Organ and Tissue Donation and Transplantation (OTDT) is a rapidly changing area of medical science and practice. Organ and tissue transplantations represent significant lifesaving and life-enhancing interventions that require careful consideration by multiple stakeholders spanning medical disciplines. Technological and pharmacological advancements have made organ and tissue transplantation increasingly viable for treating related medical conditions. Changing social norms have also led to shifting perceptions of the acceptability of organ and tissue donation. Within this context, there is a need for renewed consideration of the ethical issues and principles guiding organ and tissue donation and transplantation in Canada.
The overarching principle that guides OTDT is public trust, which requires that the expressed intent either for or against donation will be honoured and respected within the donation and medical systems, and that the best interests of the potential donor are always of paramount importance; policies and mechanisms that guide OTDT should aim to maintain and foster that public trust. The CMA acknowledges and respects the diverse viewpoints, backgrounds, and religious views of physicians and patients and therefore encourages physicians to confront challenges raised by OTDT in a way that is consistent with both standards of medical ethics and patients’ values and beliefs.
SCOPE
This policy identifies foundational principles to address the challenges surrounding deceased and living donation. In conjunction with applicable laws and regulations in Canada, the Declaration of Istanbul, the World Health Organization (WHO) Guiding Principles on Human Cell, Tissue and Organ Transplantation, and leading clinical practices this policy aims to inform physicians and other interested parties on the guiding principles of OTDT in Canada. This policy is intended to address OTDT in adult populations; the challenges, considerations, legislation, and policy surrounding pediatric and neonatal OTDT are unique and deserve focused attention.
Physicians should be aware of relevant legislation, regulatory requirements, and policies in the jurisdiction in which they practice. Physicians are encouraged to refer to the various Canadian specialty societies that deal directly with OTDT for up-to-date information and policy, as well as innovative techniques and approaches.
GUIDING PRINCIPLES
The practice of OTDT is of great value to patients and society. The CMA supports the continued development of greater capacity, efficiency, and accessibility in OTDT systems in co-ordination with comprehensive and compassionate end-of-life care for Canadians while acknowledging the importance of justice, informed consent, beneficence, and confidentiality to this practice.
1. JUSTICE
There is a continuous need to improve the efficiency and effectiveness of OTDT in an effort to narrow the gap between demand and supply in what remains a scarce, lifesaving resource. The principle of justice should continue to guide the equitable allocation of organs and tissues in a manner that is externally justifiable, open to public scrutiny, and balances considerations of fairness (e.g., medical need or length of time on the wait-list) with medical utility (e.g., transplantation success). There should be no discrimination based on social status or perceived social worth. Lifestyle or behavioral factors should only be considered when clear evidence indicates that those factors will impact the medical probability of success. OTDT should also not rely on the patient’s ability to pay; such actions are inconsistent with the principles that underlie Canada’s publicly-funded health system. Of note, living donation to a loved one or acquaintance (via a directed donation) is regarded as ethically acceptable if potential donors are informed of all options, including that of donating in a non-directed fashion.
All levels of government should continue to support initiatives to improve the OTDT system, raise public awareness through education and outreach campaigns, and fund ongoing research, such that any Canadian who may wish to donate their tissues or organs are given every reasonable opportunity to do so. Potential donor identification and referral, while legislated in many jurisdictions, is an important area of continued development as failure to identify donors deprives families of the opportunity to donate and deprives patients of potential transplants.
To diminish inequities in the rates of organ donation between jurisdictions, federal and provincial governments should engage in consultations with a view to implementing a coordinated, national strategy on OTDT that provides consistency and clarity on medical and legal standards of informed consent and determination of death, and institutes access to emerging best practices that support physicians, providers, and patients. Efforts should be made to ensure adequate engagement with potential donors from communities that have historically had lower living donor rates to help reduce inequities in access to living donation. Policymakers should also continue to explore and appraise the evidence on policy interventions to improve the rates of organ donation in Canada – for example, see a brief overview of opt-in vs. opt-out donation systems in the background to this policy.
2. INFORMED CONSENT AND VOLUNTARINESS
Organ and tissue donation must always be an autonomous decision, free of undue pressure or coercion. By law, the potential organ donor, or their substitute decision-maker, must provide informed consent. Physicians should direct patients to appropriate resources if that patient has expressed interest to become a donor after their death. If a potential donor has not made an expression of intent for or against donation, substitute decision-makers, families, or loved ones may be approached to provide authorization for donation. It should also be noted that consent indicates a willingness to donate, but that donation itself hinges on factors such as medical suitability and timing.
End-of-life decisions must be guided by an individual's values and religious or philosophical beliefs of what it means to have a meaningful life and death. The autonomy of an individual should always be respected regarding their wish, intent, or registered commitment to become a donor after death. Input from family and loved-ones should always be considered in the context of the potential donor’s wishes or commitments – these situations must be handled on a case-by-case basis with respect for cultural and religious views while maintaining the autonomously expressed wishes of the potential donor. Physicians should make every reasonable effort to be aware and considerate of the cultural and religious views of their patients as they pertain to OTDT. Likewise, Canadian medical schools, relevant subspecialties, and institutions should provide training and continuing professional development opportunities on OTDT, including both medicolegal implications and cultural competency.
To protect the voluntariness of the potential donor’s decision, public appeals to encourage altruistic donation should not seek to compensate potential donors through payment and should not subvert established systems of organ allocation. Any exploitation or coercion of a potential donor must be avoided. However, remuneration from officially sanctioned sources for the purpose of reimbursement of costs associated with living donation (e.g., transfer to another location or lost wages during the procedure), may be considered when no party profits financially from the exchange. The CMA supports proposed amendments to the Criminal Code and the Immigration and Refugee Protection Act that criminalizes or otherwise seeks to prevent the coercive collection and transplantation of organs domestically and internationally (i.e., organ trafficking – see relevant guidelines on trafficking ). The CMA also discourages Canadians from participating in organ tourism as either a recipient or donor; physicians should not take part in transplantation procedures where it is reasonable to suspect that organs have been obtained without the donor’s informed consent or where the donor received payment (from WHO Guiding Principle 7); however, in accordance with physicians’ commitment to the well-being of the patient and the professional responsibilities relating to the patient-physician relationship in the CMA Code of Ethics and Professionalism, physicians have an obligation to treat a post-tranplant patient if requested after the patient has participated in organ tourism; physicians should be aware of any legal or regulatory obligations they may have to report a patient’s organ tourism to national authorities, taking into consideration their duties of privacy and confidentiality to the patient. ,
3. BALANCING BENEFICENCE AND NON-MALEFICENCE
Balancing beneficence and non-maleficence means to: Consider first the well-being of the patient; always act to benefit and promote the good of the patient; provide appropriate care and management across the care continuum; take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm occurs; recognize the balance of potential benefits and harms associated with any medical act; and act to bring about a positive balance of benefits over harms.
Deceased Donation
Prospective donors can benefit from the knowledge that they can potentially save lives after their own deaths. However, potential donors must not be harmed by the act of donating. In accordance with the Dead Donor Rule, organ or tissue procurement should never be the cause of death. Moreover, the care of the dying patient must never be compromised by the desire to protect organs for donation or expedite death to allow timely organ retrieval. Physicians determining that a potential donor has died should not be directly involved in tissue or organ removal from the donor or subsequent transplantation procedures, nor should they be responsible for the care of any intended recipients of such tissues and organs (from WHO Guiding Principle 2). Leading clinical criteria, in conjunction with legally prescribed definitions of death and procedures, should inform the determination of death before donation procedures are initiated.
DCD should be practiced in compliance with the regulations of individual transplant centers, relevant legislation, and leading Canadian clinical guidelines including the national recommendations for donation after cardiocirculatory death in Canada and the guidelines for the withdrawal of life-sustaining measures. Patients undergoing medical assistance in dying (MAiD) may also be eligible for organ and tissue donation – see relevant policy guidelines.
Living Donation
Living donors are motivated to act primarily for the benefit of the recipient. The perceived acceptability of living donation varies from person to person; living donation is deemed to be ethically acceptable when the potential benefits outweigh the potential risks of living donation; living donation is not ethically acceptable where there is a material risk of death of the donor; living donors must provide informed consent, meet medical and psychological requirements, and receive appropriate follow-up care. It is not necessary for the potential donor to be biologically or emotionally related to the recipient.
4. CONFIDENTIALITY AND PRIVACY
Current practice protects the privacy of both donor and recipient and does not allow donation teams, organ donation organizations, or transplant teams to inform either party of the other’s identity. The continuation of this practice is encouraged at the present time to protect the privacy of both donors and recipients. In addition, healthcare providers should consider the privacy and confidentiality implications of practices employed throughout the assessment and post-operative periods – patient consent should be obtained for practices involving any loss of privacy or confidentiality (e.g. group education sessions, etc.).
Deceased Donation
A person’s choice about whether or not they intend to donate organs and tissues after their death is individual and, like other health-related information, should be considered private. The right to privacy regarding personal health information extends beyond the declaration of death.
Living Donation
Whenever possible, potential donor and recipients should be cared for and evaluated by separate medical teams. In the case of non-directed donations, it may be necessary for information to be shared between donor and recipient teams (e.g. recipient’s underlying disease and risk for recurrence); however, such information should be limited to what is necessary for making an informed choice. Conversely, the CMA recognizes that the choice and process of directed donation is one that is deeply personal, which is likely to result in the intersection of both donor and recipient pathways of care. In such cases, the same onus of confidentiality may not apply given the choices of the donor and recipient involved.
Approved by the CMA Board of Directors December 2019
The objective of this policy is to provide guidance to physicians and institutions by identifying a set of guiding principles and commitments to promote equity and diversity in medicine (as defined in the Guiding Principles section). We address equity and diversity in medicine to improve circumstances and opportunities for all physicians and learners as part of our efforts to create a more collaborative and respectful culture and practice of medicine. To achieve this, we must redress inequities, bias, and discrimination in learning and practice environments.
Individual protection from bias and discrimination is a fundamental right of all Canadians. By embracing the principles of equity and diversity, we can systematically address root causes and reduce structural barriers faced by those who want to enter the medical profession and those practicing medicine. In so doing, we improve their opportunities for advancement, health, and livelihood.
The principles of equity and diversity are grounded in the fundamental commitment of the medical profession to respect for persons. This commitment recognizes that everyone has equal and inherent worth, has the right to be valued and respected, and to be treated with dignity. When we address equity and diversity, we are opening the conversation to include the voices and knowledge of those who have historically been under-represented and/or marginalized. It is a process of empowerment—where a person can engage with and take action on issues they define as important. Empowerment involves a meaningful shift in experience that fosters belonging in the profession and draws on community supports.
As part of equity and diversity frameworks, inclusion is often articulated to refer to strategies used to increase an individual’s ability to contribute fully and effectively to organisational structures and processes. Inclusion strategies are specific organisational practices or programs focused on encouraging the involvement and participation of individuals from diverse backgrounds to integrate and value their perspectives in decision-making processes. Robust processes for inclusion are a vehicle to achieving equity and diversity. Thus, in this policy, the process of inclusion is understood to be positioned at the nexus of the overarching principles of equity and diversity.
Equity and diversity initiatives can be carefully structured to complement and strengthen merit-based approaches. Enhanced support and appropriate methods of evaluation that increase equity of opportunity (for example, equity in training, hiring processes, and in access to resources) provide all physicians and learners with a fair opportunity to cultivate and demonstrate their unique capabilities and strengths, and to realize their full potential.
Promoting equity and diversity fosters a just professional and learning culture that cultivates the diverse perspectives within it, reflects the communities physicians serve, and promotes professional excellence and social accountability as means to better serve patients. An increasingly diverse medical population provides opportunities for underserviced populations to receive better access to medical services and bolsters the management of clinical cases through the contribution of different points of view. Evidence indicates that when demonstrably more equity and diversity in medicine is achieved, physicians experience greater career satisfaction, health and wellness, and a sense of solidarity with the profession while patients experience improved care and a more responsive and adaptable health care system. Evidence further indicates that realizing the full potential of human capital is an essential driver of innovation and health system development.
This policy is consistent with the CMA Code of Ethics and Professionalism and the CMA Charter of Shared Values and strives to be in the spirit of the recommendations relevant to health made in the report of the Truth and Reconciliation Commission of Canada. The policy is informed by a body of evidence described in the accompanying Background document that includes a Glossary of terms.
GUIDING PRINCIPLES
A clear set of principles and commitments to improving equity and diversity demonstrates that we hold ourselves accountable to recognizing and challenging behaviours, practices, and conditions that hinder equity and diversity and to promoting behaviours, practices, and conditions that will achieve these goals.
Achieving equity in medicine
Equity refers to the treatment of people that recognizes and is inclusive of their differences by ensuring that every individual is provided with what they need to thrive, which may differ from the needs of others. It is a state in which all members of society have similar chances to become socially active, politically influential, and economically productive through the absence of avoidable or remediable differences among groups of people (defined socially, economically, demographically, or geographically). Equity in the medical profession is achieved when every person has the opportunity to realize their full potential to create and sustain a career without being unfairly impeded by discrimination or any other characteristic-related bias or barrier. To achieve this, physicians must 1) recognize that structural inequities that privilege some at the expense of others exist in training and practice environments and 2) commit to reducing these by putting in place measures that make recruitment, retention, and advancement opportunities more accessible, desirable, and achievable. To that end, physicians must apply evidence-based strategies and support applied research into the processes that lead to inequities in training and practice environments.
Fostering diversity in medicine
Diversity refers to observable and non-observable characteristics which are constructed—and sometimes chosen—by individuals, groups, and societies to identify themselves (e.g., age, culture, religion, indigeneity, ethnicity, language, gender, sexuality, health, ability, socio-economic and family status, geography). The barriers to diversity in medicine are broad and systemic. Individuals and groups with particular characteristics can be excluded from participation based on biases or barriers. Even when they are included, they are often not able to use the full range of their skills and competencies. As with improving equity, the benefits of a more diverse medical profession include improved health outcomes, system-level adaptation, and physician health and wellness. To achieve these benefits, the medical profession must become increasingly diverse by striving to create, foster, and retain physicians and learners who reflect the diversity of the communities they serve and it must be responsive to the evolving (physical, emotional, cultural, and socioeconomic) needs of patients.
Promoting a just professional and learning culture
Physicians value learning and understand that it reflects, and is informed by, the professional culture of medicine. A just professional and learning culture is one of shared respect, shared knowledge, shared opportunity, and the experience of learning together. An environment that is physically and psychologically safe by reducing bias, discrimination, and harassment is critical to creating and sustaining such a culture. To achieve this, the profession must strive to integrate cultural safety by fostering and adopting practices of cultural competence and cultural humility. Physicians and leaders across all levels of training, practice, and health settings, and through formal and informal mentorships, must also promote and foster environments where diverse perspectives are solicited, heard, and appreciated. In this way, diverse individuals are both represented in the professional culture of medicine and actively involved in decision-making processes in all aspects of the profession.
Fostering solidarity within the profession
Solidarity means standing alongside others by recognizing our commonality, shared vulnerabilities and goals, and interdependence. It is enacted through collective action and aims. To show solidarity within the profession means making a personal commitment to recognizing others as our equals, cultivating respectful, open, and transparent dialogue and relationships, and role modelling this behaviour. Solidarity enables each of us to support our colleagues in meeting their individual and collective responsibilities and accountabilities to their patients and to their colleagues. Being accountable to these goals and to each other means taking action to ensure the principles that guide the medical profession are followed, responding justly and decisively when they are not, and continually searching for ways to improve the profession through practice-based learning and experience.
Promoting professional excellence and social accountability
Engaged and informed research and action on equity and diversity is critical to promoting professional excellence and social accountability in medicine as means to better serve patients. Professional excellence is a fundamental commitment of the profession to contribute to the development of and innovation in medicine and society through clinical practice, research, teaching, mentorship, leadership, quality improvement, administration, and/or advocacy on behalf of the profession or the public. Social accountability is a pillar of the commitment to professional excellence by focusing those efforts on fostering competence to address the evolving health needs of the patients and communities physicians are mandated to serve. For care to be socially accountable, and to achieve professional excellence, physicians must provide leadership through advocacy and through action: advocacy about the benefits of addressing equity and diversity to achieve equitable health outcomes; and actions to be responsive to patient, community, and population health needs through high-quality evidence-based patient care.
RECOMMENDATIONS
To accomplish equity and diversity in medicine, organizational and institutional changes will be required across many facets of operation and culture including leadership, education, data gathering/analysis, and continuous improvement through feedback and evaluation of policies and programs. To achieve this, the CMA seeks to provide direction on broad action areas that require further specific actions and development measures in specific recruitment, training, and practice contexts. The CMA recommends:
All medical organizations, institutions, and physician leaders:
A. Take a leadership role in achieving greater equity and diversity by co-creating policies and processes that apply to them, and the individuals therein, in an accountable and transparent manner. This includes:
1. Identifying and reducing structural inequities, barriers, and biases that exist in training and practice environments to create fair opportunities for all physicians and learners; and providing the appropriate platforms, resources, and training necessary to do so to effect change collaboratively.
2. Practicing and promoting cultural safety, cultural competence, and cultural humility.
3. Providing training on implicit bias, allyship, cultural safety, cultural competence, and cultural humility, structural competence, and the value of diversity in improving health outcomes.
4. Ensuring a process is in place to review all workforce and educational policies, procedures, and practices toward considering their impact on equity and diversity. Areas of consideration include (but are not limited to) recruitment, promotion, pay, leave of absence, parental leave, resources and support, and working/learning conditions and accommodations.
5. Ensuring safe, appropriate, and effective avenues exist for those who may have experienced discrimination, harassment, or abuse in training and practice environments to report these events outside of their supervisory/promotional chain. Those experiencing these events should also be able to seek counselling without the fear of negative consequences.
6. Working towards creating and appropriately funding equity and diversity Chairs, Committees, or Offices with a mandate to investigate and address issues in equity and diversity.
7. Promoting and enabling formal and informal mentorship and sponsorship opportunities for historically under-represented groups.
B. Encourage the collection and use of data related to equity and diversity through research and funding, and, specifically, review their data practices to ensure:
1. Historically under-represented groups are meaningfully engaged through the co-development of data practices.
2. Data regarding the representation of under-represented groups is being systematically and appropriately collected and analyzed.
3. Information collected is used to review and inform internal policy and practice with the aim of reducing or eliminating system-level drivers of inequity.
4. Findings relating to these data are made accessible.
C. Support equity and diversity in recruitment, hiring, selection, appointment, and promotion practices by:
1. Requesting and participating in training to better understand approaches and strategies to promote equity and diversity, including implicit bias and allyship training that highlights the roles and responsibilities of all members of the community with emphasis on self-awareness, cultural safety, and sensitivity to intersectionalities.
2. Studying organizational environments and frameworks and identifying and addressing hiring procedures, especially for leadership and executive positions, that perpetuate institutional inequities and power structures that privilege or disadvantage people.
3. Adopting explicit criteria to recruit inclusive leaders and to promote qualified candidates from historically under-represented groups in selection processes.
Additional recommendations for institutions providing medical education and training:
1. Establishing programs that espouse cultural safety, cultural competence, and cultural humility.
2. Encouraging all instructors develop competencies including non-discriminatory and non-stereotyping communication, awareness of intersectionality, and cultural safety.
3. Providing training programs, at the undergraduate level onwards, that include awareness and education around stereotypes (gender and otherwise), intersectionalities, and the value of diversity in improving health outcomes.
4. Providing diversity mentorship programs that aim to support diverse candidates through education and training to graduation.
5. Promoting and funding student-led programs that create safe and positive spaces for students and principles of equity and diversity.
6. Ensuring recruitment strategies and admission frameworks in medical schools incorporate more holistic strategies that recognize barriers faced by certain populations to enable a more diverse pool of candidates to apply and be fairly evaluated.
7. Developing learning communities (such as undergraduate pipelines described in the background document) to promote careers in medicine as a viable option for individuals from historically under-represented communities.
Approved by the CMA Board of Directors December 2019
The Lancet Countdown on Health and Climate Change
Policy brief for Canada
1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the
448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the
last decade.
Recommendation: Incorporate lessons learned from recent severe wildfire seasons
into a strengthened pan-Canadian emergency response approach that anticipates
increasing impacts as the climate continues to change.
Finding: The percentage of fossil fuels powering transport in Canada remains high, though
electricity and biofuels are gaining ground. Fine particulate air pollution generated by
transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.
Recommendation: Develop provincial and territorial legislation requiring automakers to
gradually increase the annual percentage of new light-duty vehicles sold that are zero
emissions, working toward a target of 100% by 2040.
Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in
the world, with healthcare accounting for approximately 4% of the country’s total emissions.
Recommendation: Establish a sustainable healthcare initiative that assembles experts from
research, education, clinical practice, and policy to support Canada’s healthcare sector in
reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with
healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement,
charting a course for zero-emissions healthcare by 2050.
Finding: The health of Canadians is at risk due to multiple and varied risks of climate
change, including those described in this policy brief (see Figure 1). An ongoing,
coordinated, consistent and pan-Canadian effort to track, report, and create healthy
change is required.
Recommendation: Integrate health considerations into climate-related policymaking
across sectors, including in Canada’s updated 2020 Nationally Determined Contribution
Commitments under the United Nations Framework Convention on Climate Change
(UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share
in achieving the goals of the Paris Agreement.
Introduction
Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2
“The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era
will come to define the health of an entire generation.”3
However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the
climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path.
Key messages and recommendations
Health and climate change in Canada
Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in
Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie
Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples
outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least
1.5oC as compared to a 1986-2005 reference period.4
Two scenarios are possible for the remainder of the child’s life.
If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as
the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to
1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of
wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as
undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety
and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within
populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This
degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2
Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6),
temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving
Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada
Indicators of climate-related health impacts
and adaptation
This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional
recommendations can also be found in the 2017 and 2018 policy briefs.6,24
Wildfires
Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in
2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more
than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures
not only pose a threat to public health, but also result in major economic and social burdens.
2019 marks a crux point for humanity: choices and policies made in
the lead up to the 2020 UNFCCC Nationally Determined Contribution
submissions will determine whether the world follows the disastrous
high-emissions scenario, or the safer low-emissions path. Children
are taking to the streets to demand a livable world. It is the task of
today’s political leaders and other adults to exert maximal effort
within their spheres of influence in order to set a course for a
healthy response to climate change.
public transit, cycling and walking rates, and adhering to a plantrich
diet in accordance with Canada’s new food guide,
decrease emissions, and also improve health and decrease
healthcare costs.30
Canada is not on track: in 2016, total Canadian GHG emissions were
704 Mt CO2e, an increase of more than 100 Mt since 1990.31
Policies and measures currently under development but not yet
implemented are forecast to reduce national emissions to 592 Mt
CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513
MtCO2e
32—a goal which is itself too weak to represent a fair
contribution by Canada to the emissions reductions necessary to
meet the goals of the Paris Climate Change Agreement.
The Earth as a whole is warming less quickly than Canada—but still
far too fast. The IPCC and the World Health Organization have
emphasized that keeping global surface temperature warming to
1.5oC is key to obtaining the best outcomes now possible for human
health.33,34 To do so would require global net human-caused
emissions to fall by about 45% from 2010 by 2030, reaching ‘net
zero’ by 2050.34 Updated Nationally Determined Contributions to
the Paris Agreement are due to be submitted by 2020: policymakers
must integrate health considerations through proposed
interventions.
Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.*
Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission)
*N.B. Reporting for 2017 only includes evacuations up to and including July
In a mid-range GHG emissions scenario, wildfires in Canada are
projected to rise 75% rise by the end of the 21st century,36
necessitating a strong adaptive response. Human health impacts of
fire include death, trauma, and major burns,37 anxiety during
wildfire periods,35,38 and post-traumatic stress disorder, anxiety
and depression related to evacuations.39,40 Wildfire smoke also
travels vast distances41 and increases asthma and chronic
obstructive pulmonary disease exacerbations, with growing evidence
of an association with all-cause mortality.41 Impacts on health
systems can be severe: during the Fort McMurray fire hospital staff
evacuated 103 patients in a matter of hours,10,42 and the 2017 British
Columbia wildfires resulted in 700+ staff displaced, 880 patients
evacuated, and 19 sites closed by the Interior Health Authority, at a
cost of $2.7 million.12 Such devastating events also generate
significant emissions, contributing to climate change, and helping to
generate conditions conducive to future blazes.43
Much can be done to lessen the health impacts of wildfires.
Qualitative data indicates that populations who are better-briefed
on the local evacuation plan, as well as ways to lessen the risk of fire
to their property, are not only more prepared but also less
anxious.35,38 Building codes can be changed to help keep smoke out,
primary care practitioners can ensure vulnerable patients receive
at-home air filtration systems and respiratory medications prior to
wildfire season,44 public health professionals can collaborate with
municipal officials to maximize smoke forecast-informed outdoor
and well-ventilated indoor recreation opportunities,38 and health
personnel can help ensure evacuation plans are clearly
communicated.45
Sustainable and healthy transport
since 2000, they account for less than 4% of the energy used in
transport (Figure 3). This rate of change is inconsistent with the
emissions pathway required to keep today’s and future children
safe.
Support is therefore required for investments in public transit,47
and cycling infrastructure,48 creating win-wins for health by
increasing physical activity levels and improving community
cohesion, while reducing chronic disease, healthcare costs and
GHG emissions.49,50 Zero emissions vehicles also reduce air pollution
and are increasingly affordable: the up-front cost of electric vehicles
is forecast to become competitive on an un-subsidized basis from
2024 onwards.51 British Columbia recently passed legislation
requiring all new cars sold to be zero-emission by 2040.52 Other
provinces would benefit from matching this ambition.
Figure 3: Per Capita Fuel Consumption for Transport in Canada.
Source: Lancet Countdown
Transport-related pollution is harming the health of Canadians. Fine
particulate matter (PM2.5) air pollution related to land-based
transportation was responsible for approximately 1063 deaths in
2015 in Canada, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.24 Additionally,
Canada has the highest pediatric asthma rate amongst countries of
comparable income level, with nitrogen dioxide (NO2) from traffic
responsible for approximately 1 in 5 new cases of asthma in
children.46
With transport responsible for 24% of national GHG emissions in
2017,31 decarbonizing this sector must be prioritized. Progress is
entirely too slow: total fuel consumption for road transport per
capita decreased 5.4% from 2013 to 2016. While per capita
use of electricity and biofuels for transport increased by 600%
Healthcare sector emissions
Though Canadians are proud of the care they provide for one another
with this country’s system of universal healthcare,53 Lancet Countdown
analysis reveals an area which should give pause to all who endeavor to
“do no harm”: Canada’s healthcare system has the world’s third highest
emissions per capita.
Previous analysis showed healthcare sector emissions to be responsible
for 4.6% of the national total,54 as well as more than 200,000 tons of
other pollutants, resulting in 23,000 disability-adjusted life years (DALYs)
lost annually.54 Emissions from the health sector represent a strategic
mitigation target in a single-payer healthcare system straining under
the weight of an inexorably increasing burden of disease.
While Canadian healthcare sector emissions are increasing, the
world-leading Sustainable Development Unit in England reported an
18.5% decrease in National Health Service, public health and social
care system emissions from 2007-2017 despite an increase in clinical
activity.55
Despite healthcare being a provincial jurisdiction, there is a role for
pan-Canadian sustainability initiatives to unite diverse experts
spanning public health and the spectrum of clinical disciplines,
economics, sustainability science and beyond. This demands health
sector-wide education, consistent with existing efforts to increase
environmental literacy for health professionals.56
1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the
health effects of climate change: Lancet and University College London
Institute for Global Health Commission. Lancet 2009;373(9676):1693-733.
2. Watts N, Amann M, Arnell N, et al. The 2018 report of The Lancet
Countdown on health and climate change: shaping the health of nations
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change-related loss. Nature Climate Change 2018;8:275-81.
9. Yao J, Eyamie J, Henderson SB. Evaluation of a spatially resolved forest fire
smoke model for population-based epidemiologic exposure assessment. J
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id=1329321987305
21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare
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nightmare-for/.
22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al.
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23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin
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2019EF001189
26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019
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yes-mr-premier-your-province-is-shrinking/
27. Kelleya C, Mohtadib S, Canec M, Seagerc R, Kushnirc Y. Climate change in the
Fertile Crescent and implications of the recent Syrian drought. Proceedings
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28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal
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29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural
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30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health
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31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.];
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32. Environment and Climate Change Canada. Canadian Environmental Sustainability
Indicators: Progress Towards Canada’s Greenhouse Gas Emissions
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greenhouse-gas-reduction-target/2019/progress-towards-ghg-emissions-
target-en.pdf
33. Ebi K, Campbell-Lendrum D, Wyns A. The 1.5 Health Report--Synthesis on
Health and Climate Science in the IPCC SR1.5. 2018 2018.
34. Intergovernmental Panel on Climate Change. Global Warming of 1.5C--Summary
for Policymakers. 2018 October 8, 2018.
35. Christianson A. Wildland Fire Evacuations in Canada. Natural Resources
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36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire
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37. Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et
al. Black Saturday: the immediate impact of the February 2009 bushfires in
Victoria, Australia. Med J Aust 2009;191(1):11-6.
38. Dodd W, Scott P, Howard C, Scott C, Rose C, Cunsolo A, et al. Lived experience
of a record wildfire season in the Northwest Territories, Canada. Can J Public
Health 2018;109(3):327-37.
39. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder
and general psychopathology in children and adolescents following a wildfire
disaster. Can J Psychiatry 2005;50(3):137-43.
40. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress
following wildfires disaster in a rural part of Greece: a case-control population-
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41. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical Review
of Health Impacts of Wildfire Smoke Exposure. Environ Health Perspect
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42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery
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Wildfire–climate interactions. Forest Ecology and Management 2014;317:80-
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cleaners should be at the forefront of the public health response to landscape
fire smoke. Environ Health 2016;15(1):116.
45. Maguet S. Public Health Responses to Wildfire Smoke Events. BC Center for
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46. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban
burdens of paediatric asthma incidence attributable to ambient NO2 pollution:
estimates from global datasets. Lancet Planet Health 2019;3(4):e166-e78.
47. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet
physical activity recommendations. Am J Prev Med 2005;29(4):273-80.
48. United Kingdom Department of Transport. Value for Money Assessment for
Cycling Grants. 2014.
49. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects
of the London bicycle sharing system: health impact modelling study. BMJ
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and transportation-related reductions in greenhouse gas emissions in the San
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51. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al.
Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from
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References
Organisations and acknowledgements
The concept of this brief was developed by the Lancet Countdown on Health
and Climate Change.
This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose,
PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD.
Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman,
MD.
Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD;
Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their
assistance.
Contributions and review on behalf of the Lancet Countdown were provided
by Jess Beagley and Nick Watts, MBBS.
THE LANCET COUNTDOWN
The Lancet Countdown: Tracking Progress on Health and Climate Change is an
international, multi-disciplinary collaboration that exists to monitor the links
between public health and climate change. It brings together 35 academic
institutions and UN agencies from every continent, drawing on the expertise
of climate scientists, engineers, economists, political scientists, public health
professionals, and doctors. Each year, the Lancet Countdown publishes an
annual assessment of the state of climate change and human health, seeking
to provide decision-makers with access to high-quality evidence-based
policy guidance. For the full 2019 assessment, visit www.lancet
countdown.org/2019-report .
THE CANADIAN MEDICAL ASSOCIATION
The Canadian Medical Association (CMA), formed in Quebec City in 1867,
has led some of Canada’s most important health policy changes. As we
look to the future, the CMA will focus on advocating for a healthy population
and a vibrant profession.
THE CANADIAN PUBLIC HEALTH ASSOCIATION
The Canadian Public Health Association (CPHA) is a national, independent,
non-governmental organization that advances public health education,
research, policy and practice in Canada and around the world through the
Canadian Journal of Public Health, position statements, discussion
documents and other resources.
Homeless and vulnerably housed populations are heterogeneous
and continue to grow in numbers in urban and
rural settings as forces of urbanization collide with gentrification and austerity policies.2
Collectively, they face dangerous living conditions and marginalization within health care systems.3
However, providers can improve the health of people who
are homeless or vulnerably housed, most powerfully by following
evidence-based initial steps, and working with communities and
adopting anti-oppressive practices.1,4,5
Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6
Under such conditions, individuals and families face intersecting
social, mental and physical health risks that significantly increase
morbidity and mortality.7,8 For example, people who are homeless
and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports
that people who experience homelessness face life expectancies
as low as 42 years for men and 52 years for women.7
A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth,
Indigenous people (Box 1), immigrants, older adults and people
from rural communities.13,14 For example, family homelessness
(and therefore homelessness among dependent children and
youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of
the estimated 235 000 homeless people in Canada, 27.3% were
women, 18.7% were youth, 6% were recent immigrants or
migrants, and a growing number were veterans and seniors.10
Practice navigators, peer-support workers and primary care
providers are well placed to identify social causes of poor health
and provide orientation to patient medical homes.16,17 A patient’s
medical home is “a family practice defined by its patients as the
place they feel most comfortable presenting and discussing their
personal and family health and medical concerns.”18 Medical
care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated
with other services in the health care system and the community”
(https://patientsmedicalhome.ca). Primary care providers are
also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19
GUIDELINE VULNERABLE POPULATIONS CPD
Clinical guideline for homeless and vulnerably
housed people, and people with lived
homelessness experience
Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH,
Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD,
Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD,
Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW,
Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD,
Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA,
Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD
n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199
KEY POINTS
Clinical assessment and care of homeless and vulnerably housed
populations should include tailoring approaches to a person’s
gender, age, Indigenous heritage, ethnicity and history of
trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed
populations, permanent supportive housing is strongly
recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric
support, are recommended as an initial step to support primary
care and to address existing mental health, substance use and
other morbidities.
Harm-reduction interventions, such as supervised consumption
facilities, and access to pharmacologic agents for opioid use
disorder, such as opioid agonist treatment, are recommended
for people who use substances.
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ISSUE 10 E241
However, the social and health resources available to homeless
and vulnerably housed people may vary based on geographic
setting, municipal resources, housing coordination, and patients’
mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities
for care, patient mistrust of the health care system or limited
access to health services.3
Homeless and vulnerably housed people can benefit from
timely and effective health, addiction and social interventions.
Our guideline provides initial steps for practice, policy and future
research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values
such as trauma-informed and patient-centred care, and dignity
are needed to foster trust and develop sustainable therapeutic
relationships with homeless and vulnerably housed people.20,21
Scope
The purpose of this clinical practice guideline is to inform providers
and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The
guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers.
Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the
many etiologies of homelessness, such as childhood trauma, the
housing market, or the root causes of low social assistance rates
and economic inequality. Rather, this guideline aims to reframe
providers’ approach toward upstream interventions that can
prevent, treat and work toward ending the morbidity and mortality associated with homelessness.
A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led
team.22 This process recognizes the distinct rights of Indigenous
Peoples, including the right to develop and strengthen their own
economies, social and political institutions; the direct links
between historic and ongoing colonial policies and Indigenous
homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples.
