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Appropriateness in health care

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

https://policybase.cma.ca/en/permalink/policy197
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
Text
Like all scientific and medical procedures, assisted human reproduction has the potential for both benefit and harm. It is in the interests of individual Canadians and Canadian society in general that these practices be regulated so as to maximize their benefits and minimize their harms. To help achieve this goal, the Canadian Medical Association (CMA) has developed this policy on regulating these practices. It replaces previous CMA policy on assisted reproduction. Objectives The objectives of any Canadian regulatory regime for assisted reproduction should include the following: (a) to protect the health and safety of Canadians in the use of human reproductive materials for assisted reproduction, other medical procedures and medical research; (b) to ensure the appropriate treatment of human reproductive materials outside the body in recognition of their potential to form human life; and (c) to protect the dignity of all persons, in particular children and women, in relation to uses of human reproductive materials. Principles When a Canadian regulatory regime for assisted reproduction is developed, it should incorporate the following principles: For the regulation of assisted reproduction, existing organizations such as medical licensing authorities, accreditation bodies and specialist societies should be involved to the greatest extent possible. If the legislation establishing the regulatory regime is to include prohibitions as well as regulation, the prohibition of specific medical and scientific acts must be justified on explicit scientific and/or ethical grounds. If criminal sanctions are to be invoked, they should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts. Whatever regulatory agency is created should include significant membership of scientists and clinicians working in the area of assisted reproduction. Elements of a Regulatory Regime The regulation of assisted reproduction in Canada should include the following elements: Legislation to create a national regulatory body with appropriate responsibilities and accountability for coordinating the activities of organizations that are working in the area of assisted reproduction and for carrying out functions that other organizations cannot perform. The development and monitoring of national standards for research related to human subjects including genetics and reproduction. The regulatory body would work closely with the Canadian Institutes of Health Research, other federal and provincial research granting councils, the National Council on Ethics in Human Research and other such organizations. The development and monitoring of national standards for training and certifying physicians in those reproductive technologies deemed acceptable. As is the case for all post-graduate medical training in Canada, this is appropriately done through bodies such as the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. The licensing and monitoring of individual physicians. This task is the responsibility of the provincial and territorial medical licensing authorities which could regulate physician behaviour in respect to the reproductive technologies, just as they do for other areas of medical practice. The development of guidelines for medical procedures. This should be done by medical specialty societies such as the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Canadian Fertility and Andrology Society (CFAS). The accreditation of facilities where assisted reproduction is practised. There is already in Canada a well functioning accreditation system, run by the Canadian Council on Health Services Accreditation, which may be suitable for assisted reproduction facitilies. Whatever regulatory body is established to deal with assisted reproduction should utilize, not duplicate, the work of these organizations. In order to maximize the effectiveness of these organizations, the regulatory body could provide them with additional resources and delegated powers. Criminalization The CMA is opposed to the criminalization of scientific and medical procedures. Criminalization represents an unjustified intrusion of government into the patient-physician relationship. Previous attempts to criminalize medical procedures (for example, abortion) were ultimately self-defeating. If the federal government wishes to use its criminal law power to regulate assisted reproduction, criminal sanctions should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts.
