking regulatory and technological differences into account. When establishing the requirements for an informative referral, consulting specialists must acknowledge that the referring physician may not have the expertise necessary to appropriately interpret certain test results. In such cases it is the consulting specialists who should order these tests. Communication from Specialty Care to Primary Care What must not be overlooked is that referral communication is bilateral. Informative and timely communication from the consulting specialist to the referring physician is also critical for a successful referral. Such a referral can be defined as one where the patient receives appropriate and timely specialty care where all parties - patient, specialist(s), referring physician and family physician (when the referring physician is not the patient's family physician) - are aware of all of the patient's relevant interactions with the health care system as well as any follow-up care that may be required. To ensure this occurs, after the referral request is initiated, the referring physician (and family physician if different) should be informed, in a timely manner, of the status of the referral at all stages: * referral receipt * request for more information * referral acceptance/rejection (with explanation and suggested alternatives) * patient appointment has been scheduled * patient consult notes (including recommended treatment plan and follow-up) A definition of what is considered "timely" is required. Standards must be established based on what is considered to be an acceptable response time at each stage. The patient must also be promptly informed of the status of the referral request throughout the entire process. Examples of the types of information that should be conveyed include (where appropriate): * how the referral request will be processed; e.g., pooled referral or central triage * expected wait time or when the appointment has been scheduled * whether another specialist has been contacted * whether a repeat visit is required * whether the patient has been contacted about anything that is relevant to them; e.g., referred elsewhere, wait time, appointment(s) scheduled The information and communication that the referring physician requires from the consulting specialist for all referrals is much more homogeneous. In addition, there are no regulatory or technological barriers preventing the provision of this information at the appropriate stages of the referral process. This is one area where communication between physicians is within their control. Therefore, improved communication for responses to referral requests through standardized processes can be much more easily established. Unfortunately this is not the case, causing considerable effort to be undertaken by referring physicians and/or their office staff to track the status of referrals. Considerably less attention has been given to this part of the process; however, some activities described in the CMA's Referral and Consultation Process Toolbox1 do address problems regarding the referral response. Central Intake systems are an example. These often include standard response times for at least the first three stages noted above, as well as information about the specialist who has received the referral request. The previously cited guidelines developed by the CPSNS 3, the standard of practice by the CPSA4 and the guide to enhancing referrals and consultations between physicians developed by the CFPC and the Royal College5 also have recommendations for consulting specialist responses to referral requests (including information requirements and timelines). These resources can be used as a starting point for establishing referral communication standards in both directions and with patients. As an important example, the guidelines for both provincial colleges specifically indicate that the consulting specialist is responsible for arranging appointments with the patient and notifying the referring physician of the date(s). Compensation and Support Another aspect of the referral process that is not given sufficient consideration is the time and effort that is involved in preparing and responding to a referral request. Both preparing an informative referral request and responding to one is time-consuming; very little recognition is given towards this work. In some areas of the country, physicians receive compensation for participating in electronic or telephone consultation programs. This form of recognition has successfully helped avoid unnecessary referrals and should be expanded nation-wide; however, much more should be done to acknowledge this effort, especially when a specialist visit is necessary. The time referring physicians spend gathering the necessary data for a referral request, or the time consulting specialists spend analyzing this data, triaging the referrals accordingly and preparing patient consult notes, is almost never acknowledged as part of a physician compensation package. In most jurisdictions this work is considered to be just a component of a typical patient visit. Since many primary care group practices employ administrative staff who are "referral coordinators"; whose main role is to assist physicians in the data gathering and preparation that is required for an informative referral request, as well as following up on referral requests; the process of referring a patient to specialty care is much more than "just a component of a typical patient visit". Support for widespread implementation of effective information technology infrastructure can facilitate the preparation of appropriate referral requests and responses and can also encourage timely and informative communication between referring physicians and consulting specialists. Conclusion The high degree of variability in both the methods of communication and the information transferred between physicians is a significant barrier to timely access to specialty care for patients. Significant effort by physicians and their office staff is expended unnecessarily in the referral process, not only in initiating or responding to the request, but also in tracking and follow-up. While there is no single solution that will address all referral communication problems, several complementary solutions exist that can reduce this variability and wasted effort, thereby simplifying the process and facilitating appropriate, timely and informative communication between referring physicians and consulting specialists. Examples of such initiatives can be found in the CMA's Referral and Consultation Process Toolbox.1 * For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. † For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. References 1 Canadian Medical Association. Referral/Consultation Process. Available at: http://www.cma.ca/referrals. Accessed 29 Nov 2013. 2 Canadian Medical Association. Challenges with patient referrals - a survey of family physicians and other specialists; October 2012 (Unpublished). 3 College of Physicians and Surgeons of Nova Scotia. Guidelines for Physicians Regarding Referral and Consultation. Available at: http://www.cpsns.ns.ca/Portals/0/Guidelines-policies/guidelines-referral-consultation.pdf. Accessed 15 Nov 2013. 4 College of Physicians & Surgeons of Alberta. The Referral Consultation Process. Available at: http://www.cpsa.ab.ca/Libraries/standards-of-practice/the-referral-consultation-process.pdf?sfvrsn=0. Accessed 16 Sep 2014. 5 College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada. Guide to enhancing referrals and consultations between physicians. Available at: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3448. Accessed 27 Nov 2013. 6 Rapid Access to Specialist Expertise. Available at: www.raceconnect.ca. Accessed 27 Nov 2013. 7 Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013 Jan 8;7(1):e1-8. Available at: http://www.openmedicine.ca/article/view/551/492. Accessed 27 Nov 2013. 8 Wilson M. Rapid Access to Consultative Expertise: An innovative model for shared care. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/RACE-Overview-March-2014.pdf. Accessed 16 Sep 2014. 9Afkham A. Champlain BASE project: Building Access to Specialists Through e-Consultation. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Champlain-BASE-Dec2013-e.pdf. Accessed 16 Sep 2014. 10 Alberta Health Services, University of Calgary Department of Medicine. Medical Access to Service (MAS). Available at: http://www.departmentofmedicine.com/MAS/ Accessed 15 Nov 2013.
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Early childhood development

