Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


104 records – page 1 of 6.

Presentation to the House of Commons Standing Committee on Finance -December 7, 2007

https://policybase.cma.ca/en/permalink/policy9057
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
Text
It is a pleasure to address the Standing Committee on Finance today as part of your pre-budget consultations. In keeping with the theme set by the Committee, our presentation - Tax Incentives for Better Living - focuses on changing the tax system to better support the health and well being of all Canadians. Today I will share with you three recommendations improving the health of Canadians and productivity of the Canadian economy: First, tax incentives for pre-paid long-term care insurance; Second, tax incentives to retain and recruit more doctors and nurses; Third, tax incentives to enhance health system productivity and quality improvements. 1. Long Term Care insurance Canada's population is ageing fast. Yet, long-term care has received little policy attention in Canada. Unlike other countries like the UK and Germany who have systems in place, Canada is not prepared to address these looming challenges. The first of the baby-boomers will turn 65 in 2011. By 2031, seniors will comprise one quarter of the population - double the current proportion of 13%. The second challenge is the lack of health service labour force that will be able to care for this ageing population. Long-term care cannot and should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Therefore the CMA urges the Committee to consider either tax-pre-paid or tax-deferred options for funding long-term care. These options are examined in full in the package we have supplied you with today. 2. Improving access to quality care Canada's physician shortage is a critical issue. Here in Quebec, 1 in 4 people do not have access to a family physician. Overall 3.5 people in Canada do not have a family Physician. Despite this dire shortage, the Canada Student Loans program creates barriers to the training of more physicians. Medical students routinely begin their postgraduate training with debts of over $120,000. Although still in training, they must begin paying back their medical school loans as they complete their graduate training. This policy affects both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. We urge this Committee to recommend the extension of interest-free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. 3. Health System IT: increasing productivity and quality of care The last issue I will address is health system automation. Investment in information technology will lead to better, safer and cheaper patient care. In spite of the recent $400 million transfer to Canada Health Infoway, Canada still ranks at the bottom of the G8 countries in access to health information technologies. We spend just one-third of the OECD average on IT in our hospitals. This is a significant factor with respect to our poor record in avoidable adverse health effects. An Electronic Health Record (EHR) could provide annual, system-wide savings of $6.1 billion - every year - and reduce wait times and thereby absenteeism. But, the EHR potential can only be realized if physician's offices across Canada are fully automated. The federal government could invest directly in physician office automation by introducing dedicated tax credits or by accelerating the capital cost allowance related to health information technologies for patients. Before I conclude, the CMA again urges the Committee to address a long-standing tax issue that costs physicians and the health care system over $65 million a year. When you add hospitals - that cost more than doubles to over $145 million-or the equivalent of 60 MRI machines a year. The application of the GST on physicians is a consumption tax on a producer of vital services and affects the ability of physicians to provide care to their patients. And now with the emphasis on further sales tax harmonization, the problem will be compounded. Nearly 20 years ago when the GST was put into place, physician office expenses were relatively low for example: tongue depressors, bandages and small things. There was practically no use computers or information technology. How many of you used computers 20 years ago? Now Canadian physicians' could be and should be using 21st century equipment that is expensive but powerful. This powerful diagnostic equipment can save lives and save the system millions of dollars in the long run. It provides a clear return on investment. Yet, physicians still have to pay the GST (and the PST) on diagnostic equipment that costs a minimum of $500,000 that's an extra $30,000 that physicians must pay. The result of this misalignment of tax policy and health policy is that most Radiologists' diagnostic imaging equipment is over 30-years old. Canadians deserve better. It's time for the federal government to stop taxing health care. We urge the Committee to recommend the "zero-rating" publicly funded health services or to provide one-hundred percent tax rebates to physicians and hospitals. Conclusion In conclusion, we trust the Committee recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. By supporting: 1. Tax Incentives for Long-Term Care 2. Tax Incentives to Bolster Health Human Resources and, 3. Tax Incentives to Support Health System Automation. This committee can respond to immediate access to health care pressures that Canadians are facing. Delaying a response to these pressures will have an impact on the competiveness of our economy now, and with compounding effects in the future. I appreciate the opportunity of entering into a dialogue with members of the Committee and look forward to your questions. Thank you.
Documents
Less detail

Car Seat Restraints for Children – Update 2007

https://policybase.cma.ca/en/permalink/policy9066
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Health care and patient safety
Resolution
BD08-03-29
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2007-12-01
Replaces
Car Seat Restraints for Children (2001)
Topics
Health care and patient safety
Resolution
BD08-03-29
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
Text
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
Less detail

Counterfeit Drugs

https://policybase.cma.ca/en/permalink/policy9068
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Resolution
BD08-03-31
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Resolution
BD08-03-31
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Text
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Less detail

Organ and tissue donation and transplantation

https://policybase.cma.ca/en/permalink/policy14126
Date
2019-12-07
Topics
Ethics and medical professionalism
Health care and patient safety
  2 documents  
Policy Type
Policy document
Date
2019-12-07
Replaces
Organ and tissue donation and transplantation (update 2015)
Topics
Ethics and medical professionalism
Health care and patient safety
Text
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
Documents
Less detail

Equity and diversity in medicine

https://policybase.cma.ca/en/permalink/policy14127
Date
2019-12-07
Topics
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2019-12-07
Topics
Ethics and medical professionalism
Text
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
Documents
Less detail

The Lancet Countdown on Health and Climate Change - Policy brief for Canada

https://policybase.cma.ca/en/permalink/policy14257
Date
2019-11-01
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-11-01
Topics
Population health/ health equity/ public health
Text
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 for centuries to come. Lancet 2018; vol. 392: 2479–514. 3. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet 2019; vol. 394: 1836–78. 4. Government of Canada. Canada’s Changing Climate Ottawa, Ontario,; 2019. 5. Government of the Northwest Territories. Climate Observations in the Northwest Territories (1957-2012) Inuvik * Norman Wells * Yellowknife * Fort Smith. 6. Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association; 2017 October 31st, 2017. 7. Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. 8. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate 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 Expo Sci Environ Epidemiol 2016;26(3):233-40. 10. Hampshire G. Hospital heroes get patients to safety during Fort McMurray fire: 17 buses took 105 patients to safety in dramatic evacuation. CBC News. 2016. Available from: http://www.cbc.ca/news/canada/edmonton/hospital-heroesget- patients-to-safety-during-fort-mcmurray-fire-1.3574416. 11. Kirchmeier-Young M, Zwiers F, Gillett N, Cannon A. Attributing extreme fire risk in Western Canada to human emissions. Climatic Change 2017;144(2):365-79. 12. British Columbia Interior Health Authority. Wildfire Emergency Response 2017. 2018. 13. Kirchmeier-Young M, Gillett N, Zwieres F, Cannon A, Anslow F. Attribution of the Influence of Human-Induced Climate Change on an Extreme Fire Season. Earth’s Future: American Geophysical Union 2018. 14. Alberta Health. Impact of Wildfires on the Mental Health of Fort McMurray Residents: Neurotic Disorders, Daily Physician Visits within an Emergency Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and Performance Division, Analytics and Performance Reporting Branch,; 2016. 15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation of the 2013 Alberta flood from weather and climate perspectives. Climate Dynamics 2017:2881-99. 16. Canadian Broadcasting Corporation. Alberta Flood 2013: The five people we lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/ alberta-flood-deaths/. 17. United Nurses of Alberta. UNA Calgary office closed, many health facilities affected by southern Alberta flooding. 2013 June 21, 2013. 18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change, Drought and Human Health in Canada. Int J Environ Res Public Health 2015;12(7):8359-412. 19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of Drought on the Canadian Prairies. EcoHealth 2004. 20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http:// www.agr.gc.ca/eng/science-and-innovation/agricultural-practices/agriculture- and-climate/future-outlook/impact-of-climate-change-on-canadian-agriculture/? id=1329321987305 21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare for farmers. 2018. Available from: https://www.theglobeandmail.com/ canada/alberta/article-drought-in-western-canada-is-becoming-an-agricultural- nightmare-for/. 22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al. Temper-ature-related changes in airborne allergenic pollen abundance and seasonality across the northern hemisphere: a retrospective data analysis. Lancet Planet Health 2019;3(3):e124-e31. 23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017. Canadian Communicable Disease Review 2018;44(10):231-6. 24. Howard C, Rose C, Rivers N. Lancet Countdown 2018 Report: Briefing for Canadian Policymakers. Canadian Medical Association, Canadian Public Health Association, The Lancet Countdown; 2018 November. 25. a. Regional Public Health Department of Montreal. Epidemiological Investigation Heat Wave Summer 2018 in Montréal - Summary. 2019. b. Vogel MM, Zscheischler J, Wartenburger R, et al. Concurrent 2018 hot extremes across Northern hemisphere due to human-induced climate change. Earth's Future, 2019; vol. 7, 692–703. https://doi.org/10.1029/ 2019EF001189 26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019 Sept 20, 2019]; Available from: http://projects.upei.ca/climate/2014/02/16/ 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 of the National Academy of Science 2015;112 no 11: 3241–6,. 28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health 2010;55(2):123-32. 29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural synergies: climate change policy and health equity. Bull World Health Organ 2009;87(10):799-801. 30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet 2015;386(10006):1861-914. 31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.]; Available from: https://www.canada.ca/en/environment-climate-change/ services/environmental-indicators/greenhouse-gas-emissions.html 32. Environment and Climate Change Canada. Canadian Environmental Sustainability Indicators: Progress Towards Canada’s Greenhouse Gas Emissions Reduction Target. 2019 [Sept 3, 2019]; Available from: https://www.canada. ca/content/dam/eccc/documents/pdf/cesindicators/progress-towards-canada- 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 Canada; 2017. 36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire 2010;19(3):253-71. 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- based study. Int J Emerg Ment Health 2011;13(1):11-26. 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 2016;124(9):1334-43. 42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery management of healthcare services. J Bus Contin Emer Plan 2017;11(2):128- 50. 43. Liu Y, Goodrick S, Heilman W. Wildland fire emissions, carbon, and climate: Wildfire–climate interactions. Forest Ecology and Management 2014;317:80- 96. 44. Barn PK, Elliott CT, Allen RW, Kosatsky T, Rideout K, Henderson SB. Portable air 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 Disease Control; 2018. 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 2014;348:g425. 50. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area. Am J Public Health 2013;103(4):703-9. 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 sustainable food systems. Lancet 2019. 52. Zussman R. Legislation introduced to require all new cars sold in B.C. to be zero-emission by 2040. Global News Online. 2019. Available from: https:// globalnews.ca/news/5152429/legislation-introduced-electric-cars/2019. 53. Thompson N. More Canadians take pride in symbols of the country’s present than its past: survey. 2019. 54. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic- environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. 55. National Health System Sustainable Development Unit. Reducing the use of natural resources in health and social care 2018 report. 2018. 56. Parkes M, Poland B, Allison A, Cole DC, Culbert I, Gislason MK, et al. In press-Preparing for the future of public health: Ecological determinants of health and the call for an eco-social approach to public health education. Canadian Journal of Public Health 2019. DOI: 10.17269/s41997-019-00263-8. 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.
Documents
Less detail

Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

https://policybase.cma.ca/en/permalink/policy14165
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
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. GUIDELINE CMAJ
MARCH 9, 2020
VOLUME 192
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 GUIDELINE E242 CMAJ
ISSUE 10 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. GUIDELINE CMAJ
ISSUE 10 E243 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 GUIDELINE E244 CMAJ
ISSUE 10 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 GUIDELINE CMAJ
ISSUE 10 E245 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 GUIDELINE E246 CMAJ
ISSUE 10 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 GUIDELINE CMAJ
ISSUE 10 E247 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. GUIDELINE E248 CMAJ
ISSUE 10 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. GUIDELINE CMAJ
ISSUE 10 E249 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 GUIDELINE E250 CMAJ
ISSUE 10 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. References 1. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005;96(Suppl 2):S23-9. 2. 31 days of promoting a better urban future: Report 2018. Nairobi (Kenya): UN Habitat, United Nations Human Settlement Programme; 2018. Available: https://oldweb.unhabitat.org/wp-content/uploads/2019/01/Final-short-version -UN-Habitat-Urban-October-Report.pdf (accessed 2019 Apr. 1). 3. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 2007;22:1011-7. 4. Coltman L, Gapka S, Harriott D, et al. Understanding community integration in a housing-first approach: Toronto At Home/Chez Soi community-based research. Intersectionalities 2015;4:39-50. 5. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet 2014;384:1541-7. 6. Canadian definition of homelessness. Toronto: Canadian Observatory on Homelessness; 2012. Available: www.homelesshub.ca/sites/default/files/ attachments/Definition of Homelessness.pdf (accessed 2019 Apr. 1). 7. Hwang SW, Wilkins R, Tjepkema M, et al. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009;339: b4036. 8. Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ 2003;327:81. 9. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet 2014;384:1529-40. 10. Gaetz S, Dej E, Richter T, et al. The state of homelessness in Canada 2016. Toronto: Canadian Observatory on Homelessness Press; 2016. 11. Thistle J. Indigenous definition of homelessness in Canada. Toronto: Canadian Observatory on Homelessness Press; 2017. 12. Belanger YD, Awosoga O, Head GW. Homelessness, urban Aboriginal people, and the need for a national enumeration. Aboriginal Policy Studies 2013;2: 4-33. 13. Taylor M. How is rural homelessness different from urban homelessness? Toronto: The Canadian Observatory on Homelessness/Homeless Hub; 2018. Available: www.homelesshub.ca/blog/how-rural-homelessness-different -urban-homelessness (accessed 2019 Feb. 6). 14. Rodrigue S. Hidden homelessness in Canada. Cat no 75-006-X. Ottawa: Statistics Canada; 2016. 15. Gulliver-Garcia T. Putting an end to child & family homelessness in Canada. Toronto: Raising the Roof; 2016. 16. Andermann A.; CLEAR Collaboration. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ 2016; 188:E474-83. 17. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med 2013;158:169-78. 18. A new vision for Canada: family practice — the patient’s medical home 2019. Mississauga (ON): The College of Family Physicians of Canada; 2019. 19. Declaration of Alma-Ata. Proceedings of the International Conference on Primary Health Care, Alma-Ata; 1978 Sept. 6–12. Geneva: World Health Organization. 20. Magwood O, Leki VY, Kpade V, et al. Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLoS One 2019;14:e0226306. 21. Luchenski S, Maguire N, Aldridge RW, et al. What works in inclusion health: overview of effective interventions for marginalised and excluded populations. Lancet 2018;391:266-80. 22. Thistle JA, Laliberte N. Pekiwewin (Coming Home): Clinical practice guidelines for health and social service providers working with Indigenous people experiencing homelessness. Verbal concurrent session presented at the Canadian Alliance to End Homelessness Conference, 2019 Nov. 4; Edmonton. 23. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33. 24. Racine N, Killam T, Madigan S. Trauma-informed care as a universal precaution: beyond the adverse childhood experiences questionnaire. JAMA Pediatr 2019 Nov. 4 [Epub ahead of print]. doi: 10.1001/jamapediatrics.2019.3866. 25. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs 2015;36:698-709. 26. Hopper E, Bassuk E, Olivet J. Shelter from the storm: trauma-informed care in homelessness services settings. Open Health Serv Policy J 2009;2:131-51. 27. A new vision for Canada: family practice — The patient’s medical home. Mississauga (ON): College of Family Physicians of Canada; 2019. Available: www. cfpc.ca/A_Vision_for_Canada (accessed 2019 Dec. 2). 28. Valaitis RK, O’Mara L, Wong ST, et al. Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors. Prim Health Care Res Dev 2018;19:378-91. 29. Akhtar-DaneshN, Valaitis R, O’Mara L, et al. Viewpoints about collaboration between primary care and public health in Canada.BMC Health Serv Res 2013;13:311. 30. Aubry T, Goering P, Veldhuizen S, et al. A multiple-city RCT of housing first with assertive community treatment for homeless Canadians with serious mental illness. Psychiatr Serv 2016;67:275-81. 31. Cherner RA, Aubry T, Sylvestre J, et al. Housing first for adults with problematic substance use. J Dual Diagn 2017;13:219-29. 32. Goldfinger SM, Schutt RK, Tolomiczenko GS, et al. Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatr Serv 1999;50:674-9. 33. Hwang SW, Gogosis E, Chambers C, et al. Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program. J Urban Health 2011;88:1076-90. 34. Lipton FR, Nutt S, Sabatini A. Housing the homeless mentally ill: a longitudinal study of a treatment approach. Hosp Community Psychiatry 1988;39:40-5. 35. Martinez TE, Burt MR. Impact of permanent supportive housing on the use of acute care health services by homeless adults. Psychiatr Serv 2006;57:992-9. 36. McHugo GJ, Bebout RR, Harris M, et al. A randomized controlled trial of integrated versus parallel housing services for homeless adults with severe mental illness. Schizophr Bull 2004;30:969-82. 37. Rich AR, Clark C. Gender differences in response to homelessness services. Eval Program Plann 2005;28:69-81. doi: 10.1016/j.evalprogplan.2004.05.003. 38. Sadowski LS, Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009;301:1771-8. 39. Siegel CE, Samuels J, Tang D-I, et al. Tenant outcomes in supported housing and community residences in New York City. Psychiatr Serv 2006;57:982-91. 40. Stefancic A, Tsemberis S. Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: a four-year study of housing access and retention. J Prim Prev 2007;28:265-79. 41. Stergiopoulos V, Hwang SW, Gozdzik A, et al.; At Home/Chez Soi Investigators. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA 2015;313:905-15. 42. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 2004;94:651-6. 43. Young MS, Clark C, Moore K, et al. Comparing two service delivery models for homeless individuals with complex behavioral health needs: preliminary data from two SAMHSA treatment for homeless studies. J Dual Diagn 2009;5: 287-304. 44. Kozloff N, Adair CE, Palma Lazgare LI, et al. “Housing First” for homeless youth with mental illness. Pediatrics 2016;138:e20161514. 45. Gulcur L, Stefancic A, Shinn M, et al. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. J Community Appl Soc Psychol 2003;13:171-86. doi: 10.1002/casp.723. 46. Poremski D, Stergiopoulos V, Braithwaite E, et al. Effects of Housing First on employment and income of homeless individuals: results of a randomized trial. Psychiatr Serv 2016;67:603-9. 47. Booshehri LG, Dugan J, Patel F, et al. Trauma-informed Temporary Assistance for Needy Families (TANF): a randomized controlled trial with a twogeneration impact. J Child Fam Stud 2018;27:1594-604. GUIDELINE CMAJ
ISSUE 10 E251 48. Ferguson KM. Employment outcomes from a randomized controlled trial of two employment interventions with homeless youth. J Soc Social Work Res 2018;9:1-21. 49. Forchuk C, MacClure SK, Van Beers M, et al. Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric wards to shelters and “No Fixed Address”. J Psychiatr Ment Health Nurs 2008;15:569-75. 50. Gubits D, Shinn M, Wood M, et al. What interventions work best for families who experience homelessness? Impact estimates from the family options study. J Policy Anal Manage 2018;37:735-66. 51. Hurlburt MS, Hough RL, Wood PA. Effects of substance abuse on housing stability of homeless mentally Ill persons in supported housing. Psychiatr Serv 1996;47:731-6. 52. Kashner TM, Rosenheck R, Campinell AB, et al. Impact of work therapy on health status among homeless, substance-dependent veterans: a randomized controlled trial. Arch Gen Psychiatry 2002;59:938-44. 53. Pankratz C, Nelson G, Morrison M. A quasi-experimental evaluation of rent assistance for individuals experiencing chronic homelessness. J Community Psychol 2017;45:1065-79. doi: 10.1002/jcop.21911. 54. Poremski D, Distasio J, Hwang SW, et al. Employment and income of people who experience mental illness and homelessness in a large Canadian sample. Can J Psychiatry 2015;60:379-85. 55. Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry 2003; 60:940-51. 56. Wolitski RJ, Kidder DP, Pals SL, et al.; Housing and Health Study Team. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav 2010;14:493-503. 57. Conrad KJ, Hultman CI, Pope AR, et al. Case managed residential care for homeless addicted veterans. Results of a true experiment. Med Care 1998; 36:40-53. 58. Graham-Jones S, Reilly S, Gaulton E. Tackling the needs of the homeless: a controlled trial of health advocacy. Health Soc Care Community 2004;12:221-32. 59. Lapham SC, Hall M, Skipper BJ. Homelessness and substance use among alcohol abusers following participation in project H&ART. J Addict Dis 1995;14:41-55. 60. Nyamathi A, Flaskerud JH, Leake B, et al. Evaluating the impact of peer, nurse case-managed, and standard HIV risk-reduction programs on psychosocial and health-promoting behavioral outcomes among homeless women. Res Nurs Health 2001;24:410-22. 61. Nyamathi AM, Zhang S, Salem BE, et al. A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis. J Exp Criminol 2016;12:49-74. 62. Sosin MR, Bruni M, Reidy M. Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago. J Addict Dis 1995;14:1-20. 63. Towe VL, Wiewel EW, Zhong Y, et al. A randomized controlled trial of a rapid rehousing intervention for homeless persons living with HIV/AIDS: impact on housing and HIV medical outcomes. AIDS Behav 2019;23:2315-25. 64. Upshur C, Weinreb L, Bharel M, et al. A randomized control trial of a chronic care intervention for homeless women with alcohol use problems. J Subst Abuse Treat 2015;51:19-29. 65. Weinreb L, Upshur CC, Fletcher-Blake D, et al. Managing depression among homeless mothers: pilot testing an adapted collaborative care intervention. Prim Care Companion CNS Disord 2016;18. 66. Clarke GN, Herinckx HA, Kinney RF, et al. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Ment Health Serv Res 2000;2:155-64. 67. Essock SM, Frisman LK, Kontos NJ. Cost-effectiveness of assertive community treatment teams. Am J Orthopsychiatry 1998;68:179-90. 68. Essock SM, Mueser KT, Drake RE, et al. Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatr Serv 2006;57:185-96. 69. Fletcher TD, Cunningham JL, Calsyn RJ, et al. Evaluation of treatment programs for dual disorder individuals: modeling longitudinal and mediation effects. Adm Policy Ment Health 2008;35:319-36. 70. Lehman AF, Dixon LB, Kernan E, et al. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 1997;54:1038-43. 71. Morse GA, Calsyn RJ, Allen G, et al. Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hosp Community Psychiatry 1992;43:1005-10. 72. Morse GA, Calsyn RJ, Klinkenberg WD, et al. An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv 1997;48:497-503. 73. Morse GA, Calsyn RJ, Klinkenberg WD, et al. Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Community Ment Health J 2006;42:377-404. 74. Braucht GN, Reichardt CS, Geissler LJ, et al. Effective services for homeless substance abusers. J Addict Dis 1995;14:87-109. 75. Burnam MA, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. J Addict Dis 1995;14:111-34. 76. Cauce AM, Morgan CJ, Wagner V, et al. Effectiveness of intensive case management for homeless adolescents: rof a 3-month follow-up. J Emot Behav Disord 1994;2:219-27. 77. Clark C, Rich AR. Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatr Serv 2003;54:78-83. 78. Cox GB, Walker RD, Freng SA, et al. Outcome of a controlled trial of the effectiveness of intensive case management for chronic public inebriates. J Stud Alcohol 1998;59:523-32. 79. Felton CJ, Stastny P, Shern DL, et al. Consumers as peer specialists on intensive case management teams: impact on client outcomes. Psychiatr Serv 1995; 46:1037-44. 80. Grace M, Gill PR. Improving outcomes for unemployed and homeless young people: findings of the YP4 clinical controlled trial of joined up case management. Aust Soc Work 2014;67:419-37. 81. Korr WS, Joseph A. Housing the homeless mentally ill: Findings from Chicago. J Soc Serv Res 1996;21:53-68. 82. Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: a randomized controlled trial. Psychol Addict Behav 2017;31:231-41. 83. Marshall M, Lockwood A, Gath D. Social services case-management for longterm mental disorders: a randomised controlled trial. Lancet 1995;345:409-12. 84. Orwin RG, Sonnefeld LJ, Garrison-Mogren R, et al. Pitfalls in evaluating the effectiveness of case management programs for homeless persons: lessons from the NIAAA Community Demonstration Program. Eval Rev 1994;18: 153-207. 85. Rosenblum A, Nuttbrock L, McQuistion H, et al. Medical outreach to homeless substance users in New York City: preliminary results. Subst Use Misuse 2002; 37:1269-73. 86. Shern DL, Tsemberis S, Anthony W, et al. Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health 2000;90:1873-8. 87. Stahler GJ, Shipley TF Jr, Bartelt D, et al. Evaluating alternative treatments for homeless substance-abusing men: outcomes and predictors of success. J Addict Dis 1996;14:151-67. 88. Shumway M, Boccellari A, O’Brien K, et al. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155-64. 89. Toro PA, Passero Rabideau JM, Bellavia CW, et al. Evaluating an intervention for homeless persons: results of a field experiment. J Consult Clin Psychol 1997;65:476-84. 90. de Vet R, Beijersbergen MD, Jonker IE, et al. Critical time intervention for homeless people making the transition to community living: a randomized controlled trial. Am J Community Psychol 2017;60:175-86. 91. Herman DB, Conover S, Gorroochurn P, et al. Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatr Serv 2011;62:713-9. 92. Lako DAM, Beijersbergen MD, Jonker IE, et al. The effectiveness of critical time intervention for abused women leaving women’s shelters: a randomized controlled trial. Int J Public Health 2018;63:513-23. 93. Shinn M, Samuels J, Fischer SN, et al. Longitudinal impact of a family critical time intervention on children in high-risk families experiencing homelessness: a randomized trial. Am J Community Psychol 2015;56:205-16. 94. Susser E, Valencia E, Conover S, et al. Preventing recurrent homelessness among mentally ill men: a“ critical time” intervention after discharge from a shelter. Am J Public Health 1997;87:256-62. 95. Samuels J, Fowler PJ, Ault-Brutus A, et al. Time-limited case management for homeless mothers with mental health problems: effects on maternal mental health. J Soc Social Work Res 2015;6:515-39. 96. Jones K, Colson PW, Holter MC, et al. Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatr Serv 2003;54:884-90. GUIDELINE E252 CMAJ