Recommendations
The steering committee and guideline panel members developed
and approved recommendations to improve social and health
outcomes for homeless and vulnerably housed people. The order
of these recommendations highlights priority steps for homeless
health care. We list a summary of the recommendations in Table 1
and we present our list of good practice statements in Table 2.
These good practice statements are based on indirect evidence
and support the delivery of the recommendations.
The methods used to develop the recommendations are
described later in this document. A summary of how to use this
guideline is available in Box 2.
Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to
local housing coordinator or case manager (i.e., call 211 or
via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation).
Evidence summary
Our systematic review (Tim Aubry, University of Ottawa, Ottawa,
Ont.: unpublished data, 2020) identified 14 trials on permanent
supportive housing (PSH).30–43 Several trials across Canada and the
United States showed that PSH initiatives house participants more
rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30
increase the number of people who maintain stable housing at
2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and
significantly increase the percentage of days spent stably
housed.41 No trials showed a significant improvement in mental
health symptoms compared with standard care.30,31,33,34,41,42
Two studies found that the mental health of PSH participants did
not improve as much as that of usual care participants (e.g., mean
difference –0.49, 95% CI –0.85 to –0.12).30,31
The At Home/Chez Soi trial showed small improvements in quality
of life for high-needs (adjusted standardized mean difference 0.15,
95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37,
95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41
Youth receiving PSH saw larger improvements in their quality of life
during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24),
which diminished over time (mean difference 7.29, 95% CI –1.61 to
16.18).44 No trials showed a significant improvement in substance use
compared with standard care.30,33,41–43 Most trials reported no effect of
PSH on acute care outcomes (e.g., number of emergency department
visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital
admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found
no effect of PSH on job tenure, hours of work per week or hourly wage
compared with standard care.46 Participants receiving PSH may have
increased odds of employment, but this depends on the severity of
participant needs.46 One trial found no effect on income outcomes.46
Box 1: Indigenous homelessness
Indigenous homelessness is a term used to describe First Nations,
Métis and Inuit individuals, families or communities who lack
stable, permanent and appropriate housing, or the immediate
prospects, means or ability to acquire such housing. However, this
term must be interpreted through an Indigenous lens to
understand the factors contributing to this condition. These
factors include individuals, families and communities isolated
from their relationships to land, water, place, family, kin, each
other, animals, cultures, languages and identities as well as the
legacy of colonialism and genocide.11 It is estimated that urban
Indigenous people are 8 times more likely to experience
homelessness than the general population.11,12
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The certainty of the evidence was rated moderate, because
blinding of participants and personnel was not feasible in any of
the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which
could introduce high risks of detection and performance biases.
Income assistance
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation).
Evidence summary
We identified 10 trials on income-assistance interventions, including
rental assistance,47–56 financial empowerment,47 social enterprise
interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that
income-assistance interventions have on housing stability (Gary
Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020).
Rental assistance increased the likelihood of being stably housed
(OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with
case management increased the number of days in stable housing
per 90-day period compared with case management alone (mean
Table 1: Summary of evidence-based recommendations
Recommendations and clinical considerations Grade rating*
Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call
211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system.
Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized
populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those
with disabilities, refugees and migrants.
Strong recommendation
Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or
living in a low-income household
Low certainty
Assist individuals with income insecurity to identify income-support resources and access income.
Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products
/poverty-a-clinical-tool-for-primary-care-providers).
Conditional recommendation
Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs
(including mental illness and/or substance use)
Low certainty
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with
substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to
intensive case management, assertive community treatment or critical time intervention where available.
Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar
with local access points and less intensive community mental health programs.
Conditional recommendation
Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in
collaboration with a public health or community health centre for linkage to pharmacologic interventions.
Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers
to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT
access and options in your jurisdiction, in particular for buprenorphine.
Conditional recommendation
Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services
(e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as
public health or community health centre or local community services centre.
Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be
made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/
doi:10.1503/cmaj.190777/-/DC1).
Conditional recommendation
Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited.
*See Box 2 for definitions.
†211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and
referrals to health, human and social service organizations.
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difference 8.58, p < 0.004).55 Compensated work therapy was found
to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No
income interventions showed an effect on mental health
outcomes.47,52,55,56
The impact of these interventions on substance use outcomes
were mixed. Provision of housing vouchers did not affect substance
use over 3 years;55 however, compensated work therapy showed
immediate reductions in drug (reduction: –44.7%, standard error [SE]
12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p =
0.001), as well as the number of substance use–related physical
symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found
on overall quality-of-life, finances, health and social relations scores.
Provision of housing vouchers resulted in higher family-relations
score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated
with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to
improve employment rates only when there was high fidelity to the
model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54
Provision of housing vouchers had no effect on monthly income.55
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance
programs after completing the study had incentives to underreport
symptoms, which introduced high risk for measurement bias.
Case management
Identify history of severe mental illness, such as psychotic or
mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex
health needs.
Ensure access to local community mental health programs,
psychiatric services for assessment and linkage to intensive
case management, assertive community treatment or critical
time intervention where available (low certainty, conditional
recommendation).
Evidence summary
Our systematic review examined the effectiveness of standard
case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention
among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa,
Ottawa, Ont.: unpublished data, 2020). We included a total of
56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73
16 trials on intensive case management74–89 and 5 trials on critical
time intervention.90–94
Box 2: How to use and understand this GRADE guideline
(www.gradeworkinggroup.org)
This guideline supplies providers with evidence for decisions
concerning interventions to improve health and social outcomes
for people who are homeless or vulnerably housed. This guideline
is not meant to replace clinical judgment. Statements about
clinical considerations, values and preferences are integral parts of
the recommendations meant to facilitate interpretation and
implementation of the guideline. Recommendations in this
guideline are categorized according to the Grading of
Recommendations Assessment, Development and Evaluation
(GRADE) system as strong or conditional recommendations.
Strong recommendations indicate that all or almost all fully
informed patients would choose the recommended course of
action, and indicate to clinicians that the recommendation is
appropriate for all or almost all individuals. Strong
recommendations represent candidates for quality-of-care criteria
or performance indicators.
Conditional recommendations indicate that most informed
patients would choose the suggested course of action, but an
appreciable minority would not. With conditional
recommendations, clinicians should recognize that different
choices will be appropriate for individual patients, and they should
help patients arrive at a decision consistent with their values and
preferences. Conditional recommendations should not be used as
a basis for standards of practice (other than to mandate shared
decision-making).
Good practice statements represent common-sense practice, are
supported by indirect evidence and are associated with assumed
large net benefit.
Clinical considerations provide practical suggestions to support
implementation of the GRADE recommendation.
GRADE certainty ratings
High: further research is very unlikely to change our confidence in
the estimate of effect.
Moderate: further research is likely to have an important impact on
the confidence in the estimate of effect and may change the estimate.
Low: further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change
the estimate.
Very low: any estimate of the effect is very uncertain.
Table 2: Good practice statements to support delivery of care
Good practice statement
Indirect
evidence
(reference)
1. Homeless and vulnerably housed populations
should receive trauma-informed and personcentred care.
23–26
2. Homeless and vulnerably housed populations
should be linked to comprehensive primary
care to facilitate the management of multiple
health and social needs.
27
3. Providers should collaborate with public health
and community organizations to ensure
programs are accessible and resources
appropriate to meet local patient needs.
28,29
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Of 10 trials on standard case management, 10 evaluated
housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a
time-limited residential case management in which participants
in all groups accessed substantial levels of services.57 A program
tailored to women reduced the odds of depression at 3 months
(OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in
the women’s overall mental health status (mean difference 4.50,
95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female
participants receiving nurse-led standard case management
compared with those receiving standard care.60 Few studies
reported on substance use, quality of life, employment or
income outcomes.
Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are
mixed. Two trials found that participants receiving the treatment
reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect
on episodes of homelessness or number of days homeless.66,73
Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department
(mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental
health outcomes, including psychiatric symptoms, substance
use, or income-related outcomes between the treatment and
control groups.
Intensive case management reduced the number of days
homeless (pooled standardized mean difference –0.22, 95% CI
–0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in
psychological symptoms between the treatment and control
groups. However, 1 trial reported significantly greater reductions
in anxiety, depression and thought disturbances after 24 months
(mean difference change from baseline –0.32, p = 0.007), as well
as improved life satisfaction (mean difference 1.23, p = 0.001)
using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use
were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use
behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department
(mean difference 19%, p < 0.05) but did not have shorter hospital
stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on
income received from employment; however, income received
by participants through public assistance increased (e.g., mean
difference 89, 95% CI 8 to 170).78,85
Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the
odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the
final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard
care,95 but did not spend more days rehoused.90 Adults receiving
critical time intervention showed significant improvements in
psychological symptoms (mean difference –0.14, 95% CI –0.29 to
0.01).90 However, findings for children’s mental health were
mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86),
whereas changes for children aged 6–10 years and 11–16 years
were not significant.93 There were no significant effects of critical
time intervention on substance-use,90 quality-of-life90,92 or
income-related outcomes.96 Two trials reported mixed findings
on hospital admission outcomes; in 1 study, allocation to critical
time intervention was associated with reduced odds of hospital
admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of
nights in hospital (p < 0.05) in the final 18 weeks of the trial.97
However, another study reported a greater total number of
nights in hospital for the treatment group compared with usual
care (1171 v. 912).98
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias.
Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by
referral to an addiction specialist, potentially in collaboration
with public health or community health centre for linkage to
pharmacologic interventions (low certainty, conditional
recommendation).
Evidence summary
We conducted a review of systematic reviews on pharmalogic
interventions for opioid use disorder.99 Twenty-four reviews,
which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general
populations.100–123 We expanded our inclusion criteria to general
populations, aware that most studies among “general populations” had a large representation of homeless populations in
their samples. We did not identify any substantial reason to
believe that the mechanisms of action of our interventions of
interest would differ between homeless populations who use
substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on
the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and
hydromorphone for treatment of opioid use disorder.
We found pooled all-cause mortality rates of 36.1 and 11.3 per
1000 person years for participants out of and in methadone
maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to
3.86), and mortality rates of 9.5 per 1000 person years for those
not receiving buprenorphine maintenance therapy compared
with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific
mortality rates were similarly affected, with pooled overdose
mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates
of 4.6 and 1.4 per 1000 person years out of and in buprenorphine
maintenance therapy.116 Compared with nonpharmacologic
approaches, methadone maintenance therapy had no significant
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effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With
respect to morbidity, pharmacologic interventions for opioid use
disorder reduced the risk of hepatitis C virus (HCV) acquisition
(risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103
Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with
reduced illicit opioid use (standardized mean difference –1.17,
95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment
expanded access to treatment for patients unlikely to enrol in
methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear;
however, use of methadone was found to show better benefits
than nonpharmacologic interventions for retention (risk ratio
4.44, 95% CI 3.26 to 6.04).110
The certainty of evidence ranged from very low to moderate,
primarily because of inconsistency, high risk of bias and evidence
from nonrandomized studies.
Harm-reduction interventions
Identify problematic substance use, including alcohol or other
drugs.
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised
consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community
health centre or les centres locaux de services communautaires (low certainty, conditional recommendation).
Evidence summary
We conducted a review of systematic reviews on supervised
consumption facilities and managed alcohol programs.99 Two
systematic reviews, which included 90 unique observational
studies and 1 qualitative meta-synthesis reported on supervised
consumption facilities.124–126 For managed alcohol programs,
1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129
Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per
100 000 person years, p = 0.048), compared with 9% in the rest of
the city (Vancouver).124 There were 336 reported opioid overdose
reversals in 90 different individuals within the Vancouver facility
over a 4-year period (2004–2008).125 Similar protective effects
were reported in Australia and Germany. Observational studies
conducted in Vancouver and Sydney showed that regular use of
supervised consumption facilities was associated with decreased
syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe
reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space
injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter)
and fostered access to broader health support.125,126 Attendance
at supervised consumption facilities was associated with an
increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio
1.57, 95% CI 1.02 to 2.40).125
Evidence on supervised consumption facilities was rated very
low to low, as all available evidence originated from nonrandomized studies.
There was a lack of high-quality evidence for managed alcohol
programs. Few studies reported on deaths among clients of these
programs.128 The effects of managed alcohol programs on hepatic
function are mixed, with some studies reporting improvement in
hepatic laboratory markers over time, and others showing
increases in alcohol-related hepatic damage;129 however, this may
have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with
medical and social services.128 Clients experienced significantly
fewer social, health, safety and legal harms related to alcohol
consumption.129 Individuals participating in these programs had
fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129
Cost effectiveness and resource implications
Permanent supportive housing
We found 19 studies assessing the cost and net cost of housing
interventions.30,41,45,130–145 In some studies, permanent supportive
housing interventions were associated with increased cost to the
payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the
intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies,
however, employed a pre–post design.135,139,141,145 Moreover,
1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased
quality-adjusted life years, with an incremental cost-effectiveness
ratio of US$62 493 per quality-adjusted life year.136 Compared
with usual care, PSH was found to be more costly to society (net
cost Can$7868, 95% CI $4409 to $11 405).138
Income assistance
Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving
case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received
income assistance incurred additional costs of US$58 (95% CI $4
to $111) from the perspective of the payer, US$50 (95% CI –$17 to
$117) from the perspective of the health care system and US$45
(95% CI –$19 to $108) from the societal perspective. The benefit
gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146
Case management
Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150
Findings of these studies were mixed; the total cost incurred by
clients of standard case management was higher than that of
clients receiving usual or standard care61,88 and assertive
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community treatment,67,147 but lower compared with a US clinical
case-management program that included housing vouchers and
intensive case management.55 Cost-effectiveness studies using a
societal perspective showed that standard case management
was not cost effective compared with assertive community
treatment for people with serious mental disorders or those with
a concurrent substance-use disorder, as it was more expensive.67
For intensive case management, the cost of supporting housing
with this program could be partially offset by reductions in the use
of emergency shelters and temporary residences.41 Intensive case
management is more likely to be cost effective when all costs and
benefits to society are considered.41 A pre–post study showed that
providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150
Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We
identified only 1 study on the cost effectiveness of critical time
intervention that reported comparable costs (US$52 574 v.
US$51 749) of the treatment compared with the usual services
provided to men with severe mental illness.96
Interventions for substance use
We identified 2 systematic reviews that reported findings from
6 studies in Vancouver on the cost effectiveness of supervised
consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating
costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of
incident HCV infection.
Clinical considerations
Providers can, in partnership with directly affected communities,
employ a range of navigation and advocacy tools to address the
root causes of homelessness, which include poverty caused by
inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the
propagation of violence in homes and communities, inadequate
supports for patients and families living with disabilities or going
through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to
the patient’s needs and demographics, taking into account
access to services, personal preferences and other illnesses.152
Providers should also recognize the social and human value
of accepting homeless and vulnerably housed people into their
clinical practices. The following sections provide additional evidence for underserved and marginalized populations.
Women
A scoping review of the literature on interventions for homeless
women (Christine Mathew, Bruyère Research Institute, Ottawa,
Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156
and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused
specifically on homeless and vulnerably housed women. Findings
showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women
with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster
care placements, allowing women to maintain the integrity of their
family unit.158 As well, Housing First programs for families, critical
time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress,
increased self-esteem and improved quality of life for women and
their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among
homeless women. We suggest that providers focus on patient
safety, empowerment among women who have faced genderbased violence, and improve access to resources, including
income, child care and other social support services.
Youth
A systematic review on youth-specific interventions reported
findings from 4 systematic reviews and 18 RCTs.162 Permanent
supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in
significant improvements in depression scores, and family-based
therapies are also promising, resulting in reductions in youth
substance use through restoring the family dynamic. Findings on
motivational interviewing, skill building and case-management
interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits.
Refugee and migrant populations
A qualitative systematic review on homeless migrants (Harneel
Kaur, University of Ottawa, Ottawa, Ont.: unpublished data,
2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging
and access to social services, such as housing. However, employment opportunities provided a sense of independence and
improved social integration.
Methods
Composition of participating groups
In preparation for the guideline, we formed the Homeless Health
Research Network (https://methods.cochrane.org/equity/
projects/homeless-health-guidelines), composed of clinicians,
academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P.
[chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was
assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario,
Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of
homelessness (herein referred to as “community scholars”180)
were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the
participating groups and monitored competing interests.
The steering committee decided to develop a single guideline
publication informed by a series of 8 systematic reviews. The
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steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical
topic experts and community scholars who were responsible for
providing contextual expertise.
The steering committee also assembled a technical team,
which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the
responsibility to provide external review of the evidence and
drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists,
psychiatrists, public health professionals, people with lived
experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of
interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/
suppl/doi:10.1503/cmaj.190777/-/DC1.
Selection of priority topics
We used a 3-step modified Delphi consensus method (Esther
Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020) to select priority health conditions for marginalized
populations experiencing homelessness or vulnerable housing.
Briefly, between May and June 2017, we developed and conducted
a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank
and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to
keep in mind 3 priority-setting criteria when considering the
unique challenges of implementing health care for homeless or
vulnerably housed people: value added (i.e., the opportunity for a
unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e.,
the number of people who may have a disease or condition).181
The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care,
delivering care coordination and case management, and facilitating
access to adequate income. The priority marginalized populations
identified included Indigenous people; women and families; youth;
people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère
Research Institute, Ottawa, Ont.: unpublished data, 2020). Each
working group then scoped the literature using Google Scholar and
PubMed to determine a list of interventions and terms relating to
each of the priority-need categories. Each working group came to
consensus on the final list of interventions to be included (Table 3).
Guideline development
We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development
of this clinical guideline, including the identification of clinical
questions, systematic reviews of the best available evidence,
Table 3: Descriptions of priority-need interventions
Intervention Description
Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the
provision of individualized supportive services that are tailored to participants’ needs and choices,
including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing
housing) with permanent supportive housing.
Income assistance
Benefits and programs that improve socioeconomic status. This may include assistance that directly
increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and
compensated work therapy) in this category.
Case management
Standard case management allows for the provision of an array of social, health care and other services
with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of
services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each
case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental
illness by a multidisciplinary group of health care workers in the community. This team should be available
24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case
management is administered by a critical time intervention worker and is a time-limited service, usually
lasting 6–9 months.
Pharmacologic interventions for
substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine,
diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or
intranasally (e.g., naloxone).
Harm reduction for substance
use disorders
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use
substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated
alcohol to support residents with severe alcohol use disorder.
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assessment of the certainty of the evidence and development of
recommendations.182 We conducted a series of systematic reviews
to answer the following clinical question:
Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions
be considered for people with lived experience of homelessness?
Systematic reviews for each intervention were driven by a logic
model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search
terms, can be found in Appendix 3, available at www.cmaj.ca/
lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and
comparisons according to published a priori protocols.183–186 We
used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The
technical team reviewed titles, abstracts and full texts of identified
citations, selected evidence for inclusion and compiled evidence
reviews, including cost-effectiveness and resource-use data, for
consideration by the guideline panel. The technical team collected
and synthesized data on the following a priori outcomes: housing
stability, mental health, quality of life, substance use, hospital
admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty
of evidence using the GRADE approach. Where pooling of results
was not appropriate, we synthesized results narratively.
In addition to the intervention and cost-effectiveness reviews,
the technical team conducted 3 systematic reviews to collect
contextual and population-specific evidence for the populations
prioritized through our Delphi process (women, youth, refugees
and migrants) (Christine Mathew, Bruyère Research Institute,
Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University
of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally,
we conducted 1 qualitative literature review to capture patient
values and preferences, focused on the experiences of people
who are homeless in engaging with our selected interventions.20
Drafting of recommendations
The steering committee hosted a 2-day knowledge-sharing
event, termed the “Homeless Health Summit,” on Nov. 25–26,
2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all
intervention reviews were presented and discussed according to
the GRADE Evidence to Decision framework.187 After the meeting,
the steering committee drafted GRADE recommendations (Box 2)
through an iterative consensus process. All steering-committee
members participated in multiple rounds of review and revision
of the drafted clinical recommendations.
Guideline panel review
We used the GRADE Evidence to Decision framework to facilitate
the development of recommendations187–189 (Appendix 4, available
at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190777/-/DC1).
We used GRADEpro and the Panel Voice software to obtain input
from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided
considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance
of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off.
Good practice statements
We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A
good practice statement characteristically represents situations in
which a large and compelling body of indirect evidence strongly
supports the net benefit of the recommended action, which is
necessary for health care practice.191–193 Guideline-development
groups consider making good practice statements when they have
high confidence that indirect evidence supports net benefit, there
is a clear and explicit rationale connecting the indirect evidence,
and it would be an onerous and unproductive exercise and thus a
poor use of the group’s limited resources to collect this evidence.
The steering committee came to a consensus on 3 good practice
statements based on indirect evidence.
Identification of implementation considerations
We completed a mixed-methods study to identify determinants
of implementation across Canada for the guideline (Olivia
Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost
(affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to
implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019;
Gatineau, Que., July 18, 2019) with relevant stakeholders in the
field of homeless health to analyze our implementation data.
Management of competing interests
Competing interests were assessed using a detailed form adapted
from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the
Elsevier sample coauthor agreement form for a scientific project,
contingencies and communication.195 These forms were collected
at the start of the guideline activities for the steering committee,
guideline panel and community scholars. All authors submitted
an updated form in June 2019 and before publication.
The management committee iteratively reviewed these statements and interviewed participants for any clarifications and
concerns. A priori, the management committee had agreed that
major competing interests would lead to dismissal. There were
no competing interests declared.
Implementation
Our mixed-methods study (Olivia Magwood, Bruyère Research
Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to
implement, identified the following concerns regarding implementation of this guideline.
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Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to
PSH programs and informing their patients about the resources
available in the community.
The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as
administrative and human resources concerns. For example, not
all primary care providers work in a team-based comprehensive
care model and have access to a social worker or care coordinator
who can help link the patient to existing services. Furthermore,
wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible
recommendation.
Allied health practitioners and physicians do not always agree
with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients
and less experience exploring social determinants of health, such
as housing or income. The initial steps outlined in this guideline
would come at an opportunity cost for them. Stigma attached to
the condition of homelessness was recognized as an important
barrier to care for homeless populations.
Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to
increase the housing supply, income supports and human
resources. However, supervised consumption facilities, with their
range of benefits, were perceived as cost-saving.
Many interventions have the potential to increase health
equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the
initial steps and advocate on a systematic level to increase availability of services.
Suggested performance measures
We developed a set of performance measures to accompany this
guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness
or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for
income assistance over 1 year.
The proportion of eligible adults using opioids who are
offered opioid agonist therapy over 1 year.
Updates
The Homeless Health Research Network will be responsible for
updating this guideline every 5 years.
Other guidelines
This guideline complements other published guidelines. This
current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous
leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020).
The World Health Organization has developed guidelines to
promote healthy housing standards to save lives, prevent disease
and increase quality of life.196 Other guidelines specific to opioid
use disorder exist,197,198 including 1 for “treatment-refractory”
patients.199 In the United Kingdom, the National Institute for
Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National
Health Care for the Homeless Council in the US has adapted best
practices to support front-line workers caring for homeless
populations.200
How is this guideline different?
This guideline distills initial steps and evidence-based
approaches, to both homeless and vulnerably housed people,
with the assistance of patients and other stakeholders. It also
introduces a new clinical lens with upstream interventions that
provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the
experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we
hope that our stakeholder engagement inspires and equips
future students, health providers and the public health community to implement the initial step recommendations.
Gaps in knowledge
Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general
housed populations. As primary care expands its medical home
models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in
this guideline. Indeed, clinical research can refine how providers
use the initial steps protocol: housing, income, case management
and addiction. With improved living conditions, care coordination
and continuity of care, research and practice can shift to treatable
conditions, such as HIV and HCV infection, substance use disorder,
mental illness and tuberculosis.203
Medical educators will also need to develop new training
tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many
of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and
case management. Interdisciplinary primary care research and
maintenance of linkages to primary care will benefit from new
homeless health clinic networks. Monitoring transitions in care
and housing availability will be an important research goal for
Canada’s National Housing Strategy and the associated Reaching
Home program.
Conclusion
Homelessness has become a health emergency. Initial steps in
addressing this crisis proposed in this guideline include strongly
recommending PSH as an urgent intervention. The guideline also
recognizes the trauma, disability, mental illness and stigma
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facing people with lived homelessness experience and thus recommends initial steps of income assistance, intensive case management for mental illness, and harm-reduction and addictiontreatment interventions, including access to opioid agonist
therapy and supervised consumption facilities.
The successful implementation of this guideline will depend
on a focus on the initial recommendations, trust, patient safety
and an ongoing collaboration between primary health care,
mental health providers, public health, people with lived experience and broader community organizations, including those
beyond the health care field.
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Competing interests: Gary Bloch is a founding member, former board
member and currently a clinician with Inner City Health Associates
(ICHA), a group of physicians working with individuals experiencing
homelessness in Toronto, which provided funding for the development
of this guideline. He did not receive payment for work on the guideline
and did not participate in any ICHA board decision-making relevant to
this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive
payment for any aspect of the submitted work. No other competing interests were declared.
This article has been peer reviewed.
Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie,
d Wendy Muckle led
the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance
use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic
led the review on income, David Ponka and Eric Agbata led the review
on case management, Jean Zhuo Jing Wang and Sebastian Mott led the
homeless youth review, Harneel Kaur led the homeless migrant review,
Christine Mathew and Anne Andermann led the homeless women
review, Syeda Shanza Hashmi and Ammar Saad led medical student
engagement and competency review, Thomas Piggott co-led the GRADE
Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and
Nicole Kozloff contributed substantially to the substance use review,
and Neil Arya and Stephen Hwang provided critical policy information.
All of the named authors engaged in the writing and review, gave final
approval of the version of the guideline to be published, and agreed to
be accountable for all aspects of the work.
Funding: This guideline was supported by a peer-reviewed grant from
the Inner City Health Associates, and supplemental project grants from
the Public Health Agency of Canada, Employment Social Development
Canada, Canadian Medical Association and Champlain Local Integrated
Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the
guideline. The funders had no role in the design or conduct of the study;
collection, analysis and interpretation of the data; or preparation,
review or final approval of the guideline. Final decisions regarding the
protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee.
Acknowledgements: The authors thank everyone who participated in
the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members.
Endorsements: Canadian Medical Association, Canadian Public Health
Association, Canadian Federation of Medical Students, The College of
Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to
End Homelessness, Canadian Nurses Association
Disclaimer: The views expressed herein do not necessarily represent
the views of the funding agencies.
Correspondence to: Kevin Pottie, kpottie@uottawa.ca
The Canadian Medical Association (CMA) appreciates this opportunity to respond to the notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada’s intent to establish a single set of regulations under the authorities of the Tobacco and Vaping Products Act (TVPA) and the Canada Consumer Product Safety Act (CCPSA) with respect to the labelling and packaging of vaping products.1
Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use.
The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence.
Introduction
In our most recent brief, the CMA expressed its concerns regarding vaping and youth. This included marketing, flavours, nicotine levels, and reducing vaping and e-cigarette use among youths.2 In April 2019, the Council of Chief Medical Officers of Health expressed alarm at the rising number of Canadian youths who are vaping, having found this trend “very troubling.”3 The CMA concurred with this assessment and supports Health Canada’s intention to further tighten the regulations.2
Identifying Vaping Substances
The findings of a recent Canadian study indicate an increase in vaping among adolescents in Canada and the United States.4 The growing acceptance of this practice is of concern to the CMA because of the rapidly emerging popularity of vaping products such as JUUL® and similar devices.4 It will be very important to identify clearly on the packaging all the vaping substances contained therein, along with a list of ingredients, as not enough is known about the long-term effects users may face.5,6 Users need to know what they are consuming so they can make informed choices about the contents. Studies have found substances in e-cigarette liquids and aerosols such as “nicotine, solvent carriers (PG and glycerol), tobacco-specific nitrosamines (TSNAs), aldehydes, metals, volatile organic compounds (VOCs), phenolic compounds, polycyclic aromatic hydrocarbons (PAHs), flavorings, tobacco alkaloids, and drugs.”7
Nicotine Content
As Hammond et al noted in their recent study, “JUUL® uses benzoic acid and nicotine salt technology to deliver higher concentrations of nicotine than conventional e-cigarettes; indeed, the nicotine concentration in the standard version of JUUL® is more than 50 mg/mL, compared with typical levels of 3-24 mg/mL for other e-cigarettes.”4 The salts and flavours available to be used with these devices reduce the harshness and bitterness of the taste of the e-liquids. Some of its competition deliver even higher levels of nicotine.8
The CMA has expressed its concerns about the rising levels of nicotine available through the vaping process.2 They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.”9
The higher levels of nicotine in vaping devices is also of concern because it “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment.”10,11 The CMA has called on Health Canada to restrict the level of nicotine in vaping products to avoid youth (and adults) from developing a dependence.2
4
Health Warnings
The CMA reiterates, again, its position that health warnings for vaping should be similar to those for tobacco packages.12,13 We support placing warning labels on all vaping products, regardless of the size of the package. The “space given to the warnings should be sufficient to convey the maximum amount of information while remaining clear, visible, and legible. The warnings should be in proportion to the packaging available.”13 The need for such cautions is important as there is still much that is not known about the effects vaping can have on the human body.
A US study found “evidence that using combusted tobacco cigarettes alone or in combination with e-cigarettes is associated with higher concentrations of potentially harmful tobacco constituents in comparison with using e-cigarettes alone.”14 Some researchers have found that there is “significant potential for serious lung toxicity from e-cig(arette) use.”15,16
Another recent US study indicates that “adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don’t use them or any tobacco products.”17 Further, it was found that “compared with nonusers, e-cigarette users were 56 percent more likely to have a heart attack and 30 percent more likely to suffer a stroke.17
A worrisome development has emerged in the United States. The Centers for Disease Control and Prevention is working in consultation with the states of Wisconsin, Illinois, California, Indiana, and Minnesota regarding a “cluster of pulmonary illnesses linked to e-cigarette product use, or “vaping,” primarily among adolescents and young adults.”18 Additional possible cases have been identified in other states and are being investigated.
Child-Resistant Containers
The CMA supports the need for child-resistant containers in order to enhance consumer safety; we have adopted a similar position with respect to cannabis in all forms.19,20 The need to include warning labels should reinforce the need for packaging these vaping products such that they will be inaccessible to small children.
Recommendations
1. The CMA recommends more research into the health effects of vaping as well as on the components of the vaping liquids.
2. Health Canada should work to restrict the level of nicotine available for vaping products to avoid youth and adults from developing a dependence.
3. The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages. We support the proposed warning labels being placed on all vaping products.
4. The CMA recommends that all the vaping substances be identified clearly on the packaging, along with a list of ingredients.
5. The CMA supports the need for child-resistant containers.
5
1 Government of Canada. Canada Gazette, Part I, Volume 153, Number 25: Vaping Products Labelling and Packaging Regulations. Ottawa: Government of Canada; 2019. Available: http://gazette.gc.ca/rp-pr/p1/2019/2019-06-22/html/reg4-eng.html (accessed 2019 Jul 10).
2 Canadian Medical Association (CMA). Health Canada Consultation on Reducing Youth Access and Appeal of Vaping Products. Ottawa: CMA; 2019 May 24. Available: https://policybase.cma.ca/en/permalink/policy14078 (accessed 2019 Jul 10).
3 Public Health Agency of Canada. Statement from the Council of Chief Medical Officers of Health on the increasing rates of youth vaping in Canada. Ottawa: Health Canada; 2019. Available: https://www.newswire.ca/news-releases/statement-from-the-council-of-chief-medical-officers-of-health-on-the-increasing-rates-of-youth-vaping-in-canada-812817220.html (accessed 2019 Jul 24).
4 Hammond David, Reid Jessica L, Rynard Vicki L, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys BMJ. 2019; 365:2219. Available: https://www.bmj.com/content/bmj/365/bmj.l2219.full.pdf (accessed 2019 Jul 24).
5 WHO Report on the Global Tobacco Epidemic, 2019. Geneva: World Health Organization; 2019. Available: https://apps.who.int/iris/bitstream/handle/10665/326043/9789241516204-eng.pdf?ua=1 (accessed 2019 Jul 30).
6 Dinakar, C., O’Connor GT. The Health Effects of Electronic Cigarettes. N Engl J Med. 2016;375:1372-81. Available: https://www.nejm.org/doi/full/10.1056/NEJMra1502466 (accessed 2019 Jul 30).
7 National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 Jul 29).
8 Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6.
9 Barrington-Trimis JL, Leventhal AM. Adolescents’ Use of “Pod Mod” E-Cigarettes —Urgent Concerns. N Engl J Med 2018; 379:1099-1102. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1805758?articleTools=true (accessed 2019 Jul 30).
10 Chen-Sankey JC, Kong G, Choi K. Perceived ease of flavored e-cigarette use and ecigarette use progression among youth never tobacco users. PLoS ONE 2019;14(2): e0212353. Available: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212353 (accessed 2019 Jul 30).
11 U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. Available: https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf (accessed 2019 Jul 30).
12 Canadian Medical Association (CMA) CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts. Ottawa: CMA; 2017 Apr 7. Available: https://policybase.cma.ca/en/permalink/policy13641 (accessed 2019 Jul 30).
13 Canadian Medical Association. Health Canada consultation on tobacco products regulations (plain and standardized appearance) Ottawa: CMA; 2018 Sep 6. Available: https://policybase.cma.ca/en/permalink/policy13930 (accessed 2019 Jul 30).
14 Goniewicz ML. et al. Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and Combustible Cigarettes JAMA Network Open. 2018;1(8):e185937. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718096 (accessed 2019 Jul 30).
15 Chan LF. Et al. Pulmonary toxicity of e-cigarettes Am J Physiol Lung Cell Mol Physiol. 313: L193–L206, 2017 Available: https://www.physiology.org/doi/pdf/10.1152/ajplung.00071.2017 (accessed 2019 Jul 30).
16 Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control. 0:1-8, 2019.
17 American College of Cardiology. E-Cigarettes Linked to Heart Attacks, Coronary Artery Disease and Depression. Media Release March 7, 2019 Available: https://www.acc.org/about-acc/press-releases/2019/03/07/10/03/ecigarettes-linked-to-heart-attacks-coronary-artery-disease-and-depression (accessed 2019 Jul 30).
18 Centers for Disease Control and Prevention. CDC, states investigating severe pulmonary disease among people who use e-cigarettes. Media Statement 2019 Aug 17. Available: https://www.cdc.gov/media/releases/2019/s0817-pulmonary-disease-ecigarettes.html (accessed 2019 Aug 20).
19 Canadian Medical Association (CMA). Health Canada Consultation on Edible Cannabis, Extracts & Topicals Ottawa: CMA; 2019 Feb 20. Available: https://policybase.cma.ca/en/permalink/policy14020 (accessed 2019 Aug 6).
20 Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis Submission to Health Canada. 2018 Jan 19 Available: https://policybase.cma.ca/en/permalink/policy13838. (accessed 2019 Aug 6).