https://policybase.cma.ca/en/permalink/policy11476
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
Text
Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.1,2 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.3,4 Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. Even for those children who don't encounter these types of barriers, there can be problems in the early years. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.5 Just as children are susceptible to negative influences in early life, the period of rapid development means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.6 At the government and national level there are four main areas of action: Early childhood learning and care; Support for parents; Poverty reduction; and Data collection for early childhood development. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. While most of what is necessary for early childhood development will be done by governments and stakeholders outside of the health care system, there are opportunities for physicians to influence this important social determinant both through medical education, and clinical practice. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Background Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. The early childhood period is the most important development period in life.7 Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.8,9 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.10,11 According to research done by the Centers for Disease Control and Prevention in the adverse childhood event (ACE)a study, child maltreatment, neglect, and exposure to violence can significantly impact childhood development. The study involved a retrospective look at the early childhood experiences of 17,000 US adults and the impact of these events on later life and behaviour issues. An increased number of ACEs was linked to increases in risky behaviour in childhood and adolescence12 and to a number of adult health conditions including alcoholism, drug abuse, depression, diabetes, hypertension, stroke, obesity, heart disease, and some forms of cancer.13,14 The greater the number of adverse experiences in childhood the greater the likelihood of health problems in adulthood.15 A high level of ACEs was linked to language, cognitive and emotional impairment; factors which impact on school success and adult functioning.16 Finally, the study found a correlation between experiencing ACEs, suicide, and being the victim of or perpetrating intimate partner violence.17 Poverty is a significant barrier to healthy child development. Children who grow up in poor families or disadvantaged communities are especially susceptible to the physiological and biological changes associated with disease risk.18 Poverty is associated with a number of risk factors for healthy development including: unsupportive parenting, inadequate nutrition and education, high levels of traumatic and stressful events19, including higher rates of traumatic injuries20, poorer housing, lack of services, and limited access to physical activity.21 Children from low-income families score lower than children from high-income families on various measures of school readiness, cognitive development and school achievement22,23, and this gap increases over time with children of low-income families being less likely to attend post-secondary education and gain meaningful employment.24 Children who grow up in poverty are more likely to be poor as adults25,26 and to pass this disadvantage on to their own children.27,28 Children living in poverty have more problem behaviours such as drug abuse, early pregnancy, and increased criminal behaviour.29 Finally, economic hardship in childhood has been linked to premature mortality and chronic disease in adulthood.30 Early adverse events and poverty are serious impediments to healthy development, however, it is not just disadvantaged children that need attention. The early years are critical for all children regardless of socio-economic status. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.31 By 2030, 90% of morbidity in high income countries will be related to chronic diseases.32 These diseases are due in large part to risk factors such as smoking, poor nutrition, alcohol and drug abuse, and inadequate physical activity.33 These risk factors can be heavily influenced by the environment in which people live and can be increased by poor early childhood experiences.34,35 Health promotion and disease/injury prevention programs targeted at adults would be more effective if investments were made early in life on the origins of those diseases and conditions.36,37 Areas for Action While there is reason for concern regarding early childhood development, there is positive news as well. Just as children are susceptible to negative influences in early life, the period of rapid development also means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.38 Government and National: Early Childhood Learning and Care Research suggests that 90% of a child's brain capacity is developed by age five, before many children have any access to formal education.39 More than one quarter of Canadian children start kindergarten vulnerable in at least one area of development.40 Approximately two thirds of these deficiencies can be considered preventable. Evidence suggests that each 1% of excess vulnerability in school readiness leads to a reduction in GDP of 1% over the course of that child's life.41 Children who aren't ready for kindergarten are half as likely to read by the third grade, a factor that increases the risk of high school drop-out significantly. 42 While it is possible to intervene later to address these learning deficiencies, these interventions are less effective and much more costly.43 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.44,45 A recent analysis of 84 preschool programs in the United States concluded that children participating in effective pre-school programs can acquire about a third of a year of additional learning in math, language and reading skills.46 Since the implementation of the universal childcare program in Quebec, students in that province have moved from below the national average on standardized tests to above the average.47 In addition, effective early childhood learning programs offer a significant return on investment. Research done on US preschool programs found a return on investment of between four and seventeen dollars for every dollar spent on the program. Evidence from the Quebec universal child care program indicates that the program costs are more than covered by the increased tax revenues generated as a result of increased employment among Quebec mothers. For every dollar spent on the Quebec program, $1.05 is received by the provincial government with the federal government receiving $0.44.48 In terms of early childhood learning and care, Canada is lagging far behind - tied for last place among 25 countries in Organization for Economic Cooperation and Development (OECD) early childhood development indicators.b,49 Canada spends the least amount of money on early childhood learning and care of all countries in the OECD (0.25% of GDP)50, or one quarter of the recommended benchmark. Of this money, fully 65% is attributable to Quebec's universal daycare program.51 Canadian families face great pressures in finding affordable and accessible quality early childhood learning and care spots across the country. In Quebec 69% of children 2-4 regularly attend early childhood learning programs; outside of Quebec the number falls to 38.6%. The challenges for low-income families are even more pronounced with almost 65% of poor children 0-5 receiving no out-of home care.52 The federal government and the provinces and territories must work to bring Canada in line with other OECD countries on early childhood learning and care. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. Support for Parents A supportive nurturing caregiver is associated with better physical and mental health, fewer behavioural problems, higher educational achievement, more productive employment, and less involvement with the justice system and social services.53 Studies have demonstrated that improved parental-child relationships can minimize the effects of strong, prolonged and frequent stress, referred to as toxic stress54,55, and that the effects of poverty can be minimized with appropriate nurturing and supportive parenting.56 Parental support programs can act as a buffer for children at the same time as strengthening the ability of parents to meet their children's developmental needs.57 Caregivers who struggle with problems such as depression or poverty may be unable to provide adequate attention to their children undermining the attachment relationships that develop in early life. The relatively limited attention that is focused on addressing the deficiencies in time and resources of parents across all socio-economic groups can undermine healthy childhood development.58 One approach that has been shown to improve parental functioning and decrease neglect and child abuse is early childhood home visiting programs, sometimes referred to as Nurse Family partnerships. These programs provide nursing visits to vulnerable young mothers from conception until the children are between two and six depending on the program. The home visits provide prenatal support, educate parents about early childhood development, promote positive parenting, connect parents with resources, and monitor for signs of child-abuse and neglect.59 Results from several randomized controlled trials of these programs in the United States have shown that the program reduces abuse and injury, and improves cognitive and social and emotional outcomes in children. A 15 year follow-up study found lower levels of crime and antisocial behaviour in both the mothers and the children that participated in these programs.60 In Canada Nurse Family Partnerships were first piloted in Hamilton, Ontario. They are now undergoing a broader implementation and review in the Province of British Columbia. These programs should continue to be supported and expanded to all families who would benefit from this proven early childhood intervention. Many Canadian provinces have established community resources for parents. Alberta has recently announced plans to establish parent link centres across the province. These will deliver parenting programs, and be home to community resources and programs.61 Similar programs exist in other provinces such as the early years centres in Ontario62, and family resource centres in Manitoba.63 Early Childhood Development Centres in Atlantic Canada are combining child care, kindergarten and family supports into early childhood centres that are aligned with schools.64 While these programs can go a long way in reducing abuse and neglect, there is still a need for an overarching strategy to reduce neglect and child abuse across the country. As the ACE study in the United States clearly demonstrated, exposure to early adverse events such as family violence or neglect have troubling implications for adult health and behaviours.65 Action must be taken to ensure that avoidable adverse events are eliminated. The CMA Recommends that: 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. Poverty reduction In 1989 the Canadian government made a commitment to end child poverty by 2000. As of 2011, more Canadian children and their families lived in poverty than when the original declaration was made.66 Canada ranks 15th out of 17 peer countries with more than one in seven children living in poverty (15.1%).67 Canada is one of the only wealthy nations with a child poverty rate that is actually higher than the overall poverty rate.68 Child poverty is a provincial and territorial responsibility as well. As of 2012, only four provinces had child poverty strategies that met the guidelines put forward by the Canadian Paediatric Society.c,69 Poor children grow up in the context of poor families which means that solutions for child poverty must necessarily minimize the poverty of their parents.70 Efforts to increase the income as well as employment opportunities for parents, in particular single parents, must be part of any poverty reduction strategy.71 Programs, such as affordable child care, that allows parents to be active participants in the work force represent one approach72,73 Quebec's program of early childhood care has increased female workforce participation by 70,000 and reduced the child poverty rate by 50%.74 Addressing poverty could minimize problem areas in child development. According to a 2009 report by the Chief Public Health Officer of Canada, of 27 factors seen as having an impact on child development, 80% of these showed improvement as family income increased.75 Increasing income has the greatest impact on cognitive outcomes for children the earlier in life the reduction in poverty takes place.76 The federal government and the provinces and territories must work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children. The CMA Recommends that: 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. Data Collection for Early Childhood Development The evidence shows the importance of early childhood development for later success and health. In order to properly design effective interventions to mitigate developmental concerns, there is a need for appropriate data on early childhood health indicators and interventions. Given the variation in outcomes of children among different communities and demographic groups, there is a need for individual level data which is linked to the community level. This will allow providers and governments to develop appropriate interventions. Such an approach is being used by the Manitoba Centre for Health Policy, the Human Early Learning Partnership in British Columbia, and Health Data Nova Scotia. Researchers at these centres are creating a longitudinal data set by linking administrative data from a range of sources.77 Such data sets should be supported in all provinces and territories. Another tool being used to measure the progress of Canadian children is the Early Development Instrument (EDI). This tool is a 104 item checklist completed by teachers for every child around the middle of the first year of schooling. The checklist measures five core areas of early child development that are known to be good predictors of adult health, education and social outcomes. These include: physical health and well-being; language and cognitive development; social competence; emotional maturity; and communication skills and general knowledge.78,79 This tool has been used at least once in most of the provinces and territories with a commitment from most jurisdictions to continue this monitoring.80 While this is a good start, it gives only a snapshot of development. Ideally a monitoring system plots several points of time in development to identify trajectories of children. Ontario has introduced an enhanced well baby visit at 18 months. This clinical intervention could allow for the capture of development data at an earlier time. There is a need for more comprehensive information at the 18-month and middle childhood phases.81 The CMA Recommends that: 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. Medical Education: Given the importance of early childhood experiences on adult health there is a need for a greater understanding of the biological basis of adult diseases. The medical community needs to focus more attention on the roots of adult diseases and disabilities and focus prevention efforts on disrupting or minimizing these early links to later poor health outcomes.82 The science of early brain development and biology is rapidly evolving. There is a need to ensure that future and current physicians are up to date on this information and its implications for clinical practice.83 The Association of Faculties of Medicine and the Norlien foundation have partnered to provide funding and support for a series of e-learning tools on early brain and biological development.84 Continuing medical education does exist for some components of early childhood development and more work is underway. The Ontario College of Family Physicians has developed a CME that explores early childhood development for practitioners.85 These initiatives must be supported and expanded to all physicians who provide primary care to children and their families. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. Clinical Practice: While many of the threats to early childhood development lie outside of the hospital or medical clinic, there are a number of ways that physicians can help to address this important determinant of health within their practices. Primary care practitioners are uniquely qualified to address this fundamental population health issue,86 and can provide one important component in a multi-sectoral approach to healthy early childhood development.87 Screening and support for parents The health care system is the primary contact for many child-bearing mothers, and for many families, health-care providers are the only professionals with whom they have regular contact during the early years.88,89 According to data from the Institute for Clinical Evaluative Sciences, 97% of Ontario children aged zero to two are seen by a family physician.90 Within a patient-centred medical home, health-care providers can give support and information to parents about issues such as parenting, safety, and nutrition, and can link them to early childhood resourcesd, and other supports such as housing and food security programs. 91,92 Primary-care providers can help patients connect with public health departments who have many healthy baby and healthy child programs.93 Primary-care providers can ensure that screening takes place to identify risk factors to appropriate development.94 This screening should take place as early as the prenatal stage and continue throughout childhood. Screening should include regular assessments of physical milestones such as height, weight and vision and hearing etc. In addition, providers can identify risk factors such as maternal depression, substance abuse, and potential neglect or abuse.95 Given the negative consequences of early violence and neglect on childhood development96, this is a key role for primary-care providers. Screening for social issues such as poverty, poor housing and food insecurity should also be completed.97 A significant time for screening occurs at 18 months. This is the time for the last set of immunizations and in many cases the last time a child will have a regularly scheduled physician visit before the start of school.98 The 18 month well baby visit provides an opportunity to screen for not only medical concerns but child development as well. The enhanced 18 month well baby visite developed in Ontario combines parental observations and clinical judgment to screen for any risks a child might have.99 In Ontario, parental observation is captured through the Nipissing District Developmental Screen (NDDS). The parents complete this standardized tool and report the results to their physicians or other primary-care providers. The NDDS checklist is not meant to be a diagnostic tool but instead helps to highlight any potential areas of concern while also providing information to parents about childhood development. The 'activities for your child' section which accompanies the tool can also help reinforce the importance of development.100 As part of the visit primary-care providers fill out a standardized tool known as the Rourke Baby Record. This tool is an evidence based guide which helps professionals deliver the enhanced visit. This combined with the parental report through the NDDS, allows for a complete picture of the physical as well as the development health of the child at 18 months. Primary-care providers can use the results to discuss parenting and development and link children to specialized services, as necessary, and other community supports and resources. In Ontario early child development and parenting resource system pathways have been developed in many communities to help ensure that primary care providers can be aware of the resources and supports available for their patients.101 As was already noted, almost two thirds of vulnerabilities in readiness for school can be prevented.102 Appropriate identification through screening is a first step in correcting these issues. While the expansion of this approach is currently being reviewed in Nova Scotia, it should be implemented in all provinces and territories with appropriate compensation mechanisms and community based supports. Additionally, consideration should be made to developing screening tools for physicians outside of primary care, ie. emergency departments, who see children who might not have regular primary care physicians. The CMA Recommends that: 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. Literacy By 18 months disparities in language acquisition begin to develop.103 According to US research, by age four, children of families on welfare will hear 30 million less words than children from families with professional parents.104 This can lead to ongoing disparities in childhood learning as evidence suggests that exposure to reading and language from parents is fundamental for success in reading by children.105 Physicians and other primary-care providers can play a role in helping to reduce these disparities. They can encourage reading, speaking, singing and telling stories as part of a daily routine.f Studies have demonstrated that when physicians discuss literacy with parents and provide them with appropriate resources, such as developmentally appropriate children's books, increases in reading frequency and preschool language scores have been found.106 One program which has integrated reading and literacy into clinical practice is the 'Reach out and Read' program in the United States. This program partners with physicians, paediatricians, and nurse practitioners to provide new developmentally appropriate books to children ages 6 months through 5 years, as well as guidance for parents about the importance of reading.107,108 The success of this program has been significant with parents in the program being four to ten times more likely to read frequently with their children, and children scoring much higher on receptive and expressive language scores on standardized tests.109 Given the success of this program for American children, a similar program should be explored in the Canadian context. The CMA Recommends that: 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Conclusion The early years represent the most important time of development. The first five years can 'get under the skin' and influence outcomes throughout the life course. Negative experiences such as poverty, violence, poor nutrition, and inadequate parenting can determine behaviours as well as adult health outcomes. Effective early interventions can help to minimize or capitalize on these experiences. Government actions and supports to reduce poverty, child abuse, violence and to enable parents to care for their children are necessary. In addition, appropriate high quality early childhood learning and care programs are required for all Canadians regardless of socio-economic status. Finally, health care providers can play a role in identifying children at risk, supporting their parents to encourage healthy childhood development, and advocating for communities that ensure all Canadian children have the opportunity to grow up happy and healthy. References a The adverse childhood events are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member. http://www.cdc.gov/ace/prevalence.htm#ACED b The indicators used for the comparison include: Parental leave of one year with 50% of salary; a national plan with priority for disadvantaged children; subsidized and regulated child care services for 25% of children under 3; subsidized and accredited early education services for 80% of 4 year-olds; 80% of all child care staff trained; 50% of staff in accredited early education services tertiary educated with relevant qualification (this is the only indicator that Canada met); minimum staff-to-children ratio of 1:15 in pre-school education; 1.0% of GDP spent on early childhood services; child poverty rate less than 10%; near-universal outreach of essential child health services. UNICEF (2008) The child care transition: A league table of early childhood education and care in economically advanced countries. Available at: http://www.unicef-irc.org/publications/pdf/rc8_eng.pdf c To meet the CPS guidelines a province/territory requires anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specific targets. d For a list of some of the resources available for early childhood development across the country please see the Canadian Paediatric Society Resource Page: http://www.cps.ca/en/first-debut/map/community-resources e For more detailed information on the enhanced 18 month well baby visit please see the Canadian Paediatric Society Position statement- Williams R & J Clinton. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa, ON; 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (Accessed 2014 Jan 24). For resources available to Ontario primary-care providers please visit: http://machealth.ca/programs/18-month/default.aspx f For information and resources on early literacy please see the Canadian Paediatric Society at: http://www.cps.ca/issues-questions/literacy 1 Williams R et.al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 2 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 3 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. 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Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 31 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 32 Bygbjerg IC. Double Burden of Noncommunicable and Infectious Diseases in Developing Countries. Science Vol.337 21 September 2012 pp.1499-1501. Available: http://health-equity.pitt.edu/3994/1/Double_Burden_of_Noncommunicable_and_Infectious_Diseases.pdf (accessed 2014 Mar 11). 33 World Health Organization. Global Status Report on Non-Communicable diseases 2010. Chapter 1: Burden: mortality, morbidity and risk factors. Geneva, Switzerland; 2010. Available: http://www.who.int/nmh/publications/ncd_report_chapter1.pdf (accessed 2014 Mar 11). 34 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 35 Dreyer BP. To Create a Better World for Children and Families: The Case for Ending Childhood Poverty. Acad. Pediat. Vol 13 No 2. Mar-Apr 2013. Available: http://download.journals.elsevierhealth.com/pdfs/journals/1876-2859/PIIS1876285913000065.pdf (accessed 2013 Dec 10). 36 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 37 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 38 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. Available: http://media.nzherald.co.nz/webcontent/document/pdf/201347/Full-report-text1.pdf (accessed 2014 Mar 3). 39 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 40 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 41 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 42 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 43 Heckman JJ. The Case for Investing in Disadvantaged Young Children. Available: http://heckmanequation.org/content/resource/case-investing-disadvantaged-young-children (accessed 2014 Feb 6). 44 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011. 45 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013. Available: http://ec.europa.eu/justice/fundamental-rights/files/c_2013_778_en.pdf (accessed 2013 Jan 24). 46 Yoshikawa H et al. Investing in Our Future: The Evidence Base on Preschool Education. Society for Research in Child Development & Foundation for Child Development. New York (NY); 2013. Available: http://fcd-us.org/sites/default/files/Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf (accessed 2014 Feb 6). 47 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 48 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 49 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2012 Jan 24). 50 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 51 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 52 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 53 Shonkoff JP et.al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 54 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 55 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 56 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 57 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 58 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 59 Knoke D. Early childhood home visiting programs. Centres of Excellence for Children's Well-Being. Toronto(ON); 2009. Available: http://cwrp.ca/sites/default/files/publications/en/HomeVisiting73E.pdf (accessed 2014 Mar 7). 60 Mercy JA, Saul J. Creating a Healthier Future Through Early Interventions for Children. JAMA June 3, 2009 Vol 301, No.21. 61 Government of Alberta. Alberta improves supports for families. Edmonton(AB); 2014. Available: http://alberta.ca/release.cfm?xID=356434F454042-9B0A-23FD-4AD0402F87D70805 (accessed 2014 Jan 7). 62 Ontario Ministry of Education. Ontario Early Years Centres: Frequently asked questions. Toronto (ON):N.D. Available: http://www.oeyc.edu.gov.on.ca/questions/index.aspx (accessed 2015 Jan 30). 63 Healthy Child Committee of Cabinet. Starting Early, Starting Strong: Manitoba's Early Childhood Development Framework. Government of Manitoba, Winnipeg (MB); 2013. Available: http://www.gov.mb.ca/cyo/pdfs/sess_ECD_framework.pdf (accessed 2014 Jan 10). 64 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 65 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 66 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 67 Conference Board of Canada. Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Jun 20). 68 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 69 Ibid. 70 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 71 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 72 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 73 Fauth B, Renton Z & Solomon E. Tackling child poverty and promoting children's well-being: lessons from abroad. National Children's Bureau. London (UK); 2013. Available: http://www.ncb.org.uk/media/892335/tackling_child_poverty_1302013_final.pdf (accessed 2014 Jan 10). 74 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 75 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 76 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 77 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 78 Human Early Learning Partnership. Early Development Instrument. N.D. Available: http://earlylearning.ubc.ca/edi/ (accessed 2014 Oct 8). 79 Adamson P. Child well-being in rich countries: A comparative overview: Innocenti Report Card 11. UNICEF, Florrence, Italy; 2013. Available: http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf (accessed 2014 Jan 10). 80 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://firstwords.ca/wp-content/uploads/2014/05/Early-Years-Study-3.pdf (accessed 2014 Feb 11). 81 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 82 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 83 Garner AS et al. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129;e224. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662.full.pdf+html (accessed 2014 Feb 11). 84 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 85 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 86 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 87 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 88 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 89 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 90 The Minister of Children and Youth announces that every child will receive and enhanced 18-month visit: Family Physicians Play Key Roles in Healthy Child Development. Toronto(ON). Available: http://ocfp.on.ca/docs/cme/enhanced-18-month-well-baby-visit-key-messages-for-family-physicians.pdf?sfvrsn=1 (accessed 2012 Feb 20). 91 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 92 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 93 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 94 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 95 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21). 96 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 97 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 98 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 99 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 100 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 101 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 102 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 103 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 104 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 105 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10). 106 Ibid. 107 Reach out and Read. Reach Out And Read: The Evidence. Boston (MA); 2013. Available: https://www.reachoutandread.org/FileRepository/Research_Summary.pdf (accessed 2014 Mar 5). 108 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 109 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10).
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Appropriateness in health care