ISSUE 10 97. Tomita A, Herman DB. The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatr Serv 2012;63: 935-7. 98. Jones K, Colson P, Valencia E, et al. A preliminary cost effectiveness analysis of an intervention to reduce homelessness among the mentally ill. Psychiatr Q 1994;65:243-56. 99. Magwood O, Salvalaggio G, Beder M, et al. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS ONE 15(1):e0227298. https://doi.org/10.1371/journal.pone.0227298. 100. Bahji A, Bajaj N. Opioids on trial: a systematic review of interventions for the treatment and prevention of opioid overdose. Can J Addict 2018;9:26-33. 101. Clark N, Lintzeris N, Gijsbers A, et al. LAAM maintenance vs methadone maintenance for heroin dependence. Cochrane Database Syst Rev 2002;(2):CD002210. 102. Ferri M, Davoli M, Perucci CA. Heroin maintenance treatment for chronic heroin-dependent individuals: a Cochrane systematic review of effectiveness. J Subst Abuse Treat 2006;30:63-72. 103. Gowing L, Farrell MF, Bornemann R, et al. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev 2011;(8):CD004145. 104. Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioiddependent pregnant women: a comprehensive review. Addiction 2012; 107(Suppl 1):5-27. 105. Karki P, Shrestha R, Huedo-Medina TB, et al. The impact of methadone maintenance treatment on HIV risk behaviors among high-risk injection drug users: a systematic review. Evid Based Med Public Health 2016;2:pii: e1229. 106. Kirchmayer U, Davoli M, Verster AD, et al. A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence. Addiction 2002;97: 1241-9. 107. Larney S, Gowing L, Mattick RP, et al. A systematic review and meta-analysis of naltrexone implants for the treatment of opioid dependence. Drug Alcohol Rev 2014;33:115-28. 108. Lobmaier P, Kornør H, Kunøe N, et al. Sustained-release naltrexone for opioid dependence. Cochrane Database Syst Rev 2008;(2):CD006140. 109. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014;(2):CD002207. 110. Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009;(3):CD002209. 111. Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database Syst Rev 2011;(4):CD001333. 112. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev 2017;9:CD012021. 113. Roozen HG, de Waart R, van der Windt DAWM, et al. A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence. Eur Neuropsychopharmacol 2006;16:311-23. 114. Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev 2017;4:CD011983. 115. Simoens S, Matheson C, Bond C, et al. The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Br J Gen Pract 2005;55:139-46. 116. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550. 117. Helm S, Trescot AM, Colson J, et al. Opioid antagonists, partial agonists, and agonists/antagonists: the role of office-based detoxification. Pain Physician 2008;11:225-35. 118. Strang J, Groshkova T, Uchtenhagen A, et al. Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. Br J Psychiatry 2015;207:5-14. 119. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv 2014;65:158-70. 120. Weinmann S, Kunstmann W, Rheinberger P. Methadone substitution — a scientific review in the context of out-patient therapy in Germany [article in German]. Z Arztl Fortbild Qualitatssich 2004;98:673-82. 121. Wilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug Alcohol Depend 2015;149:225-31. 122. Klimas J, Gorfinkel L, Giacomuzzi SM, et al. Slow release oral morphine versus methadone for the treatment of opioid use disorder. BMJ Open 2019;9: e025799. 123. Maglione MA, Raaen L, Chen C, et al. Effects of medication assisted treatment (MAT) for opioid use disorder on functional outcomes: a systematic review. J Subst Abuse Treat 2018;89:28-51. 124. Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review. Curr HIV/AIDS Rep 2017;14:161-83. 125. Potier C, Laprévote V, Dubois-Arber F, et al. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend 2014;145:48-68. 126. McNeil R, Small W. ‘Safer environment interventions’: a qualitative synthesis of the experiences and perceptions of people who inject drugs. Soc Sci Med 2014;106:151-8. 127. Muckle W, Muckle J, Welch V, et al. Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse. Cochrane Database Syst Rev 2012;12:CD006747. 128. Ezard N, Dolan K, Baldry E, et al. Feasibility of a Managed Alcohol Program (MAP) for Sydney’s homeless. Canberra (AU): Foundation for Alcohol Research and Education; 2015. 129. Nielsen E, Novotna G, Berenyi R, et al. Harm reduction interventions for chronic and severe alcohol use among populations experiencing homelessness: a literature review. Regina: University of Regina, Carmichael Outreach Inc.; 2018. 130. Basu A, Kee R, Buchanan D, et al. Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care. Health Serv Res 2012;47:523-43. 131. Culhane DP, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Hous Policy Debate 2002;13:107-63. 132. Dickey B, Latimer E, Powers K, et al. Housing costs for adults who are mentally ill and formerly homeless. J Ment Health Adm 1997;24:291-305. 133. Gilmer TP, Manning WG, Ettner SL. A cost analysis of San Diego County’s REACH program for homeless persons. Psychiatr Serv 2009;60:445-50. 134. Gilmer TP, Stefancic A, Ettner SL, et al. Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Arch Gen Psychiatry 2010;67:645-52. 135. Hunter S, Harvey M, Briscombe B, et al. Evaluation of housing for health permanent supportive housing program. Santa Monica (CA): RAND Corporation; 2017. 136. Holtgrave DR, Wolitski RJ, Pals SL, et al. Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV. AIDS Behav 2013;17:1626-31. 137. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009;301:1349-57. 138. Latimer EA, Rabouin D, Cao Z, et al.; At Home/Chez Soi Investigators. Costeffectiveness of Housing First intervention with intensive case management compared with treatment as usual for homeless adults with mental illness: secondary analysis of a randomized clinical trial. JAMA Netw Open 2019; 2:e199782. 139. Lenz-Rashid S. Supportive housing program for homeless families: Foster care outcomes and best practices. Child Youth Serv Rev 2017;79:558-63. 140. Lim S, Gao Q, Stazesky E, et al. Impact of a New York City supportive housing program on Medicaid expenditure patterns among people with serious mental illness and chronic homelessness. BMC Health Serv Res 2018;18:15. 141. McLaughlin TC. Using common themes: cost-effectiveness of permanent supported housing for people with mental illness. Res Soc Work Pract 2010;21: 404-11. 142. Mares AS, Rosenheck RA. A comparison of treatment outcomes among chronically homelessness adults receiving comprehensive housing and health care services versus usual local care. Adm Policy Ment Health 2011;38:459-75. 143. Pauley T, Gargaro J, Falode A, et al. Evaluation of an integrated cluster care and supportive housing model for unstably housed persons using the shelter system. Prof Case Manag 2016;21:34-42. 144. Schinka JA, Francis E, Hughes P, et al. Comparative outcomes and costs of inpatient care and supportive housing for substance-dependent veterans. Psychiatr Serv 1998;49:946-50. 145. Srebnik D, Connor T, Sylla L. A pilot study of the impact of housing firstsupported housing for intensive users of medical hospitalization and sobering services. Am J Public Health 2013;103:316-21. 146. Evans WN, Sullivan JX, Wallskog M. The impact of homelessness prevention programs on homelessness. Science 2016;353:694-9. GUIDELINE CMAJ
ISSUE 10 E253 147. Clark RE, Teague GB, Ricketts SK, et al. Cost-effectiveness of assertive community treatment versus standard case management for persons with cooccurring severe mental illness and substance use disorders. Health Serv Res 1998;33:1285-308. 148. Lehman AF, Dixon L, Hoch JS, et al. Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry 1999;174:346-52. 149. Wolff N, Helminiak TW, Morse GA, et al. Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatry 1997;154:341-8. 150. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med 2000;18:603-8. 151. Hwang SW. Homelessness in health. CMAJ 2001;164:229-33. 152. National Clinical Guideline Centre (UK). Patient experience in adult NHS services: improving the experience of care for people using adult NHS services — patient experience in generic terms. NICE Clinical Guidelines No 138. London (UK): Royal College of Physicians; 2012. Available: www.ncbi.nlm.nih.gov/ books/NBK115230 (accessed 2019 Dec. 12). 153. Jonker IE, Sijbrandij M, Van Luijtelaar MJA, et al. The effectiveness of interventions during and after residence in women’s shelters: a meta-analysis. Eur J Public Health 2015;25:15-9. 154. Rivas C, Ramsay J, Sadowski L, et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane Database Syst Rev 2015;(12):CD005043. 155. Speirs V, Johnson M, Jirojwong S. A systematic review of interventions for homeless women. J Clin Nurs 2013;22:1080-93. 156. Wathen CN, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289:589-600. 157. Constantino R, Kim Y, Crane PA. Effects of a social support intervention on health outcomes in residents of a domestic violence shelter: a pilot study. Issues Ment Health Nurs 2005;26:575-90. 158. Gubits D, Shinn M, Wood M, et al. Family options study: 3-year impacts of housing and services interventions for homeless families. 2016. doi: 10.2139/ ssrn.3055295. 159. Milby JB, Schumacher JE, Wallace D, et al. To house or not to house: the effects of providing housing to homeless substance abusers in treatment. Am J Public Health 2005;95:1259-65. 160. Nyamathi AM, Leake B, Flaskerud J, et al. Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color. Res Nurs Health 1993;16:11-21. 161. Nyamathi A, Flaskerud J, Keenan C, et al. Effectiveness of a specialized vs. traditional AIDS education program attended by homeless and drug-addicted women alone or with supportive persons. AIDS Educ Prev 1998;10:433-46. 162. Wang JZ, Mott S, Magwood O, et al. The impact of interventions for youth experiencing homelessness on housing, mental health, substance use, and family cohesion: a systematic review. BMC Public Health 2019;19:1528. 163. Couch J. ‘My life just went zig zag’: refugee young people and homelessness. Youth Stud Aust 2011;30:22-32. 164. Couch J. ‘Neither here nor there’: refugee young people and homelessness in Australia. Child Youth Serv Rev 2017;74:1-7. 165. Couch J. On their own: perceptions of services by homeless young refugees. Dev Pract 2012;(31):19-28. 166. D’Addario S, Hiebert D, Sherrell K. Restricted access: The role of social capital in mitigating absolute homelessness among immigrants and refugees in the GVRD. Refuge 2007;24:107-15. 167. Dwyer P, Brown D. Accommodating “others”?: housing dispersed, forced migrants in the UK. J Soc Welf Fam Law 2008;30:203-18. 168. Flatau P, Smith J, Carson G, et al. The housing and homelessness journeys of refugees in Australia. AHURI Final Rep No 256. Melbourne (AU): Australian Housing and Urban Research Institute Limited; 2015. 169. Hulín M, Hulínová VA, Martinkovic M, et al. Housing among persons of international protection in the Slovak Republic. Rajagiri J Soc Dev 2013;5. 170. Idemudia ES, Williams JK, Wyatt GE. Migration challenges among Zimbabwean refugees before, during and post arrival in South Africa. J Inj Violence Res 2013;5:17-27. 171. Im H. A social ecology of stress and coping among homeless refugee families. Vol. 73, Dissertation Abstracts International Section A: Humanities and Social Sciences. University of Minnesota Digital Conservancy; 2012:355. Available: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=psyc9&NEWS= N&AN=2012-99130-061 (accessed 2019 Sept. 1). Login required to access content. 172. Kissoon P. From persecution to destitution: a snapshot of asylum seekers’ housing and settlement experiences in Canada and the United Kingdom. J Immigr Refug Stud 2010;8:4-31. 173. Kissoon P. An uncertain home: refugee protection, illegal immigration status, and their effects on migrants’ housing stability in Vancouver and Toronto. Can Issues 2010;64-7. 174. Mostowska M. Migration and homelessness: the social networks of homeless Poles in Oslo. J Ethn Migr Stud 2013;39:1125-40. 175. Mostowska M. Homelessness abroad: “place utility” in the narratives of the Polish homeless in Brussels. Int Migr 2014;52:118-29. 176. Paradis E, Novac S, Sarty M, et al. Homelessness and housing among status immigrant, non-status migrant, and Canadian-born Families in Toronto. Can Issues 2010. 177. Sherrell K, D’Addario S, Hiebert D. On the outside looking in: the precarious housing situations of successful refugee claimants in the GVRD. Refuge 2007;24:64-75. 178. Sjollema SD, Hordyk S, Walsh CA, et al. Found poetry: finding home — a qualitative study of homeless immigrant women. J Poetry Ther 2012;25:205-17. 179. Walsh CA, Hanley J, Ives N, et al. Exploring the experiences of newcomer women with insecure housing in Montréal Canada. J Int Migr Integr 2016;17: 887-904. 180. Kendall CE, Shoemaker ES, Crowe L, et al. Engagement of people with lived experience in primary care research: living with HIV Innovation Team Community Scholar Program. Can Fam Physician 2017;63:730-1. 181. Swinkels H, Pottie K, Tugwell P, et al.; Canadian Collaboration for Immigrant and Refugee Health (CCIRH). Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. CMAJ 2011;183:E928-32. 182. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction — GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64: 383-94. 183. Pottie K, Mathew CM, Mendonca O, et al. PROTOCOL: A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness. Campbell Syst Rev 2019;15:e1048. 184. Magwood O, Gebremeskel A, Ymele Leki V, et al. Protocol 1: The experiences of homeless and vulnerably housed persons around health and social services. A protocol for a systematic review of qualitative studies. Cochrane Methods Equity; 2018. Available: https://methods.cochrane.org/equity/sites/methods.cochrane. org.equity/files/public/uploads/protocol-_the_experiences_of_homeless_and_ vulnerably_housed_persons_around_health_and_social_services.pdf (accessed 2019 Dec. 12). 185. Kpade V, Magwood O, Salvalaggio G, et al. Protocol 3: Harm reduction and pharmacotherapeutic interventions for persons with substance use disorders: a protocol for a systematic review of reviews. Cochrane Methods Equity; 2018. 186. Wang J, Mott S, Mathew C, et al. Protocol: Impact of interventions for homeless youth: a narrative review using health, social, Gender, and equity outcomes. Cochrane Methods Equity; 2018. Available: https://methods.cochrane.org/ equity/sites/methods.cochrane.org.equity/files/public/uploads/youth_narrative _review_protocol.pdf (accessed 2019 Dec. 12). 187. Alonso-Coello P, Oxman AD, Moberg J, et al.; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ 2016;353:i2089. 188. Alonso-Coello P, Schünemann HJ, Moberg J, et al.; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ 2016;353:i2016. 189. Schünemann HJ, Mustafa R, Brozek J, et al.; GRADE Working Group. GRADE Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical practice and public health. J Clin Epidemiol 2016;76:89-98. 190. GRADEpro GDT: GRADEpro Guideline Development Tool [software]. Hamilton (ON): McMaster University; 2015 (developed by Evidence Prime, Inc.). Available: https://gradepro.org (accessed 2019 Feb. 1). 191. Tugwell P, Knottnerus JA. When does a good practice statement not justify an evidence based guideline? J Clin Epidemiol 2015;68:477-9. 192. Guyatt GH, Alonso-Coello P, Schünemann HJ, et al. Guideline panels should seldom make good practice statements: guidance from the GRADE Working Group. J Clin Epidemiol 2016;80:3-7. 193. Guyatt GH, Schünemann HJ, Djulbegovic B, et al. Guideline panels should not GRADE good practice statements. J Clin Epidemiol 2015;68:597-600. 194. Drazen JM, de Leeuw PW, Laine C, et al. Toward more uniform conflict disclosures: the updated ICMJE conflict of interest reporting form. JAMA 2010;304:212-3. GUIDELINE E254 CMAJ
ISSUE 10 195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid publishing conflict and a proposed agreement for co-author teams [editorial]. Biol Conserv 2014;176:277-80. 196. WHO housing and health guidelines. Geneva: World Health Organization; 2018. 197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician 2019;65:321-30. 198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in Substance Misuse. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2018;190:E247-57. 199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56. 200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8. 201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www. homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12). 202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician 2018;64:170-2. 203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content /uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1). 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
Documents
Less detail