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on potential markets for cannabis health products that would not require practitioner oversight.1
The CMA’s approach to cannabis is grounded in public health policy. It includes promotion of health and
prevention of problematic use; access to assessment, counseling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines2 and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation,3 and recommendations regarding Bill C-45.4 As well, we submitted comments to Health Canada with respect to the consultation on the proposed regulatory approach for the Cannabis Act, Bill C-45.5 We also responded to Health Canada’s recent Consultation on Edible Cannabis, Extracts & Topicals.6
Overview
The CMA first expressed its concerns about the sale of natural health products containing cannabis in our response to the proposed regulatory approach to the Cannabis Act, Bill C-45.5 We recognize that, in general, health products include prescription health products, non-prescription drugs, natural health products, cosmetics and medical devices. Although all these products are regulated by Health Canada, they are subject to different levels of scrutiny for safety, efficacy and quality, and in some cases, industry does not need to provide scientific evidence to support the claims made on the label.
Health Claims
As with all health products, the CMA supports an approach in which higher risk products, that is, those for which health claims are made, must be subject to a more meticulous standard of review. Rigorous scientific evidence is needed to support claims of health benefits and to identify potential risks and adverse reactions.
We support Health Canada’s proposal that authorized health claims for cannabis health products (CHP) would be permitted for treatment of minor ailments, on the strict condition they are substantiated via a strong evidentiary process. It is the view of the CMA that all such products making a health claim must be reviewed thoroughly for efficacy, as well as safety and quality, for the protection of Canadians.5
Recent experience in the United States supports this approach. A warning letter was sent to Curaleaf Inc. of Wakefield, Massachusetts, by the US Food and Drug Administration (FDA) “for illegally selling unapproved products containing cannabidiol (CBD) online with unsubstantiated claims that the products treat cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety, among other conditions or diseases.”7
This is not the first time it was necessary for the FDA to take such action. The agency had sent letters on previous occasions to other businesses over claims “to prevent, diagnose, treat, or cure serious diseases, such as cancer. Some of these products were in further violation of the Federal Food, Drug and Cosmetic Act because they were marketed as dietary supplements or because they involved the addition of CBD to food.”7
The CMA shares the FDA’s concerns that such claims “can put patients and consumers at risk by leading them to put off important medical care.”7 A study conducted by Dalhousie University found that only 35.8% of respondents were familiar with the biochemical properties of CBD when asked what cannabinoid they thought was potentially a pain killer.8 Systematic reviews and guidelines have highlighted the state of the science and the limited indications for which there is evidence.9,10,11
Both cannabis and CBD specifically have been approved for use in a few conditions, but more research is needed in this rapidly growing field. For example, medical cannabinoids have been approved in several jurisdictions for the treatment of multiple sclerosis but the evidence of how well it works is limited. As the Canadian authors note, “carefully conducted, high-quality studies with thought given to the biologic activity of different cannabis components are still required to inform on the benefits of cannabinoids for patients with MS.”12 Consumers need to be reassured that health claims are being assessed thoroughly so they can make informed decisions.13
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Packaging and Labelling Requirements
The CMA has laid out its position with respect to packaging and labelling with respect to cannabis products.5,6 Strict packaging requirements are necessary as their wider availability raises several public health issues, not the least of which is ingestion by young children. Requirements for tamper-resistant and child-proof containers need to be in place to enhance consumer safety. To reiterate:
a requirement for plain and standard packaging
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause a poisoning
Prescription Drugs Containing Cannabis
The CMA addressed prescription drugs containing cannabis in a previous brief.5 The level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence to support claims of efficacy is needed for a DIN but not for an NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product. As a result, consumers presently do not have enough information to choose appropriate products.
Prescription drugs are subject to Health Canada’s pharmaceutical regulatory approval process, based on each drug’s specific indication, dose, route of administration and target population. Health claims need to be substantiated via a strong evidentiary process. All potential prescription medications containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs (e.g., Marinol® and Sativex®), to protect Canadians from further misleading claims.
The CMA urges caution especially around exemptions for paediatric formulations that would allow for traits that would “appeal to youth.” The CMA understands that these products, used under strict health professional supervision, should be child friendly, for example, regarding palatability, but we do not support marketing strategies that would suggest their use is recreational (e.g., producing them in candy or animal formats).
Recommendations
1. The CMA recommends that all cannabis health products, including those with CBD, making a health claim must be reviewed thoroughly for efficacy, as well as safety and quality, for the protection of Canadians.
2. The CMA recommends that strict packaging requirements be put in place with respect cannabis health products as their wider availability raises several public health issues, not the least of which is ingestion by young children.
3. The CMA recommends tamper-resistant and child-proof containers need to be in place to enhance consumer safety.
4. The CMA recommends that all potential prescription medications containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs to protect Canadians from further misleading claims.
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1Health Canada. Document: Consultation on Potential Market for Cannabis Health Products that would not Require Practitioner Oversight. Ottawa: Health Canada; 2019. Available: https://www.canada.ca/en/health-canada/programs/consultation-potential-market-cannabis/document.html (accessed 2019 Aug 8).
2 Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH. 2017 Aug;107(8):e1-e12. Available: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&. (accessed 2019 Aug 8).
3 Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada – Task Force on cannabis, legalization and regulation. Ottawa: CMA; 2016 Aug 29. Available: https://policybase.cma.ca/en/permalink/policy11954 (accessed 2019 Aug 8).
4 Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of Commons Health Committee. Ottawa: CMA; 2017 Aug 18. Available: https://policybase.cma.ca/en/permalink/policy13723
(accessed 2019 Aug 8).
5 Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis. Ottawa: CMA; 2018 Jan 19. Available: https://policybase.cma.ca/en/permalink/policy13838 (accessed 2019 Aug 8).
6 Canadian Medical Association (CMA). Health Canada Consultation on Edible Cannabis, Extracts & Topicals Ottawa: CMA; Available: https://policybase.cma.ca/en/permalink/policy14020 (accessed 2019 Aug 8).
7 Food and Drug Administration (FDA). FDA warns company marketing unapproved cannabidiol products with unsubstantiated claims to treat cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety. Media Release. Silver Spring, MD: FDA; 2019 Jul 23. Available: https://www.fda.gov/news-events/press-announcements/fda-warns-company-marketing-unapproved-cannabidiol-products-unsubstantiated-claims-treat-cancer (accessed 2019 Aug 15).
8 Charlebois S., Music J., Sterling B. Somogyi S. Edibles and Canadian consumers’ willingness to consider recreational cannabis in food or beverage products: A second assessment. Faculty of Management: Dalhousie University; May, 2019 Available: https://cdn.dal.ca/content/dam/dalhousie/pdf/management/News/News%20%26%20Events/Edibles%20and%20Canadian%20Consumers%20English_.pdf (accessed 2019 Aug 20).
9 Allan GM. Et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician. Feb 2018;64(2):111. Available: https://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Aug 29).
10 Health Canada. Information for Health Care Professionals. Cannabis (marihuana, marijuana) and the cannabinoids) Dried or fresh plant and oil administration by ingestion or other means Psychoactive agent. Ottawa: Health Canada; October 2018. Available: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf (accessed 2019 Aug 29).
11 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press; 2017. Available: http://www.nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx (accessed 2019 Aug 29).
12 Slaven M., Levine O. Cannabinoids for Symptoms of Multiple Sclerosis JAMA Network Open. 2018;1(6):e183484. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706491 (accessed 2019 Aug 26).
13 Food and Drug Administration (FDA). What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD Consumer Updates. Silver Spring, MD: FDA; 2019 July 17. Available: https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis (accessed 2019 Aug 29).
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians.
Seniors Care
Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai.
Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live.
The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process.
The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii
Recommendation:
The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii
Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes.
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Recommendation:
The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv
Access to Care
Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well.
However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues.
There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1.
Figure 1. The Patient’s Medical Home, 2019
The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems
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safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars.
Recommendation:
The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Sustainability plans.
Digital/Virtual Care
Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health.
While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries.
To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x
There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined.
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In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii
Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy.
Recommendation:
The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy.
Climate Change and Health
Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future.
The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease.
Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world.
Recommendation:
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The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice).
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i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19).
ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018.
iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf
iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf
v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19.
vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19.
vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19.
viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19.
ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9.
x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709.
xi Financial Consumer Agency of Canada. About FCAC.
xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on Reducing Youth Access and Appeal of Vaping Products - Consultation on Potential Regulatory Measures.1
Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use.
The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence.
The CMA has stated its position to the federal government on electronic cigarettes and vaping clearly in recent years.2,3 In our April 2017 submission on Bill S-5 to the Senate Standing Committee on Social Affairs, Science and Technology we recommended that the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.2 We also argued that the government should take the same approach to plain and standardized packaging regulations for e-cigarettes as has now been implemented for tobacco products.2
In our most recent brief we addressed the two main issues outlined in the government’s Notice of Intent with respect to the advertising of vaping products: the placement of that advertising and the use of health warnings.3,4 We expressed concerns that the proposed regulations leave too wide an opening for vaping manufacturers to promote their products, especially to youth. Further, we reiterated our position that health warnings for vaping should be like those being considered for tobacco packages.
This brief will address the issues of greatest concern to the CMA with respect to vaping and youth. This includes marketing, flavours, nicotine levels, and reducing vaping and e-cigarette use among youths.
Introduction
The Council of Chief Medical Officers of Health have expressed alarm at the rising number of Canadian youths who are vaping, finding this trend “very troubling.”5 The Canadian Medical Association concurs with this assessment and appeals to the federal government to move urgently on this important public health issue.
As our knowledge about the risks of using e-cigarettes increases, there is an even greater imperative to dissuade youth from taking up the habit. This is important because those youth “who believe that e-cigarettes are not harmful or are less harmful than cigarettes are more likely to use e-cigarettes than youth with more negative views of e-cigarettes.”6
Marketing
The e-cigarette marketplace is evolving quickly as new products emerge. The industry has made clever use of social media channels to promote their wares by taking advantage of the belief that they are a safer alternative to cigarettes.7 They have also promoted “innovative flavoring and highlighted the public performance of vaping.”7 It is no surprise that the United States Food and Drug Administration (FDA) has referred to youth vaping as an “epidemic,” calling it “one of the biggest public health challenges currently facing the FDA.”8 As the US National Academies of Sciences, Engineering, and Medicine has noted “young people who begin with e-cigarettes are more likely to transition to combustible cigarette use and become smokers who are at risk to suffer the known health burdens of combustible tobacco cigarettes.”9
However, some of the efforts employed to convince youth to take up vaping are especially troublesome. As the
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US Centers for Disease Control and Prevention (CDC) reported, “one in 5 (US) high school students and 1 in 20 middle school students reported using e-cigarettes in the past 30 days in 2018,” a significant rise in the number of high school students between 2011 and 2018.10 The use of social media campaigns employing “influencers” to capture more of the youth and young adult market or influence their choices shows the need to be especially vigilant.11 In an attempt to counter this influence, a group of over 100 public health and anti-tobacco organizations from 48 countries “are calling on Facebook, Instagram, Twitter and Snap to take “swift action” to curb advertising of tobacco products on their platforms.”12
As much as the industry is making major efforts to attract or sway customers through advertising, youth themselves may hold the key to countering that pressure. A recent US study found that “adolescents generally had somewhat negative opinions of other adolescents who use e-cigarettes. Building on adolescents’ negativity toward adolescent e-cigarette users may be a productive direction for prevention efforts, and clinicians can play an important role by keeping apprised of the products their adolescent patients are using and providing information on health effects to support negative opinions or dissuade formation of more positive ones.”13 Health Canada can play a major role in encouraging and facilitating peer-to-peer discussions on the risks associated with vaping and help to offset the social media influencers.14
We reiterate the concerns we expressed in our recent brief on the potential measures to reduce advertising of vaping products and to help diminish their appeal to youth. The CMA noted that the sections most problematic to the Association were those encompassing public places, broadcast media, and the publications areas.3 Vaping advertisements should not be permitted at all in any of these spaces, with no exceptions.3 These areas need to be addressed on an urgent basis.
Flavours
As of 2013, over 7,000 flavours had been marketed in the US.15 The data indicated that “about 85% of youth who used e-cigarettes in the past 30 days adopted non-tobacco flavors such as fruit, candy, and dessert.”15 Flavours are helpful in attracting youth, especially when coupled with assertions of lower harm.13 And they have been successful in doing so, as evidenced by the rise in the rates of vaping among youth.8, 16
The addition of a wide variety of flavours available in the pods makes them taste more palatable and less like smoking tobacco.16,17,18 The concern is that e-cigarettes “may further entice youth to experiment with e-cigarettes and boost e-cigarettes’ influence on increased cigarette smoking susceptibility among youth.”15 More worrisome, flavoured e-cigarettes “are recruiting females and those with low smoking-risk profile to experiment with conventional cigarettes.”19
Limiting the availability of “child-friendly flavors” should be considered to reduce the attraction of vaping to youth.19 In a recent announcement, the US FDA has proposed to tighten e-cigarette sales and “remove from the market many of the fruity flavors …blamed on fueling “epidemic” levels of teen use.”20 As we have noted in previous submissions, the CMA would prefer to see flavours banned to reduce the attractiveness of vaping to youth as much as possible, a sentiment shared by other expert groups. 2,3,21
Nicotine Levels
One of the most popular devices to vape with is JUUL™, entering the US market in 2015.22 JUUL’s™ nicotine pods contain 5% nicotine salt solution consisting of 59 mg/mL in 0.7 mL pods.17 Some of JUUL’s™ competition have pods containing even higher levels (6% and 7%).17
The CMA is very concerned about the rising levels of nicotine available through the vaping process, especially by the newer delivery systems. They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.”23
Nicotine, among other issues, “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment.15,24 In addition to flavours, and to ease delivery and to make the taste more pleasant, nicotine salts are added to make the e-liquid “less harsh and less bitter” and “more
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palatable despite higher nicotine levels.”17
Addressing the Rise in Youth Vaping
There are many factors that lead youth to experiment with vaping and e-cigarettes. For some it is simple curiosity, for others it is the availability of different flavours while still others perceive vaping as “cool,” especially when they can use the vapour to perform “smoke tricks.”25 The pod devices themselves (e.g., JUUL™) help enhance the allure because of the “unique aesthetic appeal of pod devices, ability to deliver nicotine at high concentrations and the convenience of using them quickly and discreetly.”26
As vaping continues to grow in popularity, it will not be easy to curb youths’ enthusiasm for it. However, it is too important of a public health issue to not intervene More research is needed into how youth perceive vaping and e-cigarettes as they do not hold a universally positive view of the habit.7,13 As well, there is evidence to suggest that many are coming to see vaping as being “uncool” and that there are potential health consequences to continued use.25
In view of the still-evolving evidence of the safety of vaping and e-cigarettes, “strategic and effective health communication campaigns that demystify the product and counteract misconceptions regarding e-cigarette use are needed.”25 Further, “to reduce youth appeal, regulation efforts can include restricting the availability of e-cigarette flavors as well as visible vapors.”25 Another approach to consider is the state of Colorado’s recent creation of “a health advisory recommending that health care providers screen all youth specifically for vaping, in addition to tobacco use, because young people may not necessarily associate tobacco with vaping.”27
Recommendations
1. The CMA calls for all vaping advertising to be strictly limited. The restrictions on the marketing and promotion of vaping products and devices should be the same as those for tobacco products.
2. The CMA recommends the limitation of number of flavours available to reduce the attractiveness of vaping to youth.
3. Health Canada should work to restrict the level of nicotine available for vaping products to avoid youth becoming addicted.
4. Health Canada must play a major role in encouraging and facilitating peer-to-peer discussions on the risks associated with vaping and help to offset the social media influencers.
5. Health Canada must develop communication campaigns directed at youth, parents and health care providers to demystify vaping and e-cigarettes and that create a link between tobacco and vaping.
1 Government of Canada. Reducing Youth Access and Appeal of Vaping Products - Consultation on Potential Regulatory Measures. Ottawa: Health Canada; 2019. Available: https://www.canada.ca/en/health-canada/programs/consultation-reducing-youth-access-appeal-vaping-products-potential-regulatory-measures.html (accessed 2019 Apr 11).
2 Canadian Medical Association (CMA). CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Nonsmokers’ Health Act and to make consequential amendments to other Acts. Ottawa: CMA; 2017 Apr 7. Available: https://policybase.cma.ca/en/permalink/policy13641 (accessed 2019 May 13).
3 Canadian Medical Association (CMA). Health Canada consultation on the impact of vaping products advertising on youth and non-users of tobacco products. Ottawa: CMA; 2019 Mar 22. Available: https://policybase.cma.ca/en/permalink/policy14022 (accessed 2019 May 13).
4 Government of Canada. Notice to Interested Parties – Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products. Ottawa: Health Canada; 2019. Available:
https://www.canada.ca/en/health-canada/programs/consultation-measures-reduce-impact-vaping-products-advertising-youthnon-users-tobacco-products.html (accessed 2019 Feb 27).
5 Public Health Agency of Canada. Statement from the Council of Chief Medical Officers of Health on the increasing rates of youth vaping in Canada. Health Canada; 2019. Available: https://www.newswire.ca/news-releases/statement-from-the-council-of-chief-medical-officers-of-health-on-the-increasing-rates-of-youth-vaping-in-canada-812817220.html (accessed 2019 May 14).
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6 Glantz SA. The Evidence of Electronic Cigarette Risks Is Catching Up with Public Perception. JAMA Network Open 2019;2(3):e191032. doi:10.1001/jamanetworkopen.2019.1032. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729460 (accessed 2019 May 14).
7 McCausland K., et al. The Messages Presented in Electronic Cigarette–Related Social Media Promotions and Discussion: Scoping Review. J Med Internet Res 2019;21(2):e11953). Available: https://www.jmir.org/2019/2/e11953/ (accessed 2019 May 14).
8 Food and Drug Administration (FDA). Statement from FDA Commissioner Scott Gottlieb, M.D., on new data demonstrating rising youth use of tobacco products and the agency’s ongoing actions to confront the epidemic of youth e-cigarette use. Silver Spring, MD: FDA; February 11, 2019. Available: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-data-demonstrating-rising-youth-use-tobacco (accessed 2019 May 17).
9 National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 May 17).
10 Kuehn B. Youth e-Cigarette Use. JAMA. 2019;321(2):138. Available: https://jamanetwork.com/journals/jama/fullarticle/2720740 (accessed 2019 May 14).
11 Kirkum C. Philip Morris suspends social media campaign after Reuters exposes young 'influencers'. New York: Reuters; May 10, 2019. Available: https://www.reuters.com/article/us-philipmorris-ecigs-instagram-exclusiv/exclusive-philip-morris-suspends-social-media-campaign-after-reuters-exposes-young-influencers-idUSKCN1SH02K (accessed 2019 May 13).
12 Kirkham C. Citing Reuters report, health groups push tech firms to police tobacco marketing. New York: Reuters; May 22, 2109. Available: https://www.reuters.com/article/us-philipmorris-ecigs-socialmedia/citing-reuters-report-health-groups-push-tech-firms-to-police-tobacco-marketing-idUSKCN1SS1FX (accessed 2019 May 22).
13 McKelvey K, Popova L, Pepper JK, Brewer NT, Halpern-Felsher. Adolescents have unfavorable opinions of adolescents who use e-cigarettes. PLoS ONE 2018;13(11): e0206352. Available: https://doi.org/10.1371/journal.pone.0206352 (accessed 2019 May 14).
14 Calioa D. Vaping an 'epidemic,' Ottawa high school student says. Ottawa: CBC News; November 27, 2018. Available: https://www.cbc.ca/news/canada/ottawa/vaping-epidemic-ottawa-high-school-student-says-1.4918672 (accessed 2019 May 14).
15 Chen-Sankey JC, Kong G, Choi K. Perceived ease of flavored e-cigarette use and ecigarette use progression among youth never tobacco users. PLoS ONE 2019;14(2): e0212353. Available: https://doi.org/10.1371/journal.pone.0212353 (accessed 2019 May 17).
16 Drazen JM, Morrissey S, Campion EW. The Dangerous Flavors of E-Cigarettes. N Engl J Med 2019; 380:679-680. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMe1900484?articleTools=true (accessed 2019 May 17).
17 Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6. Available: https://www.ncbi.nlm.nih.gov/pubmed/30733312 (accessed 2019 May 20).
18 Reichardt EM., Guichon J. Vaping is an urgent threat to public health. Toronto: The Conversation; March 13, 2019. Available: https://theconversation.com/vaping-is-an-urgent-threat-to-public-health-112131 (accessed 2019 May 20).
19 Chen JC. et al. Flavored E-cigarette Use and Cigarette Smoking Susceptibility among Youth. Tob Regul Sci. 2017 January ; 3(1): 68–80. Available: https://www.ncbi.nlm.nih.gov/pubmed/30713989 (accessed 2019 May 20).
20 LaVito A. FDA outlines e-cigarette rules, tightens restrictions on fruity flavors to try to curb teen vaping. New Jersey: CNBC; March 13, 2019 Available: https://www.cnbc.com/2019/03/13/fda-tightens-restrictions-on-flavored-e-cigarettes-to-curb-teen-vaping.html (accessed 2019 Mar 20).
21 Ireland N. Pediatricians call for ban on flavoured vaping products — but Health Canada isn't going there. Toronto: CBC News; November 17, 2018 Available: https://www.cbc.ca/news/health/canadian-pediatricians-flavoured-vaping-second-opinion-1.4910030 (accessed 2019 May 20).
22 Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tobacco Control 2019;28:146-151. Available: https://tobaccocontrol.bmj.com/content/tobaccocontrol/28/2/146.full.pdf (accessed 2019 May 21).
23 Barrington-Trimis JL, Leventhal AM. Adolescents’ Use of “Pod Mod” E-Cigarettes — Urgent Concerns. N Engl J Med 2018; 379:1099-1102. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1805758?articleTools=true (accessed 2019 May 20).
24 U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. Available: https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf (accessed 2019 May 20).
25 Kong G. et al. Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults. Nicotine & Tobacco Research, 2015 Jul;17(7):847-54. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674436/pdf/ntu257.pdf (accessed 2019 May 21).
26 Keamy-Minor E, McQuoid J, Ling PM. Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study. BMJ Open. 2019;9:e026306. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500190/pdf/bmjopen-2018-026306.pdf (accessed 2019 May 21).
27 Ghosh TS, Et al. Youth Vaping and Associated Risk Behaviors — A Snapshot of Colorado. N Engl J Med 2019; 380:689-690.Available: https://www.nejm.org/doi/full/10.1056/NEJMc1900830 (accessed 2019 May 21).
Re: Standing Committee on Health’s study on violence faced by healthcare workers
Dear Mr. Casey:
I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for
consideration by the Standing Committee on Health (the Committee) as part of the study on violence
faced by healthcare workers.
The CMA is deeply concerned with the state of workplace safety in all health care settings, including
hospitals, long-term care, and home care settings. As in all experiences of violence, it is
unacceptable for healthcare workers to be victims of violence in the provision of care to patients.
While there is limited data nationally to understand the incidence of violence against healthcare
workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity.
A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in
the previous month, nearly one-third of respondents had been exposed to some form of aggressive
behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family
physicians in active practice are subjected to regular abuse from their patients or family members of
their patients.”1
These concerns were brought to the CMA’s General Council in 2015, where our members passed a
resolution calling for:
“the federal government to amend the Criminal Code by making it a specific criminal offence to
assault health care providers performing their duties.”
The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a
recognition of the role of the workplace, primarily health care settings, and safe working conditions as
having an important influence of physician health and wellness.
…/2
1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family
Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9).
Mr. Bill Casey
Addressing violence against providers in healthcare settings will require action from both federal and
provincial/territorial governments. In light of the above, the CMA respectfully submits the following
recommendations for consideration by the Committee in its study on violence against healthcare
workers:
1) The CMA recommends that the Committee on Health support the call to amend the Criminal
Code of Canada to introduce a new criminal offence for assault against a healthcare
provider performing their duty.
2) The CMA recommends that the Committee on Health support establishing monitoring of
violence against healthcare workers, that is consistent across jurisdictions, and have an active
role in responding appropriately to trends.
3) The CMA recommends that the Committee on Health support federal leadership in a pan-
Canadian approach to support workplace safety in healthcare settings, including
collaborating with the provinces and territories to improve violence prevention.
Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by
Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy
to address growing incidents of violence against health care workers.”
In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the
Committee’s report on this topic and the opportunity to collaborate on federal and
provincial/territorial action in this matter.
Sincerely,
F. Gigi Osler, BScMed, MD, FRCSC
President
c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health
Don Davies, M.P., Vice Chair Standing Committee on Health
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products under the authority of the Tobacco and Vaping Products Act (TVPA).
Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes.
This brief will address the two main issues outlined in the Notice of Intent: the placement of advertising and health warnings.
Placement of Advertising
The CMA’s approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence.
In our April 2017 submission on Bill S-5 to the Senate Standing Committee on Social Affairs, Science and Technology we recommended that the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. This would include the same approach to plain and standardized packaging regulations under consideration for tobacco products.2,
The CMA is concerned that the proposed regulations leave too wide an opening for vaping manufacturers to promote their products, especially to youth. It is from a public health perspective that the CMA is calling for all vaping advertising to be strictly limited. The CMA supports the provisions proposed for point-of-sale information. The material offered will need to have the health warnings included in this Notice of Intent.
However, the sections of the proposed regulations most problematic to the CMA are those encompassing public places, broadcast media, and the publications areas. Vaping advertisements should not be permitted at all in any of these spaces, with no exceptions.2 The advertisements permitted currently seem to have managed to find their way to youth, even if they are not directed at them, as claimed. A report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.” Social media provides an easy means of promoting vaping products and techniques, especially to youth.21 A US study found that the landscape is “being dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents, whereas the uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues.” The authors recommended that “real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals.”6
The need to address the issue of advertising around vaping is growing more urgent. Vaping is becoming more popular and more attractive to Canadian youth, especially with the arrival of more high-tech versions of electronic cigarettes such as the pod-based JUUL™. , A similar trend has been observed in the United States where a recent study indicated that “use by adolescents and young adults of newer types of e-cigarettes such as pod-based systems is increasing rapidly.”
JUUL™ entered the US market in 2015 “with a novel chemistry (nicotine salts) enabling higher concentrations in a limited aerosol plume.” JUUL’s™ nicotine levels contained 5% nicotine salt solution consisting of 59 mg/mL in 0.7 mL pods. Some of JUUL’s™ competition have pods containing even higher levels (6% and 7%).10 The nicotine salts are “less harsh and less bitter, making e-liquids more palatable despite higher nicotine levels.”10 It has been noted by researchers that “among adolescents and young adults who use them, pod-based e-cigarettes are synonymous with the brand-name JUUL™ and use is termed “juuling,” whereas “vaping” has typically been used by youths to refer to using all other types of e-cigarettes.”9
The addition of a wide variety of flavours available in the pods makes them taste more palatable and less like smoking tobacco.10, The purpose in doing so is because “smoking is not a natural behavior, like eating or drinking, the manufacturers of these devices commonly add flavoring to the liquid from which the nicotine aerosol is generated, to make the initial exposures more pleasurable. The flavoring enhances the appeal to first-time users — especially teenagers.” The CMA and other expert groups would prefer to see flavours banned to reduce the attractiveness of vaping as much as possible.2, It is very important that the pod-based systems are cited specifically to ensure they are included under the new advertising regulations for all vaping products.
Youth vaping has reached the point where the US Food and Drug Administration referred to it as an “epidemic,” calling it “one of the biggest public health challenges currently facing the FDA.” Durham Region Health Department, using data from the Ontario Student Drug Use and Health Survey conducted by CAMH and administered by the Institute for Social Research, York University, noted that 17% of high school students in that region had used an electronic cigarette in the past year (2016-17), numbers that are similar for the rest of Ontario. In the United States, a survey indicated that, among high school students, “current e-cigarette use increased from 1.5% (220,000 students) in 2011 to 20.8% (3.05 million students) in 2018;” between 2017 and 2018 alone it rose 78% (from 11.7% to 20.8%).
Concern is growing across Canada among educators seeing a rise in the number of youths turning to vaping. , , The problem has reached the point where a school official resorted to removing the doors from the washrooms to “crack down” on vaping in the school. Youth themselves are aware of the increasing problem; many are turning to YouTube to learn “vape tricks” such as making smoke rings. Some refer to the practice of vaping as “the nic;” as a University of Ottawa student noted “They call it getting light-headed. Sometimes it's cool.”
As the Canadian Paediatric Society noted in 2015, efforts to “denormalize tobacco smoking in society and historic reductions in tobacco consumption may be undermined by this new ‘gateway’ product to nicotine dependency.” , Decades of effort to reduce the incidence of smoking are in danger of being reversed. A growing body of evidence indicates that vaping can be considered the prime suspect. A Canadian study provides “strong evidence” that use of electronic cigarettes among youth is leading them to the consumption of combustible tobacco products. In a similar vein, a “large nationally representative study of US youths supports the view that e-cigarettes represent a catalyst for cigarette initiation among youths.” Granting vaping manufacturers scope to advertise will likely exacerbate this problem.
Health Warnings
The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages.2,3 We support the proposed warning labels being placed on all vaping products. The need for such warnings is important as there is still much that is not known about the effects vaping can have on the human body.
Substances that have been identified in e-cigarette liquids and aerosols include “nicotine, solvent carriers (PG and glycerol), tobacco-specific nitrosamines (TSNAs), aldehydes, metals, volatile organic compounds (VOCs), phenolic compounds, polycyclic aromatic hydrocarbons (PAHs), flavorings, tobacco alkaloids, and drugs.” Researchers have noted that there is a “striking diversity of the flavorings in e-cigarette liquids, (and that) the effects on health of the aerosol constituents produced by these flavorings are unknown.”
A US study found “evidence that using combusted tobacco cigarettes alone or in combination with e-cigarettes is associated with higher concentrations of potentially harmful tobacco constituents in comparison with using e-cigarettes alone.” Some researchers have found that there is “significant potential for serious lung toxicity from e-cig(arette) use.” ,
Another recent US study indicates that “adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don’t use them or any tobacco products.” Further, it was found that “compared with nonusers, e-cigarette users were 56 percent more likely to have a heart attack and 30 percent more likely to suffer a stroke.”32
The need for parents to be educated on the impact of vaping on children is also very important. A study examining how smoke-free and vape-free home and car policies vary for parents who are dual users of cigarettes and e-cigarettes, who only smoke cigarettes, or who only use e-cigarettes demonstrated that these parents may perceive e-cigarette aerosol as safe for children. It noted that “dual users were less likely than cigarette-only smokers to report various child-protective measures inside homes and cars.”33
Recommendations
1. The CMA calls for all vaping advertising to be strictly limited. The restrictions on the marketing and promotion of vaping products and devices should be the same as those for tobacco products.
2. The CMA recommends that vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions.
3. The CMA supports the provisions proposed in this Notice of Intent for point-of-sale information. This should include health warnings.
4. The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages. We support the proposed warning labels being placed on all vaping products.
5. The CMA recommends more research into the health effects of vaping as well as on the components of the vaping liquids.
Government of Canada. Notice to Interested Parties – Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products Ottawa: Health Canada; 2019 Available: https://www.canada.ca/en/health-canada/programs/consultation-measures-reduce-impact-vaping-products-advertising-youth-non-users-tobacco-products.html (accessed 2019 Feb 27)
Canadian Medical Association (CMA) CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts Ottawa: CMA; 2017 Apr 7. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-06.pdf (accessed 2019 Mar 1).
Canadian Medical Association. Health Canada consultation on tobacco products regulations (plain and standardized appearance) Ottawa: CMA; 2018 Sep 6 Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2019-01.pdf (accessed 2019 Mar 5)
Gagnon E. IMPERIAL TOBACCO: Kids shouldn’t be vaping; our marketing is aimed at adults. Halifax Chronicle Herald March 5, 2019 Available: https://www.thechronicleherald.ca/opinion/imperial-tobacco-kids-shouldnt-be-vaping-our-marketing-is-aimed-at-adults-289673/ (accessed 2019 Mar 8)
U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva,
CH: World Health Organization; 2016. Available https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/docs/m21_complete.pdf (accessed 2019 Mar 8)
McCausland K, Maycock B, Leaver T, Jancey J. The Messages Presented in Electronic Cigarette–Related Social Media Promotions and Discussion: Scoping Review J Med Internet Res 2019;21(2):e11953 Available: https://www.jmir.org/2019/2/e11953/ (accessed 2019 Mar 14)
Glauser W. New vaping products with techy allure exploding in popularity among youth. CMAJ 2019 February 11;191:E172-3. doi: 10.1503/cmaj.109-5710 Available: http://www.cmaj.ca/content/191/6/E172 (accessed 2019 Mar 1)
Crowe K. Canada's 'wicked' debate over vaping CBC News February 2, 2019 Available https://www.cbc.ca/news/health/vaping-juul-vype-health-canada-cigarette-smoking-nicotine-addiction-1.5003164 (accessed 2019 Mar 8)
McKelvey K et al. Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic Cigarettes. JAMA Network Open. 2018;1(6):e183535. doi:10.1001/jamanetworkopen.2018.3535 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707425 (accessed 2019 Mar 1)
Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6. doi:10.1136/tobaccocontrol-2018-054796 Available: https://www.ncbi.nlm.nih.gov/pubmed/30733312 (accessed 2019 Mar 12)
Reichardt EM., Guichon J. Vaping is an urgent threat to public health The Conversation March 13, 2019 Available: https://theconversation.com/vaping-is-an-urgent-threat-to-public-health-112131 (accessed 2019 Mar 14)
Drazen JM., Morrissey S., Campion, EW. The Dangerous Flavors of E-Cigarettes. N Engl J Med 2019; 380:679-680 Available: https://www.nejm.org/doi/full/10.1056/NEJMe1900484 (accessed 2019 Mar 13)
Ireland N. Pediatricians call for ban on flavoured vaping products — but Health Canada isn't going there CBC News November 17, 2018 Available: https://www.cbc.ca/news/health/canadian-pediatricians-flavoured-vaping-second-opinion-1.4910030 (accessed 2019 Mar 13)
Food and Drug Administration Statement. Statement from FDA Commissioner Scott Gottlieb, M.D., on new data demonstrating rising youth use of tobacco products and the agency’s ongoing actions to confront the epidemic of youth e-cigarette use Media Release February 11, 2019 Available: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm631112.htm (accessed 2019 Mar 11)
Durham Region Health Department Students’ use of e-cigarettes in the past year, 2016-2017 Quick Facts December 2018 Available https://www.durham.ca/en/health-and-wellness/resources/Documents/HealthInformationServices/HealthStatisticsReports/E-cigaretteAlternativeSmokingDeviceStudents-QF.pdf (accessed 2019 Mar 11)
Cullen KA et al. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018 Morbidity and Mortality Weekly Report November 16, 2018 Vol. 67 No. 45 Available: https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm (accessed 2019 Mar 13)
Munro N. Vaping on the rise in Nova Scotia high schools Halifax Chronicle Herald March 5, 2019 Available: https://www.thechronicleherald.ca/news/local/vaping-on-the-rise-in-nova-scotia-high-schools-289761/ (accessed 2019 Mar 11)
Soloducha A. Is your child vaping? Regina Catholic Schools educating parents as trend continues to rise CBC News March 1, 2019 Available https://www.cbc.ca/news/canada/saskatchewan/regins-catholic-schools-vaping-education-1.5039717 (accessed 2019 Mar 11)
Emde W. Growth of vaping labelled ‘crisis’ in Vernon. Kelowna Daily Courier Available http://www.kelownadailycourier.ca/life/article_253d6404-4168-11e9-934f-7b6df68fb0fd.html (accessed 2019 Mar 11)
Lathem C. Ottawa principal's solution to student vaping: Remove the washroom doors. CTV News January 9, 2019 Available https://www.ctvnews.ca/canada/ottawa-principal-s-solution-to-student-vaping-remove-the-washroom-doors-1.4246317 (accessed 2019 Mar 11))
Calioa D. Vaping an 'epidemic,' Ottawa high school student says CBC News November 27, 2018 Available https://www.cbc.ca/news/canada/ottawa/vaping-epidemic-ottawa-high-school-student-says-1.4918672 (accessed 2019 Mar 11)
Schnurr J. New data is showing a worrisome trend about vaping and smoking among teens CTV News January 18, 2019 Available https://ottawa.ctvnews.ca/new-data-is-showing-a-worrisome-trend-about-vaping-and-smoking-among-teens-1.4260008 (accessed 2019 Mar 11)
Stanwick R. E-cigarettes: Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada Policy Statement Canadian Paediatric Society March 6, 2015 (Reaffirmed February 28, 2018) Available: https://www.cps.ca/en/documents/position/e-cigarettes (accessed 2019 Mar 12)
Fairchild AL., Bayer R., Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco
“endgame.” N Engl J Med 370:4 January 23, 2014 Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1313940 (accessed 2019 Mar 12)
Hammond d. et al. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. CMAJ October 30, 2017 189 (43) E1328-E1336; Available: http://www.cmaj.ca/content/189/43/E1328 (accessed 2019 Mar 1)
Berry KM et al. Association of Electronic Cigarette Use With Subsequent Initiation of Tobacco Cigarettes in US Youths JAMA Network Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723425?resultClick=3 (accessed 2019 Mar 12)
National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24952. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 Mar 13)
Dinakar, C., O’Connor GT. The Health Effects of Electronic Cigarettes. N Engl J Med 2016;375:1372-81 Available: https://www.nejm.org/doi/full/10.1056/NEJMra1502466 (accessed 2019 Mar 13)
Goniewicz ML. et al. Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and Combustible Cigarettes JAMA Network Open. 2018;1(8):e185937 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718096 (accessed 2019 Mar 13)
Chan LF. Et al. Pulmonary toxicity of e-cigarettes Am J Physiol Lung Cell Mol Physiol 313: L193–L206, 2017 Available: https://www.physiology.org/doi/full/10.1152/ajplung.00071.2017?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed (accessed 2019 Mar 13)
Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control. 0:1-8, 2019.