https://policybase.cma.ca/en/permalink/policy11516
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
Text
CMA POLICY Appropriateness in Health Care Summary This paper discusses the concept of appropriateness in health care and advances the following definition: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. Building on that definition it makes the following policy recommendations: * Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. * Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. * Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Introduction As health systems struggle with the issue of sustainability and evidence that the quality of care is often sub-optimal, increasing attention is focused on the concept of appropriateness. A World Health Organization study published in 2000 described appropriateness as "a complex, fuzzy issue"1. Yet if the term is to be applied with benefit to health care systems, it demands definitional clarity. This policy document presents the Canadian Medical Association definition of appropriateness which addresses both quality and value. The roots of the definition are anchored in the evolution of Canadian health care over the last two decades. The document then considers the many issues confronting the operationalization of the term. It concludes that appropriateness can play a central role in positive health system transformation. Definition At the Canadian Medical Association General Council in 2013 the following resolution was adopted: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. This definition has five key components: * right care is based on evidence for effectiveness and efficacy in the clinical literature and covers not only use but failure to use; * right provider is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care; * right patient acknowledges that care choices must be matched to individual patient characteristics and preferences and must recognize the potential challenge of reconciling patient and practitioner perceptions; * right venue emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others; * right time indicates care is delivered in a timely manner consistent with agreed upon bench marks. It is essential to appreciate that the "right cost" is a consequence of providing the right care, that it is an outcome rather than an input. In other words, if all five components above are present, high quality care will have been delivered with the appropriate use of resources, that is, at the right cost. Equally, however, it should be cautioned that right cost may not necessarily be the affordable cost. For example, a new drug or imaging technology may offer small but demonstrable advantages over older practices, but at an enormous increase in cost. Some might argue that right care includes the use of the newer drug or technology, while others would contend the excessive opportunity costs must be taken into consideration such that the older practices remain the right care. An Evolving Canadian Perspective from 1996 to 2013 In a pioneering paper from 1996 Lavis and Anderson wrote: ...there are two distinct types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided. The differences between the two parallel the differences between two other concepts in health care: effectiveness and cost-containment...An appropriate service is one that is expected to do more good than harm for a patient with a given indication...The appropriateness of the setting in which care is provided is related to cost effectiveness2. This very serviceable definition moved beyond a narrow clinical conception based solely on the therapeutic impact of an intervention on a patient, to broader contextual consideration focused on venue. Thus, for example, the care provided appropriately in a home-care setting might not be at all appropriate if given in a tertiary care hospital. Significantly, the authors added this important observation: "Setting is a proxy measure of the resources used to provide care"2. This sentence is an invitation to expand the original Lavis and Anderson definition to encompass other resources and inputs identified over the ensuing decades. Three elements are especially important. Timeliness became an issue in Canadian health care just as the Lavis and Anderson paper appeared. In 1997 almost two-thirds of polled Canadians felt surgical wait times were excessive, up from just over half of respondents a year earlier3. By 2004 concern with wait times was sufficiently pervasive that when the federal government and the provinces concluded the First Ministers' Agreement, it included obligations to provide timely access to cancer care, cardiac care, diagnostic imaging, joint replacement and sight restoration4. These rapid developments indicate that timeliness was now considered an essential element in determining the appropriateness of care. A second theme that became prominent in health care over the last two decades was the concept of patient-centredness. When the Canadian Medical Association released its widely endorsed Health Care Transformation in Canada in 2010, the first principle for reform was building a culture of patient-centred care. Succinctly put, this meant that "health care services are provided in a manner that works best for patients"5. To begin the process of operationalizing this concept CMA proposed a Charter for Patient-centred Care. Organized across seven domains, it included the importance of: allowing patients to participate fully in decisions about their care; respecting confidentiality of health records; and ensuring care provided is safe and appropriate. This sweeping vision underscores the fact that care which is not matched to the individual patient cannot be considered appropriate care. A third significant development over the last two decades was heightened awareness of the importance of scopes of practice. This awareness arose in part from the emphasis placed on a team approach in newer models of primary care6, but also from the emergence of new professions such as physician assistants, and the expansion of scopes of practice for other professionals such as pharmacists7. As the same health care activity could increasingly be done by a wider range of health professionals, ensuring the best match between competence required and the service provided became an essential element to consider when defining appropriateness. Under-qualified practitioners could not deliver quality care, while overly-qualified providers were a poor use of scarce resources. To summarize, as a recent scoping review suggested, for a complete conceptualization of appropriateness in 2013 it is necessary to add the right time, right patient and right provider to the previously articulated right care and right setting8. Why Appropriateness Matters The most frequent argument used to justify policy attention to appropriateness is health system cost. There is a wealth of evidence that inappropriate care - avoidable hospitalizations, for example, or alternative level of care patients in acute care beds - is wide spread in Canada9; eliminating this waste is critical to system sustainability. In Saskatchewan, for example, Regina and Saskatoon contracted in 2011 with private clinics to provide a list of 34 surgical procedures. Not only were wait times reduced, but costs were 26% lower in the surgical clinics than in hospitals for doing the same procedures10. There is, however, an equally important issue pointing to the importance of ensuring appropriate care: sub-optimal health care quality. In the United States, for example, a study evaluated performance on 439 quality indicators for 30 acute and chronic conditions. Patients received 54.9% of recommended care, ranging from a high of 78.7% for senile cataracts to 10.5% for alcohol dependence11. A more recent Australian study used 522 quality indicators to assess care for 22 common conditions. Patients received clinically appropriate care in 57% of encounters, with a range from 90% for coronary artery disease to 13% for alcohol dependence12. While no comparable comprehensive data exist for Canada, it is unlikely the practices in our system depart significantly from peer nations. Focusing on appropriateness of care, then, is justified by both fiscal and quality concerns. Methodology: the Challenge of Identifying Appropriateness While there is a clear need to address appropriateness - in all its dimensions - the methods by which to assess the appropriateness of care are limited and, to date, have largely focused on the clinical aspect. The most frequently used approach is the Rand/University of California Los Angeles (Rand) method. It provides panels of experts with relevant literature about a particular practice and facilitates iterative discussion and ranking of the possible indications for using the practice. Practices are labeled appropriate, equivocal or inappropriate13. A systematic review in 2012 found that for use on surgical procedures the method had good test-retest reliability, interpanel reliability and construct validity14. However, the method has been criticized for other short-comings: panels in different countries may reach different conclusions when reviewing the same evidence; validity can only be tested against instruments such as clinical practice guidelines that themselves may have a large expert opinion component2; Rand appropriateness ratings apply to an "average" patient, which cannot account for differences across individuals; and, finally, Rand ratings focus on appropriateness when a service is provided but does not encompass underuse, that is, failure to provide a service that would have been appropriate9. The Rand method, while not perfect, is the most rigorous approach to determining clinical appropriateness yet devised. It has recently been suggested that a method based on extensive literature review can identify potentially ineffective or harmful practices; when applied to almost 6000 items in the Australian Medical Benefits Schedule, 156 were identified that may be inappropriate15. This method also presents challenges. For example, the authors of a study using Cochrane reviews to identify low-value practices note that the low-value label resulted mainly from a lack of randomized evidence for effectiveness16. Assessing the appropriateness of care setting has focused almost exclusively on hospitals. Some diagnoses are known to be manageable in a community setting by primary care or specialty clinics. The rate of admissions for these ambulatory care sensitive conditions (ACSCs) - which fell from 459 per 100,000 population in 2001-02 to 320 per 100,00 in 2008-09 - is one way of gauging the appropriateness of the hospital as a care venue9. A second measure is the number of hospital patients who do not require either initial or prolonged treatment in an acute care setting. Proprietorial instruments such as the Appropriateness Evaluation Protocol (AEP)17or the InterQual Intensity of Service, Severity of Illness and Discharge Screen for Acute Care (ISD-AC)18 have been used to assess the appropriateness of hospital care for individual patients. While these instruments have been applied to Canadian hospital data19,20, there is a lack of consensus in the literature as to the reliability and utility of such tools21-23. Benchmarks exist for appropriate wait times for some types of care in Canada through the work of the Wait Time Alliance4. These include: chronic pain, cancer care, cardiac care, digestive health care, emergency rooms, joint replacement, nuclear medicine, radiology, obstetrics and gynecology, pediatric surgery, plastic surgery, psychiatric illness, and sight restoration. The recommendations are based on evidence-informed expert opinion. The other two domains of appropriateness - right patient, right provider - as yet have no objective tools by which to assess appropriateness. Barriers Determining appropriateness demands a complex and time-consuming approach, and its operationalization faces a number of barriers. The availability of some health care services may be subject to political influence which will over-ride appropriateness criteria. For example, recommendations to close smaller hospitals deemed to be redundant or inefficient may not be implemented for political reasons. Patient expectations can challenge evidence-based appropriateness criteria. In a primary care setting, for instance, it may be difficult to persuade a patient with an ankle sprain that an x-ray is unlikely to be helpful. The insistence by the patient is compounded by an awareness of potential legal liability in the event that clinical judgment subsequently proves incorrect. Choosing Wisely Canada recommends physicians and patients become comfortable with evidence-informed conversations about potentially necessary care24. Traditional clinical roles are difficult to revise in order to ensure that care is provided by the most appropriate health professional. This is especially true if existing funding silos are not realigned to reflect the desired change in practice patterns. Finally, and perhaps most importantly, even if agreed upon appropriateness criteria are developed, holding practitioners accountable for their application in clinical practice is extremely difficult due to data issues25. Chart audits could be conducted to determine whether appropriateness criteria were met when specific practices were deployed, but this is not feasible on a large scale. Rates of use of some practices could be compared among peers from administrative data; however, variation in practice population might legitimately sustain practice variation. For diagnostic procedures it has been suggested that the percentage of negative results is an indicator of inappropriate use; however, most administrative claim databases would not include positive or negative test result data26. This data deficit must be addressed with health departments and regional health authorities. Important Caveats There are several additional constraints on the use of the concept by health system managers. First, the vast majority of practices have never been subject to the Rand or any other appropriateness assessment. Even for surgical procedures clinical appropriateness criteria exist for only 10 of the top 25 most common inpatient procedures and for 6 of the top 15 ambulatory procedures in the United States. Most studies are more than 5 years old27. Second, while the notion is perhaps appealing to policy makers, it is incorrect to assume that high use of a practice equates with misuse: when high-use areas are compared to low use areas, the proportion of inappropriate use has consistently been shown to be no greater in the high-use regions28,29. Finally, it is uncertain how large a saving can be realized from eliminating problematic clinical care. For example, a US study modeling the implementation of recommendations for primary care found that while a switch to preferentially prescribing generic drugs would save considerable resources, most of the other items on the list of questionable activities "are not major contributors to health care costs"30. What is important to emphasize is that even if dollars are not saved, by reducing inappropriate care better value will be realized for each dollar spent. Policy Recommendations These methodological and other challenges31 notwithstanding, the Canadian Medical Association puts forward the following recommendations for operationalizing the concept of appropriateness and of clinical practice. 1. Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. Jurisdictions should develop a framework32 for identifying potentially inappropriate care, including under-use. This involves selecting criteria by which to identify and prioritize candidates for assessment; developing and applying a robust assessment methodology; and creating mechanisms to disseminate and apply the results. Frameworks must also include meaningful consideration of care venue, timeliness, patient preferences and provider scope of practice. International examples exist for some aspects of this exercise and should be adapted to jurisdictional circumstances. Necessarily, a framework will demand the collection of supporting data in a manner consistent with the following 2013 General Council resolution: The Canadian Medical Association supports the development of data on health care delivery and patient outcomes to help the medical profession develop an appropriateness framework and associated accountability standards provided that patient and physician confidentiality is maintained. 2. Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. Both trainees and practicing physicians should have access to education and guidance on the topic of appropriateness and on practices that are misused, under-used, or over-used. Appropriately designed continuing education has been shown to alter physician practice. Point of care guidance via the electronic medical record offers a further opportunity to alert clinicians to practices that should or should not be done in the course of a patient encounter33. An initiative co-led by the Canadian Medical Association that is designed to educate the profession about the inappropriate over use of diagnostic and therapeutic interventions is Choosing Wisely Canada. The goal is to enhance quality of care and only secondarily to reduce unnecessary expenditures. It is an initiative consistent with the intent of two resolutions from the 2013 General Council: The Canadian Medical Association will form a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. The Canadian Medical Association believes that fiscal benefits and cost savings of exercises in accountability and appropriateness in clinical care are a by-product rather than the primary focus of these exercises. 3. Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Practitioners should be provided with incentives to eliminate inappropriate care. These incentives may be financial - delisting marginal activities or providing bonuses for achieving utilization targets for appropriate but under-used care. Any notional savings could also be flagged for reinvestment in the health system, for example, to enhance access. Giving physicians the capacity to participate in audit and feedback on their use of marginal practices in comparison to peers generally creates a personal incentive to avoid outlier status. Public reporting by group or institution may also move practice towards the mean30. In any such undertakings to address quality or costs through changes in practice behaviour it is essential that the medical profession play a key role. This critical point was captured in a 2013 General Council resolution: The Canadian Medical Association will advocate for adequate physician input in the selection of evidence used to address costs and quality related to clinical practice variation. Conclusion When appropriateness is defined solely in terms of assessing the clinical benefit of care activities it can provide a plausible rational for "disinvestment in" or "delisting of" individual diagnostic or therapeutic interventions. However, such a narrow conceptualization of appropriateness cannot ensure that high quality care is provided with the optimal use of resources. To be truly useful in promoting quality and value appropriateness must be understood to mean the right care, provided by the right provider, to the right patient, in the right venue, at the right time. Achieving these five components of health care will not be without significant challenges, beginning with definitions and moving on to complex discussions on methods of measurement. Indeed, it may prove an aspirational goal rather than a completely attainable reality. But if every encounter in the health system - a hospitalization, a visit to a primary care provider, an admission to home care - attempted to meet or approximate each of the five criteria for appropriateness, a major step towards optimal care and value will have been achieved across the continuum. Viewed in this way, appropriateness has the capacity to become an extraordinarily useful organizing concept for positive health care transformation in Canada. Approved by CMA Board on December 06, 2014 References 1. World Health Organization. Appropriateness in Health Care Services, Report on a WHO Workshop. Copenhagen: WHO; 2000. 2. Lavis JN, Anderson GM. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ. 1996;154(3):321-8. 3. Sanmartin C, Shortt SE, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ. 2000;162(9):1305-10. 4. Wait Time Alliance. Working to Improve Wait Times Across Canada. Toronto: Wait Time Alliance; 2014. Available: http://www.waittimealliance.ca. (accessed April 18, 2013) 5. Canadian Medical Association. Health Care Transformation in Canada. Ottawa: Canadian Medical Association; 2010. 6. Canadian Medical Association. CMA Policy: Achieving Patient-centred Collaborative Care. Ottawa: Canadian Medical Association; 2008. 7. Maxwell-Alleyne A, Farber A. Pharmacists' expanded scope of practice: Professional obligations for physicians and pharmacists working collaboratively. Ont Med Rev. 2013;80(4):17-9. 8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3)342-9. 9. Canadian Institute for Health Information. Health Care in Canada 2010. Ottawa: CIHI; 2010. 10. MacKinnon J. Health Care Reform from the Cradle of Medicare. Ottawa: Macdonald-Laurier Institute; 2013. 11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348(26):2635-45. 12. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5. 13. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63. 14. Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65(11):1133-43. 15. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-60. 16. Garner S, Docherty M, Somner J, et al. Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews. J Health Serv Res Policy. 2013;18(1):6-12. 17. Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19(8):855-71. 18. Mitus AJ. The birth of InterQual: evidence-based decision support criteria that helped change healthcare. Prof Case Manag. 2008;13(4):228-33. 19. DeCoster C, Roos NP, Carriere KC, Peterson S. Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review. CMAJ. 1997;157(7):889-96. 20. Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group. CMAJ . 1998;158(10):1289-96. 21. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F. How valid are utilization review tools in assessing appropriate use of acute care beds? CMAJ. 2000;162(13):1809-13. 22. McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds. A systematic review of methods and results. Health policy. 2000;53(3):157-84. 23. Vetter N. Inappropriately delayed discharge from hospital: what do we know? BMJ. 2003;326(7395):927-8. 24. Choosing Wisely Canada. Recent News. Ottawa: Choosing Wisely Canada; 2015. Available: www.choosingwiselycanada.org. (accessed Dec 2014) 25. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:d4519. 26. Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-9. 27. Lawson EH, Gibbons MM, Ingraham AM, Shekelle PG, Ko CY. Appropriateness criteria to assess variations in surgical procedure use in the United States. Arch Surg. 2011;146(12):1433-40. 28. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987;258(18):2533-7. 29. Keyhani S, Falk R, Bishop T, Howell E, Korenstein D. The relationship between geographic variations and overuse of healthcare services: a systematic review. Med care. 2012;50(3):257-61. 30. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med. 2011;171(20):1856-8. 31. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23. 32. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE. Identifying existing health care services that do not provide value for money. Med J Aust. 2009;190(5):269-73. 33. Shortt S GM, Gorbet S. Making medical practice safer: the role of public policy. Int J Risk Saf Med. 2010;22(3):159-68.
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Guiding principles for the optimal use of data analytics by physicians at the point of care