Health Canada consultation on vaping products labelling and packaging regulations

https://policybase.cma.ca/en/permalink/policy14124
Date
2019-09-05
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-09-05
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
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).
Documents
Less detail

Health Canada consultation on potential market for cannabis health products that would not require practitioner oversight

https://policybase.cma.ca/en/permalink/policy14125
Date
2019-09-03
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-09-03
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
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 4 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. 5 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).
Documents
Less detail

Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
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. 4 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 5 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);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
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. 6 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: 7 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). 8 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.
Documents
Less detail

Health Canada consultation on reducing youth access and appeal of vaping products

https://policybase.cma.ca/en/permalink/policy14078
Date
2019-05-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-05-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Text
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 4 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 5 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). 6 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).
Documents
Less detail

Standing Committee on Health’s study on violence faced by healthcare workers

https://policybase.cma.ca/en/permalink/policy14052
Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
Text
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
Documents
Less detail

Health Canada consultation on the impact of vaping products advertising on youth and non-users of tobacco products

https://policybase.cma.ca/en/permalink/policy14022
Date
2019-03-22
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-03-22
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
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)
Documents
Less detail

CMA Letter to the Legislative Committee on Bill C-30: Clean Air Act

https://policybase.cma.ca/en/permalink/policy8714
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to participate in the review of the Clean Air Act, Bill C- 30. The CMA, first founded in 1867, currently represents more than 64,000 physicians across the country. Our mission includes advocating for the highest standard of health and health care for all Canadians and we are committed to activities that will result in healthy public policy. The Environment: A Key Determinant of Health The physical environment is a key determinant of a population's health and the medical profession is concerned about environmental conditions that contribute to declining health in individuals and the population as a whole. Physicians have been part of an early warning system of scientists and other health professionals calling attention to the effects on human health of poor air quality because we see the impact in our practice and in our communities. There is strong evidence that air pollution is the most harmful environmental problem in Canada in terms of human health effects. We know from the smog health studies undertaken by the Ontario Medical Association (OMA), Health Canada and others, about the public health crisis created by polluted air in many parts of Canada. And it is a crisis. A study by the federal government estimated that 5,900 premature deaths occur annually in eight large Canadian cities. This is a conservative estimate as the study focused on the short-term impact of smog pollutants using time-series studies. This study was never extrapolated to the whole Canadian population, but we know that only approximately one third of the Canadian population, mainly residents of large, urban areas, were included in the analysis.1 The OMA Illness Costs of Air Pollution study estimated that there were 5,800 premature deaths due to air pollution in Ontario alone in 2005, and examined both short-term and long-term health impacts. The OMA projected that the annual figure will grow to 10,000 premature deaths by 2026 unless effective steps are taken to reduce smog.2 In addition to premature deaths, the OMA estimated that there were 16,000 hospital admissions and 60,000 emergency room visits in Ontario in 2005 because of respiratory and cardiovascular illnesses associated with air pollution exposure. During that same year, the OMA also estimated that there were 29 million minor illness days, defined as days where individuals either suffered from asthma symptoms or had to restrict their activities. Most of the people affected by these so-called minor illness days are children. In British Columbia, the Provincial Officer for Health published a conservative estimate in 2004 that air pollution in B.C. is causing between 140 and 400 premature deaths, 700 to 2,100 hospital stays, and between 900 and 2,750 emergency room visits each year.3 The direct and indirect costs of air pollution on the health of Canadians are estimated to be in the billions of dollars. According to the Ontario Medical Association, in 2005, air pollution costs in Ontario were estimated at: - $374 million in lost productivity and work time; - $507 million in direct health care costs; - $537 million in pain and suffering due to non-fatal illness; and - $6.4 billion in loss due to premature death.4 In Canada the environment is currently considered to be the most important issue facing society. In a recent poll by the Strategic Counsel for the Globe & Mail/CTV5 a majority of respondents ranked the impact of toxic chemicals, air and water pollution and global warming as life threatening. The environment, while a major concern today for the general public, has been of concern to physicians for some time. CMA, Health and the Environment In 1991 the CMA, released a policy paper Health, the Environment and Sustainable Development6 that clearly linked health and the environment. Building on the 1987 Brundtland Report (World Commission on Environment and Development, Our Common Future) that tied sustainable development to the environment and the economy, the CMA inserted health into this pair of interactions and stated that "continued environmental degradation will increase hazard to human health." The paper concluded with a number of recommendations for governments, the health sector, and physicians in support of environmentally sustainable development. The CMA has continued to give attention to environmental issues urging the government, prior to Canada's ratification of the Kyoto Protocol, to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2002, the CMA also recommended that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern. Clean Air Act: A Physicians Perspective Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that there are benefits of treatment even if a patient cannot be cured. Sometimes we just reduce their symptoms, or slow their rate of decline. But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We must commit to measures of success in terms of real improvement in health. It is through this lens that the CMA urges that you view the Clean Air Act to ensure that it is health-relevant. The CMA would like to commend this government for acknowledging the impact of the physical environment on human health and we are encouraged that the Act recognizes the intimate connection between greenhouse gas reductions and improved air quality. Air pollution does not respect provincial borders therefore it is very important to establish national objectives and Canada wide standards that are strong and consistent across the country. To be health relevant national air quality objectives must result in air quality improvements. To this end, regardless of whether they are called objectives or standards, national air quality targets must protect the health of all Canadians and must be binding. Voluntary air quality guidelines guarantee no health benefit. The federal government must ensure that there is a regulatory framework in place to ensure that the standards are mandatory across the country. The annual reporting to Parliament on the attainment of the national air quality objectives and the effectiveness of measures to attain the objectives, as outlined in the Act, is very important. Transparency in reporting is essential to the integrity of any program, but is integral to the determination of health benefit. The International Panel on Climate Change's Fourth Assessment report released on February 2, 2007, concluded that global warming is unequivocal and that human activity is the main driver, asserting with near certainty - more than 90 percent confidence - that carbon dioxide and other heat-trapping greenhouse gases from human activities have been the main causes of warming since 1950. Its Third Assessment report: Climate Change 2001: Working Group II: Impacts, Adaptation and Vulnerability noted that global climate change will have a wide range of impacts on human health. "Overall, negative health impacts are expected to outweigh positive health impacts. Some health impacts would result from changes in the frequencies and intensities of extremes of heat and cold and of floods and droughts. Other health impacts would result from the impacts of climate change on ecological and social systems and would include changes in infectious disease occurrence, local food production and nutritional adequacy, and concentrations of local air pollutants and aeroallergens, as well as various health consequences of population displacement and economic disruption."7 Given the indisputable impact of greenhouse gas increases on climate change and its connection to human health, it is critical to ensure that Canada is moving quickly to reduce greenhouse gas emissions. The Clean Air Act and the subsequent notice of intent sets out short, medium and long term targets and timelines for the reduction of greenhouse gas emissions in Canada. The target setting approach proposed in the Act, based on emission intensity in the short and medium term is not health relevant. To be health relevant, targets should be presented in the context of overall emissions, i.e., emissions reductions minus emissions increases. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect. Just as slowing the progression of a disease can never be considered a cure, attempting only to limit the growth of those emissions cannot result in true success by any measure. It is not until 2050 that the government has committed to achieving an absolute reduction in greenhouse gas emissions of between 45 - 65% of 2003 levels. Based on the emission intensity targets in the Clean Air Act, emissions and air pollution levels will, in fact, continue to rise as will the health consequences. In order to protect the health of Canadians the government needs to set policies, with targets and timelines that maximize absolute reductions in greenhouse gases, which are consistent with the scale and urgency of the challenge. To ensure that prescribed policies result in the intended environment and health outcomes, short and medium-term targets for absolute emission reductions would benchmark progress and allow for mid-course corrections, if they were needed. With respect to indoor air quality, physicians have long been proponents of initiatives to reduce exposure to contaminants such as second-hand tobacco smoke. The CMA is concerned about the impact on human health of exposure to high levels of radon and the associated increased risk of lung cancer. The intention to develop measures to address indoor air quality through a national radon strategy is a positive step. It is important that our patients are made aware of such threats in their homes, and also that they are presented with a way to reduce their exposure. Environmentally related illness is essentially the combined result of exposure and vulnerability. We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation. Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where the federal government is critical, and where the measures of success will be the most important. Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air as well as in our water and soil. Clean air is absolutely fundamental to a healthy population - without it all else is irrelevant. Actions to curb air pollution must be taken in all sectors and levels of society in a concerted, non-partisan effort with the health of the population and the planet as our yardstick of success. Thank you for the opportunity to provide our comments on Bill C-30, the Clean Air Act. We look forward to working with you to improve the Clean Air Act and ensure that the measure of its success will benefit the health of Canadians. Sincerely Colin J. McMillan, MD, CM, FRCPC, FACP President 1 S. Judek, B. Jessiman, D. Stieb, and R. Vet. 2005. Estimated Number of Excess Deaths in Canada Due to Air Pollution". Health Canada and Environment Canada. http://www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_32bk2_e.html#top 2 Ontario Medical Association. 2005. The Illness Costs of Air Pollution: 2005-2026 Health and Economic Damage Estimates. Toronto: OMA. 3 B.C. Provincial Health Officer. 2004. Every Breath You Take: Air Quality in British Columbia, A Public Health Perspective. 2003 Annual Report. Victoria: Ministry of Health Services. 4 Ontario Medical Association , 2005 5 GLOBE/CTV POLL Climate concerns now top security and health One in four label environmental issues as most important, The Globe and Mail, Fri 26 Jan 2007, Page: A1, Section: National News , Byline: Brian Laghi 6 Health, the Environment and Sustainable Development, Canadian Medical Association , 1991 7 WMO Intergovernmental Panel on Climate Change, Climate Change 2001, IPPC Third Assessment Report: Working Group II: Impacts, Adaptation and Vulnerability, accessed Feb 7, 2007 http://www.grida.no/climate/ipcc_tar/wg2/348.htm
Documents
Less detail