American College of Cardiology. E-Cigarettes Linked to Heart Attacks, Coronary Artery Disease and Depression. Media Release March 7, 2019 Available: https://www.acc.org/about-acc/press-releases/2019/03/07/10/03/ecigarettes-linked-to-heart-attacks-coronary-artery-disease-and-depression (accessed 2019 Mar 13)
Drehmer JE, Nabi-Burza E, Hipple Walters B, et al. Parental Smoking and E-cigarette Use in Homes and Cars. Pediatrics. 2019;143(4):e20183249 Available: https://pediatrics.aappublications.org/content/early/2019/03/07/peds.2018-3249 (accessed 2019 Mar 13)
Auditing Physician Billings
Purpose:
The CMA has developed a set of guiding principles to assist in the formation and modification of provincial/territorial billing audit processes. These principles will ensure that billing audit systems are fair, transparent, effective and timely, and that they uphold their original objectives of ensuring the accountability of public expenditures and educating physicians on appropriate billing practices.
Background:
As payments to physicians are made through public monies, the integrity of the payment system is validated through physician billing audits and reviews. Audits and reviews are usually prompted by: billings that appear to be outside of the “norm,” patient complaints, physician complaints or a “focus” on a particular service/area of practice/group of physicians. Each province/territory is responsible for and has in place particular processes and procedures to review physician billings.
Billing audits can be stressful events that, regardless of the audit outcome, have had adverse effects on a physician’s health and practice. Although changes over the years in billing audit practices have occurred, they have not addressed all of the physicians’ concerns. Inadequacies in the existing procedures, such as the lack of a clear decision-making process, established review timelines and options for recourse still remain.
In response to this situation, many provinces/territories are reviewing and modifying their existing billing audit process. The CMA and Canada’s physicians believe in an open, accountable and transparent health care financing system. It is for this reason that the CMA has developed this set of principles related to the key components of the audit process to ensure it is fair, efficient, effective and serves the purpose it was originally intended – to ensure the accountability of public funds and to educate physicians on proper billing practices.
Principles:
Education on proper billing practices:
The audit and review process must be undertaken as an educational exercise. In a fee based system, billing code use and interpretation are complex and can often lead to unintentional errors. If or when inconsistencies occur, the physician must be alerted and provided with the opportunity to explain his/her billing behaviour.
To assist in moving the audit and review process from under a cloud of perceived punishment to that of educational enlightenment, the repayment of any funds shall not commence until the audit and review process is complete and all appeal options have been exercised.
As part of this overall educational framework, it is recommended that all newly licensed physicians be offered an educational program on proper billing interpretations, procedures and practices, and of the audit process itself.
Fair, Transparent and Timely Process:
In order for the audit and review process to be perceived as fair, it must operate at arms length from governments and the Colleges. As a profession, physicians have been granted the privilege of self-regulation by society. Given that medicine is a highly complex art and science, physicians are the only group truly qualified to set and maintain standards and to uphold accountability in matters of professional behaviour.
The billing audit and review process must observe the principles of “Natural Justice” in that the:
audit findings must be both impartial and be seen to be impartial and
physicians affected by the findings must be offered a fair hearing by being given notice in writing of the findings; the opportunity to respond to the findings; all of the information to prepare a response; sufficient time to prepare a response; and an oral hearing if there is a dispute on factual matters or if requested by the physician.
Physicians should be informed that legal counsel and assistance can be retained at any stage of the audit and review process. Physicians should consult with their respective provincial/territorial division or the Canadian Medical Protective Association (CMPA) to see whether such assistance is available, or with lawyers who specialize in this field.
Specific time limits should be adhered to in the auditing and reviewing of a physician’s billings practice, particularly related to when the review period should commence and to the duration of the review period. For example, billings should not be reviewable more than 24 months after the service is rendered and the review period should not be greater than 12 months. These limitation periods recognize that physicians will not be able to recall, with certainty, the vast amount of information contained in a patient’s medical record over the past 10 years – the average length of time in which medical records must be held. It also ensures that audits and reviews are conducted in a timely fashion minimizing undue stress and hardship on the physician and, in light of the health human resources shortage, enabling them to re-focus their attention and energy on taking care of their patients.
Informed Decision-Makers:
Audits and reviews to determine whether there has been any incorrect or inaccurate billing should be undertaken solely by a physician’s peers, and where possible, consisting of physicians from the same specialty and subspecialty and with similar practice type, geography and demography. This peer review group shall consider age-gender distribution and the morbidity of the patients as well as other pertinent matters in arriving at its findings and conclusions.
Outcomes:
Any conclusions and/or findings from an audit and review must be prepared in a written report and forwarded, in a timely manner, to the physician and the paying agency. If either party is not satisfied with the findings, they have the option of launching an appeal.
The preferred route would be to pursue and use Alternative Dispute Resolution processes since they tend to encourage a more co-operative climate resulting in fair and appropriate settlements, while avoiding the excessive financial, psychological and procedural costs that can be associated with formal court proceedings.
Conclusion:
These guiding principles are the product of an international, provincial and territorial scan of billing audit practices. They have undergone extensive consultation with the provincial/territorial medical associations and national medical organizations.
They should be used to form the foundation of and to guide any reviews or modifications to existing provincial/territorial audit and review processes.
CMA Policy, Medical Professionalism, 2002.
Student Behaviour Guide_Natural.Justice.htm, Dec. 2002
The Canadian Medical Association urges federal/provincial/territorial governments to explore tax incentives as a possible component of a broad comprehensive strategy to increase physical activity.
The Canadian Medical Association urges federal/provincial/territorial governments to explore tax incentives as a possible component of a broad comprehensive strategy to increase physical activity.
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The Canadian Medical Association urges federal/provincial/territorial governments to explore tax incentives as a possible component of a broad comprehensive strategy to increase physical activity.
I. PURPOSE
While Canada is undergoing significant social, political and economic change, the Canadian Medical Association (CMA) remains committed to the delivery of high quality health care and to safeguarding the national integrity of the health system. However, given the need for the federal government to gain control over our deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority.
In this regard, CMA appreciates the invitation to submit its views on the 1995 pre-budget consultations that are underway. One overriding objective of the brief is to provide the Committee with a better understanding of the current pressures on physicians across Canada that have arisen as a direct result of past government decisions in this area. It is our firmly-held position that the health care system in general, and the medical profession in particular, have paid more than their fair share in terms of contributing to debt management.
This brief focusses on five somewhat distinct areas of concern to Canadian physicians: (1) federal health transfers to the provinces; (2) taxable health benefits; (3) the goods and services tax (GST); (4) Registered Retirement Savings Plan (RRSP) contributions, and (5) the Lifetime Capital Gains Exemption (LCGE) for Small Businesses. In each case, the brief contains specific recommendations as to what the government should do, and more importantly what the government should not do, to balance its short-term deficit reduction targets against longer-term Canadian values.
To summarize, good health policy and prudent economic policy go hand-in-hand provided the principles of fairness and good management practices are observed. If change is to come within an overall policy framework that is strategic, coordinated and fair and which preserves (or augments) the integrity of Canada's health care system, it behooves us to avoid short-term, stop-gap initiatives. As the government's 1994 Throne Speech put it "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health, change must take place within the context of a longer-term integrated view.
II. BACKGROUND...."Medicare Is A Shared Value"
Canada's system of universal health insurance is still one of the best in the world. Experts from around the world travel many thousands of miles to study and, in some cases, emulate our system.
For most Canadians, medicare is a highly cherished, integral component of our social fabric. While Medicare's popularity has not diminished over the past 30 years, it is sometimes taken for granted in these difficult economic times. Recent public opinion surveys indicate that 84% of Canadians (with the highest response in Quebec) see medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians are of the opinion that the system provides high quality care. 1
At the same time, however, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term 2 and they are right.
As much loved as the Canadian medicare system is, there is a large and growing consensus that we need to make changes. This brief is not about maintaining the status quo. Rather, it is about managing the changes required in the long-term best interests of all Canadians and of the physicians who are ultimately responsible for serving those interests, subject to the fiscal realities confronting government.
III. CONSIDERATIONS
CMA acknowledges that there is a pressing need, now more than ever, for the federal government to balance a number of competing social and economic policy challenges. In a time when deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Health care is no exception, having done so for quite some time. At the same time, we must re-evaluate the variety of services provided or paid for by government.
Deficit Management, but at what Costs?
As of 1993/94, Canada's net public debt stood at $508.2 billion, or $17,484 for every Canadian. Combined with the debts of the provinces and territories, our national debt is in excess of $700 billion. Not to understate the case, currently one-third of each revenue dollar the government collects is allocated to debt service payments on the federal debt. 3 CMA believes enough is enough: we must not pass this burden on to future generations of Canadians.
The federal government has managed to run operating surpluses for five of the past seven years. 4 While this is necessary it is no longer sufficient to meet our fiscal challenges. Maintaining the status quo would mean that debt service payments would further crowd out government expenditures at an accelerated rate.
While the government's first priority should be to get us "out of hock", there is an equally- compelling need to respect the longstanding and fundamental principle of fairness/equity that help define Canadian society. One step toward meeting these twin objectives is to consider all possible methods of repatriating that portion of the national debt held by the international lending community. Some experts have argued that Canada, as a country, can no longer afford to have "massive leakages" in interest payments to individuals/countries abroad. 5 In so doing, we would also repatriate our ability as a sovereign nation to set and maintain social policy objectives. This involves guarding against the persistent "tyranny of the deficit" and the influence that international bond rating agencies can exert on the economy.
Facts and Fallacies about Health Spending
In reviewing expenditures in the public sector, some would suggest that health and health care spending are "out of control". This is a myth. While it is true that Canada spends 10.0% (1993) of Gross Domestic Product (GDP) on health care (second highest among OECD countries), the reality is that the public sector share of total health care expenditures has fallen from 76.4% in 1975 to approximately 71.9% in 1993 6 (falling to the lowest third of OECD countries).
This process of reducing real public sector expenditures, in the absence of a well-coordinated and planned framework, has not always been in the best interests of health and health care. Specifically, federal offloading in terms of unilateral reductions in health cash transfers to the provinces have been followed by:
* the elimination of entire programs, such as dental insurance programs for children and universal drug insurance programs;
* hospital closures (e.g., 52 hospitals in Saskatchewan);
* massive regionalization of health programs and the attendant disempowerment of community hospital boards;
* the reduction of total bed capacity by as much as 20% in some provinces;
* the reduction in medical school enrolment by 10% and a planned 10% reduction in post-MD residency slots;
* global medical care expenditure caps in virtually every province in Canada;
* individual physician income thresholds in at least five provinces;
* a moratorium on interprovincial mobility of physicians;
* legislative overrides of duly-negotiated contracts for health care providers;
* widespread restrictions on the operation of high technology equipment; and
* the de facto "expropriation" of physician business practices without compensation (e.g., Saskatchewan pathologists).
These repercussions also serve to underline the fact that change is the only constant in the health care system. Many physicians across the country have expressed concerns that such changes or "threats" to our health care system are already beginning to have serious consequences for individual patients in terms of access to needed medical facilities. If the national integrity of medicare is to survive, federal fiscal policy changes must be assessed within a larger and longer-term framework; one that respects the need for innovation and professionalism in the health care system.
Physicians as Responsible Professionals
Some mistakenly argue that physician expenditures are responsible for the increasing costs to the health care system. The reality is that physician expenditures as a proportion of total health care expenditures in Canada have declined from 15.7% in 1975 to 15.1 in 1991. 7 Furthermore, physician expenditures constitute a declining share of GDP. Given the recent round of unilateral reductions in medical care spending in many jurisdictions, this percentage share will continue to drop significantly as more recent data become available.
As health care resources have become increasingly constrained, physicians have taken on added responsibilities at the macro, meso and micro levels to better manage our health resources.
* At the "macro" level, within the provinces and territories, the medical profession has been engaged in formalized consultation structures known as "Joint Management Committees" or "Administrative Councils" with government and other stakeholders to ensure value for money within a diminishing "real" globe of publicly-available resources for health care.
* At the "meso" or institutional level, physicians are working hand-in-hand with health care administrators and other community stakeholders to "rationalize" services so as to provide the best value for money in all areas. In addition, to give a greater voice for choice and improve overall accountabilities in the system, physicians are providing formal input to governments that are looking to regionalize health system operations.
* At the "micro" or clinical level, physicians have been taking the lead in developing and disseminating clinical practice guidelines (CPGs) to ensure that the care provided is both appropriate and cost-effective. More can and is being done, in collaboration with government, to ensure responsible use of the taxpayer's dollar while meeting the needs of individual patients.
At all levels, physicians will continue to involve themselves as capable and responsible professionals. As the health policy agenda continues its rapid pace, physicians and the organizations that represent them should be viewed as "agents" for, rather than "objects" of, change.
Good Health Policy Means Good Economic Policy
Agencies such as the World Economic Forum, 8 tell us that our system of financing health care is one of Canada's greatest assets in competing in the new world economic order. We should heed this advice, as the Prime Minister recently observed. Compared to the United States, this economic advantage takes the form of 30 percent lower health spending (measured as a percent of GDP or in per capita expenditures) while providing for universal medical benefits and high quality care. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy should be mutually reinforcing.
Aside from the complementary nature of the relationship between health and the economy, this fundamental concept also suggests that we need to take a longer-term, more integrated and more strategic approach to managing our collective debt and debt-servicing challenges. The federal government can no longer simply shift its financial obligations onto the backs of lower levels of government or individual Canadians without consultation or advance notice.
We need to re-evaluate the full range of government- provided or -funded services. Again, however, if federal fiscal reductions are to take place, the principles of fairness and equity must begin to guide the development of sustainable economic and health policies. While there are no doubt trade-offs that can and must be made, if the price of getting our fiscal house in order is losing a national treasure - i.e., our health care system, it is a price too high to be paid.
To summarize, we have set out a series of principles that should serve to guide the Committee in its decision-making, they are:
* take the longer-term view;
* adopt a system-wide, integrated approach for fiscal management;
* strive for a strategic approach that mutually reinforces health and economic policies; and
* strengthen the fundamental foundation of fairness and equity.
These four principles form the building blocks of the remainder of CMA's submission.
IV. ISSUES
Canada is at a social, political and economic crossroad. The challenge to this Committee and to this Government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of economic opportunity while preserving that which is of fundamental importance to Canadian society as a whole. As the Committee looks to striking the right balance, there are five specific areas of concern that the CMA wishes to bring to your attention on behalf of the Canadian medical profession.
The Temptation to Reduce Federal Health Transfers
CMA commends this Government for exempting EPF health transfers from the extended freeze that was applied to other provincial transfer programs in its spring 1994 budget. We would have been surprised had this Government done anything else, given that medicare is the "Liberal legacy" of the 1960s and given the Liberal Party's consistent opposition to the previous government's "policy by stealth" (i.e., Bill C-69; Bill C-96).
The fact is that medicare's contribution to getting our "fiscal house in order" is already large and continues to grow. In specific terms, the Committee will know that over the 1986/87 to 1995/96 fiscal period, it is estimated that $42.108 billion will have been removed via reductions in Established Program Financing for health and post-secondary education. For health alone, over $30 billion will have been removed from the system by fiscal year 1995/96. 9 Even with a resumption of GNP minus three percent growth formula in per capita EPF entitlements for health, beginning next spring, reduced cash contributions to medicare programs will continue to contribute to the attainment of the government's fiscal targets.
Given the unprecedented health reforms taking place across the country, Canadians and the health care system can ill afford another federal fiscal shock. The system is already balkanizing, with poorer regions not being able to fiscally sustain some basic health care benefits. Any further acceleration in the rate of reduction in federal cash transfers will all but assure the demise of the national integrity of medicare programs.
Moreover, any further reductions in federal health-related cash transfers will: (1) significantly hamper or stall the work of the newly-created National Health Forum; (2) further reduce the capacity for enforcement of national health principles under federal law; (3) exacerbate health-related problems of dealing with child poverty and problems of reducing health inequalities by socio-economic class; and (4) increase other areas of federal direct program expenditures in the context of renewed efforts to provincial program "uploading" (e.g., Canada Pension Plan Disability Program).
A propos of health and economy going hand-in hand, it is useful to remind ourselves of the importance of maintaining the comparability of health benefits across Canada in terms of promoting regional development, shared opportunity and efficient resource allocation. Poor regions of this country are already finding it difficult to compete for scarce new business investment capital. The implications of competing from a more uneven playing field in terms of being able to offer only "bare bones" publicly-financed health benefits will further widen the gap between the "have" and "have not" provinces.
It is for these reasons that the CMA joins with other national health organizations 10 in recommending the following:
1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION;
2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES;
3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT.
Taxable Health Benefits
Canadians have already been dealt one blow with the increasing de-insurance of health care services (e.g., reduction of out-of-country benefits to an unfair and dangerous level, elimination or reduction in drug benefit programs). In the context of funding those services that remain public benefits, only the cruellest government would strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits that taxes were raised to pay. If implemented, this proposal would be tantamount to nothing less than double taxation.
Fairness and equity would suggest that the government should be doing more, not less at the legislative and regulatory levels to promote the availability of private health insurance benefits in areas increasingly vacated by government cutbacks.
This is why CMA makes the following recommendation:
4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED;
Goods and Services Tax (GST)
When the GST was introduced in 1991, preoccupation with implementation issues resulted in a number of fundamental injustices at the micro level. One such injustice was dealt to the medical profession. Physicians, like other Canadians, expect to pay their fair share of taxes. We do not however, accept what essentially amounts to double taxation.
Physicians in practice in Canada are in the unique, unenviable and unfair position of being forced to absorb all the GST on business inputs. Unlike all other professions, physicians are precluded from being able to pass on the tax to consumers (with provincial health insurance plans as payment in full) or from claiming input tax credits (ITCs) since insured medical services are deemed to be "tax exempt".
Unlike other professions, physicians cannot claim input credits for the imputed taxes associated with providing needed medical care. In fact, all of the following health professionals are capable of recouping from patients the GST paid on inputs because their revenues are not restricted by government: dentists; optometrists; chiropractors; physiotherapists; chiropodists; osteopaths; audiologists; speech therapists; occupational therapists and psychologists. Physicians are still angrily awaiting remedial steps to correct this injustice.
To be clear, CMA is not asking for preferential treatment for Canadian physicians. What we want is the same fair and equitable treatment from the federal government accorded to other self-employed professional groups. Like physicians, other professions are purchasing inputs and paying GST; but unlike physicians, they are able to recoup the GST.
Given this oversight in the legislation and regulations, physicians have already been asked to pay (over and above the GST paid by other professional groups) a cumulative total of $250 million since its introduction of the tax in 1991. The magnitude of this tax paid is not in dispute (as a result of a study prepared by KPMG).
While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians in Canada employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening could be at least as high as 1,000 full-time jobs lost.
In addition, the tax-induced distorting effects in terms of efficient resource allocation in the health care system cannot be measured, but are thought to be significant. A goal of health reform in many parts of the country is to move care services out of institutions and into the community. Current federal GST policy, by taxing supplies in a clinical practice setting but not in a hospital setting, acts to discourage this shift in emphasis.
No other issue in recent years has raised the ire of individual practitioners as much as the imposition of this most unfair and inequitable tax on business inputs. Understanding that the Minister of Finance is in the process of consulting with the provinces as to the nature of a replacement tax for the GST, we are confident that this oversight will be remedied.
In the interests of fundamental fairness/equity and allocative efficiency, CMA respectfully recommends the following:
5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST;
6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST;
7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES.
Registered Retirement Savings Plan (RRSP)
Canadian physicians, while receiving a large proportion of their professional earnings from the public sector (94%), do not benefit as self-employed individuals from defined benefit plans or from publicly-financed pension benefits that accrue to employed professionals. They, like other self-employed individuals, must plan and fund their own retirement. Fairness/equity once again demands that there be symmetry between money-purchase (MP) and defined-benefit (DB) retirement plans. This is all the more important for physicians because of their compressed period of lifetime earnings in relation to other groups.
This Committee will have heard various calls for either reducing the annual contribution limit or taxing assets within RRSPs. Such arguments are both specious and patently unfair. Both propositions potentially involve double taxation.
Experts both within and outside government argue, quite correctly, that the current policy be maintained, and that equity between employees and the self-employed before the taxman be assured.
It is for these reasons, that CMA has led an unprecedented alliance for the preservation of retirement savings, and recommends the following:
8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT;
9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE;
10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES.
Lifetime Capital Gains Exemption (LCGE) for Small Businesses
Most Canadian physicians are independent, self-employed practitioners. As such, they have the ability if they are incorporated to claim the LCGE when they sell their practices. Over time, several provinces have accorded physicians the right to incorporate (e.g., Prince Edward Island, New Brunswick, Alberta, British Columbia, and the Yukon Territory), in other jurisdictions, physician incorporation is under active review (e.g., Nova Scotia, Quebec, Ontario and the Northwest Territories). While physicians have benefited from incorporation on a limited basis, this issue takes on added importance when one considers the "national" move towards incorporation allowing a greater number of eligible physicians to claim the LCGE.
Recent health reforms have also underscored the importance of maintaining the current policy.
Previously, physicians were free to move their practices from one location to another to meet the changing health needs of Canadians. Over the past two years, provincial governments have moved to restrict inter-provincial mobility of physicians and indeed mobility within any given province or territory. These "barriers" not only restrict the number of new entrants into the system in addition to those who wish to move to other areas of the country, but also can be thought of as increasing the capitalized value of established practices. Indeed, with the advent of regional physician resource plans across Canada, the cost of establishing a new practice can be expected to continue to grow at an unprecedented rate. So while some physicians have yet to claim the LCGE, it is reasonable to think that they will some time in the future.
As the health needs of Canadians change, and as people move, medical care services will have to respond accordingly. The elimination of the LCGE, by significantly increasing the purchase price of a new medical practice, unnecessarily and unfairly raises additional economic barriers to shifting practices in response to changing community health needs.
CMA therefore recommends:
11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES.
V. TRADE-OFFS
To summarize: in broad terms the health care sector has already paid its fair (and to a larger extent unfair) share.
Everyone who has appeared before this Committee will argue that cuts should not occur in their backyard. They can't all be right! The government of Canada must decide where its priorities lie over the longer-term. Deficit reduction targets can no longer be met by simply chipping away at the full range of federally-sponsored programs. The national integrity of national health insurance programs, given their importance to Canada's economic, social and political future must be on the short list of safeguarded social programs.
If further reductions in federal health transfers are deemed appropriate, the Committee should be prepared to publicly acknowledge that the principles of universality or comprehensiveness (i.e., the choice between covering everyone versus everything) will have to be fundamentally re-examined. Given the degree of support for the universality principle, if the federal government is serious about further reducing its direct or indirect contributions to health, then it must reconsider the range of core benefits that will be made available to Canadians. In fact, we may now have reached the point where we need to get back to basics; reminding ourselves of the original medicare promise, which was to protect Canadians from the spectre of personal bankruptcy associated with large and unexpected health care bills. Not to pay the day-to-day ("grocery") bill of health care.
The recently-announced National Health Forum, chaired by the Prime Minister, will provide an important opportunity to assess the breadth and depth of publicly-financed health care.
The contribution of medicine to the health of Canadians and to the economy is just too important to be traded off. Physicians are still feeling the "aftershocks" of recent federal fiscal decisions. They have also had to absorb sharp unilateral reductions at the provincial level. The provinces of Nova Scotia, Prince Edward Island and Alberta - to name only three - have disproportionately singled out the medical profession on a net earnings basis in decreasing health funding.
Taken together, these fiscal forces could trigger an unprecedented exodus of physicians from Canada. As governments move to restrict the ability of physicians to provide needed medical care, CMA is increasingly concerned about the growing number of physicians who are being actively recruited by the United States, and those who feel they have no alternative but to leave the country.
At a macro level, we as a society, must recognize that we are in a North American labour market, and as such, each physician heading south represents both a short-term pain and long-term pain.
VI. SUMMARY OF RECOMMENDATIONS
The CMA offers the following recommendations to the Committee in its deliberations:
1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION;
2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES;
3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT.
4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED;
5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST;
6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST;
7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES.
8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT;
9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE;
10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES.
11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES.
_______________
1 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8, No. 8, September, 1993.
2 Ibid.
3 Agenda: Jobs and Growth: Creating A Healthy Fiscal Climate (The Economic and Fiscal Climate), Department of Finance, October 1994.
4 Economic and Fiscal Reference Tables, Department of Finance, September 1994; Annual Financial Report of the Government of Canada, Fiscal Year, 1993/94.
5 Valaskakis K.: The Debt Monster, Montreal Gazette, November 5, 1994.
6 National Health Expenditures in Canada, 1975-1993. Health Canada.
7 Ibid.
8 World Economic Forum 1991: The World Competitiveness report 1990, Institut pour l'étude des méthodes de direction de l'entreprise, Lausanne, Switzerland.
9 Thomson A 1991: Federal Support for Health Care: A Background Paper. Health Action Lobby, Ottawa, June 1991.
10 See the 1995/96 Pre-Budget Submission to the Standing Committee on Finance by the Health Action Lobby (HEAL), November 15, 1994.
Millions of Canadians are planning for their retirement relying on Registered Retirement Savings Plans (RRSPs) and private pension plans, either as their only future retirement income or to supplement the Canada Pension Plan (CPP) and Quebec Pension Plan (QPP). Approximately 5 million contribute to RRSPs. Another 3.7 million participate in registered pension plans (RPPs). Some are independent business people, others work in family businesses. Some are self-employed or work for organizations that have opted for RRSPs instead of RPPs. Our Alliance is representative of this Canadian diversity.
The objective of the Alliance is to maintain the current provisions of the Income Tax Act (the Act) and Income Tax Regulations (the Regulations) governing retirement savings. The current system is fundamentally good for the economy of Canada, and any changes made for short term deficit reduction will ultimately harm the economy in general and small and medium-sized business, in particular. Research shows that RRSPs are an important tool for small business retirement planning. Only in recent years have limits been adjusted to bring similar protection to those afforded under RPPs.
We have only just started to achieve a measure of equitable treatment for the retirement savings of the self-employed and employees not protected by employer pension plans. The current system provides for the harmonization of all tax-assisted retirement savings arrangements, which will only be achieved when the limits on money-purchase arrangements (including RRSPs) attain the equivalent limits already set for defined-benefit arrangements, such as employer pension plans.
Changes to RRSPs alone will discriminate against the self-employed and against employees without employer pension plans. These Canadians form the majority of the workforce now and in the future.
Arguments in favour of changes to the current system are based on two assumptions: firstly, that Canadians are saving sufficient income for their retirement and will continue to do so regardless of tax increases; and secondly, that the cost to the Government in lost tax revenues is enormous. Neither of these assumptions is valid.
Background
The fiscal theory underlying retirement savings is decades old. Contributions to registered plans are deductible and all earnings are exempt from tax until benefits are paid out from those plans. In essence the retirement savings system consists of a deferral of tax on contributions and earnings.
The pension tax reform of 1989-1990 does not change the underlying fiscal theory. It aims to achieve equity between the employed and the self-employed and between defined benefit arrangements and money-purchase arrangements (including RRSPs).
That equity was achieved by phasing in a higher contribution limit for money-purchase arrangements so that they could, in the future, provide a retirement income comparable to that furnished by a defined benefit arrangement. This objective of achieving equivalence permeates the Act and the Regulations and has resulted in a substantial and continuing realignment of retirement savings arrangements in Canada. That realignment, with its attendant compliance costs, borne by employers and employees, was based on the acceptance of the premises behind pension tax reform, which acceptance Canadians have demonstrated.
This realignment had a gestation period of over 5 years. 1 From the 1984 federal budget, which sought complete equity but with massive compliance costs, to the 1985 federal budget, which sought lesser compliance costs but with diminished equity, there issued pension tax reform, which yields substantial equity with substantial compliance costs.
The Auditor General, in his 1988 report, estimated that pension tax reform would necessitate $330 million in start-up costs and $15 million in annual reporting costs. The Department of Finance disagreed and estimated that start-up costs would be from $60 to $70 million and that the annual reporting costs would be between $10 and $15 million. The independent consultant's report, upon which the Auditor General's report was based, had said that the start-up costs would be $395 million.
Accordingly, Canadians have already borne many of the costs of retooling the retirement savings system and will continue to do so. Having paid those costs, surely Canadians are entitled to the measure of equity that the system promises.
Governing Principles
There are disquieting rumours about possible changes to the current retirement savings system. As yet, the government has said little on this issue, other than to say that the retirement system is not inviolable.
The Alliance seeks to maintain the status quo. We should, therefore, deal with the principles that underlie the current system, and which continue to hold true: internal fairness and the accumulation of sufficient retirement income.
Internal Fairness
The current system was reformed to deliver internal fairness - if not quite yet, by 1996. It allows individuals to accumulate a pre-determined amount of private retirement savings. Taxpayers may, on a tax-assisted basis, earn a lifetime pension at the rate of $1,722 per year. In other words, an employee with 35 years of service may be entitled, on retirement, to an annual lifetime pension of $60,270. That level of tax assistance has been available to members of defined benefit plans since 1977. It has been frozen at that level since that time and will remain frozen until 1996.
The money purchase limits, including RRSP limits, have been phased in to eventually provide equivalent benefits. Accordingly, the annual RRSP limits, when fully instituted in 1996, will allow the self-employed to accumulate retirement savings equivalent to those of members of defined benefit plans.
Thus, one of the rationales underlying the current retirement savings structure is to eliminate the earlier discrimination against the self-employed. The self-employed will now be allowed to achieve retirement savings equivalent to those available to employees. RRSPs are not an isolated program under the Act, but rather an integral component of an indissoluble whole.
Accumulation of Sufficient Retirement Income
The limits set by pension tax reform are intended to provide a level of retirement income that will allow retired individuals to maintain their standard of living. It is generally felt that a retirement income equal to about 60-70 percent of pre-retirement income should not result in a marked change in one's standard of living.
Increasingly, it appears that individual taxpayers will need to rely more on private retirement savings and less on public programmes. It is important, therefore, that the tax system permit the accumulation of retirement savings sufficient to allow taxpayers to maintain their pre-retirement standard of living.
Indeed, it does not appear possible for money-purchase arrangements to reach, in most cases, the replacement ratio of 60 to 70 percent. Consider the following example. 2 Let us consider two taxpayers earning $50,000 and $100,000 respectively, in 1993 who maximize their contributions to RRSPs. What replacement income ratio can these taxpayers attain?
Assume that the taxpayers are married and that the annuity to be purchased from the RRSP, at retirement, has the following characteristics: post-retirement indexation at 3% per annum with a spousal survivor benefit of two-thirds. 3 The results of this hypothetical are:
[TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]
RRSP as a percentage of final year's salary at a 1993 salary of $50,000 ($100,000)
Retirement Age
Savings Start Age
25
35
45
55
41.0% (31.6%)
24.7% (19.0%)
11.2% (8.6%)
60
54.4% (41.9%)
35.1% (26.7%)
19.0% (14.6%)
65
72.2% (55.7%)
48.8% (37.6%)
29.4% (22.6%)
[TABLE END]
The above table indicates, for example, that a 35-year old earning $50,000 in 1993 can, at most, earn a pension from an RRSP equal to 48.8% of his final year's income, if his retirement commences at age 65. In other words, after 30 years of working and saving, that individual will have a retirement income of less than half of his pre-retirement income. This is below the income replacement threshold assumed by pension tax reform itself. For the taxpayer earning $100,000 in 1993, his RRSP pension will be 37.6% of this pre-retirement income.
The only individual who attains an adequate replacement ratio, on these assumptions, is the 25-year old who saves for 40 years. It follows that, although the pension tax system espouses equivalence with the defined benefit pension plan, it does not attain it in practice.
Inequities in the Current System
In the current North American context, the limits of Canadian tax assistance for retirement savings are not generous. The equivalent money purchase and defined benefit limits for the United States, for example, are more than twice as generous as the Canadian limits. In addition, the Canadian system does not provide for deferrals of salary, as does the United States system.