https://policybase.cma.ca/en/permalink/policy11812
Last Reviewed
2020-02-29
Date
2016-02-27
Topics
Health information and e-health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2016-02-27
Topics
Health information and e-health
Text
Electronic tools are now being used more widely in medicine than ever before. A majority of physicians in Canada have adopted electronic medical records (EMRs)-75% of physicians use EMRs to enter or retrieve clinical patient notes, and 80% use electronic tools to access laboratory/diagnostic test results. The increased use of point-of-care tools and information repositories has resulted in the mass digitization and storage of clinical information, which provides opportunities for the use of big data analytics. Big data analytics may come to be understood as the process of examining clinical data in EMRs cross-referenced with other administrative, demographic and behavioural data sources to reveal determinants of patient health and patterns in clinical practice. Its increased use may provide opportunities to develop and enhance clinical practice tools and to improve health outcomes at both point-of-care and population levels. However, given the nature of EMR use in Canada, these opportunities may be restricted to primary care practice at this time. Physicians play a central role in finding the right balance between leveraging the advantages of big data analytics and protecting patient privacy. Guiding Principles for the Optimal Use of Data Analytics by Physicians at the Point of Care outlines basic considerations for the use of big data analytics services and highlights key considerations when responding to requests for access to EMR data, including the following: * Why will data analytics be used? Will the safety and effectiveness of patient care be enhanced? Will the results be used to inform public health measures? * What are the responsibilities of physicians to respect and protect patient and physician information, provide appropriate information during consent conversations, and review data sharing agreements and consult with EMR vendors to understand how data will be used? As physicians will encounter big data analytics in a number of ways, this document also outlines the characteristics one should be looking for when assessing the safety and effectiveness of big data analytics services: * protection of privacy * clear and detailed data sharing agreement * physician-owned and -led data collaboratives * endorsement by a professional or recognized association, medical society or health care organization * scope of services and functionality/appropriateness of data While this guidance is not a standalone document-it should be used as a supplemental reference to provincial privacy legislation-it is hoped that it can aid physicians to identify suitable big data analytics services and derive benefits from them. Introduction This document outlines basic considerations for the use of big data analytics services at the point of care or for research approved by a research ethics board. This includes considerations when responding to requests for access to data in electronic medical records (EMRs). These guiding principles build on the policies of the Canadian Medical Association (CMA) on Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records,1 Principles Concerning Physician Information2 and Principles for the Protection of Patients' Personal Health Information,3 the 2011 clinical vignettes Disclosing Personal Health Information to Third Parties4 and Need to Know and Circle of Care,5 and the Canadian Medical Protective Association's The Impact of Big Data on Healthcare and Medical Practice.6 These guiding principles are for information and reference only and should not be construed as legal or financial advice, nor is this document a substitute for legal or other professional advice. Physicians must always comply with all legislation that applies to big data analytics, including privacy legislation. Big data analytics in the clinical context involves the collection, use and potential disclosure of patient and physician information, both of which could be considered sensitive personal information under privacy legislation. Big data analytics has the potential to improve health outcomes, both at the point of care and at a population level. Doctors have a key role to play in finding the right balance between leveraging the advantages of big data (enhanced care, service delivery and resource management) and protecting patient privacy.7 Background A majority of physicians in Canada have adopted EMRs in their practice. The percentage of physicians using EMRs to enter or retrieve clinical patient notes increased from 26% in 2007 to 75% in 2014. Eighty percent of physicians used electronic tools to access laboratory/diagnostic test results in 2014, up from 38% in 2010.8 The increasingly broad collection of information by physicians at the point of care, combined with the growth of information repositories developed by various governmental and intergovernmental bodies, has resulted in the mass digitization and storage of clinical information. Big data is the term for data sets so large and complex that it is difficult to process them using traditional relational database management systems, desktop statistics and visualization software. What is considered "big" depends on the infrastructure and capabilities of the organization managing the data.9 Analytics is the discovery and communication of meaningful patterns in data. Analytics relies on the simultaneous application of statistics, computer programming and operations research. Analytics often favours data visualization to communicate insight, and insights from data are used to guide decision-making.10 For physicians, big data analytics may come to be understood as the process of examining the clinical data in EMRs cross-referenced with other administrative, demographic and behavioural data sources to reveal determinants of patient health and patterns in clinical practice. This information can be used to assist clinical decision-making or for research approved by a research ethics board. There are four types of big data analytics physicians may encounter in the provision of patient care. They are generally performed in the following sequence, in a continuous cycle11,12,13,14: 1. Population health analytics: Health trends are identified in the aggregate within a community, a region or a national population. The data can be derived from biomedical and/or administrative data. 2. Risk-based cost analysis: Populations are segmented into groups according to the level of risk to the patient's health and/or cost to the health system. 3. Care management: Clinicians are enabled to manage patient care according to defined care pathways and clinical protocols informed by population health analytics and risk-based cost analysis. Care management includes the following: o Clinical decision support: Outcomes are predicted and/or alternative treatments are recommended to clinicians and patients at the point of care. o Personalized/precision care: Personalized data sets, such as genomic DNA sequences for at-risk patients, are leveraged to highlight best practice treatments for patients and practitioners. These solutions may offer early detection and diagnosis before a patient develops disease symptoms. o Clinical operations: Workflow management is performed, such as wait-times management, mining historical and unstructured data for patterns to predict events that may affect care. o Continuing education and professional development: Longitudinal performance data are combined across institutions, classes, cohorts or programs with correlating patient outcomes to assess models of education and/or develop new programs. 4. Performance analytics: Metrics for quality and efficiency of patient care are cross-referenced with clinical decision-making and performance data to assess clinical performance. This cycle is also sometimes understood as a component of "meaningful" or "enhanced" use of EMRs. How might physicians encounter big data analytics? Many EMRs run analytics both visibly (e.g., as a function that can be activated at appropriate junctures in the care pathway) and invisibly (e.g., as tools that run seamlessly in the background of an EMR). Physicians may or may not be aware when data are being collected, analyzed, tailored or presented by big data analytics services. However, many jurisdictions are strengthening their laws and standards, and best practices are gradually emerging.15 Physicians may have entered into a data sharing agreement with their EMR vendor when they procured an EMR for their practice. Such agreements may include provisions to share de-identified (i.e., anonymized) and/or aggregate data with the EMR vendor for specified or unspecified purposes. Physicians may also receive requests from third parties to share their EMR data. These requests may come from various sources: * provincial governments * intergovernmental agencies * national and provincial associations, including medical associations * non-profit organizations * independent researchers * EMR vendors, service providers and other private corporations National Physician Survey results indicate that in 2014, 10% of physicians had shared data from their EMRs for the purposes of research, 10% for chronic disease surveillance and 8% for care improvement. Family physicians were more likely than other specialists to share with public health agencies (22% v. 11%) and electronic record vendors (13% v. 2%). Specialists were more likely than family physicians to share with researchers (59% v. 37%), hospital departments (47% v. 20%) and university departments (28% v. 15%). There is significant variability across the provinces with regard to what proportion of physicians are sharing information from their EMRs, which is affected by the presence of research initiatives, research objectives defined by the approval of a research ethics board, the adoption rates of EMRs among physicians in the province and the functionality of those EMRs.16 For example, there are family practitioners across Canada who provide data to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The CPCSSN is a multi-disease EMR surveillance and research system that allows family physicians, epidemiologists and researchers to understand and manage chronic care conditions for patients. Health information is collected from EMRs in the offices of participating family physicians, specifically information about Canadians suffering from chronic and mental health conditions and three neurologic conditions, including Alzheimer's and related dementias.17 In another example, the Canadian Partnership Against Cancer's Surgical Synoptic Reporting Initiative captures standardized information about surgery at the point of care and transmits the surgical report to other health care personnel. Surgeons can use the captured information, which gives them the ability to assess adherence to the clinical evidence and safety procedures embedded in the reporting templates, to track their own practices and those of their community.18 The concept of synoptic reporting-whereby a physician provides anonymized data about their practice in return for an aggregate report summarizing the practice of others -can be expanded to any area in which an appropriate number of physicians are willing to participate. Guiding principles for the use of big data analytics These guiding principles are designed to give physicians a starting point as they consider the use of big data analytics in their practices: * The objective of using big data analytics must be to enhance the safety and/or effectiveness of patient care or for the purpose of health promotion. * Should a physician use big data analytics, it is the responsibility of the physician to do so in a way that adheres to their legislative, regulatory and/or professional obligations. * Physicians are responsible for the privacy of their individual patients. Physicians may wish to refer to the CMA's policy on Principles for the Protection of Patients' Personal Health Information.19 * Physicians are responsible for respecting and protecting the privacy of other physicians' information. Physicians may wish to refer to the CMA's policy on Principles Concerning Physician Information.20 * When physicians enter into and document a broad consent discussion with their patient, which can include the electronic management of health information, this agreement should convey information to cover the elements common to big data analytics services. * Physicians may also wish to consider the potential for big data analytics to inform public health measures and enhance health system efficiency and take this into account when responding to requests for access to data in an EMR. * Many EMR vendors provide cloud-based storage to their clients, so information entered into an EMR may be available to the EMR vendor in a de-identified and/or aggregate state. Physicians should carefully read their data sharing agreement with their EMR vendor to understand how and why the data that is entered into an EMR is used, and/or they should refer to the CMA's policy on the matter, Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records.21 * Given the dynamic nature of this emerging tool, physicians are encouraged to share information about their experiences with big data analytics and its applications with colleagues. Characteristics of safe and effective big data analytics services 1. Protection of privacy Privacy and security concerns present a challenge in linking big data in EMRs. As data are linked, it becomes increasingly difficult to de-identify individual patients.22 As care is increasingly provided in interconnected, digital environments, physicians are having to take on the role of data stewardship. To that end, physicians may wish to employ conservative risk assessment practices-"should we" as opposed to "can we" when linking data sources-and obtain express patient consent, employing a "permission-based" approach to the collection and stewardship of data. 2. A clear and detailed data sharing agreement Physicians entering into a contract with an EMR vendor or other third party for provision of services should understand how and when they are contributing to the collection of data for the purposes of big data analytics services. There are template data sharing agreements available, which include the basic components of safe and effective data sharing, such as the model provided by the Information and Privacy Commissioner of Ontario.23 Data sharing agreements may include general use and project-specific use, both of which physicians should assess before entering into the agreement. When EMR access is being provided to a ministry of health and/or regional health authority, the data sharing agreement should distinguish between access to administrative data and access to clinical data. Physicians may wish to refer to the CMA's policy on Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records.24 3. Physician-owned and -led data collaboratives In some provinces there may exist opportunities to share clinical data in physician-owned and -led networks to reflect on and improve patient care. One example is the Physicians Data Collaborative in British Columbia, a not-for-profit organization open to divisions of family practice.25 Collaboratives such as this one are governed by physicians and driven by a desire to protect the privacy and safety of patients while producing meaningful results for physicians in daily practice. Participation in physician-owned data collaboratives may ensure that patient data continue to be managed by physicians, which may lead to an appropriate prioritization of physicians' obligations to balance patient-centred care and patient privacy. 4. Endorsement by a professional or other recognized association or medical society or health care organization When considering use of big data analytics services, it is best to select services created or endorsed by a professional or other recognized association or medical society. Some health care organizations, such as hospitals, may also develop or endorse services for use in their clinical environments. Without such endorsement, physicians are advised to proceed with additional caution. 5. Scope of services and functionality/appropriateness of data Physicians may wish to seek out information from EMR vendors and service providers about how big data analytics services complement the process of diagnosis and about the range of data sources from which these services draw. While big data analytics promises insight into population health and practice trends, if it is not drawing from an appropriate level of cross-referenced sources it may present a skewed picture of both.26 Ultimately, the physician must decide if the sources are appropriately diverse. Physicians should expect EMR vendors and service providers to make clear how and why they draw the information they do in the provision of analytics services. Ideally, analytics services should integrate population health analytics, risk-based cost analysis, care management services (such as point-of-care decision support tools) and performance analytics. Physicians should expect EMR vendors to allocate sufficient health informatics resources to information management, technical infrastructure, data protection and response to breaches in privacy, and data extraction and analysis.27,28 Physicians may also wish to consider the appropriateness of data analytics services in the context of their practices. Not all data will be useful for some medical specialties, such as those treating conditions that are relatively rare in the overall population. The potential for new or enhanced clinical practice tools informed by big data analytics may be restricted to primary care practice at this time.29 Finally, predictive analytics often make treatment recommendations that are designed to improve the health outcomes in a population, and these recommendations may conflict with physicians' ethical obligations to act in the best interests of individual patients and respect patients' autonomous decision-making).30 References 1 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 2 Canadian Medical Association. Principles concerning physician information [CMA policy]. CMAJ 2002 167(4):393-4. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD02-09.pdf 3 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2010. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 4 Canadian Medical Association. Disclosing personal health information to third parties. Ottawa: The Association; 2011. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Disclosure_third_parties-e.pdf 5 Canadian Medical Association. Need to know and circle of care. Ottawa: The Association; 2011. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Need_to_know_circle_care-e.pdf 6 Canadian Medical Protective Association. The impact of big data on healthcare and medical practice. Ottawa: The Association; no date. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_14_big_data_design-e.pdf 7 Kayyali B, Knott D, Van Kuiken S. The 'big data' revolution in US health care: accelerating value and innovation. New York: McKinsey & Company; 2013. p. 1. 8 College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National physician survey, 2014. National results by FP/GP or other specialist, sex, age and all physicians. Q7. Ottawa: The Colleges and Association; 2014. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2014/08/2014-National-EN-Q7.pdf 9 Anonymous. Data, data everywhere. The Economist 2010 Feb 27. Available: www.economist.com/node/15557443 10 Anonymous. Data, data everywhere. The Economist 2010 Feb 27. Available: www.economist.com/node/15557443 11 Canada Health Infoway. Big data analytics in health. Toronto: Canada Health Infoway; 2013. Available: www.infoway-inforoute.ca/index.php/resources/technical-documents/emerging-technology/doc_download/1419-big-data-analytics-in-health-white-paper-full-report (accessed 2014 May 16). 12 Ellaway RH, Pusic MV, Galbraith RM, Cameron T. 2014 Developing the role of big data and analytics in health professional education. Med Teach 2014;36(3):216-222. 13 Marino DJ. Using business intelligence to reduce the cost of care. Healthc Financ Manage 2014;68(3):42-44, 46. 14 Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev 2013;91(10):50-70. 15 Baggaley C. Data protection in a world of big data: Canadian Medical Protective Association information session [presentation]. 2014 Aug 20. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_2014_carmen_baggaley-e.pdf 16 College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National physician survey, 2014. National results by FP/GP or other specialist, sex, age and all physicians. Q10. Ottawa: The Colleges and Association; 2014. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2014/08/2014-National-EN-Q10.pdf 17 Canadian Primary Care Sentinel Surveillance Network. Available: http://cpcssn.ca/ (accessed 2014 Nov 15). 18 Canadian Partnership Against Cancer. Sustaining action toward a shared vision: 2012-2017 strategic plan. Toronto: The Partnership; no date. Available: www.partnershipagainstcancer.ca/wp-content/uploads/sites/5/2015/03/Sustaining-Action-Toward-a-Shared-Vision_accessible.pdf 19 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 20 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 21 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 22 Weber G, Mandl KD, Kohane IS. Finding the missing link for big biomedical data . JAMA 2014;311(24):2479-2480. doi:10.1001/jama.2014.4228. 23 Information and Privacy Commissioner of Ontario. Model data sharing agreement. Toronto: The Commissioner; 1995. Available: www.ipc.on.ca/images/Resources/model-data-ag.pdf 24 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 25 Physicians Data Collaborative. Overview. Available: www.divisionsbc.ca/datacollaborative/home 26 Cohen IG, Amarasingham R, Shah A, Xie B, Lo B. The legal and ethical concerns that arise from using complex predictive analytics in health care. Health Aff 2014;33(7):1139-1147. 27 Rhoads J, Ferrara L. Transforming healthcare through better use of data. Electron Healthc 2012;11(1):e27. 28 Canadian Medical Protective Association. The impact of big data and healthcare and medical practice. Ottawa: The Association; no date. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_14_big_data_design-e.pdf 29 Genta RM, Sonnenberg A. Big data in gastroenterology research. Nat Rev Gastroenterol Hepatol 2014;11(6):386-390. 30 Cohen IG, Amarasingham R, Shah A, Xie B, Lo B. The legal and ethical concerns that arise from using complex predictive analytics in health care. Health Aff 2014;33(7):1139-1147.
Documents
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Risk management education programmes