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Boxing (Update 2001)

https://policybase.cma.ca/en/permalink/policy192
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Boxing (1986)
Topics
Population health/ health equity/ public health
Text
The CMA recommends to the appropriate government authorities that all boxing be banned in Canada. Until such time, strategies to prevent injury should be pursued. Background The CMA considers boxing a dangerous sport. While most sports involve risk of injury, boxing is distinct in that the basic intent of the boxer is to harm and incapacitate his or her opponent. Boxers are at significant risk of injuries resulting in brain damage. Boxers are susceptible not only to acute life-threatening brain trauma, but also to the chronic and debilitating effects of gradual cerebral atrophy. Studies demonstrate a correlation between the number of bouts fought and the presence of cerebral abnormalities in boxers. There is also a risk of eye injury including long-term damage such as retinal tears and detachments. Recommendations: - CMA supports a ban on professional and amateur boxing in Canada. - Until boxing is banned in this country, the following preventive strategies should be pursued to reduce brain and eye injuries in boxers: - Head blows should be prohibited. CMA encourages universal use of protective garb such as headgear and thumbless, impact-absorbing gloves - The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting. - The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce standard criteria for referees, ringside officials and ringside physicians to halt sparring or boxing bouts when a boxer has experienced blows that place him or her at imminent risk of serious injury. - The World Boxing Council, World Boxing Association and other regulatory bodies should encourage implementation of measures advocated by the World Medical Boxing Congress to reduce the incidence of brain and eye injuries. - CMA believes that the professional responsibility of the physician who serves in a medical capacity in a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not influence the physician’s medical judgment. - Further long term outcome data should be obtained from boxers in order to more accurately establish successful preventive interventions. CMA encourages ongoing research into the causes and treatments of boxing-related injuries, and into the effects of preventive strategies.
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Cannabis for Medical Purposes

https://policybase.cma.ca/en/permalink/policy10045
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) has always recognized the unique requirements of those individuals suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief. However, there are a number of concerns, primarily related to the limited evidence to support many of the therapeutic claims made regarding cannabis for medical purposes, and the need to support health practitioners in their practice.1,2,3,4 While the indications for using cannabis to treat some conditions have been well studied, less information is available about many potential medical uses. Physicians who wish to authorize the use of cannabis for patients in their practices should consult relevant CMPA policy5 and guidelines developed by the provincial and territorial medical regulatory authorities to ensure appropriate medico-legal protection. The CMA’s policy Authorizing Marijuana for Medical Purposes6, as well as the CMA’s Guidelines For Physicians In Interactions With Industry7 should also be consulted. The CMA makes the following recommendations: 1. Increase support for the advancement of scientific knowledge about the medical use of cannabis. The CMA encourages the government to support rigorous scientific research into the efficacy for therapeutic claims, safety, dose-response relationships, potential interactions and the most effective routes of delivery, and in various populations. 2. Apply the same regulatory oversight and evidence standards to cannabis as to pharmaceutical products under the Food and Drug Act, designed to protect the public by the assessment for safety and efficacy. 3. Increase support for physicians on the use of cannabis for medical purposes in their practice settings. As such, CMA calls on the government to work with the CMA, The College of Family Physicians of Canada, the Royal College of Physicians and Surgeons, 2 and other relevant stakeholders, to develop unbiased, accredited education options and licensing programs for physicians who authorize the use of cannabis for their patients based on the best available evidence. Background In 2001, Health Canada enacted the Marihuana Medical Access Regulations (MMAR). These were in response to an Ontario Court of Appeal finding that banning cannabis for medicinal purposes violated the Charter of Rights and Freedoms.8 The MMAR, as enacted, was designed to establish a framework to allow legal access to cannabis, then an illegal drug, for the relief of pain, nausea and other symptoms by people suffering from serious illness where conventional treatments had failed. While recognizing the needs of those suffering from terminal illness or chronic disease, CMA raised strong objections to the proposed regulations. There were concerns about the lack of evidence on the risks and benefits associated with the use of cannabis. This made it difficult for physicians to advise their patients appropriately and manage doses or potential side effects. The CMA believes that physicians should not be put in the untenable position of gatekeepers for a proposed medical intervention that has not undergone established regulatory