Furthermore, inequities exist in the provision of supplementary retirement benefits. Supplementary benefits are those in excess of the $60,270 benchmark pension discussed above. They also include benefits that the Regulations, and the Department of National Revenue, do not allow to be paid from a registered pension plan. Servants of the people, such as Members of Parliament and Members of Provincial Legislatures, benefit from the privileged status of the payor of the pension, in that security of the pension promise is not an issue. Self-employed individuals and ordinary employees, on the other hand, must be concerned with the funding of their pension promise.
Requirement for Informed and Thoughtful Debate
In the early 1990s, annual contributions to RRSPs and RPPs exceeded $33 billion. Trusteed pensions, not including consolidated revenue fund plans, held $235 billion in assets at the end of 1992. The book value of the assets of such plans stood at $268 billion at the end of the first quarter of 1994. RRSP assets, not including self-directed plans, totalled $147 billion at the end of 1992.
In his discussion paper entitled Creating a Healthy Fiscal Climate: The Economic and Fiscal Update, released October 18, 1994, the Minister of Finance has indicated that the tax expenditure associated with all retirement savings for 1991 was $14.9 billion.
It is not surprising, therefore, that the Department of Finance should cast a covetous eye at the retirement savings system. We are concerned that a search for easy sources of revenue might prompt the government to change the existing rules in the Act governing retirement savings. It is submitted, however, that changes to the system, although fiscally attractive in the short term, would be detrimental to Canadian taxpayers in the long run.
Deficit reduction should not be the sole motivating factor for change to the retirement savings system. The existing complex web of rules governing retirement savings should only be touched if there are compelling reasons, unrelated to immediate deficit reduction, to effect change. This is particularly so given the recent and unfinished reform of retirement savings arrangements in this country.
It is clear that this debate has not yet begun and cannot be completed before the next federal budget. The prudent approach, therefore, is to defer any change to the retirement savings system until that debate has taken its course.
A Framework for the Debate
The following parameters should govern any consideration of the changes to the retirement savings system.
1. The Principle of Even-Handedness
It is clear that all components of the retirement savings structure are interrelated. As a result, it would be unfair to single out RRSPs for detrimental treatment. RRSP savings are no different from other forms of retirement savings.
2. A Tax Increase
According to a recent study of the Canada Tax Foundation, 3.7 million Canadians contributed to RPPs, and 4.8 million Canadians contributed to RRSPs, in the 1992 taxation year. 4 In that year, 69.7 percent of contributors to RPPs and 60.5 percent of contributors to RRSPs were in the middle income range ($25,000 to $60,000).
Obviously, the participation rate by Canadians in retirement savings arrangements is quite high. A change to the retirement savings regime, by limiting deductibility of contributions for example, would be viewed as a tax increase by users of these arrangements. Indeed, for those individuals, any negative change to the retirement savings arrangement will have the same effect as a tax increase.
3. Job Creation
The quest for deficit reduction should not obscure the important role that government can play in creating an environment conducive to increasing employment opportunities. As the government has previously stated, the bulk of job creation must come from small and medium-sized businesses. As a result, the current retirement savings regime, and in particular RRSP investments, should be viewed as an asset, and not a liability.
The ability to deduct savings for retirement has the effect of increasing aggregate private savings as a source of funds for capital investment. 5 Reducing the tax incentive for retirement savings could have the effect of reducing the amount of "pooled" capital funds that could be made available for entrepreneurial activities. It would also add to the cost of doing business in Canada and stifle future employment opportunities.
The rules in the Income Tax Act that permit RRSP contributors to put investments in small businesses are insufficient at present and must be strenghtened if the government wants to encourage job creation. Canada's Economic Challenges 6 shows that small business is playing an increasing role in the economy. Any reduction in the existing schedule of limits will hurt the ability of small business to create jobs.
Indeed, the government should consider measures to increase the access by small and medium businesses to the retirement savings capital pool. The latest report of the House of Commons Industry Committee makes the point well:
Ottawa should use tax incentives to help improve the competitiveness of the Canadian small business sector...One way the government can increase small business access to capital would be to permit owners, operators and other major shareholders to use funds from their registered retirement savings plans to buy equity in their business...that would increase the availability of such "love capital". 7
4. The Tax Expenditure Calculation
As indicated earlier, it is said that the tax expenditure for all retirement savings for 1991 was $14.9 billion. That number suggests that the Government of Canada bears a high cost for its retirement savings system. However, it is our view that the calculation of that cost is not correct, with the result that the number is inflated.
The Department of Finance's calculation of the tax expenditure cost is arrived at by adding the value of deductions associated with contributions and the value of the tax shelter on earnings. From that result is subtracted the revenue generated from withdrawals. For example, for the 1991 taxation year, the $14.9 billion number noted above is calculated as follows:
Tax expenditure (RRSP)
= value of deductions + value of tax shelter - taxes on withdrawals
= $3.310 billion + $2.960 billion - .735 million
= $5.535 billion
Tax expenditure (RPP)
= value of deductions + value of tax shelter - taxes on withdrawals
= $4.460 billion + $8.950 billion - 4.030 billion
= $9.38 billion
Tax expenditure (RRSP + RPP) = $5.535 billion + $9.38 billion = $14.915 billion.
The Government of Canada has itself admitted that its calculation of tax expenditures is subjective. In the case of tax deferrals, it has further stated that:
Estimating the cost of tax deferrals presents a number of methodological difficulties since, even though the tax is not currently received, it may be collected at some point in the future. 8
The government has also specifically commented on tax expenditures associated with retirement savings:
It should be noted that the RRSP/RPP tax expenditure estimates do not reflect a mature system because contributions currently exceed withdrawals. Assuming a constant tax rate, if contributions equalled withdrawals, only the non-taxation of investment would contribute to the net tax expenditure. As time goes by and more retired individuals have had the opportunity to contribute to RRSPs throughout their lifetime, the gap between contributions and withdrawals will shrink and possibly even become negative. An upward bias in the current estimates can therefore be expected to decline. 9
The method used to calculate the tax expenditure costs associated with retirement savings is based on the "current cash-flow" model. In effect, the calculation takes a snapshot of a given year and does not take into account future income flows. As indicated above, the calculation adds the value in a year of tax deductions to the lost tax on earnings, and subtracts the tax generated from withdrawals.
We argue that that model is flawed. Current demographics show that the system is not yet mature since contributions will exceed withdrawals for some time.
Once the baby boom generation begins to retire, withdrawals will exceed contributions. Substantial revenues will be generated for the fisc, revenues necessary to support government programs of the day. The value of the tax on those withdrawals is totally ignored in the static model adopted by the Department of Finance.
Statistics Canada projects that the proportion of the Canadian population aged 70 and over will increase from 7.84% in 1991 to 10.6% in 2010. The numbers of such individuals will increase from 2.102 million in 1991, to 3.355 million in 2010, a 59.6 percent increase. Those individuals will be drawing pensions, both from RRSPs and RPPs. Those pensions will be taxed and will benefit the fisc.
Furthermore, there is evidence to suggest that the calculation adopted by the Government greatly over-values the cost to the fisc. A US commentator has suggested that government also gains "additional corporate tax revenue on the extra capital stock that results from higher savings. The government's official revenue estimates ignore this increase in corporate tax receipts." 10
To restate the position, the tax expenditure calculation adopts a static approach, both by considering only the current year's cash flows and by ignoring any secondary effects of the retirement savings pool. Until the true cost of the retirement savings system can be ascertained, the current estimates cannot be relied upon to justify change to the tax rules governing retirement savings.
Trade-Offs
While the Alliance recognizes the need for the Government to get its fiscal house in order, with a particular emphasis on the expenditure side of the equation, a proper balance must be struck between short-term solutions and longer-term consequences.
One important consideration is the long-term pain that would result from Canadians having less financial flexibility to properly plan for their retirement. This long-term consequence must be measured against the short-term gain in revenues that would result from a freeze or reduction in the contributions to RRSPs and RPPs.
At a time when the Government is encouraging greater self-reliance in matters of finance, further limiting Canadians' ability to adequately plan for their retirement would serve to aggravate the public future dependence on government programs. Looking at current demographic trends, it is important to ensure that all Canadians have an opportunity to set aside necessary financial resources that will be drawn upon (and taxed) at the time of retirement. If the government is looking to become more efficient in its delivery of public sector programs, it should also ensure that the private sector is allowed sufficient flexibility to meet its needs. In this context, the current retirement savings plans should be considered an investment in the future and should not be tampered with or diminished.
Recommendations
I THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT.
II THE ALLIANCE RECOMMENDS THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM SHOULD INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE.
III THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES.
_______________________
1 Appendix A to this submission details the historical development of pension tax reform.
2 Taken from Sylvain Parent, FSA, FCIA, RRSP income replacement levels: a case study, 1993 Pension & Tax Reports; 4:93-94.
3 Further assumptions are as follows: rate of return is 7.5% per annum; yearly salary increases are 5.5% per annum; mortality is 80% of the average of the 1983 Group Annuity Mortality rates for males and females.
4 Perry, David B, Everyone's Tax Shelter At Risk, Canadian Tax Highlights, Volume 2, number 10, October 19, 1994; p. 75.
5 Andrews and Bradford, Savings Incentives in a Hybrid Income Tax, Studies of Government and Finance, The Brookings Institution, Washington, DC; February, 1988.
6 Department of Finance, January, 1994, p. 30.
7 Special Report, The Public Sector, October 24, 1994.
8 Government of Canada, Personal and corporate income tax expenditures, December 1993, p.4.
9 Ibid., p.53.
10 Feldstein, Martin. The Effects of Tax-Based Incentives on Government Revenue and National Saving, NBER Working Paper #4021, March 1992. This position has been dismissed, out of hand and with no reasons, by two Canadian commentators: Ingerman, Sid and Rowley, Robin, Tax Losses and Retirement Savings, Canadian Business Economics, Vol. 2, No. 4, Summer 1994, pp. 46-54.
The CMA is pleased to have this opportunity to address the Canadian Panel on Violence Against Women. As a professional organization with a leadership role in societal issues affecting health, it is both appropriate and important for the CMA to be actively involved in addressing the problems associated with violence. The extremely high incidence of abuse, the associated severe physical, mental and psychological health problems and the significant role played by physicians in recognizing and caring for victims make this a priority for organized medicine.
The CMA has significant experience and expertise in this field. In 1984, the CMA General Council passed a resolution stating:
"That Health and Welfare Canada and the Provincial Ministries of Health and Education
alert the Canadian public to the existence of family violence, including wife assault, child
abuse, and elder abuse, and to the services available which respond to these problems,
and that organized medicine (through such vehicles as professional journals, newsletters,
conferences and formal medical education) alert the physicians of Canada to the problem
and that all physicians learn to recognize the signs of family violence in their daily contact
with patients and undertake the care and management of victims using available
community resources." (Resolution #84-47)
The CMA calls the Panel's attention to four major areas of concern: Recognition and Treatment, Education and Training, Protocol Development and Research.
1. Recognition and Treatment:
Recognition includes acknowledging the existence and prevalence of abuse and identifying
victims of violence. Violence against women is clearly a health issue and one that should be given a very high priority. Statistics indicate that nearly one in eight Canadian women will be subject to spousal violence in her lifetime and that one in five will be a victim of sexual assault. Violence against women is a major determinant of both short -and long-term health problems including traumatic injury, physical and psychological illnesses, alcohol/drug addiction and death. Furthermore, although it is critically important to recognize that abuse crosses all racial and socio-economic boundaries, there are strong indications that certain groups are particularly vulnerable to abusive acts (e.g., pregnant, disabled and elderly women).
Recognition includes acknowledging and understanding the social context within which violence occurs. Violence is not an isolated phenomenon, but is part of the much broader issue of societal abuse of women.
Physicians are often the first point of contact for patients who have been abused physically, sexually, mentally and/or psychologically. They have a vital role to play in identifying victims and providing treatment and supportive intervention including appropriate referral. Abuse is not always readily apparent, however, and may go undetected for extended periods of time. Numerous studies have shown that both physicians and patients often fail to identify abuse as an underlying cause of symptoms. Such delays can result in devastating and sometimes fatal consequences for patients. Even in those cases where abuse is apparent, both physicians and patients often feel uncomfortable talking openly about the abuse and the circumstances surrounding it. It is the physician's role and responsibility to create a safe and supportive environment for the disclosure and discussion of abuse.
Furthermore, the lack of resources for support services or the lack of awareness of what services are available to provide immediate and follow-up care to patients in need may discourage physicians from acknowledging the existence of abuse and identifying victims. It is clear that improvement in the ability and the degree to which victims of abuse are recognized and given appropriate assistance by physicians and other caring professionals in a non-threatening environment is urgently required.
Individuals who are abused usually approach the health care system through primary contact with emergency departments or other primary care centres. The care available in such settings is acute, fragmented and episodic. Such settings are not appropriate for the victims of violence.
The challenge that we, as physicians, recognize is to be able to provide access in a coordinated way to medical, social, legal and other support services that are essential for the victim of violence. This integration of services is essential at the point of initial recognition and contact. The CMA has been involved with eight other organizations in the Interdisciplinary Project on Domestic Violence (IPVD), the primary goal of which is to promote interdisciplinary co-operation in the recognition and management of domestic violence.
2. Education and Training: The spectrum of abuse is complex; the victims are diverse; expertise in the field is developing. The current system of medical education neither provides health care personnel with the knowledge or skills nor does it foster the attitude to deal adequately with this issue. Some of CMA's divisions have played an active role in this area. For instance, the Ontario Medical Association has developed curriculum guidelines and medical management of wife abuse for undergraduate medical students. It is ,important that there be more involvement by relevant medical groups in developing educational and training programs and more commitment from medical educators to integrate these programs and resources into the curriculum.
Programs must be developed and instituted at all levels of medical education in order that physicians can gain the requisite knowledge and skills and be sensitive to the diversity of victims of violence.
The CMA believes that the educational programs must result in: 1) understanding of the health consequences of violence; 2) development of effective communication skills; and, 3) understanding of the social context in which violence occurs.
Understanding of the social context in which violence occurs will require an examination of the values and attitudes that persist in our society, including a close consideration of the concepts of gender role socialization, sexuality and power. This is required in order to dispel the pervasive societal misconceptions held by physicians and others which act as barriers to an effective and supportive medical response to patients suffering the effects of violence.
3. Development of Protocols: The CMA recognizes the need for more effective management and treatment of the spectrum of problems associated with violence against women. Health care facilities, professional organizations and other relevant groups are challenged to formulate educational and policy protocols for integrated and collaborative approaches to dealing with prevention of abuse and the management of victims of violence.
The CMA and a number of its divisions have been active in this area:
In 1985, the CMA prepared and published Family Violence: Guidelines for Recognition and Management (Ghent, W.R., Da Sylva, N.P., Farren, M.E.), which dealt with the signs and symptoms, assessment and management, referral assistance and medical records with respect to wife battering, child abuse and abuse of the elderly;
The Ontario Medical Association published Repons on Wife Assault in January 1991. This document, endorsed by the CMA, examines the problem of wife assault from a medical perspective and outlines approaches to treatment of the male batterer and his family;
The Medical Society of Nova Scotia has developed a handbook entitled Wife Abuse: A Handbook for Physicians, advising on the identification and management of cases involving the battering of women;
The New Brunswick Medical Society has produced a series of discussion papers on violence and in conjunction with that province's Advisory Council on the Status of Women, has produced a graphic poster depicting physical assault on pregnant women as a way of urging physicians to be alert for signs of violence against women;
The Medical Society of Prince Edward Island has worked cooperatively with the provincial Department of Health and Social Services and the Interministerial Committee on Family Violence to produce a document entitled Domestic Violence: A Handbook for
Physicians.
The CMA encourages continued involvement by the medical profession in the development of initiatives such as these and welcomes the opportunity to work in collaboration with other professionals involved in this area.
4. Research The CMA has identified violence against women as a priority health issue. Like rriany other areas in women's health, there is a need for research focusing on all aspects of violence and the associated problems. More specifically, the CMA maintains that there should be more research on the incidence of abuse (particularly as it relates to particular groups), on ways to facilitate the disclosure by victims of abuse and on the effectiveness of educational and prevention programs.
The CMA recognizes that the medical profession must show a greater commitment to ending abuse of women and providing more appropriate care and support services to those who are victims of violence. The CMA possesses unique skills and expertise in this area and welcomes the opportunity to work with the Panel on this challenging social and health problem.
Concussions and head injuries are a common occurrence in sport and leisure activities, and frequently occur in occupational settings as well. While the majority of individuals who suffer from a concussion will recover with time, others may be at risk for serious and lasting complications. These include (1) children; (2) previous history of head injury or concussion; (3) prior mental health symptoms; and (4) missed diagnosis and management.
This aim of this advocacy and policy document is to improve safety during activity by raising awareness of concussions, and by working to improve the detection and safe management of concussions when they occur. It is not a clinical practice guideline. It should not be perceived as a plea to avoid sports or leisure activities, but rather as a call for safer sporting, leisure, and occupational practices. The documented health benefits that result from establishing an active lifestyle in youth and maintaining it throughout life cannot be overstated.
Achieving balance of safe play in sport, leisure and occupational activities while promoting greater physical activity levels for Canadians would have the effect of reducing health care costs in Canada, while promoting a healthier concussion recovery culture for all Canadians.
Therefore, to promote better concussion and head trauma awareness and prevention, as well as better management/treatment practices, the following policy recommendations for key target audiences across all levels of sport, leisure, and occupational activity are made.
Key Concussion & Head Injury Principles:
a) The detection of concussions and head injury should be a shared responsibility and any stakeholder/observer to such an injury should verbally raise their concerns that a concussion may have occurred.
i. It is important to understand that individuals with a possible concussion, or head injury, may not be able to recognize that they are suffering from a concussion;
ii. It is important to recognize that engrained within popular culture are dangerous notions (e.g., to minimize, ignore, downplay, or play through the pain, etc.) that cause individuals/observers to ignore the real, often hidden, dangers of such injuries.
b) Broadly speaking, access to the latest edition of the internationally recognized Concussion Recognition Tool (CRT) should be promoted/available to help identify the signs and symptoms of a possible concussion;
c) Any individual who sustains more than a minor head injury should be immediately removed from play, activity, or occupation, and not permitted to return on the same day3 (regardless of whether a concussion is later suspected).
i. These individuals should be the subject of observation for developing/evolving concussion symptoms or emergency warning signs (especially within the first 4 hours post-injury, but also up to 48 hours when red-flag symptoms are present).
d) Following first aid principles, where an individual displays signs of a serious head or spinal injury, that individual should lie still (not moving their head or neck) until a qualified individual has performed an evaluation; to determine whether emergency evacuation for medical assessment is necessary.
e) Any individual with a suspected concussion (especially where red-flag symptoms are present), or more severe traumatic brain injury, should be promptly evaluated by a physician to:
i. Either rule-out or confirm a diagnosis via an appropriate medical assessment; and
ii. Institute the provision of an age-appropriate follow-up care plan (including progressive return to school, work, and play protocols) if such an injury is confirmed.1
f) Ideally, a physician knowledgeable in concussion management determines when, and how, a concussed individual should progressively return to both cognitive (school or work) and physical activities.
g) Following a suspected, or diagnosed concussion, an individual should not return to play, or resume any activity associated with a heightened risk of head trauma, until cleared by a physician to do so.1
Recommendations For:
1. Physicians:
Should:
a) Where possible, encourage safe play practices in sports, and where appropriate, educate patients about the risks of head injuries (associated with high-risk behavior in sports, leisure and occupational activities).
b) Gain/maintain, through relevant continuous medical education, competencies related to the assessment, diagnosis and management of concussion according to most current clinical practice recommendations (e.g., latest edition of the CRT, SCAT, Child SCAT, Acute Concussion Evaluation Tool, etc.).
c) Be aware that clinical practice guidelines and assessment tools exist to assist in assessing and treating concussed individuals (e.g., Ontario Neurotrauma Foundation, Parachute Canada, etc.).
d) When assessing a patient with a potential concussion:
i. Rule out the presence of more severe traumatic brain and musculoskeletal injury;
ii. Assess for any previous concussion history, risk factors and newly arising complications;
iii. Educate and instruct parents, athletes and any individual that sustains a concussion about what to do, and what to expect, in the post concussive phase. (This should be based on the most current age-appropriate concussion management guidelines);4
iv. Provide individualized recommendations on how to optimally apply the progressive return-to-school, work, and play strategies with consideration for the specificities of the patient’s usual activities and responsibilities;4
v. Work to provide concussed patients timely access for medical reassessment in the event of worsening or persistent symptoms (including mental health); and
vi. In the presence of persistent or worsening symptoms (including mental health), consider what external, evidence based, concussion resources may be necessary as well as referral.
2. Medical Colleges & Faculties:
Should:
a) Promote/support medical education regarding; awareness, detection/diagnosis; and the appropriate management of concussions, throughout the continuum of medical education (undergraduate, post-graduate, and continuing medical education).
b) Support research in concussion prevention, detection, and treatment or management.
3. Athletes in Contact/Collision Sports:
Should:
a) (Prior to the commencement of the sporting season) be given age-appropriate instruction2 to understand:
i. How to identify the signs and symptoms of a possible concussion using the latest edition of the internationally recognized CRT (e.g. Concussion Recognition Tool, or Concussion Awareness Training Tool (CATT));
ii. The risks associated with concussion (including long term and mental health); especially, the risks of potentially life-threatening complications associated with continued sport participation, while presenting with signs or symptoms of a possible concussion;
iii. What to do/expect if a concussion is ever suspected (including for teammates), and the expected role of the athlete and team members;
iv. Removal and progressive returns to school, work and play policies/procedures, and the expected role of the athlete in the recovery process; and
v. How to foster a healthy sporting culture (that promotes: safe play practices; fosters concussion/injury prevention and reporting; peer-to-peer support; and combat injury stigmatization).
b) Have such instruction reinforced periodically throughout the sporting season as needed.
c) Be aware of, and seek treatment for, potentially serious mental health issues that may arise post-concussive injury.
4. Parents with Minors in Contact/Collision Sports:
Should:
a) Prior to the commencement of a sporting season, request and be open to receiving instruction2 on:
i. How to identify the signs and symptoms of a possible concussion using the latest edition of the internationally recognized CRT (e.g. Concussion Recognition Tool, or Concussion Awareness Training Tool (CATT));
ii. The risks associated with concussion; especially, the risks of potentially life-threatening complications associated with continued sport participation, while presenting with signs or symptoms of a possible concussion;
iii. What to do/expect if a concussion is ever suspected for an athlete;
iv. Removal and progressive returns to school, work and play policies/procedures, and the expected role of the parent(s) in the recovery process; and
v. How to foster a healthy sporting culture that promotes: safe play practices; fosters concussion/injury prevention and reporting; peer-to-peer support; and combats injury stigmatization.
b) Have such instruction reinforced periodically throughout the sporting season as needed.
c) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
5. Individuals Who Sustain a Head Injury Outside of Organized Sports:
Should:
a) Be aware of possible signs and symptoms of a possible concussion, and immediately withdraw from activity and seek medical assessment a possible concussion is suspected.1
i. Refer to the latest addition of the internationally recognized CRT (Concussion Recognition Tool) for further guidance on signs and symptoms.3
b) Understand the risks associated with concussion; including the risks of potentially life-threatening complications associated with repeated head injury if signs or symptoms of a possible concussion are present.
c) In the event of a diagnosis of concussion, judiciously implement the medical recommendations received regarding their gradual return to cognitive and physical activity (including the need for medical reassessment in the presence of persistent symptoms).
d) Openly communicate their recovery needs and work with any group or individual who might support them in their recovery process (e.g., employers, family members, school, etc.).
e) Be aware of, and seek treatment for, potentially serious mental health issues that may arise post-concussive injury.
6. Coaches, Trainers, Referees, & First Responders:
Should:
a) Receive certified emergency first aid training.
b) Receive periodic education (ideally annually) on national standards regarding the signs and symptoms, potential long-term consequences, appropriate steps for initial intervention, and immediate management (including: athlete removal-from-play; observation; determining when medical assessment is necessary; and progressive return to school, work and play procedures).
c) Be trained in the use of the latest edition of the internationally recognized CRT (Concussion Recognition Tool) – to detect whether an injured individual is suffering from a concussion.2
d) Be knowledgeable and responsible to ensure safety and safe play practices are applied throughout the sporting season.
e) Be responsible for fostering a healthy sporting culture (promote safe play practices, foster concussion/injury prevention and reporting, peer-to-peer support and combat injury stigmatization).
f) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
7. Licensed Health Care Providers Involved as Therapists in Sport Environments:
Should:
a) Be fully licensed in their professional field and pursue continuing professional development to maintain competencies related to concussion and head injuries.
b) Promote the implementation of properly adapted concussion management protocols (that comply with the most current clinical recommendations, based on consideration for the specificities of each sport environment and available resources).
c) Work with qualified physicians to initiate/implement tailored medically supervised concussion management protocols that define:
i. Mutual and shared health professional responsibilities to optimize the quality, and safety of patient care (within one’s scope of practice); and
ii. The optimal corridors for timely access to medical (re)assessment with due consideration for available resources.
d) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
8. Educational Institutions & Sports Organizations:
Should:
a) (Especially in the cases involving minors) implement, and keep updated, prevention strategies to include:
i. Safety standards that include safe play policies; and
ii. Mandatory safety gear/equipment (tailored to individual sport settings).
b) Mandatory concussion and head injury protocols that work to:
i. Reduce the occurrence of concussions and head injury by promoting: safe play practices; fostering concussion/injury prevention and reporting; peer-to-peer support, and combatting injury stigmatization;
ii. Ensure the prompt detection, and standardized early management of concussion and head injuries, by informing all potential stakeholders (in the preseason phase) about the nature/risks of concussion and head injury, and how any such occurrence will be dealt with should they occur;
iii. Enshrine into practice removal-from-play, and post-injury observation of athletes;
iv. Progressively reintegrate students back into symptom guided educational and physical activities based on the most current recommendations;2
v. Reintegrate injured athletes back into unrestricted training activities and sport once medical clearance has been obtained; and
vi. Foster better lines of communication for injury management/recovery between: parents, athletes, coaches, school personnel, therapists and physicians.
vii. Address potentially serious mental health issues that may arise post-concussive injury.
9. Employers (Occupational Considerations)
Should:
a) Comply with workplace safety laws and implement safety standards to reduce the incidence of head injuries in the work environment.
b) Integrate considerations for concussion and head injury in health and safety protocols that work to:
i. Reduce the occurrence of concussions and head injury by promoting: safe practices; concussion/injury prevention and reporting; peer-to-peer support, and combats injury stigmatization;
ii. Ensure prompt detection and standardized early management of concussion and head injuries by informing potential stakeholders about the nature/risks of concussion and head injury, and how occurrences will be dealt with should they occur;
iii. Enshrine into practice/ workplace culture the removal-from-work, and post-injury observation of workers;
iv. Progressively reintegrate workers back into symptom guided cognitive and physical activities based on the most current recommendations;
v. Reintegrate injured workers with a confirmed diagnosis of concussion, progressively back into work activities only once medical clearance has been obtained; and
vi. Foster better lines of communication, and support for, injury management between: employees, employers, medical professionals and insurances.
vii. Address the potentially serious mental health issues that may arise post-concussive injury.
10. Governments & Professional Regulatory Bodies:
Should:
a) Implement comprehensive public health strategies for the Canadian population to:
i. Increase awareness that concussions can be sustained in accidents, sports, leisure and occupational contexts;
ii. Inform head injuries should be taken seriously; and
iii. Explain how and why concussions should be prevented and promptly assessed by a physician where they are suspected to have occurred.
b) Define appropriate scopes of practice for all health professionals involved in the field of concussion detection, management, and treatment.
c) Work with key stakeholders to develop compensation structures to support physicians to allocate the time necessary to: (1) conduct appropriate assessments to rule out concussions, (2) provide ongoing concussion management, and (3) develop detailed medical clearance plans.
d) Work with key stakeholders to develop standardized educational tools for physicians to provide to patients with concussions.
i. Ideally this would include contextualized tools for sports teams, schools, and employers.
e) Adopt legislation or regulation for educational institutions and community-based sport associations to establish clear expectations/obligations regarding concussion awareness and management for youth in sports (e.g., Ontario’s Rowan’s law).
i. To have meaningful impact, such initiatives must also be accompanied by: implementation funding to support the development and implementation of sport specific concussion management protocols; and monitoring/compliance programs.
f) Establish a national concussion and sports injury surveillance system (with standardized metrics) to collect detailed head and sport injury related information. Thus, providing the ability to research such injuries in an ongoing and timely manner.
g) Provide research opportunities/funding on concussions. Specific examples of research areas to prioritize include:
i. Effective prevention strategies for both adults and children in a range of sport, leisure, or occupational environments;
ii. The incidence and impact of concussions in children, and how to reduce their occurrence (inside and outside of sport);
iii. Address knowledge gaps for concussion identification, management, and medical clearance for physicians not specialized in concussion care;
iv. Explore all health professionals’ participation in concussion management providing for respective: competency, expertise, interdisciplinary collaboration, and appropriate roles;
v. Evaluate how emerging point of care diagnostics and biomarker testing will be incorporated into sport, leisure and work environments;
vi. Continued development of effective, user-friendly, and age appropriate management strategies/tools for physicians regarding concussion identification, management, and medical clearances; and
vii. Develop a harmonized understanding of “concussion” and “mild traumatic brain injury” (MTBI) constructs/concepts, so that adults with concussion signs or symptoms, who do not meet the more restrictive MTBI criteria, are properly managed.
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus Statement on Concussion in Sport - the 5th International Conference on Concussion in Sport Held in Berlin. Br J Sports Med 2017, 51: 838-847.
Parachute Canada. Canadian Guideline on Concussion in Sport. 2017. Available: http://www.parachutecanada.org/injury-topics/item/canadian-guideline-on-concussion-in-sport (accessed 2018 Jul 31).
Concussion in Sport Group. Concussion Recognition Tool 5. Br J Sports Med 2017 51: 872. Available: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097508CRT5.full.pdf (accessed 2018 July 31st). (accessed 2018 Jul 31).
Ontario Neurotrauma Foundation. Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms. Health Care Professional Version. 3rd Ed, Adults (18 + years of age). Toronto: Ontario Neurotrauma Foundation; 2018. Available: http://braininjuryguidelines.org/concussion/fileadmin/media/adult-concussion-guidelines-3rd-edition.pdf (accessed 2018 Jul 31).
Concussion in Sport Group. Sport Concussion Assessment Tool – 5th Ed. Br J Sports Med 2017, 0:1-8. Available: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097508CRT5.full.pdf (accessed 2018 July 31).
Approved by the CMA Board of Directors March 2019
The evolving needs of patients and their communities
place ever-changing demands on the health care system
to maintain and improve the quality of services provided.
Changing population demographics, increasing
complexity, and new technology make for a dynamic
system. Family physicians are at the heart of the health
care system, acting as the first point of contact and a
reliable medical resource to the communities they serve,
caring for patients and supporting them throughout all
interactions with the health care system. The Patient’s
Medical Home (PMH) is a vision that emphasizes the role
of the family practice and family physicians in providing
high-quality, compassionate, and timely care.
The success of a PMH depends on collaboration and
teamwork—from the patient’s participation in their
care to interprofessional and intraprofessional care
providers working together, to policy-makers who can
offer infrastructure support and funding. PMH 2019 was
created with invaluable feedback from a broad range of
stakeholders reflective of such a joint approach. Its goal
is to make the PMH a reality for patients and providers
across Canada.
In 2011 the College of Family Physicians of Canada
(CFPC) released A Vision for Canada: Family Practice -
The Patient’s Medical Home.1 It outlined a vision for the
future of primary care by transforming the health care
system to better meet the needs of everyone living in
Canada. The vision outlined the 10 pillars that make
up the PMH and provided detailed recommendations
to assist family physicians and their teams, as well as
policy-makers and health care system administrators, to
implement this new model across the country.
WHY A REVISED PMH?
Since 2011 many principles of the PMH vision have been
embraced in primary care reforms. New models have
been introduced across Canada (see Progress on the
PMH to Date). To better reflect current realties, meet
the evolving needs of family physicians and their teams,
and support continued implementation of the PMH, the
CFPC has developed this revised edition of the vision.
It reflects evolving realities of primary care in Canada,
including the rapid adoption of electronic medical
records (EMRs)2,3 and a shift toward interprofessional
practice structures.2
While progress has been made, there is still work to be done
to fully achieve the PMH vision. In 2016 almost 75 per cent
of Canadians rated the quality of care received from their
family physicians as good or excellent.4 In 2017 a CFPC
survey found that 79 per cent of respondents rate the care
they receive from their family doctor as excellent or good.5
However, at the same time 55 per cent of Canadians also
believed that the overall health care system still required
fundamental changes.4 In addition, Canada continues to
perform below the international average on certain aspects
of patient-centred care; for example, same- or next-day
access to appointments. While most Canadians (84.7 per
cent) have a regular doctor or place of care, they generally
report longer wait times for medical care than adults in
comparable countries.4 PMH 2019 addresses these concerns
and proposes solutions that can help further improve the
primary care system for all.
Although the specific components of the revised PMH have
been updated (see What is the Patient’s Medical Home?),
the core principles remain the same. PMH 2019 focuses on
providing high-quality, patient-centred, and comprehensive
care to patients and their families during their lifetime. It
embraces the critical role that family physicians and family
practices play in the health care system, reflecting the fact
that systems with strong primary health care deliver better
health outcomes, enhance efficiency, and improve quality of
care.6 PMH 2019 recognizes that a patient will not be able
to see their personal family physician at every visit, but can
rely on the PMH’s qualified team of health professionals to
provide the most appropriate care responding to patient
needs with continuous support and leadership from family
physicians. PMH 2019 highlights the central importance
of community adaptiveness and social accountability in
primary care with a new pillar. The importance of being
responsive to community needs through engagement, and
ensuring the provision of equitable, culturally safe, antioppressive
practise that seeks to assess and intervene into
social determinants of health (SDoH), is now more clearly
featured.
2 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PURPOSE OF THIS DOCUMENT
PMH 2019 outlines 10 revised pillars that make up a
PMH. Key attributes are defined and explained for each
pillar. Supporting research is provided to demonstrate
the evidence base for each attribute. This document
is intended to support family physicians currently
working in a PMH to better align their practice with
the PMH pillars, or assist those practices looking to
transition to a PMH. Furthermore, this document can
guide governments, policy-makers, other health care
professionals, and patients on how to structure a primary
health care system that is best-suited to meet the needs
of Canadians.
Many resources for the PMH have been developed and
will continue to be available. These include practical Best
Advice guides on a range of topics and the self-assessment
tool that can help quantify a practice’s progress toward
PMH alignment. Moving forward, additional materials
that address the new themes identified in PMH 2019 and
the tools to support physicians in the transition to PMH
structures—for example the PMH Implementation Kit—
will be available at patientsmedicalhome.ca.