Submission to House of Commons Standing Committee on Health Regarding the Common Drug Review

https://policybase.cma.ca/en/permalink/policy8719
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association represents more than 65,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. In pursuit of this mission we are developing a growing body of policy on pharmaceutical issues. In November 2003, we presented to the House of Commons Standing Committee on Health during its study of prescription drug issues. In July 2006 CMA, along with four other national organizations representing patients, health professionals, health system managers and trustees, formed the Coalition for a Canadian Pharmaceutical Strategy and released a framework and principles that we believed should govern the development of pharmaceutical strategy in this country. We understand that the current study of the Common Drug Review (CDR) is part of a larger, more comprehensive study of prescription drugs being contemplated by the House of Commons Standing Committee on Health. We look forward to assisting you with this study. In the meantime, we will note that the CDR is intimately linked to related issues such as catastrophic coverage and a national formulary, and will also briefly discuss these in our presentation. Pharmaceuticals are important to the health of Canadians. For many patients prescription drugs have prevented serious disease, reduced hospital stays, replaced surgical treatment and improved their capacity to function productively in the community. Pharmaceuticals also offer health-care system benefits by reducing other costs such as hospital expenses and disability payments. While prescription drugs offer significant benefits, expenditures on them are also growing faster than any other component of health care. It is realistic to expect that the role of prescription drugs in health care will continue to increase and that as a result government expenditures on them will rise accordingly. As patients become increasingly knowledgeable and politically aware, they will continue to expect and demand access to an expanded range of prescription drugs. CMA believes that any pharmaceutical strategy should be predicated on two pre-eminent principles, which are in keeping with longstanding Canadian values: * All Canadians should have access to safe and effective prescription drugs; and * No Canadian should be deprived of medically necessary drugs because of inability to pay. Whether the CDR serves to further these goals has been a matter of vigorous debate. Federal and provincial representatives have told the House of Commons Committee that the CDR is meeting their needs and has in some cases provided them with a higher-quality review than they could have achieved on their own. On the other hand, patient groups have charged that the CDR is an unnecessary layer of bureaucracy and a barrier between them and potentially life-saving new therapies. It is possible, if not probable, that reforms to the CDR may never completely eliminate the tension between these two viewpoints. We understand the frustration of patients and their advocates when the CDR recommends against public reimbursement or even more, when the CDR approves a drug but individual provinces refuse to include that drug on their formularies. In both these cases, sustainability of the health care system is an important and valid consideration. It would be unfortunate if our limited health care dollars, which might otherwise have been spent on disease treatment or prevention strategies of proven effectiveness, went instead to funding expensive drugs which ultimately proved no more beneficial to patients than others which cost much less. 2) General principles regarding drug review The process of reviewing drugs for inclusion in public formularies did not begin with the CDR. Before it was created, each federal and provincial formulary conducted its own review. Without the CDR, separate reviews would still be taking place. To dismantle the review process entirely would be unacceptable, both economically and politically. Within the context of an overarching goal to enhance access to medically required pharmaceuticals to the extent that they are needed, the primary purpose of a drug review process should be to help ensure access to prescription drugs for which evidence indicates safety and effectiveness in the treatment, management and prevention of disease, and/or significant benefits in quality of life. To help ensure that it achieves this purpose, we believe the following principles should apply to drug review in Canada: * The review process should be impartial and founded on the best available scientific evidence. * The primary criteria for inclusion in a formulary should be whether the drug improves health outcomes, and offers an improvement over products currently on the market. * The review process should also incorporate evaluation of the drug's cost-effectiveness. * Drugs should be evaluated not in isolation but as an integral part of the health care continuum. The review should consider: * A drug's impact on overall health care utilization. If a drug reduces a patient's hospital stay, helps an otherwise disabled patient return to work, or replaces other costlier or more invasive therapies, this should be considered in evaluating its overall cost-effectiveness. * Alternatives to the drug under review. The review should compare a drug's performance to other drugs in the same class, and to available non-drug therapies. * The review process should be flexible, taking into account the unique needs and therapeutic outcomes of individual patients, and the expertise of physicians in determining which drugs are best for their patients. * The review process should be open and transparent. We support the CDR's intent to publish the rationales for its decisions, including lay-language versions. * CDR findings are a valuable source of information on the safety and effectiveness of the drugs physicians prescribe. As such, they should be communicated to caregivers and patients as part of an ongoing strategy to encourage best practices in prescribing. * Meaningful participation by patients and health professionals should be part of the review process; we note with approval the expansion of the Canadian Expert Drug Advisory Committee to include members of the public. We also suggest that the CDR experiment with open fora and other means of obtaining public input. * A process for appealing the review's decisions should be established. * Ongoing evaluation of the review process should be required. We note that the CDR has already undergone an evaluation, and is planning to implement some of the key recommendations. Impartial evaluations should continue to take place, to assess whether the CDR is having a positive impact on the health of Canadians and of their health care system. 3) The Larger Picture The Common Drug Review does not exist in isolation. As the Coalition for a Canadian Pharmaceutical Strategy - of which CMA is a member - stressed in its 2006 statement, the elements of a comprehensive Canadian pharmaceutical strategy are interdependent and should be developed concurrently to ensure that the strategy is coherent and holistic. The CDR is interlinked with other issues concerning access to health care generally and to prescription drugs more specifically, and we suggest that the Committee also consider the following issues: a) Drugs for Rare Disorders. One controversy surrounding the CDR is that its approval rates are low for drugs for very rare disorders, many of which are first-in-class. One reason may be the cost of these drugs, which is often extremely high. It is also alleged that the Canadian Expert Drug Advisory Committee's (CEDAC) current review standards, which place a high value on large-sample clinical trials, are unable to adequately capture the value of these drugs. It has been recommended that more drugs for rare disorders be approved based on interim targets or surrogate endpoints. The ultimate measure of a drug's effectiveness is its clinical endpoint; this should not be forgotten in any process of drug approval. This issue merits closer consideration, as do all issues related to drugs for rare disorders. CMA recommends that Canada develop a policy on drugs for rare disorders, which: * Encourages their development; * Evaluates their effectiveness; and * Ensures that all patients who might benefit have reasonable access to them. b) Common Formulary. CMA recommends that Canada's governments consider the possibility of establishing a pan-Canadian formulary. Canadian patients need a national standard; 18 different levels of coverage is not acceptable. Should the CDR form the basis of this formulary? That would depend on whether evaluation proves that the CDR is the most effective vehicle. We do believe that cost control, though not the primary function of a pan-Canadian formulary, is a valid system concern. If two drugs in the same class are equally effective, it is reasonable to expect that the less expensive drug should be preferentially covered and/or prescribed. On the other hand, a pan-Canadian formulary should be flexible. It should include a process to allow patients access to off-formulary drugs if in the opinion of the attending physician the recommended product is not the right choice for them. This process should be designed so as to minimize the administrative burden on health professionals. c) Catastrophic Drug Coverage. It is now generally accepted that a pan-Canadian catastrophic drug program is needed. The point of discussion now is what type of program should be put in place. To ensure that Canadians can access the drugs they need, regardless of where they live or how much they earn, CMA recommends that federal, provincial and territorial governments, in collaboration with private insurers, assess the drug needs of Canadians, particularly those who are uninsured or under-insured, and agree on an option for providing equitable and comprehensive prescription drug coverage. As a starting point, CMA has recommended that governments give priority to a national pharmacare program to provide necessary drugs for all Canadian children and youth. Conclusion In principle, CMA believes that a process for reviewing prescription drugs for their clinical effectiveness and cost-effectiveness can contribute to improving the health of Canada's patients and our health care system. The value of the CDR will be determined by how well it performs this function. Canadian Medical Association May 14, 2007
Documents
Less detail

CMA letter to the House of Commons Standing Committee on Justice and Human Rights. Bill C-32 (An Act to amend the Criminal Code (Impaired driving) and to make consequential amendments to other Acts)

https://policybase.cma.ca/en/permalink/policy8789
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Standing Committee on Justice and Human Rights of the House of Commons concerning the study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts). The CMA supports measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code (attached). While our 1999 brief focuses primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. Recently, the CMA has published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles (attached). It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs (attached), the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues. With regard to Clause 4 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and health information privacy. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 9 of Bill-32 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 9(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 9(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could be of individuals who are not actually convicted of an offence. One should query whether the Clause 9(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 9(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 5, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 5) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.1 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.2 In our 1999 response to this Committee's issue paper on impaired driving3 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 4 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-32, must be accompanied by public awareness and education strategy. This constitutes the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is cause by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Colin J. McMillan, MD, CM, FRCPC, FACP President Attachments (3) 1 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 2 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 3 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 4 Mann et al
Documents
Less detail

Tax Incentives for Better Living - The Canadian Medical Association's 2007 pre-budget consultation brief to the Standing Committee on Finance, August 15th 2007