review processes as required for all prescription medicines. Additionally, there were concerns about medico-legal liability, and the Canadian Medical Protective Association (CMPA), encouraged those physicians that were uncomfortable with the regulations to refrain from authorizing cannabis to patients. Various revisions were made to the MMAR, and then these were substituted by the Marihuana for Medical Purposes Regulations (MMPR) in 2013/ 2014 and subsequently by the Access to Cannabis for Medical Purposes Regulations (ACMPR) in 2016 and now as part of the Cannabis Act (Section 14)9. Healthcare practitioners that wish to authorize cannabis for their patients are required to sign a medical document, indicating the daily quantity of dried cannabis, expressed in grams. For the most part, these revisions have been in response to decisions from various court decisions across the country.10,11,12 Courts have consistently sided with patients’ rights to relieve symptoms of terminal disease or certain chronic conditions, despite the limited data on the effectiveness of cannabis. Courts have not addressed the ethical position in which physicians are placed as a result of becoming the gate keeper for access to a medication without adequate evidence. The CMA participated in many Health Canada consultations with stakeholders as well as scientific advisory committees and continued to express the concerns of the physician community. As previously noted, the Federal government has been constrained by the decisions of Canadian courts. 3 The current state of evidence regarding harms of cannabis use is also limited but points to some serious concerns. Ongoing research has shown that regular cannabis use during brain development (up to approximately 25 years old) is linked to an increased risk of mental health disorders including depression, anxiety, and schizophrenia, especially if there is a personal or family history of mental illness. Long term use has also been associated with issues of attention, impulse control and emotional regulation. Smoking of cannabis also has pulmonary consequences such as chronic bronchitis. It is also linked to poorer pregnancy outcomes. Physicians are also concerned with dependence, which occurs in up to 10% of regular users. From a public and personal safety standpoint, cannabis can impact judgement and increases the risk of accidents (e.g. motor vehicle incidents). For many individuals, cannabis use is not without adverse consequences.3,13,14 Pharmaceutically prepared alternative options, often administered orally, are also available and regulated in Canada.15 These drugs mimic the action of delta-9-tetra-hydrocannabional (THC) and other cannabinoids and have undergone clinical trials to demonstrate safety and effectiveness and have been approved for use through the Food and Drug Act. Of note is that in this format, the toxic by-products of smoked marijuana are avoided.16 However, the need for more research is evident. Approved by the CMA Board in December 2010. Last reviewed and approved by the CMA Board in March 2019. References 1 Allan GM, Ramji J, Perry D, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician, 2018;64(2):111-120. Available: http://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Jan 8). 2 College of Family Physicians of Canada (CFPC). Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance. Mississauga: CFPC; 2014. Available: https://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf (accessed 2019 Jan 8). 3 The National Academies of Sciences, Engineering and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: National Academies Press; 2017. 4 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313(24):2456-73. 5 Canadian Medical Protective Association (CMPA). Medical marijuana: considerations for Canadian doctors. Ottawa: CMPA; 2018. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-marijuana-new-regulations-new-college-guidance-for-canadian-doctors (accessed 2019 Jan 8). 6 Canadian Medical Association (CMA). Authorizing marijuana for medical purposes. Ottawa: CMA; 2014. Available: https://policybase.cma.ca/en/permalink/policy11514 http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-04.pdf (accessed 2019 Jan 8). 7 Canadian Medical Association. (CMA) Guidelines for Physicians In Interactions With Industry. Ottawa: CMA; 2007. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf. (accessed 2019 Jan22). 4 8 R. v. Parker, 2000 CanLII 5762 (ON CA). Available: http://canlii.ca/t/1fb95 (accessed 2019 Jan 8). 9 Cannabis Act. Access to Cannabis for Medical Purposes. Section 14. 2018. Available: https://laws-lois.justice.gc.ca/eng/regulations/SOR-2018-144/page-28.html#h-81 (accessed 2019 Jan 8). 10 Hitzig v. Canada, 2003 CanLII 3451 (ON SC). Available: http://canlii.ca/t/1c9jd (accessed 2019 Jan 8). 11 Allard v. Canada, [2016] 3 FCR 303, 2016 FC 236 (CanLII), Available: http://canlii.ca/t/gngc5 (accessed 2019 Jan 8). 12 R. v. Smith, 2014 ONCJ 133 (CanLII). Available: http://canlii.ca/t/g68gk (accessed 2019 Jan 8). 13 Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227. 14 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: https://www.who.int/substance_abuse/publications/msbcannabis.pdf (accessed 2019 Jan 8). 15 Ware MA. Is there a role for marijuana in medical practice? Can Fam Physician 2006;52(12):1531-1533. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952544/pdf/0530022a.pdf (accessed 2019 Jan 8). 16 Engels FK, de Jong FA, Mathijssen RHJ, et.al. Medicinal cannabis in oncology. Eur J Cancer. 2007;43(18):2638-2644. Available: https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0959804907007368.pdf?locale=en_US (accessed 2019 Jan 8).