https://policybase.cma.ca/en/permalink/policy513
Last Reviewed
2020-02-29
Date
1989-10-14
Topics
Population health/ health equity/ public health
Resolution
BD90-02-34
That the Canadian Medical Association actively pursue the development of education programs in risk management in cooperation with its divisions, affiliates, and other appropriate organizations.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1989-10-14
Topics
Population health/ health equity/ public health
Resolution
BD90-02-34
That the Canadian Medical Association actively pursue the development of education programs in risk management in cooperation with its divisions, affiliates, and other appropriate organizations.
Text
That the Canadian Medical Association actively pursue the development of education programs in risk management in cooperation with its divisions, affiliates, and other appropriate organizations.
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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
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Flexibility in Medical Training (Update 2009)

https://policybase.cma.ca/en/permalink/policy9485
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Flexibility in Medical Training
Topics
Health human resources
Text
Flexibility in Medical Training (Update 2009) The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others. Definitions - Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. - Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree. - International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine. - Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes. The need for informed career decision-making and positive influences Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors. A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3 The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6 Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path. Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources. In light of the above, the CMA recommends that: 1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match); 2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs; 3. a wide-range of elective opportunities be developed and communicated at a national level; 4. electives reflect a broad spectrum of experiences, including community-based opportunities; 5. clinical experiences be introduced at the earliest possible stage of undergraduate learning; 6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and 7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning. The need for broad-based medical education In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections. Capacity of the postgraduate training system An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons: * Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine. * It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada. * It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands. * It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.] In light of the above, the CMA recommends that: 8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change; 9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates; 10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates; 11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and 12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs. Re-entry medical training system Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set. A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine. The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians. The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. Stability Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training. The CMA therefore recommends that: 13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and 14. funding for re-entry positions be specifically allocated for the entire training period. Capacity The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.] Accessibility The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period. The CMA therefore recommends that: 15. there be accessibility within re-entry postgraduate training positions including: * open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions, * that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and * recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and 16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system. Flexibility in the Workforce As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. The CMA therefore recommends that: 17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time. Accountability The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that: 18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education. 1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 2 2007 National Physician Survey Data. 3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada. 4 Ibid, page 23. 5 Ibid. 6 Ibid, page 59. 7 Ibid, page 27. 8 Ibid, page 60. 9 Ibid.
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Tuition fee escalation and deregulation in undergraduate programs in medicine (Update 2009)