What is a Patient’s Medical Home?
The PMH is a family practice defined by its patients
as the place they feel most comfortable presenting
and discussing their personal and family health and
medical concerns. The PMH can be broken down into
three themes: Foundations, Functions, and Ongoing
Development (see Table 1 and Figure 1).
The three Foundation pillars are the supporting structures
that facilitate the care provided by the PMH. All three
aspects are required for the successful implementation
and sustainability of a PMH.
The Functions are areas central to the operation of a family
practice and consist of the five core PMH pillars. These
principles govern the type of care provided by the PMH
practices to ensure it is effective and efficient for meeting
the needs of the patients, families, and communities they
serve. The pillars in this section reflect the Four Principles
of Family Medicine,7 which underlines the important
place they take in the overall PMH 2019.
The pillars in Ongoing Development are essential to
advancing the PMH vision. These areas make it possible
for physicians to provide the best possible care for
patients in various settings. Applying these pillars, the
PMH will thrive through practising quality improvement
(QI) principles to achieve the results necessary to meet
the needs of their patients, their communities, and the
broader health care community, now and in the future.
The PMH is a vision to which every practice can aspire.
Many practices across Canada have already begun
transitioning to a PMH, thanks to the dedication and
leadership of family physicians and their teams across
Table 1. 10 Pillars of the revised PMH vision
THEME PILLAR
Foundations
1. Administration and Funding
2. Appropriate Infrastructure
3. Connected Care
Functions
4. Accessible Care
5. Community Adaptiveness and Social Accountability
6. Comprehensive Team-Based Care with Family Physician Leadership
7. Continuity of Care
8. Patient- and Family-Partnered Care
Ongoing
Development
9. Measurement, Continuous Quality Improvement, and Research
10. Training, Education, and Continuing Professional Development
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 3
the country. This vision is a resource for these practices
as they engage in ongoing practice assessment and QI
initiatives. It can also assist other stakeholders, including
government planners, policy-makers, and funders to
better understand what defines an effective patientcentred
family practice. By involving patients in all stages
of the development, evaluation, and continuous quality
improvement (CQI) activities of the practice, the PMH
can contribute significantly to furthering the goals of
transformation to a patient-centred health care system.8
What the Patient’s Medical Home is Not
While it is important to understand what the PMH
aspires to be, it is also important to highlight that it is
not a one-size-fits-all solution. Solo practices in rural
or remote settings or large group practices serving
inner-city populations can align with PMH principles
by incorporating strategies that match the realities of
their unique settings. In fact, social accountability and
community adaptiveness is an important new addition
to the revised PMH vision to account for the need of
every family practice to adapt and respond to the needs
of their patients and communities. What works for one
practice will not work for all.
The PMH vision does not require that all practices be
relocated or re-engineered, or that significant financial
investments be made by physicians or other health
care professionals. Instead, system level support and
involvement is required to achieve the vision. The pillars
and attributes listed in this document are signposts along
the way to reform that aids practices on their journey.
It is important to note that this vision is not intended to
undermine or change any exciting initiatives involving
family practice currently under way across Canada
(several of which already embrace and incorporate
the medical home concept; see Progress on the PMH
to Date). Rather, it is meant to build on and strengthen
these efforts. The more that health care initiatives meet
PMH objectives, the more likely it is that the overall
goals of creating a patient-centred health care system
throughout Canada will be realized.
Figure 1. The Patient’s Medical Home
4 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PROGRESS ON THE PMH TO DATE
Since the release of the original PMH vision document,
system-level change has occurred in almost all
jurisdictions in Canada. More specifically, PMH-type
practices are gaining traction in various provinces and
currently exist in various stages of development.
The CFPC took a snapshot of PMH uptake in all provinces
in the PMH Provincial Report Card, published in early
2019.9 That report contains grades and descriptions for
progress in each province up to late 2018, which acts as
a useful gauge for where the vision stands at the time of
publication of this new edition.
Alberta
In Alberta, primary care networks (PCNs)10 were
established to link groups of family physicians and other
health care professionals. Within PCNs clinicians work
together to provide care specific to community and
population health care needs. Currently, there are 42 PCNs
operating in Alberta, comprised of more than 3,700 (or 80
per cent of) family physicians, and over 1,100 other health
care practitioners. PCNs provide care to close to 3.6 million
Albertans, 80 per cent of the population in Alberta.
Primary care clinics are being asked to collect data for
Third Next Available (TNA) appointments to improve
access for Albertans.11 TNA measures the delay patients
experience in accessing their providers for a scheduled
appointment. TNA is considered a more accurate system
measure of access than the “next available” appointment,
since the next or second next available appointment may
have become available due to a cancellation or other
event that is not predictable or reliable.
British Columbia
The British Columbia government’s new primary care
strategy focuses on expanding access to team-based
care through PCNs.12 PCNs are in the initial stages of
adoption and when fully rolled out will provide a systemlevel
change—working to connect various providers to
improve access to, and quality of, care. They will allow
patients to access the full range of health care options,
streamline referrals, and provide better support to
family physicians, nurse practitioners, and other primary
health care providers. The General Practice Services
Committee13 (GPSC; a partnership of the provincial
government and Doctors of BC) specifically references
and builds on the PMH concept in their vision for the
future of British Columbia’s health care system.
Manitoba
In Manitoba, PMHs are Home Clinics and PCNs are My
Health Teams. My Health Teams bring together teams
of health care providers (physicians, nurses, nurse
practitioners, etc.) to collaborate in providing highquality
care based on community and patient needs.14 As
suggested by the name of the initiative itself, the goal
is to improve health care by developing teams of health
care professionals who will work together to address
primary health care needs of Manitobans.15 The first two
My Health Teams were established in 2014, and there are
now 15 across the province.16 The Manitoba Centre for
Health Policy did some work assessing the impact of My
Health Teams.
New Brunswick
In 2017 the government announced the New Brunswick
Family Plan, which placed a specific emphasis on access
to team-based care. To achieve this goal, the provincial
government and the New Brunswick Medical Society
established a voluntary program called Family Medicine
New Brunswick. In this team-based model, physicians
have their own rosters of patients, but also provide a
service to all patients of doctors on their team.17 It was
announced in 2018 that 25 family physicians will be
added to the provincial health care system to ensure
more New Brunswick residents have access to a primary
care physician and to help reduce wait times.18
Newfoundland and Labrador
In 2015 the Newfoundland and Labrador government
released Healthy People, Healthy Families, Healthy
Communities: A primary health care framework for
Newfoundland and Labrador. The strategy’s goals
include ensuring “timely access to comprehensive,
person-focused primary health care services and
supports,” and “primary health care reform should work
to establish teams of providers that facilitate access to
a range of health and social services tailored to meet
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 5
the needs of the communities they serve.”19 Both goals
align with the general PMH principles. Primary health
care teams have been introduced in St. John’s and are
planned for Corner Brook and Burin.20 Many initiatives
under way as a part of this strategy are in the early stages
of development. Continuing in the direction laid out will
move Newfoundland and Labrador closer to integrating
the PMH vision in their delivery of primary health care.
Northwest Territories
The recent creation of a single Territorial Health Authority
has enabled work on primary care improvements across
the Northwest Territories. In August 2018 the NWT Health
and Social Services Leadership Council unanimously
voted in favour of a resolution supporting redesigning
the health care system toward a team- and relationshipbased
approach, consistent with PMH values. In several
regions, contracted physicians are already assigned to
regularly visit remote communities and work closely
with local staff to provide continuity of remote support
between visits. Planning is under way for implementing
PMH-based multidisciplinary care teams in several larger
regional centres, with enhanced continuity and access to
physician and nursing staff as well as co-located mental
health support and other health care disciplines. This
work is facilitated by a territory-wide EMR and increased
use of telehealth and other modalities of virtual care.
Nova Scotia
The 2017 Strengthening the Primary Health Care
System in Nova Scotia report recommended establishing
“health homes,” consisting of interprofessional,
collaborative family practice teams. The model is based
on a population health approach that focuses on wellness
and chronic disease management/prevention and
incorporates comprehensive, team-based care. There are
approximately 50 collaborative family practice21 teams
and a number of primary care teams across Nova Scotia.
Ontario
The model most aligned with the PMH framework is the
family health team (FHT).22 FHTs are comprised of family
physicians, nurse practitioners, and other health care
professionals, and provide community-centred primary care
programs and services. The 184 FHTs collectively serve over
three million enrolled Ontarians. Based on the results of a
five-year evaluation undertaken by the Conference Board
of Canada in 2014, FHTs have achieved improvements
at the organizational and service-delivery levels.23 Much
progress has also been made through patient enrolment
models. Patient enrolment, or rostering, is a process in
which patients are formally registered with a primary
care provider or team. Patient enrolment facilitates
accountability by defining the population for which the
provider is responsible. Formal patient enrolment with a
primary care physician lays the foundation for a proactive
approach to chronic disease management and preventive
care.24 Studies show that the models have achieved some
degree of success in enhancing health system efficiency
in Ontario through the reducing use of emergency
departments for non-emergent care.25
Prince Edward Island
In Prince Edward Island, primary care is provided
through five PCNs.26 Each network consists of a team
that includes family physicians, nurse practitioners,
registered nurses, diabetes educators, licensed practical
nurses, clerical staff, and in some cases dietitians and
mental health workers. They offer a broad range of
health services including diagnosis, treatment, education,
disease prevention, and screening.
Quebec
The Groupes de médecine de famille27 (GMF) is the
team-based care model in Quebec most closely aligned
with the PMH. GMF ranking (obligations, financial, and
professional supports) is based on weighted patient
rostering. One GMF may serve from 6,000 to more than
30,000 patients. The resource allocation (financial and
health care professionals) depends on the weighted
patient target under which the GMF falls. In a GMF,
each doctor takes care of their own registered patients,
but all physicians in the GMF can access medical
records of all patients. GMFs provide team-based care
with physicians, nurses, social workers, and other health
care professionals working collaboratively to provide
appropriate health care based on community needs.
Saskatchewan
Saskatchewan has made investments in a Connected
Care Strategy, which focuses on a team approach to
care that includes the patient and family, and extends
from the community to the hospital and back again. It is
about connecting teams and providing seamless care for
people who have multiple, ongoing health care needs,
with a particular focus on care in the community.28
6 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
FOUNDATIONS
PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing
each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred
care. The foundations are Administration and Funding (includes financial and governmental support and strong
governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources,
and electronic records and other digital supports), and Connected Care (practice integration with other care settings
enabled by health IT).
ADMINISTRATION
& FUNDING
PAGE 7
APPROPRIATE
INFRASTRUCTURE
PAGE 9
CONNECTED CARE
PAGE 12
Patients as partners in health care
Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a
small but powerful change in terminology. Considering and respecting patients as partners allows health care providers
to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and
feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding
the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29
Pillar 1: Administration and Funding
Practice governance and management
Effective practice governance is essential to ensuring
an integrated process of planning, coordinating,
implementing, and evaluating.30 Every PMH should
clearly define its governance and administrative structure
and functions, and identify staff responsible for each
function. While the complexity of these systems varies
depending on the practice size, the number of members
on the health care professional team, and the needs of
the population being served, every PMH should have an
organizational plan in place that helps guide the practice
operations.
From a governance perspective, policies and procedures
should be developed and regularly reviewed and
updated, especially in larger practices. These policies
and procedures will offer guidance in areas such as
organization of clinical services, appointment and
booking systems, information management, facilities,
equipment and supplies, human resources, defining PMH
team members’ clinical and administrative/management
roles and responsibilities, budget and finances, legal
and liability issues, patient and provider safety, and
CQI. In some cases, standardized defaults for these
may be available based on the province of practice and
existing structures supporting interprofessional teams.
Structures and systems need to be in place that allow
for compensated time for providers to undertake and
actively participate in CQI activities. This needs to be
scheduled and remunerated so that it is seen as being as
important and critical as clinical time.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient government funding to cover training
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 7
Practices need staff and financial support, advocacy, governance, leadership, and management in
order to function as part of the community and deliver exceptional care.
1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in
each PMH.
1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and
administrative roles of all members of PMH teams.
1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be
considered to incentivize the desired approach.
1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms
that support PMH priorities, including preventive care, population health, electronic records, community-based
care, and access to medications, social services, and appropriate specialist and acute care.
8 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
costs and financial support to ensure lost income is not a
barrier (see Pillar 10: Training, Education, and Continuing
Professional Development).
External supports
Every family practice in Canada can become a PMH
and an optimal learning environment will only be
achievable with the participation and support of all
stakeholders throughout the health care system. This
includes family physicians; other health professionals
who will play critical roles on PMH teams; federal,
provincial, and territorial governments; academic
training programs; governing bodies for physicians
and allied health care providers; and most importantly,
the people of Canada themselves, individually and in
their communities—the recipients of care provided by
the PMH.
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Given that
the structure, composition, and organization of each
PMH will differ based on community and population
needs, funding must be flexible. More specifically,
PMH practices will differ in terms of the staff they
require (clinical, administrative, etc.). Funding must
be available to ensure that PMH practices can
determine optimal staffing levels and needs, to best
meet community needs. The health care system must
also ensure that all health care professionals on the
PMH team have appropriate liability protection, and
that adequate resources are provided to ensure that
each PMH practice can provide an optimal setting for
teaching students and residents and for conducting
practice-based research. These characteristics
are also reflected in the Four Principles of Family
Medicine, reinforcing the centrality of family medicine
to the delivery of care.
Experience through new models of family practice,
such as patient enrolment models (PEMs) in Ontario,
suggests that blended funding models are emerging as
the preferred approach to paying family physicians.31–33
These models are best suited to incentivizing teambased,
patient-partnered care. The current fee-forservice
(FFS) model incentivizes a series of short
consultations that might be insufficient to address all
of the patient’s needs, while blended remuneration
provides for groups of physicians to work together to
provide comprehensive care through office hours and
after-hours care for their rostered patients. Capitation
allows for more in-depth consultations depending on
population need, rather than a volume-based model.
Research has also found that blended capitation models
can lead to small improvements in processes of care
(e.g., meeting preventive care quality targets)34 and can
be especially useful for supporting patients in managing
and preventing chronic diseases.35 The CFPC advocates
for governments to implement blended payment
mechanisms across the country to achieve better
health outcomes (see the Best Advice guide: Physician
Remuneration in a Patient’s Medical Home36 for more
information).
It is important to ensure that additional practice activities
such as leadership development, QI, and teaching are
supported through dedicated funding or protected time
intended specifically for these activities and are not
seen as financially disadvantageous.
The sustainability of Canada’s health care system
depends on a foundation of strong primary care and
family practice.37 Indeed, “high-performing primary care
is widely recognized as the foundation of an effective and
efficient health care system.”38 Future funding for health
care—in particular from the federal government through
federal, provincial, and territorial agreements—must
be sustained through appropriate and well-designed
funding agreements that incentivize PMH visions of
primary care; other medical home priorities including
preventive care, population health, EMRs; communitybased
care; along with access to medications, social
services, and appropriate specialist and acute care.
For the PMH vision to be successful and a part of the
future of family practice care in Canada, we need the
commitment and support of everyone in the Canadian
health care system, including decision makers and
patients. By working with all levels of government and
with patients, we can improve the health care system so
that everyone in Canada has access to patient-centred,
comprehensive, team-based care.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 9
Pillar 2: Appropriate Infrastructure
The shift in Canada from paper-based patient records
to EMRs is reaching saturation. As delivery of care
evolves with greater integration of technology, potential
applications to improve patient care expand.39 The
proportion of family physicians using EMRs has grown
from 16 per cent in 2004 to 85 per cent in 2017.40
As it becomes ubiquitous in health care delivery,
information technology can be of great benefit in
sharing information with patients, facilitating adherence
to treatment plans and medication regimes, and
using health information technology (HIT) in new and
innovative methods of care. However, HIT also poses new
risks and can create new barriers. Providers should be
mindful of how the application about new technologies
may hinder good quality patient care.
When properly implemented, EMRs can help track data
over time, identify patients who are due for preventive
visits, better monitor patient baseline parameters (such
as vaccinations and blood pressure readings), and
improve overall quality of care in a practice.1 EMRs can
enhance the capacity of every practice to store and recall
medical information on each patient and on the practice
population as a whole. They can facilitate sharing
information needed for referrals and consultations.
The information in an electronic record can be used
for teaching, carrying out practice-based research, and
evaluating the effectiveness of the practice change as
part of a commitment to CQI.1 EMRs and HIT actively
support other pillars in the PMH vision.
In addition to storing and sharing information, the
biggest benefit of this technology is the ability to
collect data for practice performance and health
outcomes of patients served by family practices.41 The
data allow practices to measure progress through
CQI goals. Larger-scale collection allows for the
aggregation of anonymized data sets and measuring
performance beyond the practice level.41 Strict privacy
regulations ensure that patient data remain secure
and confidential. Overall, QI and research benefit
patients by guiding more appropriate and efficient
care, which forms the basis of another key pillar of
Physical space, staffing, electronic records and other digital supports, equipment, and virtual
networks facilitate the delivery of timely, accessible, and comprehensive care.
2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems.
2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes
family physicians and other health care professionals. Practices are able to select an EMR product from a list
of regionally approved vendors.
2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary
care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools;
e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research,
evaluation, and CQI.
2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable.
2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and
interaction between team members.
2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered
nurses to meet PMH goals).
2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare.
2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements
will be met by every PMH teaching site.
the PMH vision— Pillar 9: Measurement, Continuous
Quality Improvement, and Research.
As EMR use becomes common, issues shift from rollout
to optimization in the practice. Ideally, EMRs must
be adequately supported financially and use a universal
terminology to allow for standardized data management,
and be interoperable with other electronic health
records relevant to patient care.1 Training and ongoing
technical support for effective use of technology must
also be available. Digital information sources, especially
in the sensitive areas of patient information and care
planning, require a higher level of technical support
to maintain faith in their use and application across
stakeholder groups.
A comprehensive, systematic analysis of peer-reviewed
and grey literature found that cost sharing or financial
sponsorship from governments is required to support the
high cost of EMR adoption and maintenance. Governments
in several European countries equip all primary care
practices with interoperable, ambulatory care-focused
electronic health records (EHRs) that allow information
to flow across settings to enhance the continuity
and coordination of care.1 Ensuring that government
supports enable adoption, maintenance and effective use,
coordination, and interoperability of electronic tools is
crucial for meaningful use of this technology.
A PMH will also use technology for alternative forms
of care. Virtual care is clinical interactions that do not
require patients and providers to be in the same room
at the same time.42 Virtual visits will be financially
compensated by provincial health plans. Consultations
may be asynchronous, where patients answer structured
clinical questions online and then receive care from a
physician at a later time (e-visits), or synchronous,
where patients interact with physicians in real time via
telephone (teleconsultations), videoconference (virtual
visits), or text.43 Virtual care increases accessibility
for those living in rural and remote areas, but also in
urban areas where some patients do not have a regular
primary care physician or cannot access their physician
for in-person appointments within a time frame that
meets their current needs.43 Virtual care can also be an
alternative solution for patients living in long-term care
facilities and/or with mobility issues.43
Strong communication between team members allows
PMH practices to function on a virtual basis when the
health care professionals are not stationed in the same
physical space. It is important to recognize when colocation
is not feasible and maintain effective information
flow in these situations, which may be especially relevant
in rural and remote areas.
Practices should ensure the electronic records they
use are set up to support collaboration and interaction
between all members of the team as much as possible,
which includes all health care providers within the PMH
as well as the patient’s circle of support. For example,
ensuring that when patients see someone other than
their most responsible provider is logged into the
system and is easy to review to maintain the continuity
of care. This becomes complex in situations where
providers are not co-located, and further system level
supports up to the level of more interoperable and
universal electronic records is a prerequisite for full
application of this principle.
Appropriate infrastructure in a PMH is not just
about technology—it includes efficient, effective, and
ergonomically well-designed reception, administration,
and clinical areas in the office. This is of significant
benefit to staff and patients alike.44 Having a shared
physical and/or virtual space where multiple team
members can meet to build relationships and trust,
and communicate with each other regarding patient
care is essential to creating a collaborative practice.
Team-based care thrives when care is intentional,
when planned and regular patient care meetings are
incorporated into usual PMH practice, and when these
steps are included in remuneration. This collaboration
ensures that patients are involved in all relevant
Satisfaction with virtual visits
A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of
high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their
health issue.43
10 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 11
discussions and are receiving the best care from
professionals with a comprehensive set of skills.
A family practice should be physically accessible to
patients and their families. This includes ensuring all
public areas, washrooms, and offices are wheelchair
accessible.44 An examination room should comfortably
accommodate the patient and whatever appropriate
companion, or health care professionals, who may be
in the room at the same time. Having multi-purpose
rooms also reduces or eliminates the need to wait for an
appropriate room to be available.
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Research
demonstrates that in the case of EMRs, key barriers
to adoption by family physicians include financial
and time constraints, lack of knowledgeable support
personnel, lack of interoperability with hospital and
pharmacy systems,45 as well as provincial/territorial EHR
systems. Therefore, government must assure funding
to support the PMH team in their clinical, research,
and administrative responsibilities. There must also be
support for core practice components such as EMRs,
patient-centred practice strategies such as group visits,
and electronic communications between patients and
health professionals (see Pillar 1: Administration and
Funding). EMRs should help improve the delivery of care
in community-based practices by enhancing productivity
and processes. They are not intended to reduce time
with patients, nor should they cause physician burnout
or have a negative impact on physician wellness. While
the structures supporting the PMH practices differs by
province, it is important they cover a common set of
principles enabling the base functionalities described in
this document. The system must also ensure that all health
professionals on the PMH team have appropriate liability
protection and that adequate resources are provided so
that each PMH practice can provide an optimal setting
for teaching students and residents and for conducting
practice-based research. Provider autonomy is critical
to provider wellness: as physician leadership within the
PMH is one of the key pillars, preservation of physician
autonomy, while respecting the autonomy and ensuring
the accountability of both patients and other health care
professionals, must be addressed.
Figure 2. The Patient’s Medical Neighbourhood
Pillar 3: Connected Care
Canada Health Infoway
Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal
government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative
strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada.
Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals.
Connectivity and effective communication within and
across settings of care is a crucial concept of a PMH.
This ensures that the care patients receive is coordinated
and continuous. To achieve this, each PMH should
establish, maintain, and use defined links with secondary
and tertiary care providers, including local hospitals;
other specialists and medical care clinics; public health
units; and laboratory, diagnostic imaging, physiotherapy,
mental health and addiction, rehabilitation, and other
health and social services.
Connected care is a priority for many health care
organizations in Canada. For example, the Canadian
Foundation for Healthcare Improvement (CFHI) has
established a unique program that looks at improving
care connections between providers through improved
use of technology.41 (See the Canadian Foundation for
Healthcare Improvement textbox for more information).
The Canadian Nurses Association (CNA), Canadian
Medical Association (CMA), and HEAL recognize
that giving Canadians the best health and health care
requires creating a functionally integrated health
system along the full continuum of care—a system
based on interprofessional collaborative teams that
ensure the right provider, at the right time, in the right
place, for the right care.46 Similarly, Canada Health
Infoway focuses on expanding digital health across the
system to improve quality of and access to care.
The PMH exists within the broader patient’s medical
neighbourhood (see Figure 2), with links to all other
providers in the community. It is important to maintain
connections with colleagues in health care as well as
social support organizations within the community, as
described in Pillar 5: Community Adaptiveness and
Social Accountability.
Through links within the neighbourhood, PMH practices
work with other providers to ensure timely access
for referrals/consultations and define processes for
information sharing. Establishing and maintaining
these links requires open and frequent communication
between all those involved in patient care.
12 A NEW VISION FOR CANADA Family Practice—
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Practice integration with other care settings and services, a process enabled by integrating health
information technology.
3.1 A PMH is connected with the health and social services available in the community for patient referrals.
3.2 Defined links are established between the PMH and other medical specialists, and medical care services in
the local or nearest community to ensure timely referrals.
3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information
technology. It ensures the continuity of patient information received throughout the medical and social
service settings.
Ideally PMH practices act as the central hub for patient
care by collecting and coordinating relevant patient
information from external care providers and patients.
This includes medical care and care accessed through
other health and social services; for example, services
received through home care programs. PMH practices
should also be able to share relevant information with
external providers where and when appropriate, while
strictly adhering to relevant privacy regulations. This
two-way flow of information ensures that all providers in
the network of care have access to the most accurate
and comprehensive information available, allowing them
“… to spend less time looking for information and more
time on what matters: treating the patient.” 49
Overall, connected care in the PMH and the health
system is enabled through HIT systems. PMH practices
continuously strive to work efficiently with other
providers in the patient’s medical neighborhood by
taking advantage of developing technologies that make
links quicker to establish and easier to maintain.
To use HIT systems for coordinated care, the following
are required:51
Data standardization
Interoperable EMR and other health information
systems
Real-time access to data and the ability to relay
accurate information in a timely manner
Reliable communication mechanisms between
various health and social service providers and the
PMH
Privacy for patient information
It is important to keep in mind that any patient information, generated during the provision of care,
belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act
(PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information.
Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of
EMRs50 for more information.
Canadian Foundation for Healthcare Improvement
The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative
Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with
specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait
times for accessing specialty care by enabling family physicians to more efficiently manage their patients in
primary care settings.
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14 A NEW VISION FOR CANADA Family Practice—
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FUNCTIONS
The functions describe the heart of the PMH and the care provided by PMH practices. These are the key
elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community
Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership;
Continuity of Care; and Patient- and Family-Partnered Care.
ACCESSIBLE CARE
PAGE 15
COMMUNITY ADAPTIVENESS &
SOCIAL ACCOUNTABILITY
PAGE 17
COMPREHENSIVE TEAM-BASED
CARE WITH FAMILY PHYSICIAN
LEADERSHIP
PAGE 20
CONTINUITY OF CARE
PAGE 23
PATIENT & FAMILY PARTNERED CARE
PAGE 25
Equitable and ethical practices
The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly,
accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54
Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the
CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices
in health care and public health.55
Pillar 4: Accessible Care
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 15
Accessible primary care is fundamental to a highperforming
health care system and is considered by
patients52 and other health care organizations as one
of the most important characteristics of primary health
care. For care to be accessible, all patients should have
access to a family physician who acts as their most
responsible provider and is supported by a team of
qualified health professionals. Patients must be able
to access medical care and treatment when needed.
While most Canadians currently have a regular family
doctor,4 it is important that the goal be for everyone in
Canada to have access to their own family physicians.
Accessible care is about more than just quick access to
appointments. It does include timely access principles,
but also advanced access, virtual access, and teambased
approaches to care that ensure patients can be
seen by the most appropriate provider when they need
to be seen.
Because visits occur for different reasons it is not useful
to define appropriate wait times for each type of visit
unlike in other areas of health care, such as surgery.
Therefore, the focus in family practice should be on
enhancing access to ensure patients can access care
when they feel it is necessary. This is not to say that
family physicians in a PMH must be on call 24/7/365,
but that methods for patients to access care through
the design of practice operations and scheduling
should be given more attention. On the other hand,
as patients are offered more choice (e.g., by phone or
e-communication), they should also expect practices
to establish realistic parameters for what is reasonable.
Practices should communicate clearly about what kind of
provider availability and response time is reasonable to
expect depending on access method and availability of
resources. Obtaining this understanding from a practice’s
patients and striving to meet these expectations is a
By adopting advanced and timely access, virtual access, and team-based approaches, accessible
care ensures that patients can be seen quickly.
4.1 A PMH ensures patients have access to medical advice, and information on available care options 24
hours a day, 7 days a week, 365 days a year.
4.2 Every patient is registered with a PMH.
4.3 PMH practices offer scheduling options that ensure timely access to appropriate care.
4.4 When the patient’s personal family physician is unavailable, appointments are made with another
physician, nurse, or other qualified health professional member of the PMH team.
4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking
system.
4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and
safe, high-quality care.
After-hours care
A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services
from other health care providers seen as a key for improving patient access.59
Accessible care
Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment
and also consults another provider in the interim), improves health outcomes, leads to better patient and provider
satisfaction, and reduces emergency visits.56–58
16 A NEW VISION FOR CANADA Family Practice—
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good way to maintain the patient-centred focus of the
practice as described in Pillar 1: Administration and
Funding. Significant shifts in providing alternative access
must be supported by funding bodies.
Same-day scheduling has been introduced in many
PMH practices to better accommodate patient needs.
Frequently referred to as doing “today’s work today,”
advanced access offers the vast majority of patients the
opportunity to book their appointments on the day they
call regardless of the reason for the visit.60 Read more
about same day scheduling in the Best Advice guide:
Timely Access to Appointments in Family Practice.61
Whenever possible, patients should have clear reasons
for the appointment at the time of booking. This ensures
that adequate time is planned for each patient visit. If
the need to address multiple problems arises, the
problems can be triaged on the spot by one of the team
and arrangements made to have these concerns dealt
with in a timely manner either during the same visit or at
another time.
It is not always possible for patients to book appointments
with their most responsible family physician. To ensure
continuity, appointments can be made with other
physicians or health care professionals in the team. The
decision about who provides care in these cases is based
on the patient’s needs, the availability of team members,
and the scope of practice for each team member. In these
cases, any relevant information from the appointment
is communicated to the most responsible provider and
taken into account in the long-term care of the patient.
PMH practices can further meet patients’ needs through
extended office hours, in which the responsibilities for
coverage and care are shared by family physicians in one
or more practices, as well as by increased involvement of
other team members. PMH practices also provide their
patients with email, after-hours telephone, and virtual
services to guide them to the right place at the right
time for the care they need. Appropriately directing
patients to the next available appointment, or to a
hospital or another emergency service, is critical to the
effective management and sustainability of our health
care system.62,63 A PMH can help ensure that patients
are aware of where they can go to access care and
health information 24 hours a day, 365 days a year by
providing this information to patients in person or via
other systems (website, voice mail messages, etc.).
In alignment with Pillar 9: Measurement, Continuous
Quality Improvement, and Research, PMH practices offer
opportunities for patients to provide feedback on the
accessibility of the practice. Specifically, patients should
have the opportunity to evaluate and provide input for the
appointment booking system. Mechanisms and supports
need to be in place to ensure that practices and governing
bodies can review and respond to feedback appropriately
and communicate this back to patients.
Determining the optimal panel size for each PMH practice
is critical to ensuring accessible and safe, high-quality
care.64 Establishing and incorporating recommendations
from the PMH vision may enable practices to consider
increasing their panel size. Actual panel size will vary
depending on the number of physicians and other team
members in the practice, the practice’s obligations and
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 17
Social accountability refers to the family physicians’
obligation to meet the needs of Canada’s
communities.66 For health care to be socially
accountable, it must be accessible by everyone and
responsive to the needs of patients, communities, and
the broader population.4 This obligation is embedded
in the Family Medicine Professional Profile and the
Four Principles of Family Medicine, highlighting that
family physicians are community-adaptive, responding
to the needs of their patients and communities.
These principles of family medicine align well with
the principles of social accountability. Family practice
is relationship-based care that embraces all issues
of need and endures over time and place of care. A
generalist keeps the whole in mind while attending
to the individual parts, the system in mind when
fixing individual problems, and the end in mind
when commencing the journey. Tools exist to help
family physicians and other health care providers
enhance their skills and training regarding social
accountability and cultural safety through many
professional organizations and cross-Canada
resource hubs like the National Collaborating
Centre of Determinants of Health67 and the National
Collaborating Centre on Aboriginal Health,68 as
examples.
PMH practices are aware of how the SDoH influence the
health of patients and communities. Family physicians are
often the best-situated primary care professionals to act on
Pillar 5: Community Adaptiveness and Social Accountability
A PMH is accountable to its community, and meets their needs through interventions at the patient,
practice, community, and policy level.
5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing,
immigration status) as relevant for the individual, community, and policy levels.
5.2 Panel size will consider the community’s needs and patients’ safety.
5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to
meet unique community needs.
5.4
Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using
the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in
doing so.
5.5
Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe,
seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender,
race, class, sexual orientation, gender identity, ability, etc.
commitment to teaching and research, and the needs
of the population being served (see Pillar 5: Community
Adaptiveness and Social Accountability). When deciding
panel size, each practice must determine how accepting
more patients into the practice might impact the
current population, the sustainability of the workload for
physicians and other members of the PMH team, and
the consequences of panel size on experience of care.
Refer to the Best Advice guide: Panel Size for more
information.65
issues that affect patients’ SDoH. Advocating for patients
and the health care system overall is a natural part of a
PMH structure. Advocacy can occur at three levels:69
Micro: In the immediate clinical environment, daily
work with individual patients and predicated on
the principles of caring and compassion
Meso: In the local community, including the
patient’s cultural community, the local community
of medical providers, and the larger civic
community, in which health professionals are
citizens as well as practitioners
Macro: In the humanitarian realm, where physicians
are concerned with the welfare of their entire
patient population and seek to improve human
welfare through healthy public policy (such as
reducing income inequality, supporting equitable
and progressive taxation, and expanding the
social safety net)
The principles of advocacy in family practice are found
in the CanMEDS–Family Medicine 201769 competency
framework, under the Health Advocate role. The
Best Advice guide: Social Determinants of Health70
describes how family physicians in the PMH can make
advocacy a practical part of their practice.
Poverty is a significant risk factor for chronic disease,
mental illness, and other health conditions. Low income
and other SDoH also present significant barriers to
accessing care.71 To meet the needs of these patients,
practices may need to extend hours, be more flexible
and responsive, and spend additional time helping
patients navigate and access necessary care. PMH
practices consider other specific community needs when
determining appropriate panel size. Demographics and
health status of the patient population can influence the
length and frequency of appointments needed, thereby
impacting a physician’s caseload.65 For example, a PMH
in a community with high rates of chronic conditions
may need to reduce the panel size to provide timely and
high-quality care, given that patients require more care
time and resources. Similarly, a patient’s social situation
may impact the time a family physician spends with
them. Family physicians and team members may need to
use a translator at clinical appointments, and may need
to provide written resources in alternative languages,
all factors affecting the time required to provide care.
Enabling PMH practices to adjust panel size based on
community needs requires governments to establish
blended payment mechanisms. These remuneration
systems ensure family physicians are adequately
compensated, and are not financially disincentivized from
spending the necessary time with patients (see Pillar 1:
Administration and Funding, for more information).
Social accountability and cultural competency
Part of the response to being more socially accountable with care offered to the community resides within each
and every health professional. While courses on cultural competency are now a standard part of medical education,
physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases
that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is
a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the
satisfaction of being an effective healer—of ourselves, our patients and our societies.
Importance of social accountability
Social accountability is a key value for health care organizations and professionals. For example, the Royal College
of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of
Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability
within their organizations and the work they do.