https://policybase.cma.ca/en/permalink/policy8830
Last Reviewed
2019-03-03
Date
2007-08-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-08-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Text
Summary of our seven recommendations Table - the fiscal impact of our seven recommendations A. Addressing the committee's questions on tax policy trade-offs 1 i. Should taxes be broadly based or targeted to a specific group of residents or business sectors? ii. What consideration should be given to the various levels and types of public goods provided by countries? iii. What is the appropriate level of corporate taxes and should they be competitive? iv. What is the appropriate form and level of personal taxes, fees and other charges and should they be competitive? B. Tax incentives supporting an enhanced and sustainable health system 2 I. Tax incentives for community-based health care practices 3 1. Accelerate health information technology investments - GST and tax incentives II. Tax incentives for healthier living 3 2. Introduce a tax on high-calorie, nutrient-poor foods to curb obesity 3. Double the Child Fitness Tax Credit 4. Increase federal Gas Tax Fund transfers for municipal transit to improve air quality III. Tax incentives supporting an efficient health care system 4 5. Bolster Health Human Resources - extend interest relief on Canada student loans for medical residents 6. Explore tax policy options for Long Term Care 7. Ensure that all Canadians are protected against catastrophic drug costs Summary 5 Summary of our seven recommendations for the Committee's consideration The Canadian Medical Association has a long-standing history of calling for a better fit for tax policy and health policy. The CMA recognizes that tax policy is important, but is just one type of policy instrument for health and health care. Accordingly we have seven principal recommendations for the Standing Committee on Finance. Recommendation 1 - Accelerate health information technology investments - GST and tax incentives That the federal government provides a one-time only $50,000 tax credit spread out over four years, for community-based health care practices to invest in interoperable electronic medical records (EMR) to allow for accelerated system integration. In addition, that the government provides a rebate for IT to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Recommendation 2 - Introduce a tax on high-calorie, nutrient-poor foods to curb obesity That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Moreover, we suggest that a portion of the revenue from this tax should be used to make healthier foods cheaper or more accessible, especially for low-income groups. Obesity costs our economy $9.6 billion per year.i Data collected for the recent Child Health Summit indicate that childhood obesity is a major issue, with 19.3% of Canadian youth aged 10 to 16 considered overweight. The Organization for Economic Cooperation and Development now ranks Canada 19th out of 20 countries surveyed. Recommendation 3 - Double the Child Fitness Tax Credit The CMA recognizes that a "high-calorie, nutrient-poor food tax" should be part of an integrated strategy to promote healthy lifestyles that would also involve better nutrition as well as physical fitness. Accordingly, we recommend that the federal government should increase the children's fitness tax credit to encourage physical fitness. Similar to Canada's Child Fitness Tax Credit, the Personal Health Investment Today (PHIT) bill in the U.S. allows for the use of up to $1,000 pre-tax dollars to cover expenses related to sports, fitness and other physical activities. We recommend that the government double the $500 children's fitness tax credit and include a retail sales tax exemption on tobacco cessation aids.ii Recommendation 4 - Increase federal Gas Tax Fund transfers for municipal transit to improve air quality The CMA suggests that the government immediately accelerate the federal Gas Tax Fund transfers to $2-billion in support of municipal transit infrastructure projects to improve air quality; with consideration of an escalator to close the municipal infrastructure gapiii. These transfers should be integrated into a national transit strategy that considers the heart and lung impacts of motor vehicle pollutioniv. Studies have proven that heart and lung disease among children increases significantly the closer they are to high density traffic. Recommendation 5 - Bolster Health Human Resources - extend the interest relief on Canada student loans for medical residents Many Canadians might not recognize that high medical student debt load is an important health human resource issue. High debt loads unduly affect both the kind of specialty that physicians-in-training choose and, ultimately, where they decide to practice. Medical student debt limits the accessibility of a medical education and may also affect the diversity of the medical profession. Thus, high medical student debt affects patients' access to quality care. Medical student debt is an area in which the federal government can make a direct difference. Unfortunately, current government policy - namely the Canada Student Loans Program (CSLP) - is a barrier and not a boost to medical students. Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to skyrocket. Consequently, we recommend that the government introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Recommendation 6 - Explore tax policy options for Long Term Care That the government considers either tax pre-paid or tax-deferred options for funding long-term health care. For example, in the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan (RDSP)v where parents and guardians can contribute to a lifetime maximum of $200,000, while, similar to the RESP program, there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. Recommendation 7 - Ensure that all Canadians are protected against catastrophic drug costs The federal government could consider establishing a catastrophic pharmaceutical program to be administered through reimbursement of provincial/territorial and private prescription drug programs as was proposed by the Kirby/Lebreton Report.vi There are currently more than one-half million Canadians without catastrophic drug coverage. A. Addressing the committee's questions on tax policy trade-offs The CMA does not pretend to be an expert on optimal tax policy. However, we have, over the last five years engaged experts that have illuminated the advantages of aligning tax policy with health policyvii. In general, the CMA recognizes that the Canadian economy and its corporate and income tax rates must compete in the global economy, particularly relative to the United States. We also see that the tax system interfaces with health at three levels: health-care financing, health-care inputs and lifestyle choices. A balance must be struck considering all three of these levels of interaction. The following section provides our views on tax-policy trade-offs as they relate to health and the economy. i. Should taxes be broadly-based or targeted to a specific group of residents or business sectors? The CMA recognizes the three main principles of tax policy: equity, efficiency and economic growth. Our most precious resource is our people: Canada's human capital. Therefore, tax policy should be used to maximize the health of our citizens, particularly the health of our children - the labour force of the future. The CMA believes in broadly based tax policy that creates incentives for integrating good nutrition and active lifestyles for all Canadians. ii. What consideration should be given to the various levels and types of public goods provided by countries? The health-care sector currently represents 10% of our economy and is likely to grow. This makes the case for immediately implementing forward-looking tax policy that encourages healthy lifestyles as well as improving system efficiencies so that billions of dollars may be saved in the future. In addition, universal health care coverage facilitates labour mobility as employees are not tied to their employers for medical coverage. This is an advantage for Canadians as well as prospective overseas talent coming to Canada. iii. What is the appropriate level of corporate taxes and should they be competitive? The CMA also believes that corporate tax policy should create incentives for companies to invest in capital, as well as labour, in order to increase productivity. Consumption taxes like the GST should not fall on publicly funded physicians with respect to goods and services required to run their practices because they cannot pass on price increases to their patients. This is inefficient and inequitable. iv. What is the appropriate form and level of personal taxes, fees and other charges and should they be competitive? The CMA believes in a progressive personal income tax system that supports social services while at the same time is not so onerous as to discourage labour in fields that are considered strategic or in short supply. Accordingly, federal personal income tax should be mindful of international personal income tax rates especially for professions (such as physicians) that are currently and will be in short supply in the future. The CMA is concerned about being able to ensure sufficient health human resources for our health-care system in the future. In this regard, income-tax policy could be used to offer an expanded range of incentives for example, to encourage physicians to continue working in Canada or return to Canada from abroad. It is important to consider that over the last ten years; well over 4,800 physicians emigrated from Canada to other countries. B. Tax incentives supporting an enhanced and sustainable health system This pre-budget submission will next set out the CMA's recommended specific tax measures that can enhance both economic and health system performance. We believe that tax policy can create incentives for Canadians to live healthier lives, improve the efficiency of our health-care system, improve community-based health care, and reinforce the value of the publicly-funded system for business. Accordingly our submission outlines three principals of health and tax policy: I. Tax incentives for community-based health-care practices II. Tax incentives for healthier living III. Tax incentives to support an efficient health-care system I. Tax incentives for community based health care practices 1. Accelerate health information technology investments - GST and tax incentives A Booz, Allen, Hamilton studyviii on the Canadian health care system estimates that the benefits of an electronic medical record (EMR) could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The physician community can play a pivotal role in helping the federal government make a connected health-care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health-care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway. Recommendation: That the federal government provide a $50,000 tax credit, spread-out over four years, for community-based health care practices to invest in interoperable EMRs to allow for system integration. In addition, the CMA recommends that the government provide a rebate for IT to physicians for the GST/HST on costs relating to health-care services provided by a medical practitioner and reimbursed by a province or provincial health plan. II. Why tax incentives for healthier living? Healthier individuals positively affect the economy in four ways.ix 1. They are more productive at work and so earn higher incomes. 2. They spend more time in the labour force, as less healthy people take sickness absence or retire early. 3. They invest more in their own education, which will increase their productivity. 4. They save more in expectation of a longer life (for example, for retirement) increasing the funds available for investment in the economy. 2. Obesity and absenteeism affect the bottom line today and tomorrow Almost 60% of all Canadian adults and 26% of our children and adolescents are overweight or obese.x Obesity costs Canada $9.6 billion per year.xi The programs and incentives in place now are clearly not working as the incidence of obesity continues to grow. The experts agree: "The economic drive toward eating more and exercising less represents a failure of the free market that governments must act to reverse."xii That is why the CMA is calling for a tax on high-calorie, nutrient-poor foods. We are not alone in calling for this tax; the World Health Organization anti-obesity strategy includes a call for "fat taxes"xiii. In addition there is support among voters for such a tax, as a recent consumer surveyxiv revealed that 75% of participants would support a tax designed to discourage consumers from purchasing high-fat, low-nutrition foods. Recommendation: That the government considers the use of taxes on sales of high-calorie, nutrient-poor foods as part of a strategy of using tax incentives to promote healthy eating in Canada. Moreover, a portion of the revenue from this tax should be applied to make healthier foods cheaper and more accessible, especially for low income groups. 3. Double the Child Fitness Tax Credit The CMA recognizes that a "high-calorie, nutrient-poor food tax" should be part of an integrated strategy to promote healthy lifestyles that would involve better nutrition as well as physical fitness. Accordingly, we recommend that the federal government increase the children's fitness tax credit to encourage physical fitness. Similar to Canada's Child Fitness Tax Credit, the Personal Health Investment Today (PHIT) bill in the U.S. allows for the use of up to $1,000 pre-tax dollars to cover expenses related to sports, fitness and other physical activities. In addition, we urge the federal government to introduce a Retail Sales Tax (RST) exemption on tobacco cessation aids, similar to the recent initiative in Ontarioxv. Recommendation: That the government doubles the $500 Children's Fitness Tax Credit and include a retail sales tax exemption on tobacco cessation aids.xvi 4. Increase federal Gas Tax Fund transfers for municipal transit to improve air quality Studies have proven that heart and lung disease among children increases significantly the closer they are to high-density traffic. The CMA suggests that the government immediately accelerate the federal Gas Tax Fund transfers to $2 billion in support of municipal transit infrastructure projects to improve air quality; with consideration of an escalator to close the municipal infrastructure gap.xvii These transfers should be integrated into a national transit strategy that considers the heart and lung impacts of motor vehicle pollution.xviii Recommendation: That the government increases the federal Gas Tax Fund tax transfers for municipal transit. III. Tax incentives supporting an efficient quality health care system 5. Bolster Health Human Resources - extend the interest relief on Canada student loans for medical residents Many Canadians might not recognize that high medical student debt load is an important health human resource issue. High debt loads unduly affect both the kind of specialty that physicians-in-training choose and, ultimately, where they decide to practice. Medical student debt limits the accessibility of a medical education and may also affect the diversity of the medical profession. Thus, high medical student debt affects patients' access to quality care. Medical student debt is an area in which the federal government can make a direct difference. Unfortunately, current government policy - namely the Canada Student Loans Program (CSLP) - is a barrier and not a boost to medical students. Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to skyrocket. Recommendation: That the government introduce changes to the Canada Student Loans Program to extend the interest-free status on Canada student loans for medical residents pursuing postgraduate training. 6. Explore tax policy options for Long Term Care Canada is in a period of accelerated population aging that will increase the proportion of seniors aged 65-plus substantially over the next 25 years. These people will need long-term care. Recommendation: That the government considers either tax pre-paid or tax-deferred options for funding long-term health care. For example, in the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan (RDSP). Parents and guardians will be able to contribute to a lifetime maximum of $200,000, and similar to the RESP program, there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. 7. Ensure that all Canadians are protected against catastrophic drug costs This is not a tax policy proposal but it is desperately needed. There are currently over one-half-million Canadians without catastrophic drug coverage. Catastrophic Drug Coverage (CDC) aims to address the issue of undue financial hardship faced by Canadians in gaining access to required drug therapies, regardless of where they live and work. In the case of truly catastrophic health needs, these Canadians would probably face the loss of their homes and be destitute, according to the Fraser Groupxix. The founders of Medicare a half-century ago established the principle of equity of access to hospitals and doctors' services for all Canadians. First Ministers agree that no Canadian should suffer undue financial hardship in accessing needed drug therapies. Affordable access to drugs is fundamental to equitable health outcomes for all our citizens. Recommendation: That the federal government could consider establishing a catastrophic pharmaceutical program to be administered through reimbursement of provincial/territorial and private prescription drug programs as was proposed by the Kirby/Lebreton Reportxx. Summary The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. We believe that tax policy can create incentives for Canadians to live healthier lives, improve the efficiency of our health care system, improve community based health care, and reinforce the value of the publicly funded system for business. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. References i P.Katzmarzyk, I. Janssen "The Economic costs associated with physical inactivity and obesity in Canada: An Update" Can J Applied Physiology 2004 Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. ii Children's Fitness Tax Credit see:www.cra-arc.gc.ca/fitness/ iii The Conference Board argues that Canadian cities are incapable of addressing the infrastructure gap on their own. The report, Canada's Cities: In Need of a New Fiscal Framework, proposes a financing model that involves all three levels of government on the grounds that infrastructure is a national issue and a national priority. See: www.infrastructure.gc.ca/research-recherche/result/precis/rp08_e.shtml iv Gauderman WJ, Vora H, McConnell R, et al. Effects of exposure to traffic on lung development from 10 to 18 years of age: a cohort study. Lancet 2007; 369: 571-577. v Federal Budget 2007. see page 83. Budget 2007 acts on the recommendations of the Panel by announcing the introduction of a new registered disability savings plan (RDSP). The plan will be available commencing in 2008 and will be based generally on the existing registered education savings plan (RESP) design. vi Standing Senate Committee on Science, Technology and Social Affairs' study, The Health of Canadians - The Federal Role (Kirby/Lebreton Report). See Chapter 7 -Expanding coverage to include protection against catastrophic drug costs. Section 7.5.1 How the plan would work on page 138. vii On April 4, 2002, the Canadian Medical Association (CMA) presented its interim report to the Commission on the Future of Health Care in Canada (the Romanow Commission). In this submission, the CMA outlined what Mr. Romanow called "bold and intriguing" changes to reaffirm and realign our health system. Specifically, the CMA report laid out an approach for the renewal of Canada's health care system comprised of three components: a health charter; a health council; and supporting legislative initiatives, including tax system reform. See: Tax and Health - Taking Another Look, May 2002, the CMA. viii Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, Booz, Allan, Hamilton, March 2005-09-06. see: www.infoway-inforoute.ca/en/ResourceCenter/ResourceCenter.aspx (accessed August 14, 2007) ix Investment in health could be good for Europe's economies, Suhrcke, McKee, Arce, Tsolova, Mortensen, BMJ 2006;333:1017-1019 (11 November), doi:10.1136/bmj.38951.614144.68 x Source: ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=4321&Src=blank&From=SubCategory accessed 08/06. xi Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. xii Swinburn, et al. International Journal of Pediatric Obesity (vol 1, p 133) (accessed Sept. 19, 2006) xiii In December, 2003, The World Health Organization proposed that nations consider taxing junk foods to encourage people to make healthier food choices. According to the WHO report, "Several countries use fiscal measures to promote availability of and access to certain foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities." See: http://en.wikipedia.org/wiki/Fat_tax xiv A recent consumer survey by conducted by eDiets.com reveals strong support for a 'fat tax' see: www.foodproductiondaily.com/news/ng.asp?n=66981-fat-tax-junk-food-obesity xv McGuinty Government Introduces Tax Break On Smoking Cessation see www.mhp.gov.on.ca/english/news/2007/073007.asp The national cost of the RST exemption would be about $12 million. xvi See endnote ii. xvii See endnote iii. xviii See endnote iv. xix Fraser Group's business is research, analysis and marketing information for financial service organizations. Our area of greatest expertise is the employee benefits sector including the group life and health and the group pension and retirement markets. Our clients include insurance companies, mutual fund companies, suppliers to the employee benefits sector and, pharmaceutical firms as well as government (estimates for the Kirby/Lebreton report on pharmaceutical strategy in 2002) and non-profit entities with a need to understand this sector. See www.frasergroup.com/aboutus.htm in addition xx See endnote v. CMA pre-budget submission to the Standing Committee on Finance Autumn 2007
Documents
Less detail