https://policybase.cma.ca/en/permalink/policy9487
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Tuition fee escalation and deregulation in undergraduate programs in medicine
Topics
Health human resources
Text
TUITION FEE ESCALATION AND DEREGULATION IN UNDERGRADUATE PROGRAMS IN MEDICINE (Update 2009) The Canadian Medical Association (CMA) is very concerned about high and rapidly escalating, undergraduate medical school tuition fees across Canada. Ontario set a precedent for the deregulation of tuition fees in May 1998 and many provinces have since followed. This policy gives universities, including medical schools, the discretion to set fees for training in those areas that lead to professional careers, such as medicine. For the 2008-2009 academic year, first-year tuition fees at most Ontario medical schools were triple the tuition fees in 1997-1998 at an average of $16,550 per year;1 this figure does not include compulsory "other fees" that can be as much as $1,700 per year.2 Irrespective of whether tuition fees have been regulated, some medical schools outside of Ontario have doubled their tuition fees within the same time period. Decreased government funding to universities is increasing the fiscal pressures on institutions and is driving these dramatic tuition fee increases. The CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant and detrimental impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. Broad Effects of High Tuition Fees Lack of Diversity Medical education in Canada has traditionally been affordable and accessible to individuals from a range of socioeconomic and ethnic groups who later serve an equally diverse population. Unfortunately, the introduction of high tuition fees may close the door to individuals who either cannot afford the high costs of a medical education or wish to avoid the prospect of significant debt load upon graduation. High tuition fees may therefore create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. The proportion of medical students from lower income families is already extremely low and decreasing further.3 Paradoxically, funds that should be injected to making tuition fees reasonable - and therefore more accessible by a broader range of society - may soon need to be allocated to creating career promotion and special financial support programs that target those groups that have been alienated by high tuition fees. Influence on Practice Choice and Practice Location ("Brain Drain") It is likely that paying off debts as quickly as possible will become a key consideration when determining practice location and specialty. For instance, more students may feel compelled to maximize their earning potential by pursuing those specialties that generate high incomes; others may choose those specialties with short training periods so they can enter the workforce and start to pay off debts sooner. Debt load may also influence where graduating physicians choose to practise medicine. The increasing willingness of American recruiters to pay off the debts of new graduates provides tremendous incentive to practise in the U.S. and explore research opportunities; unfortunately, it only aggravates the ongoing problem of the "brain drain" of Canadian physicians.4 While we have been enjoying a net gain of physicians from the U.S., we may experience net loss with physician shortages expected in the U.S. More physician retention and recruitment initiatives are needed to encourage physicians to remain in or return to Canada. This is especially true for rural and remote communities. Urban areas are often in a better financial position to offer incentives to new graduates than rural and remote communities where physician shortages are most pronounced. Effects on Rural and Remote Areas The CMA believes that governments must be made aware of the potentially negative impact of high tuition fees and student debt on physician workforce supply for the rural and remote areas of Canada. Research shows that medical students from rural and remote areas have a greater likelihood of returning to these communities to practise medicine.5 Research also shows that students of rural origin have higher student debts6 and are underrepresented in Canadian medical schools.7 Students from rural and remote communities face the challenge of not being able to live at home while they attend university. They must assume high relocation expenses and travel costs, as well as separation from their families while they are away at school. Of student respondents to the 2007 National Physician Survey, 53.1% of rural students compared with 67.4% of urban medical students had no debt upon entering medical school. When asked to predict their expected debt upon completion of medical school, 33.2% of rural students compared with 23% of urban students expected their debtload to exceed $100,000.8 Unfortunately, the introduction of high tuition fees might make both the personal and financial costs of pursuing a medical education too significant for students from rural and remote areas to even consider. As a result, this may generate fewer physicians willing to practise in these areas and exacerbate the problem most rural and remote communities already face in attracting and retaining physicians. High tuition fees might also further increase the reliance on international medical graduates in rural and remote communities. While the CMA values the contributions of international medical graduates in alleviating shortages in physician supply, it believes that Canadian governments must adopt the guiding principle of self-sufficiency in the production and retention of physicians to meet population needs. Effects on New and Potential Medical Students Medical students affected by high and escalating tuition fees will graduate with unprecedented debt loads. Enormous education costs, already a reality in some provinces, are a growing trend. In 2007, over one third (36%) of students said they expected debtloads of $80,000 or more upon completion of medical school.9 A number of factors, as highlighted below, contribute to students' financial burden and may affect their ability to pay off debts and meet financial obligations. This, in turn, may influence their choice of medical discipline and practice location. Exorbitant education costs may also result in students considering dropping out of, or taking longer to complete, their medical studies because they cannot afford the ongoing costs, or are too overwhelmed with the combined stress of their medical studies and trying to make financial ends meet. The CMA is very concerned that excessive debt loads will exacerbate the stress already experienced by medical students during their training and will have a significant and negative impact on their health and well-being. Previous Education Debt and Accumulative Debt Most Canadian medical schools make an undergraduate degree a prerequisite to application. As such, by the time most students are accepted into medical school, they may have already accumulated debt from a previous undergraduate degree. Many students have also completed postgraduate degrees before entering medical school.10 This debt continues to accumulate during the undergraduate years of medical school and into the postgraduate training period, which is anywhere from two years to seven years in duration. This does not include additional time spent doing fellowships. It may be very useful to establish a national clearinghouse of public and private financial assistance programs to help students in their search for financial support. Limited or No Employment Opportunities during Undergraduate Training Tuition fees, along with ongoing increases in living expenses, are already making it very difficult for some students to make ends meet. It makes matters worse that there are limited or no opportunities to generate income through employment during the academic year and the summer months. Given the intensity of the medical school program, some schools strongly advise against working part time. To further compound the problem, some schools have very short summer breaks. For those schools that do provide summer holidays, the holidays often start later than other university programs, by which time employment opportunities are scarce or low paying. There is also the common expectation that medical students will undertake unpaid clinical or research elective experiences during the summer to enhance their desirability for postgraduate medical programs. Limited or No Remuneration for the Clinical Clerkship During the clerkship years, there are no summertime breaks because students spend these years working in hospitals and other clinical settings. All Canadian medical students (outside of Québec) receive a relatively small stipend during their clerkship varying from $2,808 to $6,000;11 however, the stipend had previously been abolished in medical schools in Ontario and Québec in the early 1990s. Fortunately Ontario reinstated the stipend as the Final Year Medical Student Bursary in 2004.12 Unique Expenses In addition to very limited or no opportunities to generate employment income, medical students must bear a number of unique and significant costs. These include very high textbook and instrument costs, as well as a variety of expenses associated with their clerkship, such as travel to and from the clinical setting and the need for professional attire. The introduction of distributed medical education including satellite campuses, co-campuses and rural learning sites has increased the amount of travel required of medical students as well as the associated costs. Off-site electives also generate many additional expenses, including the cost for travel to the site - which may be in a different province - as well as accommodation and other living expenses. A 1999 survey of graduating medical students revealed that more than half took an off-site elective at a specific institution in order to increase their chances of being matched to that site.13 As postgraduate training becomes even more competitive, the number of students taking off-site electives may increase and so will the number of students who are adding this expense to their overall debt load. Medical students must also assume considerable costs related to interviews for residency training, including the high costs for travel to various interview sites, accommodation expenses, application fees for the resident matching service and other miscellaneous expenses. There is also a considerable fee for the qualifying examination that is written at the end of medical school. Insufficient Public Funding and Increasing Reliance on Bank Loans Government financial support programs (bursaries and loans) are not increasing to meet students' needs due to rising tuition costs and living expenses. As a consequence, the number of students who must rely on interest-bearing bank loans to help support themselves while they are in school may increase. Unlike some government programs, repayment of bank loans often cannot be postponed until after graduation and interest payment is required during the course of study; this further exacerbates students' financial stress. Residency Costs Upon graduation from medical school, students must pursue two to seven years of postgraduate training to obtain a licence to practise medicine. This training period is marked with fees for examinations as well as an annual tuition and/or registration fee. During 2008-2009, the tuition fee was as much as $3,900 in some provinces.14 Residents are also required to work long hours in hospitals and other clinical settings and have frequent on-call responsibilities. Although residents do receive a salary for this work, the remuneration is relatively modest when these factors and debt servicing payments are considered. In fact, mandatory debt maintenance can consume a very significant proportion of a resident's pay.15 The CMA opposes tuition fees for residents. While the CMA's opposition to residency tuition is based on a number of factors not limited to its financial impact, clearly, tuition fees exacerbate debt. High Practice Start-up Costs and Decreased Pay Potential Licensed physicians wanting to establish a clinical practice currently face start-up costs estimated between $30,000 and $50,000, depending on their practice specialty and type (e.g., solo versus group practice).16 Some specialties require capital investment over and above the basic start-up costs. These expenses will add to the significant debt that new physicians will bear in the next few years. Other Factors In addition to significantly higher debt load than the previous generation of new physicians, a number of factors may influence the net income of physicians and their ability to pay off debts. These include billing caps, stagnant fees for services, high malpractice insurance fees, overhead expenses and increasing non-remunerative administrative responsibilities. Summary In summary, the CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. This impact includes: * creating socioeconomic barriers to application to medical school and threatening the diversity of future physicians serving the public * exacerbating the physician brain drain to the U.S. where new physicians can pay off their huge debts more quickly * generating fewer physicians available or interested in practising in rural and remote areas of Canada Recommendations In response to its concerns regarding the deregulation of tuition fees and high tuition fee increases, the CMA recommends that: 1 governments increase funding to medical schools to alleviate the pressures driving tuition increases 2 any tuition increase should be regulated and reasonable 3 financial support systems for students be developed concomitantly or in advance of any tuition increase, be in direct proportion to the tuition fee increase and provided at levels that meet the needs of students. Appendix Glossary of Terms Undergraduate Program in Medicine, also known as "Medical School" Medical school is the period of study, usually four years in duration that leads to the doctor of medicine or "MD" degree upon graduation. Most Canadian universities require applicants to the undergraduate medicine program to have at least a three-year degree (e.g., Bachelor of Science degree) before they are eligible to apply. Although the title "Doctor" is conferred upon successful completion of the undergraduate program, an additional two to seven years or more of residency training is required before these individuals can apply for a licence to practise medicine in Canada. Clerkship The clerkship is the period during the last one to two years of undergraduate studies in medicine during which medical students work in hospitals, clinics and physicians' offices. Off-site Elective Many students take off-site electives during their clerkship. An "elective" is a course or training that is not mandatory to the curriculum, but may be elected or chosen by the student. An "off-site" elective means that the training is being provided at a location different from the medical school where the student is enrolled; for example, the elective may be in a different city, province, or even a different country. Resident Matching During the last year of undergraduate training, most graduating medical students participate in a national process that matches them with available residency training positions in Canada. Residency/Postgraduate Training Period After earning his/her MD degree and receiving the title "Doctor," additional training is required in a specific area before an individual may practise medicine in Canada. This period of training is referred to as "residency" or "postgraduate training;" the individuals undergoing the training are called "residents." Residents usually work in hospitals (also called "teaching hospitals") under the supervision of a licensed physician. Depending on the field of study, residency training may range from two to seven years or longer if subspecialty training is pursued (e.g., pediatric cardiology). At the end of residency training, individuals must pass a number of examinations to practise medicine in Canada. Fellowship A fellowship is training sought by individuals who wish to obtain expertise in a specific area of medicine above and beyond basic residency requirements. References 1 Tuition Fees in Canadian Faculties of Medicine: Session Commencing Fall 2008. Office of Research and Information Services, Association of Faculties of Medicine of Canada, November 2008. 2 Ibid. 3 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 4 "Are We Losing Our Minds? Trends, Determinants and the Role of Taxation in Brain Drain to the United States," The Conference Board of Canada, July 1999. 5 Advisory Panel Report on the Provision of Medical Services in Underserviced Regions. Canadian Medical Association, 1992. 6 2007 National Physician Survey. 7 Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL, et al. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35. [0] 8 2007 National Physician Survey. 9 2007 National Physician Survey. 10 "Educational Attainment at Time of Application of Registered and Not Registered Applicants to Canadian Faculties of Medicine - 2006-2007 (Table 105)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p154. 11 "Duration of Clinical Clerkship and Amount of Stipend in Canadian Faculties of Medicine 2008-2009 (Table 7)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p9. 12 Clinical Clerkship Stipends by Faculty of Medicine, 1995-1996 to 1999-2000, Canadian Medical Association Research Directorate, January 2000. 13 Results of the Post-Match Survey of Students Graduating 1999, Canadian Resident Matching Service. 14 "Post-MD Clinical Trainee Fees in Canadian Faculties of Medicine - 2008-2009 (Table 6)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p8. 15 2007 National Physician Survey. 16 Practice Management, MD Management Ltd.
Documents
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Household antibacterial products

https://policybase.cma.ca/en/permalink/policy9565
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Text
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
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Management of physician fatigue