18 A NEW VISION FOR CANADA Family Practice—
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Family physicians and their PMH teams are situated
at the nexus of individual and population health, and
can engage with their patients in addressing health
promotion and disease prevention in creative ways. From
accompanying individual patients through teachable
moments (e.g., the smoker with pneumonia ready to quit)
to influencing civic policy to address homelessness, the
stories entrusted to family physicians in daily practice
are powerful tools for healthy change. These teams
are also key providers in many important public health
areas, including illness and injury prevention; health
promotion; screening and managing chronic diseases;
immunizations; and health surveillance. PMH practices
prioritize delivering evidence-based care for illness and
injury prevention and health promotion, reinforcing
them at each patient visit and other counselling
opportunities. PMHs and local or regional public health
units should cultivate and maintain strong links with one
another. Health care professionals who are part of PMH
teams may take on advisory, educational, supportive, or
active roles in public health initiatives, in many different
occupational, educational, or recreational settings
throughout the community. An effective public health
system should be inextricably linked to communitybased
family physicians and PMHs, recognizing and
supporting them as essential to the achievement of the
broader population and public health goals.
While PMHs focus primarily on the care of individuals
and their families, it is important for team members to
understand and address the health challenges facing
their practice populations and the larger community.
These broader challenges represent upstream factors
(SDoH) that have greater impact on the health of patients
than do the efforts of individual physicians. However,
the relationships embedded in individual and collective
practices can be central to engaging patients and
citizens in building more just and healthier communities
and societies. For example, with the help of HIT, details
about the needs of populations can be more easily
accessed through extraction from practice EMRs, or
participation in programs such as the Canadian Primary
Care Sentinel Surveillance Network (CPCSSN).73 The
CPCSSN networks collect health information from
EMRs of participating primary care providers, extract
anonymous data, and share information on chronic
conditions with governments, health care providers,
and researchers to help inform meaningful systems
and practice change. Programs like the CPCSSN allow
practices to better understand the needs of their
communities and implement specific health promotion
and prevention programs that can contribute to the
population’s overall well-being. Initiatives like this also
ensure the avoidance of data duplication, and recognise
that practices do not need (or have the resources) to
collect data on their own. However, these data are just
a part of caring—the heart of generalism is keeping the
whole in mind while attending to its parts, whether it is
at the level of the whole patient, the whole family, or the
whole society.
To meet the needs of their diverse panel of patients, family
physicians and other team members in the PMH work to
provide anti-oppressive and culturally-safe care, seeking
to mitigate experiences of discrimination faced by many
patients based on their SDoH. This requires understanding
how historical and current injustices have impacted the
well-being of certain populations, and working to ensure a
safe and welcoming practice environment by focusing on
the principles of caring and compassion.
Sociodemographic data benefits
The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed
about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated
into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data
will also be used for planning and evaluating the FHT’s programs.74
A NEW VISION FOR CANADA Family Practice—
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Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership
Primary care practice teams
Many allied health professional organizations have prioritized the importance of working together in a team to
provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the
CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of
Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes
implementation strategies for creating a primary practice team, and general descriptions of roles found in a
collaborative team.
20 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
A broad range of services is offered by an interprofessional team. The patient does not always see
their family physician but interactions with all team members are communicated efficiently within a
PMH. The team might not be co-located but the patient is always seen by a professional with relevant
skills who can connect with a physician (ideally the patient’s own personal physician) as necessary.
6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel
of registered patients.
6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or
network, collaborating with the patient’s personal family physician to provide timely access to a broad range
of primary care and consulting services.
6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged
and supported as part of each PMH.
6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team
members may be co-located or may function as part of virtual networks.
6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the
roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers,
physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed.
6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing
ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal
medical home team.
6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles,
professional scopes of practice, and personally acquired competencies. Their roles providing both episodic
and ongoing care support and complement—but do not replace—those of the family physician.
Team-based care is a core function of the PMH. Building
a team with a diverse mix of professional backgrounds
creates an opportunity to redefine what is considered
optimal, based on the needs of the practice and the
community it serves. A high-performing team is essential
to delivering more comprehensive, coordinated, and
effective care centred on the patient’s needs. While
different circumstances call for aspects of patient care
to be provided by different health professionals, it is
important to ensure that family physician expertise is
available to all team members through consultation.
To practice effectively in an interprofessional health care
team, there must be a clear understanding of each member’s
unique contributions, including educational background,
scopes of practice and knowledge, and areas of excellence
and limitations.76 Practices that draw on the expertise of a
variety of team members are more likely to provide patients
with the care they need and respond to community needs.77
Relationships across all dynamics within a practice,
whether between a patient and family physician or
between a patient and other members of the team,
should be encouraged and supported in the PMH.
Establishing these relationships develops trust and
confidence, and works toward the ultimate goal of
achieving better health outcomes. While it should be
left to each practice to determine who does what (within
the boundaries of professional scopes of practice), the
most responsible provider for the medical care for each
patient in the practice should be the patient’s personal
family physician.
Family physicians with enhanced skills and family
physicians with focused practices play an important role in
collaborating with the patient’s personal family physician
and team to provide timely access to a range of primary
care and consulting services. They supplement their
core skills and experience with additional expertise in a
particular field, while remaining committed to their core
generalist principles.78 These doctors can draw extensively
on their generalist training and approach to disease
management and patient-centred care, enabling them to
work collaboratively at different levels of care, including
with other specialists, to meet patient needs.79 These
clinicians also serve as a resource for other physicians in
their local health system by enhancing care delivery and
learning and teaching opportunities. The Best Advice
guide: Communities of Practice in the Patient’s Medical
Home80 provides more information about intraprofessional
collaboration between family physicians.
Shared care strategies provide patients with timely access
to consultations with other specialists or family physicians
with enhanced skills at scheduled times in the family
practice office setting. The consultant might assess several
patients per visit, at which time a plan for ongoing care
can be developed and agreed to by the family physician,
consultant, other team members, and the patient.
There is no one-size-fits-all model when determining
what mix of health care professionals is right. Team
composition depends on the professional competencies,
skills, and experiences needed to address the health
needs of the patient population.81 These needs vary,
depending on the communities’ defining characteristics;
Additional members of practice teams
Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice
can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices
can also host other health care professionals, such as those employed with a regional health authority, to provide
care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other
health care professionals often carry the overhead costs associated with these practitioners working on site,
and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1:
Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly
funded and have access to the right infrastructure (physical and governance) to support the initiatives described
in this vision.
A NEW VISION FOR CANADA Family Practice—
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22 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
for example, geography, culture, language, demographics,
disease prevalence. Family physicians are encouraged
to identify the gaps in health care provision in the local
practice environment and work with other health care
providers to meet those needs as much as possible. Data
from EMRs—as well as input from patients, community
members, and stakeholders—should inform team
planning. Factors to consider include:
Patient population
Identified community health care needs
Hours available for patient access
Hours available for each physician to work
Roles and number of non-physician providers
Funds available81
Overlapping or variations of similar competencies can
result in ambiguous expectations of what a defined role is
within a practice. When teams are planned and developed,
roles should be clearly outlined. This is best done at the
local practice level relative to community needs and
resources. This approach considers changes over the
course of a health care professional’s career, including
skills development, achievement of certifications, and
professional interests.82 It is important to include time
for team members to become comfortable in their role,
at the outset of team-based care and with any changes
to the team. It is also important to recognize that
these arrangements are flexible and subject to change,
provided the team engages in discussion and reaches
consensus on needed adjustments.
Team members might be in the same office or in the same
building, but this is not necessary. For smaller and more
remote practices, or larger urban centres where proximate
physical space may be a barrier, some connections may
be arranged with peers in other sites. Applying HIT
judiciously allows for virtual referrals and consultations.
Virtual links between PMH practices and other specialists,
hospitals, diagnostic services, etc., can be enhanced with
more formal agreements and commitments to provide
timely access to care and services.
By providing patients with a comprehensive array of
services that best meet their needs, team-based care
can lead to better access, higher patient and provider
satisfaction, and greater resource efficiency.61,77,83
Although there are presently many systems in place that
support the creation of health care teams, practices can
also create a successful team on their own. To ensure
team success, providers must have a clear understanding
of the different role responsibilities and ensure that
there are tools available to engage open dialogue and
communication. Teams within the PMH are supported by
a model that is flexible and adaptable to each situation.
The skills that family physicians acquire during their
training (as described in the CanMEDS-FM framework)
make them well suited to provide leadership within
interprofessional teams. As an important part of a PMH,
teams are central to the concept of patient-centred care
that is comprehensive, timely, and continuous.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 23
Pillar 7: Continuity of Care
Continuity of care is defined by consistency over time
related to where, how, and by whom each person’s medical
care needs are addressed throughout the course of their
life.84 With strong links to comprehensive team-based
care (see Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership), continuity of care
is essential to any practice trying to deliver care truly
centred on the needs of the patient. Continuity of care
is rooted in a long-term patient-physician partnership
in which the physician knows the patient’s history from
experience and can integrate new information and
decisions from a whole-person perspective efficiently
without extensive investigation or record review.84 From
the patient’s perspective, this includes understanding
each person’s life journey and the context this brings
to current health status, and the trust they have in their
provider that is built over time.
Past studies show that when the same physician attends
to a person over time, for both minor and more serious
health problems, the patient-physician relationship is
strengthened and understanding grows—an essential
element of effective primary health care.85 The personal
physician offers their medical knowledge and expertise
for a more complete understanding of the patient as
a person, including the patient’s medical history and
their broader social context, such as personal, family,
social, and work histories (see Pillar 5: Community
Adaptiveness and Social Accountability). In this model,
patients, their families and/or personal caregivers, and
all health care providers in the PMH team are partners in
care, working together to achieve the patient’s goals and
engaging in shared decision making. Understanding the
patient’s needs, hopes, and fears, and their patterns of
response to illness, medications, and other treatments,
deepens the physician’s ability to respond to larger
trends, not just the medical issue presented at any given
appointment. Continuity of care can ideally support the
health and well-being of patients actively and in their daily
lives without focusing only on care when they are ill. The
strong physician-patient relationship developed over time
allows them to maintain good health and prevent illness
and injury, as the physician uses their deep knowledge
of their patient to work with teams of qualified health
professionals to best support the patient’s well-being.
Family physicians in the PMH, acting as the most
responsible provider, can provide continuous care
over the patient’s lifespan and develop strong
relationships with patients. Research demonstrates
that one of the most significant contributors to better
population health is continuity of care.86,87 It found
that those who see the same primary care physician
continuously over time have better health outcomes,
reduced emergency department use, and reductions
in hospitalizations versus those who receive care
from many different physicians. A Canadian study
found that after controlling for demographics and
health status, continuity of care was a predictor
of decreased hospitalization for ambulatory caresensitive
conditions (such as such as COPD, asthma,
diabetes, and heart failure) and decreased emergency
department visits for a wide range of family practicesensitive
conditions.85 Overall “the more physicians
patients see, the greater the likelihood of adverse
effects; seeking care from multiple physicians in
Patients live healthier, fuller lives when they receive care from a responsible provider who journeys
with them and knows how their health changes over time.
7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby
ensuring continuous care across the patient’s lifespan.
7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the
family practice office, hospitals, long-term care and other community-based institutions, and the patient’s
residence.
7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical
services their patients receive throughout the medical community.
the presence of high burdens of morbidity will be
associated with a greater likelihood of adverse side
effects.”86 It has been reported that a regular and
consistent source of care is associated with better
access to preventive care services, regardless of the
patient’s financial status.
Continuity of care also requires continuity in medical
settings, information, and relationships. Having most
medical services provided or coordinated in the same
place by one’s personal family physician and team
has been shown to result in better health outcomes.88
As described in Pillar 3: Connected Care, when care
must be provided in different settings or by different
health professionals (i.e., the medical neighbourhood),
continuity can still be preserved if the PMH plays a
coordination role and communicates effectively with
other providers. The PMH liaises with external care
providers to coordinate all aspects of care provided
to patients based on their needs. This includes but is
not limited to submitting and following up on referrals
to specialized services, coordinating home care, and
working with patients before and after discharge from
hospitals or other critical care centres.
In addition to this coordination role, the PMH acts as
a hub by sharing, collecting, storing, and acting as a
steward for all relevant patient information. This ensures
that the family physician, as the most responsible provider,
has a complete overview of the patient’s history. A record
of care provided for each patient should be available in
each medical record (preferably through an EMR) and
available to all appropriate care providers (see Pillar 2:
Appropriate Infrastructure for more information about
EMRs). Knowing that medical information from all sources
(i.e., providers inside and outside the PMH) is consolidated
in one location (physical or virtual) increases the comfort
and trust of patients regarding their care.
Continuity for patient health
Research demonstrates that continuity of care is a key contributor to overall population health. Patients
with a regular family physician experience better health outcomes and fewer hospitalizations as compared
to those without.69
24 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
Pillar 8: Patient- and Family-Partnered Care
External factors for patient health care
Patient- and family-partnered care is considered a key value to stakeholders across the health care system. In 2011,
the CMA and the CNA released a set of principles to guide the transformation of Canada’s health care system.91
Patient-centred care is listed as the first principle, and as a key component of improving the overall health care
experience.91 Similarly, in 2016 Patients Canada called on all levels of government to ensure that patients are at
the centre of any new health accords and future health care reform.92
* Family caregivers include relatives, partners, friends, neighbours, and other community members.
Patient-centred care is at the core of the PMH. Dr. Ian
McWhinney—often considered the “father of family
medicine”—describes patient-centred care as the
provider “enter[ing] the patient’s world, to see the illness
through the patient’s eyes … [It] is closely congruent
with and responsive to patients’ wants, needs and
preferences.”89 In this model, patients, their families and/
or personal caregivers, and all health care providers in
the PMH team are partners in care, working together
to achieve the patient’s goals and engaging in shareddecision
making. Care should always reflect the patient’s
feelings and expectations and meet their individual
needs. Refer to the Best Advice guide: Patient-Centred
Care in a Patient’s Medical Home90 for more information.
Family caregivers* play an important role in the PMH.
They help patients manage and cope with illness and can
assist physicians by acting as a reliable source of health
information and collaborating to develop and enact
treatment plans.93 The level and type of engagement
from family caregivers should always be determined
by the patient. Physicians “should routinely assess the
patient’s wishes regarding the nature and degree of
caregiver participation in the clinical encounter and
strive to provide the patient’s desired level of privacy.”94
They should revisit this conversation regularly and make
changes based on patient desires. PMH practices focus
on providing patient-centred care and ensuring that
family caregivers are included.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 25
Family practices respond to the unique needs of patients and their families within the context of
their environment.
8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’
feelings, preferences, and expectations.
8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making
process.
8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as
agreed upon with their care team.
8.4 Self-managed care is encouraged and supported as part of the care plans for each patient.
8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g.,
telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH.
8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys)
are part of ongoing planning and evaluation.
As part of their commitment to patient-centred care, PMH
practices facilitate and support patient self-management.
Self-management interventions such as support for
decision making, self-monitoring, and psychological and
social support, have been demonstrated to improve
health outcomes.95 PMH team members should always
consider recommendations for care from the patient’s
perspective. They should work collaboratively with
patients and their caregivers to develop realistic action
plans and teach problem-solving and coping. This is
particularly important for those with chronic conditions,
who must work in partnership with their physician
and health care team to manage their condition over
time. (Refer to the Best Advice guide: Chronic Care
Management in a Patient’s Medical Home96 for more
information). The goal of self-managed care should be
to build the patient’s and caregiver’s confidence in their
ability to deal effectively with illnesses, improve health
outcomes, and foster overall well-being.
To facilitate patient- and family-partnered care, a range
of user-friendly options for accessing information
and care beyond the traditional office visit should
be available to patients when appropriate. These
include email, telehealth, virtual care, mobile health
units, e-consults, home visits, same-day scheduling,
group visits, self-care strategies, patient education,
and treatment sessions offered in community settings.
Providing a range of options allows patients to access
the type of care they prefer based on individual needs.
Patients also need to be informed about how they can
access information and resources available to them; for
example, resources such as Prevention in Hand (PiH).97
Allowing patients to access to their medical records
can improve patient-provider communication and
increase patient satisfaction.98,99 The specific information
accessible to patients should be discussed and agreed
upon by the patient and their care team. Patient
education about accessing and interpreting the available
information is necessary. Facilitating this type of access
requires each PMH to have an EMR system that allows
external users to access information securely (see Pillar
2: Appropriate Infrastructure).
Patient surveys and opportunities for patients to
participate in planning and evaluating the effectiveness
of the practice’s services should be encouraged; practices
must be willing respond and adapt to patient feedback.
To strengthen a patient-centred approach, practices may
consider developing patients’ advisory councils or other
formalized feedback mechanisms (e.g., using patient surveys)
as part of their CQI processes (see Pillar 9: Measurement,
Continuous Quality Improvement, and Research).
Patient self-management
The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can
improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an
environment of learning and seeks to encourage health literacy among its patients through its various programs.
The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to
patients to remove financial barriers to access.
26 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 27
ONGOING DEVELOPMENT
Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to
Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional
Development.
MEASUREMENT,
CONTINUOUS
QUALITY
IMPROVEMENT,
AND RESEARCH
PAGE 28
TRAINING,
EDUCATION, AND
CONTINUING
PROFESSIONAL
DEVELOPMENT
PAGE 30
28 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
Continuous quality improvement
CQI is an important value among health organizations such as the CFHI.100
Pillar 9: Measurement, Continuous Quality
Improvement, and Research
CQI is an essential characteristic of the PMH vision.
It encourages health care teams to make practical
improvements to their practice, while monitoring the
effectiveness of their services, the health outcomes
and safety of their patients, and the satisfaction of
both patients and the health professionals on the team.
Every PMH is committed to establishing a CQI program
that will improve patient safety, and enhance efficiency
and quality of the services provided to patients. As
part of CQI activities, a structured approach is used
to evaluate current practice processes and improve
systems and to achieve desired outcomes.
To engage in CQI, the PMH team must identify the
desired outcomes and determine appropriate evaluation
strategies. Once the process and the desired outcome
are defined with patients, the CQI activity will track
performance through data collection and comparison
with the baseline. Performance measures can be
captured through structured observation, patient and
staff surveys (see Pillar 8: Patient- and Family-
Partnered Care), the PMH self-assessment tool,
and the practice’s EMR (see Pillar 1: Administration
and Funding and Pillar 3: Connected Care). The
indicators selected should be appropriate to each
practice and community setting, be meaningful to
the patients and community, and the CQI process
could be introduced as a practice’s self-monitoring
improvement program or as an assessment carried
out by an external group.
In some jurisdictions, funding is tied to achieving
performance targets, including those that provide
evidence for the delivery of more cost-effective care
and better health outcomes.101 Some provinces in
Canada have begun to link financial incentives to clinical
outcomes and targets that have been achieved (“pay
for performance” models).102 Although there may be
some benefits derived by this approach, there can also
be risks if funding incentives and resource supports
become overly focused on patients with certain medical
problems or on those who have greater potential to reach
prescribed targets, while at the same time care is being
delayed or denied for others.101,103 Future development
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 28
Family practices strive for progress through performance measurement and CQI. Patient safety is always
a focus, and new ideas are brought to the fore through patient engagement in QI and research activities.
9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and
the services they provide for patient and provider satisfaction.
9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH.
9.3 All members of the health professional team (both clinical and support teams), as well as trainees and
patients, will participate in the CQI activity carried out in each PMH.
9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate
in research carried out in their practice settings.
9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the
effectiveness of care and services.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 29
of financial incentive models should consider these
unintended consequences that might impair the ability
of practices to provide good quality patient care to their
full population.
The objectives that define a PMH could be used to develop
the indicators for CQI initiatives in family practices
across Canada. These criteria could be augmented
by indicators recommended by organizations such as
Accreditation Canada, Health Quality Ontario, Health
Standards Organization, and the Patient-Centered
Medical Home model in the United States. The CFPC is
committed to collaborating with these groups to further
develop the CQI process for PMHs and family practices.
Consult the CFPC’s Practice Improvement Initiative
(Pii)104 for a list of available resources.
CQI is a team activity and should involve all members
of the PMH team as well as patients and trainees. This
will ensure buy-in from the team, allow for patient
engagement and participation, and provide trainees with
valuable learning opportunities.105 PMHs are committed
to using the results of CQI initiatives to make tangible
changes in their practice to improve operations, services,
and programs.
Time and effort invested into participation in CQI
activities should be recognized as valuable and not be
disincentivized through existing remuneration models.
Dedicated time and capacity to perform these activities
should be built into the practice operational principles.
On a larger scale, PMHs function as ideal sites for
community-based research focused on patient health
outcomes and the effectiveness of care and services.
The PMH team should be encouraged and supported
to participate in research activities. They should also
advocate for medical students, residents, and trainees
to take part in these projects. In Canada, the Canadian
Primary Healthcare Research Network (CPHRN) and
the commitment of the Canadian Institutes for Health
Research’s (CIHR’s) Strategy for Patient-Oriented
Research (SPOR) are vitally important.106 The focus on
supporting patient-oriented research carried out in
community primary care settings is consistent with the
priorities of the PMH.
Competitions for research grants such as those
announced by SPOR should be strongly encouraged
and supported. PMHs are ideal laboratories for
studies that embrace the principles of comparative
effectiveness research (CER) and the priorities
defined by the CPHRN and CIHR’s SPOR project.
They provide excellent settings for multi-site research
initiatives, including projects like those currently
undertaken by the CPCSSN—a nationwide network of
family physicians conducting surveillance of various
chronic diseases.
30 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
Pillar 10: Training, Education, and
Continuing Professional Development
PMH practices serve as training sites for medical
students, family medicine residents, and those training
to become nurses and other health care professionals.107
They create space for modelling and teaching practices
focused on the essential roles of family physicians and
interprofessional teams as part of the continuum of a
health care system. One of the goals of family medicine
residency training is for residents to learn to function
as a member of an interdisciplinary team, caring for
patients in a variety of settings including family practice
offices, hospitals, long-term care and other communitybased
institutions, and patients’ residences.70,108
A PMH also models making research and QI initiatives
a standard feature of a family practice. Professional
development and opportunities to participate in these
activities should be available and supported within PMH
practices through resources, guidance, and specifically
dedicated time.
Family medicine training is increasingly focused on
achieving and maintaining competencies defined by the
CFPC’s Triple C Family Medicine Curriculum.109 Triple C
includes five domains of care: care of patients across the
life cycle; care across clinical settings (urban and rural);
a defined spectrum of clinical responsibilities; care of
marginalized/disadvantaged patients and populations;
and a defined list of core procedures. Triple C also
incorporates the Four Principles of Family Medicine and
the CanMEDS-FM Roles.
PMHs allow family medicine students and residents to
achieve the competencies of the Triple C curriculum and
to learn how to incorporate the Four Principles of Family
Medicine, the Family Medicine Professional Profile, and
the CanMEDS-FM roles into their professional lives.
Learners gain experience with patient-partnered care,
teams/networks, EMRs, timely access to appointments,
comprehensive continuing care, management of
undifferentiated and complex problems, coordination of
care, practice-based research, and CQI—essential elements
of family practice in Canada. Furthermore, PMH practices
serve as optimal sites for trainees in other medical specialties
and health professions to gain valuable experience working
in interprofessional teams and providing high quality,
patient-centred care. Medical schools and residency
programs should encourage learners to conduct some of
their training within PMH practices.
Emphasis on training and education ensures that the knowledge and expertise of family physicians can
be shared with the broader health care community, and also over time by creating learning organizations
where both students and fully practising family physicians can stay at the forefront of best practice.
10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations
for the experiential training of their students and residents.
10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks,
EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated
and complex problems, coordination of care, practice-based research, and CQI.
10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to
achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the
Four Principles of Family Medicine, and the CanMEDS-FM Roles.
10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development
(CPD) to meet the needs of their patients and their communities both individually and as a team.
10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community.
Practising family physicians must engage in CPD to keep
current on medical and health care developments and
to ensure their expertise reflects the changing needs of
their patients, communities, and learners.
Mainpro+® (Maintenance of Proficiency) is the CFPC’s
program designed to support and promote family
physicians’ CPD across all CanMEDS-FM Roles and
competencies.
CPD refers to physicians’ professional obligation to
engage in learning activities that address their own
identified needs and the needs of their patients;
enhance knowledge, skills, and competencies across all
dimensions of professional practice; and continuously
improve their performance and health care outcomes
within their scope of practice.110 Three foundational
principles for CPD in Canada have been recently
described:
Socially responsive to the needs of patients and
communities
Informed by scientific evidence and practicebased
data
Designed to achieve improvement in physician
practice and patient outcomes
CPD is inclusive of learning across all CanMEDS-FM
Roles and competencies, including clinical expertise,
teaching and education, research and scholarship, and
in practice-based QI.
PMH practices support their physicians, and all other staff
members, to engage in CPD activities throughout their
careers by creating a learning culture in the organization.
This includes providing protected time for learning and
team-based learning, and access to practice data both
to discern patient/community need and practice gaps
to inform CPD choices and to evaluate the impact of
learning on patient care. This learning culture and the
will to be constantly improving quality and access to
care is essential to ensuring that the PMH continues to
support high performing care teams.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient funding by governments to cover
costs of training and financial support to ensure lost
income and practice capacity do not prevent this.
Physicians in the PMH share their knowledge with
colleagues in the broader health care community and
with other health care professionals in the team by
participating in education, training, and QI activities
in collaboration with the pentagram partners.† This
is particularly relevant for family physicians who are
focused on a particular area of practice (possibly
holding a Certificate of Added Competence) and are
able to share their extended expertise with others. This
can happen either informally or through more official
channels. For example, physicians may participate in
activities organized by the CFPC or provincial Chapters
(e.g., Family Medicine Forum, provincial family medicine
annual scientific assemblies), or lend their expertise to
interprofessional working groups addressing specific
topics in health care. Family physicians should be
encouraged to engage in these types of events to share
their knowledge and skills for the betterment of the
overall health system.
Continuing professional development
CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA,
and CNA emphasize the value and importance of continuing education for health care professionals to improve
patient care.
† Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education
administrators; university; community; health professionals—physicians and teams
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 31
32 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
CONCLUSION
The revised PMH vision of a high-functioning primary
care system responds to the rapidly evolving health
system and the changing needs of Canadians. The pillars
and attributes described in this document can guide
practices at various stages in the transition to a PMH,
and many characteristics are found in other foundational
documents of family medicine such as the Family
Medicine Professional Profile111 and the Four Principles
of Family Medicine. Supporting resources, such as the
PMH Implementation Kit, are available to help those
new to the transition overcome barriers to change.
Although the core components of the PMH remain the
same for all practices, each practice will implement the
recommendations according to their unique needs.
The PMH is focused on enhancing patient-centredness
in the health care system through collaboration, access,
continuity, and social accountability. It is intended to
build on the long-standing historical contribution of
family physicians and primary care to the health and wellbeing
of Canadians, as well as on the emerging models
of family practice and primary care that have been
introduced across the country. Importantly, this vision
provides goals and recommendations that can serve as
indicators. It enables patients, family physicians, other
care health professionals, researchers, health planners,
and policy-makers evaluate the effectiveness of any and
all models of family practice throughout Canada.
Those family practices that meet the goals and
recommendations described in this vision will have
become PMHs, but the concept is ever evolving. As family
physicians commit to making change in their practices,
the CFPC commits to supporting developments in the
PMH by creating and promoting new resources, which
will be available through the PMH website. The CFPC
will also play an important advocacy role to ensure that
the necessary supports are in place to reach the goals of
a PMH. Every family practice across Canada should be
supported and encouraged by the public, governments,
and other health care stakeholders (the pentagram
partners) to achieve this objective. Doing so will ensure
that every person in Canada is able to access the best
possible primary care for themselves and their loved ones.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 33
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107. Hasley PB, Simak D, Cohen E, Buranosky R. Training residents to work in a
patient-centered medical home: What are the outcomes? J Grad Med Educ.
2016; 8(2): 226-231.
108. College of Family Physicians of Canada. Specific Standards for Family
Medicine Residency Programs – The Red Book. Mississauga, ON: College of
Family Physicians of Canada; 2016.
109. College of Family Physicians of Canada. Triple C Competency Based
Curriculum website. www.cfpc.ca/Triple_C/. Accessed 2019 Jan 22.
110. Filipe HP, Silva ED, Stulting AA, Golnik KC. Continuing professional
development: Best practices. Middle East Afr J Ophthalmol. 2014; 21(2): 134-141.
111. College of Family Physicians of Canada. Family Medicine Professional Profile
website. www.cfpc.ca/fmprofile/. Accessed 2019 Jan 22.
Antimicrobials (which include antibiotics) are a precious public resource and an essential tool for fighting infections in both humans and animals. Their importance to human medical, nutritional and economic security cannot be understated. Yet globally, antimicrobials are losing their effectiveness more quickly than new such drugs, treatments and therapies are being identified and introduced to market.1 Over time, this dynamic has eroded the human antimicrobial arsenal, placing the lives and futures of an unacceptable number of people at risk.
Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria, viruses, fungi and parasites come into contact with antimicrobial drugs, such as antibiotics, antivirals, antifungals, antimalarials and anthelmintics, and undergo changes. The drugs are rendered ineffective and cannot eradicate infections from the body.
AMR is an international challenge that threatens to reverse over a century of progress in public health, health care and human development attributable to antimicrobial use. Indeed, the effects of AMR are already being felt across Canada’s health care system. Currently, Canada’s dedicated investment in solutions to militate against encroaching AMR in the AMR and antimicrobial stewardship (AMS) fields (both federally and provincially/territorially) can only be viewed as wholly inadequate to address the scope of the problem and the risks it poses for the health of Canadians.
Therefore, to: (1) promote awareness of AMR; (2) incentivize investment in AMR mitigation strategies; and (3) support the mobilization of an effective suite of more clinically effective management/treatment practices and policies, the following target audience recommendations are offered.a
a All the policy recommendations made in this document are not meant to be interpreted as clinical practice guidelines. Any individual who suspects they may have an infection should promptly consult a physician.
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Key AMR principle — the “One Health” approach
a) The complexity of AMR underscores the need for coordinated action known as the “One Health” approach. The term implies integrated strategies that span the human, animal/agricultural and environmental sectors. Thus, cooperation across a wide variety of stakeholders is necessary to address the collective nature of AMR. These stakeholders include governments, health professionals, private and public partners, and the public at large.
b) The One Health approach will require attention and investment in the following domains: (1) surveillance of antimicrobial prescribing and usage; (2) infection prevention and control practices that mitigate the spread of resistant pathogens; (3) stewardship programs and practices that educate health professionals, the public, and the private sector and nudge each into more appropriate patterns of supply and demand; and (4) a program of innovation, research and development focused on diagnostics, vaccines and alternative treatments to reduce reliance on antimicrobials. This includes the development of novel antimicrobials that expand the currently available arsenal.
c) Given the global dimensions of AMR, a successful One Health approach will require ambitious investments in global AMR mitigation. Given that health infrastructure and resources are limited in low- to middle-income countries, the impacts of AMR will primarily be felt in those settings.
Recommendations
1. Physicians and allied health professionals
Should:
a) Be aware that AMR is a serious public health crisis.
b) Know that various Canadian prescribing aides/guidelines are available to assist physicians in choosing appropriate antibiotics and improving practice (e.g., Choosing Wisely Canada).
c) Know that using antibiotics appropriately can help combat AMR and that diagnosis and laboratory testing play a key role. This includes only prescribing antibiotics for conditions that are clinically infectious and of a non-viral nature. Viral infections are the greatest source of antibiotic misuse.
d) Consider delayed prescriptions and/or prioritize follow-up for patients when diagnosis is initially undifferentiated or when symptoms worsen, progress or are prolonged.
e) Know that prevention of infections through hand hygiene, vaccination and appropriate use of antibiotic prophylaxis is evidence based and effective
f) Know that durations of therapy and dosage rates for treating many infections change with time and that you should prescribe antimicrobials for the shortest effective duration (using the narrowest spectrum possible).
3
g) Consider the potential side effects of antibiotics (including C. difficile and allergic reactions) in prescribing and when counselling patients as to their potential side effects.
h) Engage in conversations with patients about antimicrobials regarding:
i. their appropriate use;
ii. their potential risks;
iii. when to delay, begin or end an antimicrobial prescription (e.g., delayed prescriptions); and
iv. when to seek medical reassessment if symptoms worsen or persist.
i) Ask your local hospital or specialty organization about educational initiatives related to antibiotic prescribing.
j) Collaborate where possible with colleagues in other prescribing professions to reduce unnecessary antimicrobial use.
2. Patients and the Canadian public
Should:
a) Be aware that AMR is a significant problem that is linked to the inappropriate use of antimicrobials like antibiotics. Therefore, commit to only taking antibiotics if they are prescribed and only as directed by an authorized health professional.
i. Never share, or use, the antibiotics of others as it may contribute to AMR and have serious consequences for your health.
b) Consider that your expectations about antimicrobials may unduly pressure physicians, and other prescribers, to provide you a prescription when an antimicrobial would not be appropriate or helpful.
c) Engage in a conversation with prescribers about:
i. whether an antimicrobial is necessary;
ii. the risks associated with taking an antimicrobial;
iii. whether there are simpler and safer options to pursue; and
iv. when you should take further actions if your symptoms worsen or do not improve.
d) Rather than keeping antimicrobials in your medicine cabinet, throwing them in the garbage/toilet or sharing them with family or friends, practise a One Health mindset. Dispose of all unused and expired antimicrobials at your local pharmacy. This will limit the spread of resistance and prevent antimicrobials from finding their way into the environment.
e) Help limit resistance by staying up to date with all recommended vaccinations, and practise good hand hygiene.
f) If you or a family member have had personal experiences with AMR, consider sharing them with local politicians (provincial/territorial and federal).
3. Governments (federal, provincial/territorial)
Should:
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a) (Including internationally) immediately make substantial, long term, coordinated and directly dedicated financial investments in AMR and AMS. Specific areas to prioritize include:
i. AMR and AMS awareness campaigns targeted to the public;
ii. campaigns that support health professionals to incorporate AMS principles into their everyday practice;
iii. detailed, and integrated, action plans based on clear metrics of success and that address the needs of communities, primary care practitioners, patients and health care organizations (including long-term care facilities);
iv. practical surveillance of antimicrobial resistance, purchasing, prescribing and use that maximizes the opportunity to respond to changing landscapes;
v. studying in detail the links, and associated risks, between animal health and agricultural practices and human health;
vi. scaling up local AMS initiatives at the provincial/territorial and national health care delivery levels;
vii. pharmaceutical development pipelines and non-pharmacological treatment options for AMR infections;
viii. inexpensive, accurate and timely point-of-care diagnostic tests (usable in the community, at the bedside or in a clinic) to optimize prescribing; and
ix. fostering clinical research, development and innovation in the fields of AMR and AMS.
b) Scale up coordination between federal and provincial/territorial AMR and AMS activities.
c) Hold regular, high-level meetings of ministers of health, agriculture and finance (both federally and provincially/territorially) to discuss the implications of unchecked AMR and how best to mobilize public finances to address it.
d) Strongly consider an arms-length, national-level taskforce to address AMR and AMS.
e) Strengthen the roles of the chief public health officer and the provincial/territorial chief medical officers in addressing AMR and AMS.
f) Undertake a timely review of the Canadian Antimicrobial Resistance Surveillance System (CARRS) with an emphasis on:
i. scaling up the system;
ii. standardizing all AMR reporting metrics across the country; and
iii. injecting adequate resources into AMR surveillance and tracking antimicrobial usage rates.
g) Establish a permanent review body on infectious disease, including pharmacists, microbiologist and other experts, to evaluate the forthcoming Pan-Canadian Action Plan on AMR and release regular progress reports.