Guidelines for Physicians in Interactions with Industry

https://policybase.cma.ca/en/permalink/policy9041
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Replaces
Physicians and the pharmaceutical industry (Update 2001)
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
GUIDELINES FOR PHYSICIANS IN INTERACTIONS WITH INDUSTRY The history of health care delivery in Canada has included interaction between physicians and the pharmaceutical and health supply industries; this interaction has extended to research as well as to education. Physicians understand that they have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their primary obligation to their patients and duties to society, and to avoid situations of conflict of interest where possible and appropriately manage these situations when necessary. They understand as well the need for the profession to lead by example by promoting physician-developed guidelines. The following guidelines have been developed by the CMA to serve as a resource tool for physicians in helping them to determine what type of relationship with industry is appropriate. They are not intended to prohibit or dissuade appropriate interactions of this type, which have the potential to benefit both patients and physicians. Although directed primarily to individual physicians, including residents, and medical students, the guidelines also apply to relationships between industry and medical organizations. General Principles 1. The primary objective of professional interactions between physicians and industry should be the advancement of the health of Canadians. 2. Relationships between physicians and industry are guided by the CMA's Code of Ethics and by this document. 3. The practising physician's primary obligation is to the patient. Relationships with industry are inappropriate if they negatively affect the fiduciary nature of the patient-physician relationship. 4. Physicians should resolve any conflict of interest between themselves and their patients resulting from interactions with industry in favour of their patients. In particular, they must avoid any self-interest in their prescribing and referral practices. 5. Except for physicians who are employees of industry, in relations with industry the physician should always maintain professional autonomy and independence. All physicians should remain committed to scientific methodology. 6. Those physicians with ties to industry have an obligation to disclose those ties in any situation where they could reasonably be perceived as having the potential to influence their judgment. Industry-Sponsored Research 7. A prerequisite for physician participation in all research activities is that these activities are ethically defensible, socially responsible and scientifically valid. The physician's primary responsibility is the well-being of the patient. 8. The participation of physicians in industry sponsored research activities must always be preceded by formal approval of the project by an appropriate ethics review body. Such research must be conducted according to the appropriate current standards and procedures. 9. Patient enrolment and participation in research studies must occur only with the full, informed, competent and voluntary consent of the patient or his or her proxy, unless the research ethics board authorizes an exemption to the requirement for consent. In particular, the enrolling physician must inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of the physician's participation and must advise prospective subjects that they have the right to decline to participate or to withdraw from the study at any time, without prejudice to their ongoing care. 10. The physician who enrolls a patient in a research study has an obligation to ensure the protection of the patient's privacy, in accordance with the provisions of applicable national or provincial legislation and CMA's Health Information Privacy Code. If this protection cannot be guaranteed, the physician must disclose this as part of the informed consent process. 11. Practising physicians should not participate in clinical trials unless the study will be registered prior to its commencement in a publicly accessible research registry. 12. Because of the potential to influence judgment, remuneration to physicians for participating in research studies should not constitute enticement. It may cover reasonable time and expenses and should be approved by the relevant research ethics board. Research subjects must be informed if their physician will receive a fee for their participation and by whom the fee will be paid. 13. Finder's fees, whereby the sole activity performed by the physician is to submit the names of potential research subjects, should not be paid. Submission of patient information without their consent would be a breach of confidentiality. Physicians who meet with patients, discuss the study and obtain informed consent for submission of patient information may be remunerated for this activity. 14. Incremental costs (additional costs that are directly related to the research study) must not be paid by health care institutions or provincial or other insurance agencies regardless of whether these costs involve diagnostic procedures or patient services. Instead, they must be assumed by the industry sponsor or its agent. 15. When submitting articles to medical journals, physicians must state any relationship they have to companies providing funding for the studies or that make the products that are the subject of the study whether or not the journals require such disclosure. Funding sources for the study should also be disclosed. 16. Physicians should only be included as an author of a published article reporting the results of an industry sponsored trial if they have contributed substantively to the study or the composition of the article. 17. Physicians should not enter into agreements that limit their right to publish or disclose results of the study or report adverse events which occur during the course of the study. Reasonable limitations which do not endanger patient health or safety may be permissible. Industry-Sponsored Surveillance Studies 18. Physicians should participate only in post-marketing surveillance studies that are scientifically appropriate for drugs or devices relevant to their area of practice and where the study may contribute substantially to knowledge about the drug or device. Studies that are clearly intended for marketing or other purposes should be avoided. 19. Such studies must be reviewed and approved by an appropriate research ethics board. The National Council on Ethics in Human Research is an additional source of advice. 20. The physician still has an obligation to report adverse events to the appropriate body or authority while participating in such a study. Continuing Medical Education / Continuing Professional Development (CME/CPD) 21. This section of the Guidelines is understood to address primarily medical education initiatives designed for practicing physicians. However, the same principles will also apply for educational events (such as noon-hour rounds and journal clubs) which are held as part of medical or residency training. 22. The primary purpose of CME/CPD activities is to address the educational needs of physicians and other health care providers in order to improve the health care of patients. Activities that are primarily promotional in nature, such as satellite symposia, should be identified as such to faculty and attendees and should not be considered as CME/CPD. 23. The ultimate decision on the organization, content and choice of CME/CPD activities for physicians shall be made by the physician-organizers. 24. CME/CPD organizers and individual physician presenters are responsible for ensuring the scientific validity, objectivity and completeness of CME/CPD activities. Organizers and individual presenters must disclose to the participants at their CME/CPD events any financial affiliations with manufacturers of products mentioned at the event or with manufacturers of competing products. There should be a procedure available to manage conflicts once they are disclosed. 25. The ultimate decision on funding arrangements for CME/CPD activities is the responsibility of the physician-organizers. Although the CME/CPD publicity and written materials may acknowledge the financial or other aid received, they must not identify the products of the company(ies) that fund the activities. 26. All funds from a commercial source should be in the form of an unrestricted educational grant payable to the institution or organization sponsoring the CME/CPD activity. 27. Industry representatives should not be members of CME content planning committees. They may be involved in providing logistical support. 28. Generic names should be used in addition to trade names in the course of CME/CPD activities. 29. Physicians should not engage in peer selling. Peer selling occurs when a pharmaceutical or medical device manufacturer or service provider engages a physician to conduct a seminar or similar event that focuses on its own products and is designed to enhance the sale of those products. This also applies to third party contracting on behalf of industry. This form of participation would reasonably be seen as being in contravention of the CMA's Code of Ethics, which prohibits endorsement of a specific product. 30. If specific products or services are mentioned, there should be a balanced presentation of the prevailing body of scientific information on the product or service and of reasonable, alternative treatment options. If unapproved uses of a product or service are discussed, presenters must inform the audience of this fact. 31. Negotiations for promotional displays at CME/CPD functions should not be influenced by industry sponsorship of the activity. Promotional displays should not be in the same room as the educational activity. 32. Travel and accommodation arrangements, social events and venues for industry sponsored CME/CPD activities should be in keeping with the arrangements that would normally be made without industry sponsorship. For example, the industry sponsor should not pay for travel or lodging costs or for other personal expenses of physicians attending a CME/CPD event. Subsidies for hospitality should not be accepted outside of modest meals or social events that are held as part of a conference or meeting. Hospitality and other arrangements should not be subsidized by sponsors for personal guests of attendees or faculty, including spouses or family members. 33. Faculty at CME/CPD events may accept reasonable honoraria and reimbursement for travel, lodging and meal expenses. All attendees at an event cannot be designated faculty. Faculty indicates a presenter who prepares and presents a substantive educational session in an area where they are a recognized expert or authority. Electronic Continuing Professional Development (eCPD) 34. The same general principles which apply to "live, in person" CPD events, as outlined above, also apply to eCPD (or any other written curriculum-based CPD) modules. The term "eCPD" generally refers to accredited on-line or internet-based CPD content or modules. However, the following principles can also apply to any type of written curriculum based CPD. 35. Authors of eCPD modules are ultimately responsible for ensuring the content and validity of these modules and should ensure that they are both designed and delivered at arms'-length of any industry sponsors. 36. Authors of eCPD modules should be physicians with a special expertise in the relevant clinical area and must declare any relationships with the sponsors of the module or any competing companies. 37. There should be no direct links to an industry or product website on any web page which contains eCPD material. 38. Information related to any activity carried out by the eCPD participant should only be collected, used, displayed or disseminated with the express informed consent of that participant. 39. The methodologies of studies cited in the eCPD module should be available to participants to allow them to evaluate the quality of the evidence discussed. Simply presenting abstracts that preclude the participant from evaluating the quality of evidence should be avoided. When the methods of cited studies are not available in the abstracts, they should be described in the body of the eCPD module. 40. If the content of eCPD modules is changed, re-accreditation is required. Advisory/Consultation Boards 41. Physicians may be approached by industry representatives and asked to become members of advisory or consultation boards, or to serve as individual advisors or consultants. Physicians should be mindful of the potential for this relationship to influence their clinical decision making. While there is a legitimate role for physicians to play in these capacities, the following principles should be observed: A. The exact deliverables of the arrangement should be clearly set out and put in writing in the form of a contractual agreement. The purpose of the arrangement should be exclusively for the physician to impart specialized medical knowledge that could not otherwise be acquired by the hiring company, and should not include any promotional or educational activities on the part of the company itself. B. Remuneration of the physician should be reasonable and take into account the extent and complexity of the physician's involvement. C. Whenever possible, meetings should be held in the geographic locale of the physician or as part of a meeting which he/she would normally attend. When these arrangements are not feasible, basic travel and accommodation expenses may be reimbursed to the physician advisor or consultant. Meetings should not be held outside of Canada, with the exception of international boards. Clinical Evaluation Packages (Samples) 42. The distribution of samples should not involve any form of material gain for the physician or for the practice with which he or she is associated. 43. Physicians who accept samples or other health care products are responsible for recording the type and amount of medication or product dispensed. They are also responsible for ensuring their age-related quality and security and their proper disposal. Gifts 44. Practising physicians should not accept personal gifts of any significant monetary or other value from industry. Physicians should be aware that acceptance of gifts of any value has been shown to have the potential to influence clinical decision making. Other Considerations 45. These guidelines apply to relationships between physicians and all commercial organizations, including but not limited to manufacturers of medical devices, nutritional products and health care products as well as service suppliers. 46. Physicians should not dispense pharmaceuticals or other products unless they can demonstrate that these cannot be provided by an appropriate other party, and then only on a cost-recovery basis. 47. Physicians should not invest in industries or related undertakings if this might inappropriately affect the manner of their practice or their prescribing behaviour. 48. Practising physicians affiliated with pharmaceutical companies should not allow their affiliation to influence their medical practice inappropriately. 49. Practising physicians should not accept a fee or equivalent consideration from pharmaceutical manufacturers or distributors in exchange for seeing them in a promotional or similar capacity. 50. Practising physicians may accept patient teaching aids appropriate to their area of practice provided these aids carry at most the logo of the donor company and do not refer to specific therapeutic agents, services or other products. Medical Students and Residents 51. The principles in these guidelines apply to physicians-in training as well as to practising physicians. 52. Medical curricula should deal explicitly with the guidelines by including educational sessions on conflict of interest and physician-industry interactions.
Documents
Less detail