https://policybase.cma.ca/en/permalink/policy11127
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
Text
Health systems around the world are struggling with how to best meet the health needs of their populations. Health leaders speak with urgency about the need to improve the individual experience of care, improve the health of populations, and maximize return on investments. Physicians concur - they are continually focused on providing better care to their patients. Concurrently, concerns over patient safety have arisen over the last two decades, rooted in studies of adverse events. The incidence of adverse events (AEs) in acute care hospitals has been reported in the United States (US),1,2,3 Australia,4 United Kingdom,5 and Canada.6 Between 5% and 20% of patients admitted to hospital experience one or more AEs; between 36.9% - 51% of these AEs are preventable; and AEs contribute billions of dollars through additional hospital stays as well as other costs to the system, patients and the broader society.7 Leape et al. maintain that more than two-thirds of AEs are preventable.8 These outcomes have prompted decision makers, policy makers and healthcare providers to examine contributing factors, including the increasingly complex health system and its impact on the well-being of providers. Patient safety and physician well-being are the key drivers leading to restrictions on resident and/or physician duty hours aimed at reducing their fatigue. The European Working Time Directive (EWTD) was first established in 1993 to place limits on all workers' hours throughout Europe under the umbrella of health and safety legislation. That directive included physicians but excluded doctors in training. In 2000, a new directive passed to include the "junior doctor" constituency accompanied by a requirement that by 2009 all health systems in the European Union limit resident work to a maximum of 48 hours averaged per week. The intention was to improve the working lives of doctors in training and to increase patient safety. A systematic review on the impact of the EWTD on postgraduate medical training, patient safety, or clinical outcomes found studies to be of poor quality with conflicting results.9 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) in the US adopted a set of duty hour regulations for physicians in training. The ACGME issued revised regulations that went into effect in July 2011, reflecting the recommendations of a 2008 Institute of Medicine report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, calling for elimination of extended duty shifts (more than 16 hours) for first year residents, increasing days off, improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks, and increasing oversight by more senior physicians.10 The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error. In 2013, the National Steering Committee on Resident Duty Hours released Canada's first comprehensive, collaborative and evidence-based report on fatigue and duty hours for Canada's approximately 12,000 residents. The Committee stresses that a comprehensive approach is necessary in order to enhance safety and wellness outcomes. Fatigue risk management is a predominant theme in the recommendations. Fatigue management systems are in place in other sectors/industries that have a low threshold for adverse outcomes including aviation, transportation, and the Department of National Defence. In 2010, the Canadian Nurses Association released a position statement Taking Action on Nurse Fatigue that speaks to system, organizational and individual level responsibilities of registered nurses. There are currently no specific policies in Canada for physicians in practice with respect to fatigue management. Given the heterogeneity of medical practice (i.e. various specialties) and of the practice settings (i.e. rural and remote versus urban, clinic versus hospital, etc.), the solutions emanating from a fatigue management policy may be different - one size will not fit all. Impact of Physician Fatigue Patient Safety Sleep deprivation is the condition of not having enough sleep and can be either chronic or acute. It impairs cognitive and behavioural performance. "Sleep is required for the consolidation of learning and for the optimal performance of cognitive tasks. Studies of sleep deprivation have shown that one night without sleep negatively affects the performance of specific higher cognitive functions of the prefrontal cortex and can cause impairment in attention, memory, judgment, and problem solving."(p. 1841)11 A seminal study by Williamson and Feyer found that after 17-19 hours without sleep, performance on some cognitive and motor performance tests was equivalent or worse than that at a blood alcohol concentration (BAC) of 0.05%.12 Wakefulness for 24 hours is equivalent to a blood alcohol level of 0.10%.13 A chronic sleep-restricted state can cause fatigue, which is a subjective feeling of tiredness, lack of energy and motivation. A large body of research exists linking sleep deprivation/fatigue, performance and adverse patient outcomes, particularly for medical residents. 14,15,16,17,18,19, 20, 21,22, 23,24 However, literature on the impact on performance varies based on a number of factors. There are significant inter-individual differences in the global response to sleep loss, as well as significant intra-individual variations in the degree to which different domains of neurobehavioral function (e.g., vigilance, subjective sleepiness, and cognitive performance) are affected. Inter-individual differences are not merely a consequence of variations in sleep history. Rather, they involve trait-like differential vulnerability to impairment from sleep loss. 25 Evidence suggests an inconclusive relationship between duty hour reductions (primarily those implemented in the US) and patient safety, suggesting that restrictions on consecutive duty hours have not had the anticipated impact on this crucial outcome as anticipated.26 Several large studies have revealed only neutral or slightly improved patient mortality and other clinical parameters since implementation of the ACGME work hour limits in the US.27,28, 29,30 In complex and ever changing health systems, it is difficult to isolate the impact of restricted duty hours alone. Research on the effects of practicing physician sleep deprivation and extended work shifts on clinical outcomes is limited and inconclusive.31, 32 The issue of physician fatigue is complex, and is affected by much more than duty hours. Other contributing factors affect performance including work patterns, individual response to sleep loss, experience of the worker, the context of which sleep deprivation is necessary, hours of actual sleep, patient volume, patient turnover and patient acuity, environmental factors, personal stressors, workload, etc. Limiting work hours alone is not sufficient to address sleep deprivation among physicians. Reduced or disturbed periods of sleep, more consecutive days or nights of work, shift variability, and the volume of work all increase fatigue and thus can contribute to errors. One of the biggest concerns with a fatigue management strategy is continuity of care, linked to the number of transfers of care (handover) among providers. Transfers of care inevitably increase in an environment of work hour limitations.33, 34 Handovers are considered critical moments in the continuity of patient care and have been identified as a significant source of hospital errors, often related to poor communication. There is a growing body of literature on how to do these well and how to teach this well. This is an important skill for physicians in the context of a fatigue management strategy: "Standardization of the handover process has been linked to a reduction in the number of errors related to information transfers. In addition, effective mechanisms for the transfer of information at transition points have been recognized as patient safety enablers."35 Provider Well-being Provider well-being (physical, mental, occupational) is linked to system performance and patient outcomes. It is affected by fatigue and work patterns including night shift and extended hours. Comprehensive, systematic reviews of the health effects of on-call work in 2004 showed that nighttime work interrupted sleep patterns, aggravated underlying medical conditions, and increased the risk of cardiovascular, gastrointestinal, and reproductive dysfunction.36,37.38 Other research suggests an elevated risk of breast cancer,39,40 prostate cancer,41 colorectal cancer,42 asthma43, diabetes,44 and epilepsy45 for shift workers. Disruption of the body's circadian rhythms is thought to be one of the main pathways for adverse health effects from shift work, particularly for work schedules that involve night work. Given that 24-hour work is unavoidable in various industries, including healthcare, researchers have evaluated different shift schedules designed to reduce some of the negative health effects of working at night. Optimal shift schedules are aligned as much as possible with the circadian rhythm, promote adaptation of the circadian rhythm with shift work, reflect workers' needs and preferences, and meet organizational or productivity requirements. The following interventions appear to have the most beneficial effects on the health of shift workers:46 * Schedule changes including changing from backward (counterclockwise) to forward (clockwise) rotation, from eight hour to 12 hour shifts, and flexible working conditions, self-scheduling, and ergonomic shift scheduling principles * Controlled exposure to light and day; * Behavioural approaches such as physical activity, scheduled naps and education about sleep strategies; and * Use of pharmacotherapy (i.e. caffeine and melatonin) to promote sleep, wakefulness, or adaptation Sleep deprivation and on-call shifts consistently point to deterioration of mood resulting in depression, anger, anxiety, hostility, and decreased vigilance.47 ,48, 49 A Canadian study found that shift workers reported significantly higher burnout, emotional exhaustion, job stress and psychosomatic health problems (e.g. headaches, upset stomach, difficulty falling asleep) than workers on a regular day schedule.50 Prolonged duty hours by residents has been found to contribute to marital problems, pregnancy complications, depression, suicide and substance abuse,51 as well as serious conflicts with attending physicians, other residents, and nurses, in addition to increased alcohol use and instances of unethical behaviour.52 Surprisingly however, the abolishment of 24-hour continuous medical call duty for general surgery residents at one facility in Quebec was associated with self-reported poorer quality of life.53 In contrast to other recommendations on the health benefits of 8 hr shifts, the risk of a work safety incident increases markedly after more than eight hours on duty. The risk in the twelfth hour is almost double than in the eighth hour (and more than double the average risk over the first eight hours on duty).54 Extended work duration and nighttime work by interns is associated with an increased risk of reported percutaneous injuries (PIs).55 Fatigue was reported more often as a contributing factor for nighttime compared with daytime injuries. Fatigue was also more commonly reported as a contributing factor to PIs that occurred after extended work than those that occurred after non-extended work.56 Other research found that residents were most exposed to blood-borne pathogens through needle punctures or cuts during overnight duty periods.57 Health care facilities that have physicians working in them have a role in supporting and promoting provider well-being, including providing enablers of extending and continuing resiliency such as nutritious food, on call rooms, appropriate numbers of staff, locums, etc. They also have a role in working jointly and collaboratively with physicians to ensure that on-call schedules do not place work demands on individual physicians that prevent the physicians from providing safe patient care and service coverage. For example, research with emergency physicians suggests that a nap at 3 AM improves performance in physicians and nurses at 7:30 AM compared to a no-nap condition despite the fact that memory temporarily worsened immediately after the nap.58 Individual resilience, intergenerational differences, illness-related issues, as well as family commitments also need to be considered. Physicians should also be encouraged to take the necessary time to rest and recover on their time off. The obligation of physicians to provide after hour coverage and care is unavoidable and should be considered by an individual when they choose a career in medicine, and as a physician in managing their schedule/call. A review of 100 studies from around the world indicates the culture of medicine contributes to doctors ignoring the warning signs of fatigue and stress and in many cases suffering from undiagnosed ailments such as stress and depression, or from burnout.59 The authors suggest the culture of medicine is such that doctors feel they don't need help; they put their patients first. Of the 18% of Canadian doctors who were identified as depressed, only a quarter of them considered getting help and only two per cent actually did. The report suggests that burnout from working long hours and sleep deprivation because of understaffing seems to be the biggest problem worldwide.60 The Canadian Medical Protective Association (CMPA) states that physicians should consider their level of fatigue and if they are clinically fit to provide treatment or care.61 Fatigue is not a sign of weakness. All members of the health care team should support their colleagues in recognizing and managing sleep deprivation and fatigue. Physician fatigue has several ethical dimensions. The Canadian Medical Association Code of Ethics states that physicians have an ethical responsibility to self-manage their fatigue and well-being. 62 However, physicians must be trained and competent to know their own limits and evaluate their own fatigue level and well-being. The system must then support physicians in this recognition. The doctrine of informed consent is another dimension of physician fatigue. If physician fatigue is an added risk for any aspect of patient care, whether it is surgical or medical, elective or emergent, then some have argued that the doctrine of informed consent suggests that physicians have an obligation to inform patients of that risk.63 ,64 "The medico-legal considerations for physicians centre on the ethical duty to act in the best interests of their patients. This may mean that if a physician feels that his or her on-call schedule endangers or negatively impacts patient care, reasonable steps are taken to ensure patients do not suffer as a result and that the physician is able to continue providing an adequate level of care for patients."65 System Performance Addressing physician fatigue may have workforce implications. Physician workload is multifaceted comprised of clinical, research, education and administrative activities. If physician workload or duty hours are reduced, any one of these activities may be impacted. It has been suggested that implementing fatigue management strategies such as a workload ceiling for physicians may result in a greater need for physicians and thus increase system costs. However, new models of team based care delivery that incorporate technology, reduce redundancy, utilize a team based approach, and optimize the role of physicians offer an opportunity to better manage physician fatigue without necessarily requiring more physicians. Other strategies also need to be explored to improve the on-the-ground efficiency of physicians. Some of the strategies to address practicing physician sleep deprivation/fatigue such as scheduling changes and reduced workload may affect access to care, including wait times. Surgeons or others may have to cancel surgeries or other procedures because of fatigue and hours of work, forcing rescheduling of surgery/procedures and potentially increasing wait times. This is particularly relevant given Canada's large geography and varied distribution of physicians. Therefore, flexibility in strategies to address physician sleep deprivation/fatigue are needed to reflect the variety of practice types and settings in existence across the country, in particular solo practices; rural, remote and isolated sites; community locations; etc. The same holds true for smaller specialties, which has been the experience in the UK with the implementation of the EWTD. Fatigue management is a competency that needs to be taught, modelled, mentored, and evaluated across the medical education continuum, from medical student to practicing physician. Recommendations 1. Educate physicians about the effects of sleep deprivation and fatigue on the practice of medicine and physician health, and how to recognize and manage their effects. 2. Create a national tool-box of self-awareness tools and fatigue management strategies and techniques. 3. Advocate for the integration of fatigue management into the continuum of medical education. 4. Advocate for the creation of system enablers with the flexibility to: * Consider the full workload of physicians (clinical, teaching, administrative, research, etc.); * Optimize scheduling to coordinate on call and other patient care following call; and * Implement organizational/institutional level fatigue risk management plans. 5. Develop and advocate for implementation of standardized handover tools. 6. Enhance and reaffirm a culture within medicine that focuses on patient-centered care. 7. Reaffirm the culture shift within medicine that encompasses physician well-being. 8. Encourage physicians treating physicians to be aware of the aggravating effects of fatigue on their well-being and practice. Conclusion Physicians are interested in how to best meet the needs of the population, in continually improving the care provided to Canadians. To do so requires that they also care for themselves including managing the effects of sleep deprivation and fatigue. It is a complex issue that requires multifaceted solutions. Strategies must address physician fatigue at an individual, organizational/institutional and system level. References 1 Leape, LL, Brennan, TA, Laaird, N, Lawthers, AG, Logalio, AR, Barnes, BA et al. (1991).The nature of adverse events in hospitalized patients. New England Journal of Medicine 324 (6): 377-384 2 Brennan, TA, Leape, LL, Nan, M, et al. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324:370-376. 3 Thomas, E., Studdert, D., Burstin, H., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 38(3): 261-71. 4 Wilson, RL, Runciman, WB, Gibberd, RW, et al. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia 163: 458-471. 5 Vincent, C, Neale, G, & Woloshynowych, M. (2001). Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 322: 517-9. 6 Baker, G., Norton, P., Flintoft, V., Balis, R., Brown, A., Cox, J., et al. (2004). The Canadian adverse event study: the incidence of adverse events among hospitalized patients in Canada. Canadian Medical Association Journal, 170(11): 1678-1686. 7 Jeffs, L., Law, M., Baker, G., & Norton, P. (2005). Patient Safety Research in Australia, United Kingdom, United States and Canada: A Summary of Research Priority Areas, Agenda-Setting Processes And Directions for Future Research in the Context of their Patient Safety Initiatives. Retrieved from http://www.patientsafetyinstitute.ca/English/news/eventProceedings/Documents/2005%20Research%20Retreat%20-%20Patient%20Safety%20Research%20Backgrounder%20Paper.pdf 8 Leape, L., Brennan, T., Laaird, N., Lawthers, A., Logalio, A., Barnes, B. et al. (1991). The nature of adverse events in hospitalized patients. New England Journal of Medicine 324 (6): 377-384. 9 Moonesinghe, S., Lowery, J., Shahi, N., Millen, A., & Beard, L. (2011). Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review. BMJ 342:d1580. 10 Ulmer, C., Wolman, D., & Johns, M. (eds.) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. (2008). Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press. 11 Krueger, K. & Halperin, E. (2010). Perspective: Paying Physicians to Be On Call: A Challenge for Academic Medicine. Academic Medicine 85 (12); 1840-1844. 12 Williamson, A. & Feyer, A. (2000). Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication. Occupational and Environmental Medicine 57: 649-655. 13 Dawson, D. & Reid, K. (1997). Fatigue, Alcohol and Performance Impairment. Nature 388: 235. 14 Arnedt, J., Owens, J., Crouch, M., et al. (2005). Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion. Journal of American Medical Association 294(9): 1025-33. 15 Howard, S., Gaba, D., Smoth, B., et al. (2003). Simulation Study of Rested Versus Sleep-deprived Anesthesiologists. Anesthesiology 98:1345-1355 16 Philbert, I. (2005). Sleep Loss and Performance in Residents and Nonphysicians: A Meta-analytic Examination. Sleep 28: 1392-1402. 17 Lockley, S., Barger, L., Ayas, N., Rothschild, J., Czeisler, C. et al. (2007). Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance. The Joint Commission Journal on Quality and Patient Safety 3(11): 7-18. 18 Eastridge, B., Hamilton, E., O'Keefe, G., Rege, R., Valentine, R. et al. (2003). Effect of sleep deprivation on the performance of simulated laproscopic surgical skill. The American Journal of Surgery 186: 169-174 19 Taffinder, N., McManus, I., Hul, Y., Russell, R., & Darzi, A. (1998). Effect of Sleep Deprivation on Surgeon's Dexterity on Laparsoscopy Simulator. The Lancet 352: 1191. 20 Rothschild, J., Keohane, C., Rogers, S., et al. (2009). Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA 302:1565-72. 21 Lockley, S., Cronin, J., Evans, E., Cade, B., Lee, C., et al. (2004). Effect of Reducing Interns' Weekly Work Hours on Sleep and Attentional Failures. N Engl J Med 351: 1829-1837. 22 Landrigan, C., Rothschild, J., Cronin, J., Kaushal, R., Burdick, E., et al. (2004). Effect of Rreducing Interns' Work Hours on Serious Medical Errors in Intensive-care Units. N Engl J Med 351: 1838-1848. 23 Barger, L., Ayas, N., Cade, B., Cronin, J., Rosner, B., et al. (2006). Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures. PLoS Med 3(12): 2440-2448. 24 Landrigan, C., Rothschild, J., Cronin, J., et al. (2004). Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units. New England Journal of Medicine 351:1838-48. 25 Van Dongen, H., Baynard, M., Maislin, G., et al. (2004). Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of a trait-like differential vulnerability. Sleep 27: 423-433. 26 Philibert,I., Nasca, T., Brigham, T., & Shapiro, J. (2013). Duty-Hour Limits and Patient Care and Resident Outcomes: Can High-Quality Studies Offer Insight into Complex Relationships? Annu. Rev. Med 64: 467-83. 27 Volpp, K., Rosen, A., Rosenbaum, PR., et al. (2007). Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following the ACGME Resident Duty Hour Reform. JAMA 298: 975-983. 28 Volpp, K., Rosen, A., Rosenbaum, P., et al. (2007). Mortality Among Patients in VA Hospitals in the First 2 Years Following ACGME Resident Duty Hour Reform. JAMA 298(9): 984-992. 29 Antiel, R., Reed, D., Van Arendonk, K., Wightman, S., Hall, D., Porterfield, J., et al. (2013). Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns. JAMA Surg 148(5):448-455. 30 Drolet, B., Sangisetty, S., Tracy, T., & Cioffi, W. (2013). Surgical Residents' Perceptions of 2011 Accreditation Council for Graduate Medical Education Duty Hour Regulations. JAMA Surg 148(5): 427-433. 31 Chang, L., Mahoney, J., Raty, S., Ortiz, J., Apodaca, S., & De La Garza II, R. (2013). Neurocognitive effects following an overnight call shift on faculty anesthesiologists. Acta Anaesthesiol Scand 57: 1051-1057. 32 Sharpe, J., Weinberg, J., Magnotti, L., Nouer, S., Yoo, W., Zarzaur, B. et al. (2013). Outcomes of Operations Performed by Attending Surgeons after Overnight Trauma Shifts. J Am Coll Surg 216:791- 799. 33 Olsen, E., Drage, L., Auger, R. (2009). Sleep Deprivation, Physician Performance, and Patient Safety. Chest 136: 1389-1396. 34 Choma, N., Vasilevskis, E., Sponsler, K., Hathaway, J., & Kripalani, S. Effect of the ACGME 16-Hour Rule on Efficiency and Quality of Care: Duty Hours 2.0. JAMA INTERN MED 173 (9): 819-821. 35 Canadian Medical Protective Association. (2013). CMPA Risk Fact Sheet: Patient Handover. Retrieved January 13, 2014 from https://oplfrpd5.cmpa-acpm.ca/documents/10179/300031190/patient_handovers-e.pdf 36 Nicol, A., Botterill, J., (2004). On-call Work and Health: A Review. Environmental Health 3: 1-11. 37 Knutsson, A. & Boggild, H. (2010). Gastrointestinal disorders among shift workers. Scand J Work Environ Health 36(2): 85-95. 38 Vyas, M., Garg, A., Iansavichus, A., Costella, J., Donner, A., Laugsand, L., et al. (2012). Shift work and vascular events: systematic review and meta-analysis. British Medical Journal 345: e4800 doi: 10.1136/bmj.e4800 39 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 40 Fritschi, L., Glass, D., Heyworth, J., Aronson, K., Girschik, J., Boyle, T., et al. (2011). Hypotheses for mechanisms linking shiftwork and cancer. Medical Hypotheses 77:430-436. 41 Kubo, T., Ozasa, K., Mikami, K., Wakai, K., Fujino, Y., Watanabe, Y., et al. (2006). Prospective cohort study of the risk of prostate cancer among rotating-shift workers: findings from the Japan Collaborative Cohort Study. American Journal of Epidemiology 164(6): 549-555. 42 Schernhammer, E., Laden, F., Speizer, F., Willett, W., Hunter, D., Kawachi, I., et al. (2003). Night-shift work and risk of colorectal cancer in the Nurses' Health Study. Journal of the National Cancer Institute 95(11):825-828. 43 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 44 Ibid 45 Ibid 46 Occupational Cancer Research Centre and the Institute for Work & Health. Can the health effects of shift work be mitigated? A summary of select interventions. Retrieved March 10, 2013 from http://www.occupationalcancer.ca/wp-content/uploads/2012/09/Summary_intervention-research_FINAL.pdf 47 Eastridge, B., Hamilton, E., O'Keefe, G., Rege, R., Valentine, R. et al. (2003). Effect of Sleep Deprivation on the Performance of Simulated Laproscopic Surgical Skill. The American Journal of Surgery 186: 169-174. 48 Krueger, K. & Halperin, E. (2010). Perspective: Paying Physicians to Be On Call: A Challenge for Academic Medicine. Academic Medicine 85(12); 1840-1844. 49 Haines, V., Marchand, A., Rousseau, V., & Demers, A. (2008).The mediating role of work-to-family conflict in the relationship between shiftwork and depression. Work & Stress 22(4):341-356. 50 Jamal, M. (2004). Burnout, stress and health of employees on non-standard work schedules: a study of Canadian workers. Stress and Health 20:113-119. 51 Woodrow, S., Segouin, C., Armbruster, J., Hamstra, S., & Hodges, B. (2006). Duty Hours Reforms in the United States, France and Canada: Is It Time to Refocus our Attention on Education? Academic Medicine 81(12): 1045-1051. 52 Baldwin, D., Daugherty, S., Tsai, R., et al. (2003). A National Survey of Residents' Self-reported Work Hours: Thinking Beyond Specialty. Academic Medicine 78:1154-1163. 53 Hamadani, F., Deckelbaum, D., Sauve, D., Khwaja, K., Razek, T., & Fata, P. (2013). Abolishment of24-HourContinuousMedical Call Duty in Quebec: A Quality of Life Survey of General Surgical Residents Following Implementation of the New Work-Hour Restrictions. J Surg 70: 296-303. 54 Folkard, S. & Tucker, P. (2003). Shift work, safety and productivity. Occupational Medicine 53: 95-101. 55 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 56 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 57 Parks, D., Yetman, R., McNeese, M., Burau, K., & Smolensky, M. (2000). Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiology International 17(1): 61-70. 58 Smith-Coggins, R., Howard, S., Mac D., Wang, C., Kwan, S., Rosekind, M., Sowb, Y., Balise, R., Levis, J., Gaba, D. (2006). Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med, 48(5): 596-604. 59 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 60 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 61 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care 62 Canadian Medical Association. (2011). Canadian Medical Association Code of Ethics. Ottawa: Author. 63 Mercurio. M. & Peterec, S. (2009). Attending Physician Work Hours: Ethical Considerations and the Last Doctor Standing. Pediatrics 124:758-762. 64 Czeisler, C., Pellegrini, C., & Sade, R. (2013). Should Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent? Ann Thorac Surg 95:757-766. 65 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care
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Medical assistance fund