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4. Health care institutions and organizations
Should:
a) Implement strategic AMR plans that are coordinated, cross-departmental and adopted institution wide. These should be premised on:
i. standardized and comprehensive reporting metrics for AMR and antimicrobial usage;
ii. tailored infection prevention and control programs to screen for and effectively prevent new AMR infections;
iii. improving public and professional awareness of AMR organization wide;
iv. improving conservation measures such as prescribing practices (audit and feedback, incentives programs, etc.); and
v. supporting and incentivizing appropriate prescribing of antimicrobials.
b) Evaluate whether existing policies and procedures, diagnostics and testing capacities, and multidisciplinary and organizational cultures are strategically geared toward combatting AMR.
c) Where possible, develop collaborations with other local health institutions, clinical researchers and community, public and private partners to promote AMS.
5. Accreditation and regulatory bodies
Should:
a) Regularly review and establish meaningful criteria for accreditation, ethical codes and regulatory practice standards surrounding AMR and AMS so that practitioners and health institutions can be informed, supported and kept up to date on emerging AMR trends, practices and issues.
b) Adopt profession-specific mandatory requirements for AMR and AMS (proper credentialing and training, regular updating of knowledge and competence for prescribing antimicrobials, appropriate data collection regarding antimicrobial usage, etc.) as part of credentialing.
c) Work to promote, support and enhance existing AMS practices and programs.
d) Collaborate with health institutions, professional health associations and other accreditation and regulatory bodies to implement AMS goals/plans.
6. Colleges and faculties for medicine and allied health professions
Should:
a) Promote and support more educational resources for AMS and AMR, throughout the continuum of education (undergraduate, postgraduate and continuing education).
i. Topics for these resources should include (1) awareness of AMR and AMS, (2) appropriate diagnostic testing, (3) strategies to minimize antimicrobial use and (4) personal prescribing practices.
b) Promote and support research on AMR and the implementation and dissemination of effective AMS strategies.
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1 Public Health Agency of Canada. Tackling antimicrobial resistance and antimicrobial use: a pan-Canadian framework for action. Ottawa: Public Health Agency of Canada; 2017. Available: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/drugs-health-products/tackling-antimicrobial-resistance-use-pan-canadian-framework-action/tackling-antimicrobial-resistance-use-pan-canadian-framework-action.pdf (accessed 2018 Aug 10).
BACKGROUND TO CMA POLICY
Antimicrobial Resistance
See also CMA Policy Antimicrobial Resistance PD19-08
OVERVIEW
The world is at the tipping point of a post-antibiotic era. “Worldwide, we are relying more heavily on antibiotics to ensure our medical, nutritional, and economic security; while simultaneously causing the decline of their usefulness with overuse and ill-advised use.” It is estimated that the world’s use of antimicrobials increased by 65% between 2000 and 2015 — mainly in low- to middle-income countries.
Dr. Margaret Chan, the former head of the World Health Organization (WHO), described antimicrobial resistance (AMR) as a slow-moving tsunami for public health. Other experts have characterized AMR as a looming “antibiotic apocalypse,” warning that all countries “will face disastrous consequences if the spread of AMR is not contained.” Others are now calling AMR the “climate change” of health care. According to the UK’s review on AMR, an estimated 10 million people globally will die annually by 2050, and AMR will surpass cancer to become the leading cause of death.
AMR occurs when “microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). … As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.” Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs.” “Nightmare bacteria,” as they have been dubbed, are bacterial strains that no conventional antimicrobial can effectively treat; their incidence is on the rise.
AMR represents a unique challenge for the medical profession as it is estimated that as many as 50% of current antibiotic prescriptions are either inappropriate or unnecessary. In addition, taking an antimicrobial involves potentially considerable exposure to side effects or risk. At stake are many currently routine, and lifesaving, forms of medical treatment. Critically, these include many medications for currently treatable bacterial infections, and many forms of surgery (including cesarean delivery), radiation therapy, chemotherapy and neonatal care.4
THE UNDERLYING DYNAMICS OF AMR
AMR is driven by a complex set of interlocking factors. These include: (1) increased global travel and medical tourism; (2) inappropriate, and unnecessarily high, use of antimicrobials in the agrifood sector; (3) poor medical prescribing practices; (4) inadequate implementation of infection prevention and control measures; (5) lack of knowledge, inappropriate expectations and misuse of antimicrobials on the part of the general public; (6) availability of poor-quality antimicrobials; (7) lack of access to rapid, affordable and accurate rapid diagnostic tools and infrastructure; (8) inadequate and underused surveillance data from AMR surveillance systems; (9) international travel rates; and (10) low commercial interest in, or support for, new antimicrobial research and development.
To make progress on AMR, we need to carefully think about how to address its various drivers. Antimicrobial stewardship (AMS) is a term describing coordinated efforts, at any program level, to: (1) promote the appropriate use of antimicrobials; (2) improve patient outcomes; (3) reduce microbial resistance and preserve the effectiveness of antimicrobials; and (4) decrease the spread of infections caused by multidrug-resistant organisms. AMS efforts are based on the “One Health” approach. These include: (1) surveillance; (2) conservation of existing AM effectiveness; (3) innovation through research and development; and (4) infection prevention and control.
Fundamentally, AMR can be thought of as a collective action problem, similar in character to the problem of climate change.3, While all stakeholders have a role to play in combatting AMR, each has very different resources, abilities and perspectives on AMR. Canada and much of the developed world have the luxury of health infrastructures, finances and regulatory frameworks that can make AMR mitigation possible. But in low- to middle-income countries — places where antibiotics might be the only real health care available — the very discussion of AMS can be perceived as threatening. Simply put, this illustrates the fact that solutions to AMR need to mobilize and leverage a collective strategy that is as broad and as connected as possible. To be successful, these solutions will need to do so in a manner that acknowledges the local reality of health care delivery.
Global investment in antimicrobial research and development is underwhelming, a dynamic described as a “drying up” of the pharmaceutical pipeline.8 This is evidenced by the recent large-scale withdrawal of major pharmaceutical companies from antimicrobial research and development, reflecting the lack of profitability in this area. On the pharmaceutical side, there are clear barriers to companies investing in the development of novel antimicrobials. Underlying factors include: (1) 10-year timelines, and an estimated minimum $1 billion price tag for development; (2) high development failure rates for new antimicrobials; (3) the inevitable emergence of resistance to any newly developed antimicrobial; (4) antimicrobials being offered at relatively cheap dosage rates over shorter durations of use; and (5) the need to preserve the efficacy of any antimicrobial’s future use, which limits their economic viability.8
WHAT ARE THE CANADIAN CONTEXTS?
AMR is already a major costly public health challenge in both the US and Canada. AMR infections are clearly linked to poorer health outcomes, longer hospital stays and higher mortality rates.3 The Public Health Agency of Canada (PHAC) estimates that roughly 18,000 hospitalized Canadians contract drug-resistant infections per year. The Canadian Patient Safety Institute estimates that 8,000 Canadian patients die annually with an AMR-related infection. It is estimated that close to 23 million antibiotic prescriptions are written annually for patients in Canada, the approximate equivalent to 1.6% of the population being on an antimicrobial on any given day.
An action plan in Canada is being developed by PHAC. On the surface, the action plan appears comprehensive in that it outlines a One Health approach.10 However, despite commitments to take comprehensive, measurable action on AMS, Canadian leadership on AMR has historically lagged because of a lack of concrete coordination between PHAC and the provinces and because it has been challenging to implement local initiatives systemically.
Previous shortcomings were highlighted in the Auditor General of Canada’s 2015 report and again in a 2017 issue brief by HealthCareCAN.18 Although efforts continue and the action plan is set for release at some point in 2019, concerns remain that: (1) the scope of coordinated efforts with the provinces and territories requires an interest in cooperation that may not exist between the two levels of government; (2) relative to the scope of the problem, sufficient and dedicated resources won’t be allocated; and (3) efforts on the industrial and agricultural fronts may not be sufficiently coordinated with AMR efforts for human health.
In the spring of 2018 the House of Commons Standing Committee on Health (HESA) released a report outlining 10 recommendations for action on AMR in Canada. Although the federal government “accepted” most of the committee’s recommendations, no meaningful (and dedicated) AMR funding has been announced in advance of the action plan’s launch. Indeed, the federal government’s response to the HESA report sought to downplay the need for either urgent action or additional resources. This was done by pointing to nominal federal AMR efforts over the span of more than a decade.
It should be noted that a small number of excellent localized AMS initiatives exist and have begun yielding promising local AMS results in Canada. AMR and AMS champions such as Choosing Wisely Canada, Do Bugs Need Drugs, and the Association of Medical Microbiology and Infectious Disease Canada have long argued that with proper resourcing, localized initiatives can be scaled up to a systemic level of application within provincial health care systems.
GLOBALLY, WHERE DOES AMR STAND?
Urgent action is required at an international level to combat AMR. Although AMR remains a complex public health challenge, the benefits of AMS are clear. The preservation of these precious resources will save lives and can positively affect both quality of care and health care delivery costs.7,14 Globally, many higher income nations and, increasingly, middle-income countries have now developed AMR/AMS action plans. Like the situation in Canada, these emerging and existing global action strategies remain largely unimplemented. Initial cash infusions into the AM drug development pipeline are beginning to emerge.8
Despite this, experts warn that such investments are too short term and wholly inadequate to address the scope of the looming AMR crisis.8, This reflects the many complexities that exist in the implementation of AMR action plans, owing in large part to: (1) a general lack of resources or prioritization; (2) complacency about AMR as a pressing public health concern; (3) difficulties in generalizing local AMS efforts; (4) coordination between sectorial actors; and (5) a lack of tangible AMR metrics and evidence.
If AMS gains are to be made in low- and middle-income countries, the impact of limited resources in those settings will need to be considered.13 Realistically these countries will require various forms of monetary incentives and assistance to be able to effectively adopt AMR programs. If such support is not provided, human health rights will be affected and global AMS efforts will be undermined. Finally, there are now well-established calls for an international model, even a treaty, to be implemented on AMR/AMS.12,
The Canadian Medical Association appreciates this opportunity to respond to Health Canada’s consultation on the proposed regulations for edible cannabis, cannabis extracts, and cannabis topicals.
The CMA’s approach to cannabis is grounded in public health policy. It includes promotion of health and prevention of problematic use; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation, recommendations regarding Bill C-45. As well, we submitted comments to Health Canada with respect to the consultation on the proposed regulatory approach for the Cannabis Act, Bill C-45.
Canada’s physicians have a longstanding concern about the health risks associated with consuming cannabis. , Consumers use these products for both recreational and medical purposes, compelling the need for accuracy in the labeling as well as quality control in the manufacturing process.10
Cannabis Edibles, Extracts and Topicals
Cannabis will have a different effect on the user, depending on whether it is smoked or ingested, as in an edible. It has been found that “smoking marijuana results in clinical effects within 10 minutes, peak blood concentrations occur between 30 and 90 minutes, and clearance is complete within 4 hours of inhalation. Oral THC does not reach significant blood concentration until at least 30 minutes, with a peak at approximately 3 hours, and clearance approximately 12 hours after ingestion.” Because of the delay in absorption when ingested, people might consume more to feel the psychoactive effects faster. This might lead to the consumption of very high doses and result in toxic effects, such as anxiety, paranoia and in rare cases, a psychotic reaction with delusions, hallucinations, incoherent speech and agitation.
Rates of use of edibles are not well known. A recent study in California high schools found that “polyuse via multiple administration methods was a predominant pattern of cannabis use and report the first evidence, to our knowledge, of triple product polyuse of combustible, edible, and vaporized cannabis among youths.”
We are limiting our response to Health Canada’s consultation questions that pertain to the CMA’s position with respect to cannabis and relate to our expertise and knowledge base.
Proposed THC limits for the new classes of cannabis products
Standardization within all classes of cannabis products in a legal regime is essential. Tetrahydrocannabinol (THC) levels in black market products can vary widely so one can never be assured of the strength being purchased, creating the potential for significant harm. ,
Experience in jurisdictions where cannabis has been legalized has shown that restrictions on the potency of products (i.e., THC limits) are necessary, given the higher risks of harm associated with higher potencies.2 Prohibition of high potency products is important.3
THC limits should be based on the best available evidence of safety for consumers. The increased potency of cannabis over the years raises concerns about its use in edibles, extracts and topicals, offering a significant challenge with respect to regulating their use. This becomes particularly worrisome with respect to preadolescents and adolescents who should avoid using cannabis due to concerns with the impact on the developing brain.2 Use has been associated with a “significant increased risk of developing depression or suicidality in young adulthood.”
More research is needed with respect to the effects of cannabis on all age groups, especially children, adolescents and seniors. Saunders et al describe the case of an elderly patient with a history of coronary artery disease suffering what appears to have been a myocardial infarction after ingesting most of a marijuana lollipop that contained 90 mg of THC. Such cases demonstrate how crucial it is to establish appropriate levels of THC. This is an especially important consideration because “consuming cannabis-infused edibles may inadvertently result in toxicity because absorption can take hours, compared with minutes when smoking. An individual who does not yet feel an effect may over-consume.”
Small children and people with cognitive impairment will not be able to read labels, so preventive measures are very important, as with any pharmaceutical. Since legalizing cannabis, Colorado’s Rocky Mountain Poison & Drug Center has reported an increase in calls related to edible exposures. Children can accidentally eat products that contain cannabis, making them ill enough to seek medical assistance.
The CMA maintains that the proposed draft regulations of 10 mg per discrete unit and package is too high and should be established at a maximum of 5 mg per dose, given the higher risks of overconsumption with edibles, the risks of accidents in children and the experience in other jurisdictions. Colorado’s limit was set at 10 mg per unit, and health authorities recognize that a lower limit would have been warranted to prevent more accidents. Other preventive measures, such as child proof packaging, are considered in other sections of this brief.
The amount of THC must be displayed clearly and prominently on the package to help prevent accidental or overconsumption of the product.
Rules addressing the types of ingredients and additives that could be used in edible cannabis, cannabis extracts, and cannabis topicals appropriately address public health and safety risks while enabling sufficient product diversity
The CMA concurs with the proposed regulations. Experience in areas such as caffeinated, high-sugar alcoholic beverages provides ample evidence to proceed with restraint concerning the types of ingredients and additives that may be permitted in edible cannabis, cannabis extracts, and cannabis topicals.
Proposed new rules for the packaging and labelling of the new classes of cannabis products
The CMA reiterates its position with respect to the packaging and labelling of cannabis products as presented in its submission on the proposed approach to the regulation of cannabis.5 This includes:
a requirement for plain and standard packaging
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause an overdose.
Plain and standardized packaging is necessary with respect to edibles as their wider availability raises several public health issues, not the least of which is ingestion by young children. It is imperative that the packages and labels of edibles not resemble popular confectionaries, for example. As the Canadian Paediatric Society has noted, “the unintended consumption of edibles manufactured to look like sweets by younger children is particularly concerning.”15 Also, by “restricting the extent to which marijuana edibles can look and taste like familiar sweets, (it) could also keep the psychological barriers to marijuana initiation among children and adolescents from being lowered.” The CMA has adopted similar positions with respect to tobacco and vaping products. , ,
It is recognized that these regulations are targeted at products meant for the adult market, but the entry of these new classes also creates challenges beyond that audience. Teens are attracted to vaping cannabis rather than smoking it because “smoke is not combusted and also may allow for more covert use given the reduction in odor.” , As well, as “edibles have no odor, they are largely undetectable to parents.”23
The CMA views this as an opportunity to educate Canadians about the health, social and economic harms of cannabis especially in young people. Package inserts must outline and reinforce the health risks involved; they must also be designed by governments and health professionals, not cannabis producers or distributors.
Inserts should include:5
information on securing the product in the home to prevent access by youth and children,
recommendations not to drive or to work with hazardous chemicals or operate equipment while using the contents of the package,
information on the health and social consequences (including legal penalties) of providing cannabis to those under a designated minimum age for purchasing, and
contact information for hotlines for poison control and for crisis support.
Cannabis topicals, as outlined in the proposed regulations, would fall under the category of health products and be found in non-prescription drugs, natural health products, and cosmetics. The CMA believes that all health claims need to be substantiated with sufficient evidence that meets standards for efficacy, besides safety and quality, to protect Canadians from misleading claims.5 This is important because the level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence for effectiveness is needed for a DIN but not for an NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product.5
Requirements for tamper-resistant and child-proof containers need to be in place to enhance consumer safety. More research is required to address the environmental concerns with extra packaging, which would result from single dose packaging. It is critical to put in place measures that make it difficult to ingest large doses of THC. Simply adding grooves to chocolate bars or baked goods, for example, separating different doses, is insufficient to prevent people, particularly children, from ingesting more than a dose (which in of itself is designed for an adult). As well, there is no guarantee that the THC is spread out uniformly throughout the product.
More research is needed with respect to “determining risks and benefits through proper clinical trials;” that includes determining the safest level of THC for extracts and topicals to reassure consumers will not be harmed by these products.18
With regards to cannabidiol (CBD), it would seem that “published data from around the world has taught us that misleading labels as well as harmful contaminants are real and actual problems for CBD products.”18 Health claims need to be substantiated via a strong evidentiary process. There will be a need for careful monitoring of the health products released in the market and the health claims made.5 Experience has shown that regulations can and will be circumvented, and these activities will have to be addressed.
Edible cannabis and the requirement for all products to be labelled with a cannabis-specific nutrition facts table
Yes. The CMA supports the use of a cannabis-specific nutrition facts table (NFT) as described in the proposed regulations.1 These products should have the same standards and regulations applied to them as traditional food products do under the Food and Drugs Regulations. As such, a cannabis-specific nutrition facts table will help consumers differentiate them from standard food products.
The proposal for the labelling of small containers and the option to display certain information on a peel-back or accordion panel
The size of the container should not be an impediment to supplying consumers with the necessary information to make informed choices. Manufacturers should be required to use whatever method (peel-back or accordion panel) is most efficient and conveys all the necessary information. As the CMA noted in a recent brief with respect to tobacco labeling the “amount of space given to the warnings should be sufficient to convey the maximum amount of information while remaining clear, visible, and legible. The warnings should be in proportion to the packaging available, like that of a regular cigarette package.”20 Adding warnings on individual cigarettes, as we recommended, illustrates that it is feasible to apply important information to even the smallest surfaces.20
It is important to note that key information should be visible on the external part of the container, including the standardized cannabis symbol, ingredients and warnings.
Proposal that the standardized cannabis symbol would be required on vaping devices, vaping cartridges, and wrappers
Yes. As noted earlier, the CMA called for strict packaging requirements around both tobacco and vaping products.22 The requirement for the standardized cannabis symbol is an extension of that policy and to the labelling of cannabis products in general.5
Proposed new good production practices, such as the requirement to have a Preventive Control Plan, appropriately address the risks associated with the production of cannabis, including the risk of product contamination and cross-contamination
Yes. The CMA concurs with this requirement.
The requirement that the production of edible cannabis could not occur in a building where conventional food is produced
Yes. The CMA concurs with this requirement. Separate facilities are necessary to prevent cross-contamination for the protection of consumer health and safety.
Conclusion
The CMA supports the federal government’s commitment to a three-year legislative review as it affords the opportunity to evaluate the regulations’ impact and adjust them as needed. It continues to be important to have good surveillance and monitoring systems, as well as to continue to learn from other jurisdictions where cannabis is legal for recreational purposes.
Public education and awareness must accompany the introduction of new forms of cannabis, emphasizing the risks of accidental ingestion and overconsumption. It should also emphasize the need for safe storage of cannabis products, as well as personal possession limits.
Much more research is needed into the impact of these new classes across all age groups, and into public health strategies that discourage use and increase harm reduction practices. It is fundamental that profit driven commercialization is rigorously controlled through taxation, regulation, monitoring and advertising controls, in a manner that is consistent with a public health approach.
Government of Canada. Canada Gazette, Part I, Volume 152, Number 51: Regulations Amending the Cannabis Regulations (New Classes of Cannabis) Ottawa: Health Canada; 2018. Available: http://www.gazette.gc.ca/rp-pr/p1/2018/2018-12-22/html/reg4-eng.html (accessed 2018 Dec 22).
Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of
evidence and recommendations. AJPH. 2017 Aug;107(8):e1-e12. Available: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed& (accessed 2019 Feb 01).
Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana.
CMA submission to the Government of Canada – Task Force on cannabis, legalization and regulation.
Ottawa: CMA; 2016 Aug 29. Available: https://policybase.cma.ca/en/permalink/policy11954 (accessed 2019 Feb 01).
Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of
Commons Health Committee. Ottawa: CMA; 2017 Aug 18. Available: https://policybase.cma.ca/en/permalink/policy13723 (accessed 2019 Feb 01).
Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis. Ottawa: CMA; 2018 Jan 19. Available: https://policybase.cma.ca/en/permalink/policy13838 (accessed 2019 Feb 04).
Canadian Medical Association (CMA). Health risks and harms associated with the use of marijuana.
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Canadian Medical Association (CMA). A public health perspective on cannabis and other illegal drugs.
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Based on a well-established collaboration addressing concussion, the Canadian Academy of Sport and Exercise Medicine (CASEM) the College of Family Physicians of Canada (CFPC), and the Canadian Medical Association (CMA) are pleased to submit this brief to the Subcommittee on Sport-Related Concussions (SCSC) of the House of Commons Standing Committee on Health.
About the Canadian Academy of Sport and Exercise Medicine (CASEM)
CASEM is a physician member-based organization comprised of 850 medical doctors from many specialties who have specialized training and skills in sport and exercise related injuries/illnesses for active patients of all ages and abilities, including concussion care. CASEM physicians hold national and international leadership roles in concussion care. Namely, at the national level, CASEM chairs the Canadian Concussion Collaborative (CCC) and at the international level, several CASEM members played leadership roles in the development of the International Consensus Statements on Concussion in Sport which is the key document that establishes concussion management recommendation every 4 years.
About the College of Family Physicians of Canada (CFPC)
The CFPC is the professional organization that represents more than 38,000 family physician members across the country. The College establishes the standards for, and accredits, postgraduate family medicine training for Canada’s 17 medical schools. It reviews and certifies continuing professional development programs, and materials, that enable family physicians to meet certification and licensing requirements. The CFPC provides high-quality services, supports family medicine teaching and research, and advocates on behalf of family physicians and the specialty of family medicine.
About the Canadian Medical Association (CMA)
The Canadian Medical Association unites 85,000 physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Along with CASEM, the CMA is a co-founding member of the CCC.
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KEY KEY THEMESTHEMES AND RECOMMENDATIONSAND RECOMMENDATIONS:
In this brief, CASEM, CFPC, and the CMA submit a series of recommendations under two key themes. Taken as a whole, we believe these will help inform the Subcommittee’s study on how to improve concussion awareness, prevention and treatment for all Canadians. Background information regarding the groups and initiatives mentioned in the key themes and recommendations, is provided in the subsequent part of this document.
KEY THEME #1:
The impacts of concussion and the benefits of awareness efforts are slowly becoming better known at the higher levels of sport participation that received support for the implementation of proper concussion management strategies (namely through the Canadian Concussion Protocol Harmonization Project). Further efforts and government funding should address the issue at all levels of sport participation. This must include school-based sport programs, and concussion occurring in other contexts (e.g. leisure, occupation, etc.).
RECOMMENDATIONS related to key theme #1:
#1.1 The federal government should commission and fund the development and evaluation of additional efforts to improve awareness and proper management of concussion at all levels of sport participation and contexts where concussions occur in Canada.
#1.2 Since “key aspects of concussion prevention, detection and management occur prior to, as well as after, the initial medical intervention”1, “public health strategies should be developed and implemented to address the issue of concussions.”1
#1.3 Given their competencies and expertise in this area, “family physicians2 and sport and exercise medicine (SEM) physicians should play a central role in the design and implementation of strategies that work in conjunction with families, schools, sports organizations, employers and governments to educate, support and empower the implementation of proper concussion prevention, detection and management protocols.”1
#1.4 Any future effort to improve concussion awareness and management should, whenever possible, be evidenced-informed, and aim for synergy with ongoing Canadian initiatives.
#1.5 Innovative dissemination strategies that have the potential to reach all levels of sport participation and contexts where concussions occur should be considered and evaluated (e.g. massive open online course or MOOC 3).
1 The Role of Family Physicians and physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. A joint position statement of CASEM, CFPC, and the CMA. 2017 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105
2 This is not meant to exclude the possible role of other health care disciplines, such as nurse practitioners, that can be involved in the diagnosis and medical management of concussions in some Canadian jurisdictions.
3 https://www.ulaval.ca/les-etudes/mooc-formation-en-ligne-ouverte-a-tous/commotion-cerebrale-prevention-detection-et-gestion-dans-mon-milieu.html
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KEY THEME #2:
For the majority of Canadians affected by a concussion, family physicians play a central role in concussion identification and management through the recovery process. However, where persistent concussion symptoms arise, family physicians and their patients require timely access to SEM physicians, and multidisciplinary care for the development and implementation of individualized treatment plans. As it presently stands, access to such expert medical and multidisciplinary resources for concussion is very limited (especially in rural and remote regions). To complicate matters, Canadians affected by a concussion are all too often uncertain how best to navigate a health care system that isn’t well organized to address their unique needs.
RECOMMENDATIONS related to key theme #2:
#2.1 Medical schools and organizations should maintain continuous efforts aiming for the rapid integration of the most current clinical practice recommendations about concussion.
#2.2 Initial care for Canadians affected by a concussion should be coordinated by the patient’s family physician.
#2.3 To work in collaboration with their family physicians, patients affected by persistent symptoms following a concussion should have timely access to medical experts on concussion and allied professionals with expertise in concussion management.
#2.4 The potential of telemedicine strategies or other virtual network to improve access to concussion experts for support in the management of concussion should be considered and evaluated. BACKGROUNDBACKGROUND::
The challenging dynamics of concussion: Sport-related concussion seriously impacts the health and well-being of Canadians across the country; to say nothing of the costs to the health care system and concussed individuals. Canadian statistics show that among children and youth (10-18 years) who visit an emergency department for a sports-related head injury, 39% were diagnosed with concussions, while a further 24% were possible concussions.4
Between 2003 and 2013 in Ontario, a 4.4-fold increase of pediatric concussion-related consultations has been observed, with a sharp increase between 2010 and 2013 and nearly 35000 visits in 2013.5 Although, the precise reasons for this increased incidence of concussion are unknown, the study suggests that “…concussion education and awareness, improved diagnosis of
4 https://www.canada.ca/en/canadian-heritage/services/concussions.html
5 Zemek et al. J Pediatr 2017; 181: 222-8 (https://doi.org/10.1016/j.jpeds.2016.10.067)
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concussion, and revised concussion guidelines advocating stricter follow-up…” played an important role.
The body of knowledge regarding concussion is rapidly and constantly changing; a dynamic that is unlikely to change for the foreseeable future. One important limitation of our knowledge about concussion is the lack of information on the true burden of concussion in Canada. A significant proportion of all concussions are not captured by traditional health-related databases, or clinical research, because individuals often do not consult a physician. One positive and recent development that will help better understand the true burden of sport related concussion in youth occurred in November 2018 when a group of more than 30 Canadian researchers including CASEM and CFPC leaders on concussion received $12 million from the National Football League “Play Smart, Play Safe” initiative.6 This 3-year longitudinal cohort study will evaluate diagnostic tools, prognostic indicators, prevention strategies, and treatment strategies. This study will characterize the true incidence rate and recovery characteristics of concussion in high school-based sport settings.
Psychological and social factors must also be considered. Attitudes and awareness towards injury are complicating factors that highlight the need for improved concussion prevention and awareness. These include injury minimization, the lack of a visible injury, and a general lack of both pre and post-injury awareness. Those closely associated with a concussed individual (coaches, co-workers, employers, or an injured individual themselves) may have an incentive, or experience pressure, to hide/downplay injury or avoid medical assessment due to stigma.7 The natural human predilection towards downplaying the nature of injury is another important factor to consider, especially where, post-injury, the effects aren’t clearly visible. A concussed individual may lack the mental acuity to be able to understand that their symptoms require medical attention.
Another area to consider is the availability of qualified health care resources. Family physicians, whether in primary care settings or emergency departments, and SEM physicians, are generally the first medical professionals seen by a person who has sustained a concussion during a sport, leisure or occupational activity. They are the first point of contact for proper management, advice, and education regarding that person’s gradual return to cognitive (e.g. school and work) and physical activities (e.g. sport, exercise or work).8 Gaps in medical training, and the fast-paced evolution of concussion best practices, means that clinicians sometimes struggle to maintain up-to-date knowledge regarding the detection and treatment of concussions. These factors are further complicated by ambiguous scopes of practice across the multidisciplinary professions involved
6 https://www.ucalgary.ca/utoday/issue/2018-11-16/nfl-gives-significant-funding-help-youth-shred-burden-concussion
7 Delaney J, Caron J, Correa J, et al. Why Professional Football Players Choose not to Reveal their Concussion Symptoms During a Practice or Game. Clin J Sport Med, 2018, 28(1): 1-12.
8 College of Family Physicians of Canada & Canadian Academy of Sport and Exercise. Joint Position Statement - The Role of Family Physicians and Physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. 2017.
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with concussion management. Finally, there is general lack of available medical experts on concussion to whom family physicians can refer patients that present persistent symptoms.
Our recommendations also take into consideration the following factors:
The simple principles of initial concussion management6-8 are within the scope of practice of family physicians.
In the vast majority (80-90%) of cases, once simple principles of initial management have been implemented, concussion is a condition that will evolve favorably within 7-10 days.8
Even with proper initial management, some concussion patients will present with persistent symptoms that require a multidisciplinary team approach.
“Persistent symptoms” has been defined as more than 4 weeks in youth and more than 2 weeks in adults.9
Access to physicians with added competencies in concussion care (e.g. SEM Physicians, Physiatrists, Neurologists), and allied health professionals with experience in treating specific presentations of concussions is limited, especially in Canada’s rural and remote areas.
CASEM & CFPC’s concussion efforts to date: Since 2012, CASEM has played a key role in the evolution of concussion care in Canada by leading the work of the CCC10. The CCC is composed of 18 health organizations concerned with concussions that aim “to improve education about concussions, and the implementation of best practices for the prevention and management of concussions”. The CFPC has been involved with the CCC from the start. In 2015, the CCC published 2 key recommendations in a document entitled “Recommendations for policy development regarding sport-related concussion prevention and management in Canada”11 that state:
Organizations responsible for operating, regulating or planning sport and sporting events with a risk of concussion should be required to develop/adapt and implement a concussion management protocol, based on current best practices, that is customized for their context and available resources.
In situations where timely and sufficient availability of medical resources qualified for concussion management is lacking, multidisciplinary collaborative approaches should be used to improve concussion management outcomes while facilitating access to medical resources where appropriate.
Since 2015, the CCC has contributed a multidisciplinary health care perspective to key concussion-related initiatives in Canada. The first of these initiatives was initiated in January 2015 by Sport Canada and led to the creation of a Federal-Provincial-Territorial working group (FTP-WG) on
9 McCrory et al. Consensus statement on concussion in sport. (2017) https://bjsm.bmj.com/content/51/11/838
10 https://casem-acmse.org/resources/canadian-concussion-collaborative/
11 https://bjsm.bmj.com/content/49/2/88
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concussion that brings together sport, education, government and health stakeholders. Later in 2015, the mandate letters from Prime Minister Trudeau asked the Minister of Health and the Minister of Sport and Persons with Disabilities to collaborate on a national strategy on concussion. The Federal government budgeted $1.4 million to allow the Public Health Agency of Canada to work with provinces and territories to develop harmonized concussion management guidelines across Canada.12 Most of that work has been accomplished by funding to Parachute for the development of the Canadian guideline on concussion in sport.13 Members of the CCC and concussion leaders from the CFPC and CASEM were closely involved.
Since 2016, one of the CASEM and CFPC leaders on concussion developed a Massive Open Online Course (MOOC) to develop general awareness on concussion and facilitate the implementation of proper concussion management protocols in specific settings. After 4 iterations of that French language MOOC, over 8000 participants have accessed it. Presently an English version is being developed in collaboration between Laval University and the University of Calgary.
In August 2017, CASEM and CFPC, published a joint position statement entitled “The role of family physicians and physicians with added competencies in sport and exercise medicine in a public health approach to concussions”14 that is directly related to the recommendations presented in this brief.
Finally, since mid-2018, CASEM and CFPC have partnered with the Canadian Medical Association (CMA) to completely revamp the CMA’s policy on Head Injury in Sport. To foster high-level advocacy, cultural sensitivity, and awareness messaging on concussion, it has been redeveloped for a host of target audiences from all relevant perspectives. It is set for release in early 2019.
CONCLUSIONCONCLUSION:
Concussion is a pressing public health issue in Canada. The members of the SCSC should keep in mind that concussions are not limited to higher level organized sport. It’s a sudden, and unwanted challenge that hundreds of unsuspecting and unprepared Canadians face each day. These concussions occur in a range of situations, inside and outside of sports settings, and often go untreated; with a potential for tragic consequences.
To truly address the issue and make progress towards the objectives expressed by Prime Minister Trudeau in the mandate letters, the Government of Canada must provide significant investments. To make progress across the spectrum of sports, leisure and other context where concussions
12 https://www.budget.gc.ca/2016/docs/plan/ch5-en.html 13 The Canadian guideline on concussion in sport was part of the Parachute-led Concussion Protocol Harmonization Project.
14 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105
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occur, the Government funding should minimally represent a 10-fold increase from the initial $1.4M budgeted in 2016.
With their respective membership, tools and resources, CASEM and the CFPC can play an important role in addressing the burden that concussions place on Canadians. With this brief, we are expressing the willingness of our organizations to collaborate with the government in the design and implementation of strategies to systemically address concussion from all causes as a public health issue. To be successful this must occur across all levels of sport participation and include: leisure, school-based sports, occupational activities and address the rural and remote areas of the country.
On behalf of CASEM, and the CFPC, we would welcome the opportunity, and privilege, to present and discuss these recommendations with your Committee.
Respectfully submitted,
Dr. Paul Watson
CASEM President
Dr. Pierre Fremont
Chair of the CFPC’s SEM Committee and Past President of CASEM
Dr.Tatiana Jevremovic
Past President of CASEM
Dr. Gigi Osler
CMA President
Contacts: Dawn Haworth, Executive Director, CASEM
dhaworth@casem-acmse.org
613 748 5851 – ext 1
Artem Safarov, Director of Health Policy and Government Relations, CFPC
asafarov@cfpc.ca
905-629-0900 x 249