Achieving Patient-Centred Collaborative Care

https://policybase.cma.ca/en/permalink/policy9060
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
Text
ACHIEVING PATIENT-CENTRED COLLABORATIVE CARE (2008) The Canadian Medical Association (CMA) recognizes that collaborative care is a desired and necessary part of health care delivery in Canada and an important element of quality, patient-centred care. The CMA considers patient-centred care to be the cornerstone of good medical practice. This is reflected in the first principle of the CMA Code of Ethics, which states that physicians have a fundamental responsibility to "Consider first the well-being of the patient." As patient advocates, physicians strive to ensure that their patients receive the best possible care. The CMA supports greater collaboration among providers in the interest of better patient care. In the context of clinical practice, the CMA defines collaborative care as follows: "Collaborative care entails physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each others' skills and knowledge. This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice personalities and skill sets of the individuals. The relationship must be beneficial to the patient, and acceptable to the physician and other providers. If designed appropriately, collaborative care models have the potential to: * improve access to care; * enhance the quality and safety of care; * enhance the coordination and efficiency of care; and * enhance provider morale and reduce burnout within health professions. To realize this full potential, the profession acknowledges and accepts that it has a central role to play in the evolution of a team-based approach to care. These policy principles have been prepared by the Canadian Medical Association in order to ensure that the evolution of collaborative care in Canada is built around the needs of individual patients and groups of patients. This policy is founded on the CMA's document, Putting Patients' First: Patient-Centred Collaborative Care - A Discussion Paper. Principles for Collaborative Care The medical profession supports collaborative care, both in the hospital and in the community, as one of the essential elements of health care delivery in Canada. In the interests of enhancing the evolution of patient-centred collaborative care, the CMA proposes the following "critical success factors" and principles to address meaningfully the issues and barriers identified by physicians and bring clarity to the discussions. 1. PATIENT-CENTRED CARE First and foremost, medical care delivered by physicians and health care delivered by others should be aligned around the values and needs of patients. Collaborative care teams should foster and support patients, and their families, as active participants in their health care decision-making. New models should have the potential to empower patients to enhance their role in prevention and self-care. Models of collaborative care must be designed to meet the needs of patients. Collaborative models of practice must reduce fragmentation and enhance the quality and safety of care provided to patients. It is the patient who ultimately must make informed choices about the care he or she will receive. 2. RECOGNITION OF THE PATIENT-PHYSICIAN RELATIONSHIP The mutual respect and trust derived from the patient-physician relationship is the cornerstone of medical care. This trust is founded on the ethical principles that guide the medical profession as defined in the CMA Code of Ethics. The impact of collaborative models of practice on this relationship, and hence the patient's satisfaction and experience with their care, is unknown. Models of collaborative care must support the patient-physician relationship. Entry into and exit from a formal collaborative care arrangement must be voluntary for both the patient and the physician. A common Code of Ethics should guide the practice of collaborative care teams. Every resident of Canada has the right to access a personal family physician. † 3. PHYSICIAN AS THE CLINICAL LEADER Effective teams require effective leadership. A defined clinical leader is required to ensure proper functioning of the team and to facilitate decision-making, especially in complex or emergent situations. In collaborative care the clinical leader is responsible for maximizing the expertise and input of the entire team in order to provide the patient with comprehensive and definitive care. It is important to differentiate "clinical leadership" from "team coordination." The CMA defines a clinical leader as: "The individual who, based on his or her training, competencies and experience, is best able to synthesize and interpret the evidence and data provided by the patient and the team, make a differential diagnosis and deliver comprehensive care for the patient. The clinical leader is ultimately accountable to the patient for making definitive clinical decisions." Whereas, the team coordinator is defined as: "The individual, who, based on his or her training, competencies and experience, is best able to coordinate the services provided by the team so that they are integrated to provide the best care for the patient." The concept of "most responsible physician" has been and continues to be used to identify the individual who is ultimately responsible for the care of the patient. The "most responsible physician" is responsible for collecting, synthesizing and integrating the expert opinion of physician and non physician team members to determine the clinical management of the patient. Similarly, the presence of a defined clinical leader in a collaborative care setting creates clarity for patients, their families and the health care team by making lines of communication and responsibility clear, ultimately improving the quality and safety of care. In the CMA's opinion, the physician is best equipped to provide clinical leadership. This does not necessarily imply that a physician must be the team coordinator. Many teams will exist in which the physician will have a supporting role, including those focused on population health and patient education. We believe the most effective teams are ones in which the leadership roles have been clearly defined and earned. Some physicians may be prepared to play both roles; however, other members of the team may be best suited to serve as team coordinator. Currently, patients rely on, and expect, physicians to be clinical leaders in the assessment and delivery of the medical care they receive. In a collaborative care environment this expectation of physician leadership will not change. Team members will have specific knowledge and expertise in their respective disciplines. Physicians, by virtue of their broad and diverse knowledge, training and experience, have a unique appreciation of the full spectrum of health and health care delivery in their field of practice and are therefore best qualified to evaluate and synthesize diverse professional perspectives to ensure optimal patient care. The physician, by virtue of training, knowledge, background and patient relationship, is best positioned to assume the role of clinical leader in collaborative care teams. There may be some situations in which the physician may delegate clinical leadership to another health care professional. Other health care professionals may be best suited to act as team coordinator. 4. MUTUAL RESPECT AND TRUST Trust between individuals and provider groups evolves as knowledge and understanding of competencies, skills and scopes of practice are gained. Trust is also essential to ensuring that the team functions efficiently and maximizes the contributions of all members. Funders and providers should recognize the importance of team building in contributing to team effectiveness. Collaborative care funding models should support a more formalized and integrated approach to both change management and team building. As relationships are strengthened within the team, so too are trust and respect. Physicians and all team members have an opportunity to be positive role models to motivate and inspire their colleagues. All team members ought to make a commitment to respect and trust each other with the knowledge that it will lead to enhanced care for patients and a more productive work environment for all. To serve the health care needs of patients, there must be a collaborative and respectful interaction among health care professionals, with recognition and understanding of the contributions of each provider to the team. In order to build trust and respect within the team it is essential that members understand and respect the professional responsibility, knowledge and skills that come with their scope of practice within the context of the team. 5. CLEAR COMMUNICATION In collaborative care environments, it is essential that all members of the team communicate effectively to provide safe and optimal care. Effective communication is essential to ensure safe and coordinated care as the size of the team expands to meet patient needs. It is the responsibility of all team members to ensure that the patient is receiving timely, clear and consistent messaging. Physicians can take a leadership role in modeling effective communications throughout the team. In particular, there is an opportunity to enhance the consultation and referral process, in order to provide clear and concise instructions to colleagues and optimize care. Sufficient resources, including dedicated time and support, must be available to the team to maximize these communication requirements. Effective communication within collaborative care teams is critical for the provision of high quality patient care. Planning, funding and training for collaborative care teams must include measures to support communication within these teams. Mechanisms must be in place within a collaborative team to ensure that both the patients, and their caregiver(s) where appropriate, receive timely information from the most appropriate provider. Effective and efficient communications within the collaborative care team, both with the patient and among team members, should be supported by clear documentation that identifies the author. A common, accessible patient record in collaborative care settings is desirable to ensure appropriate communication between physicians and other health care professionals, to prevent duplication, coordinate care, share information and protect the safety of patients. An integrated electronic health record is highly desirable to facilitate communication and sharing among team members. 6. CLARIFICATION OF ROLES AND SCOPES OF PRACTICE In order for the team to function safely and efficiently, it is critically important that the scope of practice, roles and responsibilities of each health care professional on the team be clearly defined and understood. In turn, the patient, as a team member, should also have a clear understanding of the roles and scopes of practice of their providers. Collaborative care must first and foremost serve the needs of patients, with the goal of enhancing patient care; collaborative care is not contingent upon altering the scope of practice of any provider group and must not be used as a means to expand the scope of practice and/or independence of a health professional group. Changes in the scope of practice of all provider groups must be done with oversight from the appropriate regulatory authority. Where non-physicians have been provided with an opportunity to undertake activities related to patient care typically unique to the practice of medicine (e.g., ordering tests), they must not do so independently but undertake these activities within the context of the team and in a manner acceptable to the clinical leader. The role and scope of practice of each member of the collaborative care team should be clearly understood and delineated in job descriptions and employment contracts. A formal process for conflict resolution should be in place so that issues can be dealt with in a timely and appropriate manner. 7. CLARIFICATION OF ACCOUNTABILITY AND RESPONSIBILITY In the context of providing optimal care, providers must be accountable and responsible for the outcome of their individual practice, while sharing responsibility for the proper functioning of the collaborative care team. This individual responsibility is required so that regardless of the number and diversity of providers involved in the team, patients can be assured that their well-being is protected and that the team is working toward a common goal. In collaborative care teams, a physician should be identified as the person most responsible for the clinical care of individual patients, and as such must be accountable for the care rendered to patients. This is consistent with the commitment made by the physician in the doctor-patient relationship, mirrors the clinical training of the physician relative to other providers, is reflective of the current state of tort law as it applies to medical practice, and is compatible with the structure of care delivery in hospitals and in the community. Clearly, this type of arrangement does not eliminate the necessity for all providers to be accountable for the care that they provide. It is essential that all providers be responsible and accountable for the care that they provide and for the well-being of the patient. As clinical leader, the physician should be responsible for the clinical oversight of an individual patient's care. 8. LIABILITY PROTECTION FOR ALL MEMBERS OF THE TEAM As discussed earlier in this paper, the resolution of the multiplicity of liability issues that result from care delivered by teams requires clearly defined roles and responsibilities in the team setting and the absolute requirement for appropriate and sufficient liability coverage for each health professional. The August 2006 statement of the Canadian Medical Protective Association, Collaborative Care: A medical liability perspective, identifies issues of concern to physicians and proposes solutions to reduce those risks. All members of a collaborative care team must have adequate professional liability protection and/or insurance coverage to accommodate their scope of practice and their respective roles and responsibilities within the collaborative care team. Physicians, in their role as clinical leaders of collaborative care teams, must be satisfied with the ongoing existence of appropriate liability protection as a condition of employment of, or affiliation with, other members on collaborative care teams. Formalized procedures should be established to ensure evidence of this liability protection. 9. SUFFICIENT HUMAN RESOURCES AND INFRASTRUCTURE Collaborative models of health care delivery hold the promise of enhancing access to care for patients at a time of serious health human resource shortages. However, effective patient-centred collaborative care depends on an adequate supply of physicians, nurses and other providers. Governments and decision-makers must continue to enhance their efforts to increase the number of physicians and nurses available to provide health care services. Collaborative care should not be seen as an opportunity for governments to substitute one care provider for another simply because one is more plentiful or less costly than the other. In addition, governments must understand that co-location of individuals in a team is not a requirement for all collaborative care. Where team co-location does not exist, appropriate resources must be dedicated to ensure communication can be timely, effective and appropriate between providers. Governments, at all levels, must address the serious shortage of physicians to ensure quality patient care for Canadians. The effective functioning of a collaborative care team depends on the contribution of a physician. Governments must enhance access to medical care by increasing the number of physicians and providers, and not by encouraging or empowering physician substitution. 10. SUFFICIENT FUNDING & PAYMENT ARRANGEMENTS Funding must be present to support all aspects of the development of collaborative care teams. At the practice level, remuneration methods for physicians, irrespective of their specialty, must be available to facilitate collaborative care arrangements and environments in which physicians practice. All care delivery models, including collaborative care teams, must have access to adequate and appropriate resources. This includes, but should not be limited to, funding for health human resources, administration/management infrastructure, liability protection, clinical and team/administrative training, team building, and information technology. Remuneration models should be established in a manner that encourages providers to participate effectively in the delivery of care and team effectiveness. Reimbursement models must be configured to remunerate the communicator, coordinator, manager, and other roles and responsibilities of providers necessary for the success of collaborative care practice. The ability of a physician to work in a collaborative care team must not be based on the physician's choice of remuneration. Similarly, patients should not be denied access to the benefits of collaborative practice as a result of the physician's choice of payment model. Collaborative care relationships between physicians and other health care providers should continue to be encouraged and enhanced through appropriate resource allocation at all levels of the health care system. Physicians should be appropriately compensated for all aspects of their clinical care and leadership activities in collaborative care teams. Physicians should not be expected to incur the cost of adopting and maintaining health information technology capabilities that facilitate their ability to participate in collaborative practice teams. Governments must fund and support in an ongoing manner, both financially and technically, the development and integration of electronic health records. 11. SUPPORTIVE EDUCATION SYSTEM Canada is renowned for a quality medical education system and for the early efforts to enhance interprofessional training. The success of collaborative care requires a commitment towards interprofessional education and is contingent upon the positive attitudes and support of educators. To facilitate a sustainable shift toward collaborative practice, these efforts must be continued and enhanced in a meaningful way. However, governments and educators must ensure that the availability and quality of medical education is not compromised for medical trainees. Interprofessional education, at the undergraduate, postgraduate and continuing education levels, is necessary to facilitate a greater understanding of the potential roles, responsibilities and capabilities of health professions, with the overall goal of building better health care teams founded on mutual respect and trust. Governments must understand the importance of interprofessional education and fund educational institutions appropriately to meet these new training needs. Educational opportunities must exist at all levels of training to acquire both clinical knowledge and team effectiveness/leadership training. Interprofessional education opportunities must not come at the expense of core medical training. High quality medical education must be available to all medical trainees as a first priority. 12. RESEARCH AND EVALUATION More research and evaluations are necessary to demonstrate the benefits of collaborative care, to foster greater adoption by providers and to attract the necessary investment by governments. Quality management systems must be built into the team to ensure efficiencies can be recorded. Measures of the quality of care, cost effectiveness and patient and provider satisfaction should be evaluated. Research into the effectiveness of collaborative care models on health outcomes, patient and provider satisfaction and health care cost effectiveness should be ongoing, transparent and supported by governments. Quality assessment measures must be incorporated into the ongoing work of collaborative care teams. † Where the term "family physician" is used, it is also meant to include general practitioners.
Documents
Less detail

Concussion in Sport, Leisure, and Occupational Settings

https://policybase.cma.ca/en/permalink/policy14023
Date
2019-03-02
Topics
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Policy document
Date
2019-03-02
Replaces
Head injury and sport (2011)
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
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
Documents
Less detail

104 records – page 1 of 6.