https://policybase.cma.ca/en/permalink/policy11699
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Text
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
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Supporting the enactment of Bill C-14, Medical Assistance in Dying

https://policybase.cma.ca/en/permalink/policy13693
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
Text
In this submission to the House of Commons Standing Committee on Justice and Human Rights, the CMA’s feedback is focused on three of the legislative objectives of Bill C-14, given their relevance to the CMA’s Principles-based Recommendations for a Canadian Approach to Assisted Dying. On behalf of its more than 83,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. i) Robust Safeguards First, the CMA supports the legislative objective of ensuring a system of robust safeguards to the provision of medical assistance in dying. The safeguards proposed by Bill C-14 include: patient eligibility criteria, process requirements to request medical assistance in dying, as well as monitoring and reporting requirements. The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. ii) Consistent, Pan-Canadian Framework Second, the CMA supports the legislative objective that a consistent framework for medical assistance in dying in Canada is desirable. In addition to robust safeguards, key measures proposed by Bill C-14 support the promulgation of a consistent framework across jurisdictions include legislating definitions for “medical assistance in dying” and “grievous and irremediable condition.” The CMA’s Principles-based Recommendations reflect on the subjective nature of what constitutes “enduring and intolerable suffering” and a “grievous and irremediable condition” as well as the physician’s role in making an eligibility determination. iii) End-of-Life Care Coordination System Thirdly, the CMA supports the objective to develop additional measures to support the provision of a full range of options for end-of-life care and to respect the personal convictions of health care providers. The fulfilment of these commitments with federal non-legislative measures will be integral to supporting the achievement of access to care, respecting the personal convictions of health care providers, and developing a consistent, pan-Canadian framework. The CMA encourages the federal government to rapidly advance its commitment to engage the provinces and territories in developing a pan-Canadian end-of-life care coordinating system. It will be essential for this system to be in place for June 6, 2016. At least one jurisdiction has made a system available to support connecting patients with willing providers. Until a pan-Canadian system is available, there will be a disparity of support for patients and practitioners across jurisdictions. iv) Respect Personal Convictions Finally, it is the CMA’s position that Bill C-14, to the extent constitutionally possible, must respect the personal convictions of health care providers. In the Carter decision, the Supreme Court of Canada emphasized that any regulatory or legislative response must seek to reconcile the Charter rights of patients wanting to access assisted dying and physicians who choose not to participate in medical assistance in dying on grounds of conscientious objection. The CMA’s Principles-based Recommendations achieves an appropriate balance between physicians’ freedom of conscience and the assurance of effective and timely patient access to a medical service. From the CMA’s significant consultation with our membership, it is clear that physicians who are comfortable providing referrals strongly believe it is necessary to ensure the system protects the conscience rights of physicians who are not. While the federal government has achieved this balance with Bill C-14, there is the potential for other regulatory bodies to implement approaches that may result in a patchwork system. The CMA’s position is that the federal government effectively mitigate this outcome by rapidly advancing the establishment of the pan-Canadian end-of-life care coordinating system. CMA Supports Cautious Approach for “Carter Plus” The CMA must emphasize the need for caution and careful study in consideration of “Carter Plus”, which includes: eligibility of mature minors, eligibility with respect to sole mental health conditions, and advance care directives. The CMA supports the federal government’s approach not to legislate these issues, rather to study them in greater detail. Word count: 750
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Principles for providing information about prescription drugs to consumers

https://policybase.cma.ca/en/permalink/policy189
Last Reviewed
2019-03-03
Date
2003-03-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2003-03-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Principles For Providing Information About Prescription Drugs To Consumers Approved by the CMA Board of Directors, March 2003 Since the late 1990's expenditures on direct to consumer advertising (DTCA) of prescription drugs in the United States have increased many-fold. Though U.S.-style DTCA is not legal in Canada1, it reaches Canadians through cross-border transmission of print and broadcast media, and through the Internet. It is believed to have affected drug sales and patient behaviour in Canada. Other therapeutic products, such as vaccines and diagnostic tests, are also being marketed directly to the public. Proponents of DTCA argue that they are providing consumers with much-needed information on drugs and the conditions they treat. Others argue that the underlying intent of such advertising is to increase revenue or market share, and that it therefore cannot be interpreted as unbiased information. The CMA believes that consumers have a right to accurate information on prescription medications and other therapeutic interventions, to enable them to make informed decisions about their own health. This information is especially necessary as more and more Canadians live with chronic conditions, and as we anticipate the availability of new products that may accompany the "biological revolution", e.g. gene therapies. The CMA recommends a review of current mechanisms, including mass media communications, for providing this information to the public. CMA believes that consumer information on prescription drugs should be provided according to the following principles. 2 Principle #1: The Goal is Good Health The ultimate measure of the effectiveness of consumer drug information should be its impact on the health and well-being of Canadians and the quality of health care. Principle #2: Ready Access Canadians should have ready access to credible, high-quality information about prescription drugs. The primary purpose of this information should be education; sales of drugs must not be a concern to the originator. Principle #3: Patient Involvement Consumer drug information should help Canadians make informed decisions regarding management of their health, and facilitate informed discussion with their physicians and other health professionals. CMA encourages Canadians to become educated about their own health and health care, and to appraise health information critically. Principle #4: Evidence-Based Content Consumer drug information should be evidence based, using generally accepted prescribing guidelines as a source where available. Principle #5: Appropriate Information Consumer drug information should be based as much as possible on drug classes and use of generic names; if discussing brand-name drugs the discussion should not be limited to a single specific brand, and brand names should always be preceded by generic names. It should provide information on the following: * indications for use of the drug * contraindications * side effects * relative cost. In addition, consumer drug information should discuss the drug in the context of overall management of the condition for which it is indicated (for example, information about other therapies, lifestyle management and coping strategies). Principle #6: Objectivity of Information Sources Consumer drug information should be provided in such a way as to minimize the impact of vested commercial interests on the information content. Possible sources include health care providers, or independent research agencies. Pharmaceutical manufacturers and patient or consumer groups can be valuable partners in this process but must not be the sole providers of information. Federal and provincial/territorial governments should provide appropriate sustaining support for the development and maintenance of up-to-date consumer drug information. Principle #7: Endorsement/ Accreditation Consumer drug information should be endorsed or accredited by a reputable and unbiased body. Information that is provided to the public through mass media channels should be pre-cleared by an independent board. Principle #8: Monitoring and Revision Consumer drug information should be continually monitored to ensure that it correctly reflects current evidence, and updated when research findings dictate. Principle #9: Physicians as Partners Consumer drug information should support and encourage open patient-physician communication, so that the resulting plan of care, including drug therapy, is mutually satisfactory. Physicians play a vital role in working with patients and other health-care providers to achieve optimal drug therapy, not only through writing prescriptions but through discussing proposed drugs and their use in the context of the overall management of the patient's condition. In addition, physicians and other health care providers, and their associations, can play a valuable part in disseminating drug and other health information to the public. Principle #10: Research and Evaluation Ongoing research should be conducted into the impact of drug information and DTCA on the health care system, with particular emphasis on its effect on appropriateness of prescribing, and on health outcomes. 1 DTCA is not legal in Canada, except for notification of price, quantity and the name of the drug. However, "information-seeking" advertisements for prescription drugs, which may provide the name of the drug without mentioning its indications, or announce that treatments are available for specific indications without mentioning drugs by name, have appeared in Canadian mass media. 2 Though the paper applies primarily to prescription drug information, its principles are also applicable to health information in general.
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Funding the continuum of care

https://policybase.cma.ca/en/permalink/policy9719
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
Text
FUNDING THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom. After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services. Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA. By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria. Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services. Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment. First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12 There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions. General Principles The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding. * Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living; * home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences; * there should be quality and accreditation standards for both public and private service delivery; * there should be uniform approaches to needs assessment for home care and long-term care; * there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component; * there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage; * there should be recognition and financial support for informal care givers; * there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage; * there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and * provision should be made for pre-funding long-term care from public and private sources. Prevention and Health Promotion The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians. One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations. The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level. The CMA recommends that: the federal government continue funding of the national immunization strategy consistent with the original three-year funding program; governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level. Pharmaceuticals Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket. The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income. In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion. The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15 Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16 Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories). Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions. The CMA recommends that: governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies; such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs; * a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income); * FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both; * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and, * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs); the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective; the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies; the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program. Home Care Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18 According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21 In light of the foregoing, the CMA believes that: optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status; the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation; support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community; strategies should be implemented to reduce wait times for accessing publicly funded home and community care services; integrated service delivery systems should be created for home and community care services; and any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion. The CMA recommends that: governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;" governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care; governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and governments undertake pilot studies to support informal caregivers and long-term care patients, including those that: a) explore tax credits and/or direct compensation to compensate informal caregivers for their work, b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations, c) expand income and asset testing for residents requiring assisted living and long-term care, and d) promote information on advance directives and representation agreements for patients. Mental Health Care In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24 The CMA recommends that: the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act; in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research. Long-term Care According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26 The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27 A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28. This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care. Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund. A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs. The federal government has several options available to promote the pre-funding of long-term care: Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance. Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care. Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29. Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta. In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity. The CMA recommends that: governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited. End-of-life Care The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31 The CMA recommends that: governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care. References 1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools. 1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957. 2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970. 3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984. 4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964. 5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008. 6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997. 7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002. 8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002. 9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09. 10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08. 11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08. 12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007. 13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003. 14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08. 15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09. 16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB. 17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005. 18 Service Canada. Employment insurance (EI) compassionate care benefits. http://142.236.154.112/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09. 19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007. 20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42. 21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15. 22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000. 23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006. 24 Canadian Healthcare Association. September 2009. 25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005. 26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006. 27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007. 28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009. 29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09. 30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09. 31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
Documents
Less detail

National advance care planning toolkit website

https://policybase.cma.ca/en/permalink/policy11190
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
BD14-05-162
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
BD14-05-162
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
Text
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
Less detail

Advanced care directive functionality

https://policybase.cma.ca/en/permalink/policy11191
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
BD14-05-163
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
BD14-05-163
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
Text
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
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Advance care plans

https://policybase.cma.ca/en/permalink/policy11215
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC14-19
The Canadian Medical Association supports the integration of advance care plans within patient records.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC14-19
The Canadian Medical Association supports the integration of advance care plans within patient records.
Text
The Canadian Medical Association supports the integration of advance care plans within patient records.
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CMA supports all physicians in CMA's policy on euthanasia and assisted suicide.

https://policybase.cma.ca/en/permalink/policy11220
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Ethics and medical professionalism
Resolution
GC14-24
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Ethics and medical professionalism
Resolution
GC14-24
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
Text
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
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Summary of federal legislation/regulations

https://policybase.cma.ca/en/permalink/policy11922
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Physician practice/ compensation/ forms
Resolution
GC16-46
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Physician practice/ compensation/ forms
Resolution
GC16-46
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
Text
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
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Medical assistance in dying education

https://policybase.cma.ca/en/permalink/policy11941
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Ethics and medical professionalism
Resolution
GC16-48
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Ethics and medical professionalism
Resolution
GC16-48
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
Text
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
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