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Climate Change and Human Health

https://policybase.cma.ca/en/permalink/policy9809
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
Text
Climate Change and Human Health Background Climate change is increasingly recognized as a significant threat facing society and has the potential to be one of the greatest threats to human health in the 21st Century1. While the damage is being done now, many of the health effects may arise only decades in the future2. Possible impacts could include some or all of the following: * Increased mortality, disease and injuries from heat waves and other extreme weather events; * Continued change in the range of some infectious disease vectors (i.e. 260-320 million more cases of malaria predicted by 2080, with six billion more at risk for dengue fever); * Effects on food yields- increased malnutrition; * Increased flooding in some areas and increased droughts in others, along with other impacts on freshwater supply; * Increases in foodborne and waterborne illnesses; * Warming and rising sea levels adding to displacement and also impacting water supply through salination; * Impaired functioning of ecosystems; * Negative effects on air quality associated with ground level ozone, including increases in cardio-respiratory morbidity and mortality, asthma, and allergens; * Displacement of vulnerable populations (especially in coastal areas)1; and * Loss of livelihoods3. Most of the impacts of climate change will result from amplifying the existing health hazards found in populations4. How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities (i.e. disease burden, resources etc.) as well as their adaptive capacity5. The World Health Organization has projected that countries that have, and will likely continue to suffer the greatest effects, are those who have contributed the smallest amount to the causes of climate change.6 While the vast majority of climate change deaths will occur in developing countries with systemic vulnerabilities, a recent Health Canada report has noted that Canada is likely to experience higher rates of warming in this century than most other countries in the world. Climate change scenarios predict an increased risk of extreme weather and other climate events for all regions of Canada, with the exception of extreme cold7. Canadians most vulnerable to climate change include seniors, children and infants, socially disadvantaged individuals, and those with pre-existing medical conditions such as cardiovascular disease8. Those living in cities could be especially vulnerable due to the impact of the heat island effect. However, given their greater access to emergency, health, social, and financial resources, they might also have the greatest adaptive capacity9. The health consequences of climate change have the potential to be more severe in far northern regions. Populations in Canada's north including aboriginals have already begun to see differences in their hunting practices as a result of changing ice patterns10, and the melting of permanent snowpacks11. Changes in ice patterns have also led to increased injuries12. In some places in the North, climate changes have led to greater risks from avalanches, landslides and other hazards13. Further problems are related to the infrastructure in Northern Canada, with some communities already noticing degradation of structures due to the thawing of the permafrost14. Given that much of the Northern infrastructure is already in disrepair, this represents a considerable problem. Geographic isolation, and a lack of resources may further exacerbate the situation15. What CMA has done? Physicians have a critical role to play in advancing public understanding of the potential impact of climate change on health and promoting health protecting responses. The CMA has been working on the issue of climate change and human health for a number of years. CMA was supportive of Canada's ratification of the Kyoto Protocol, and urged the Government of Canada to commit to choosing a climate change strategy that satisfied Canada's international commitments while also maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2007, a number of resolutions were passed at General Council calling on government to properly plan for the health impacts of climate change and put in place measures to mitigate the impact of climate change on vulnerable populations in Canada's north. In that same year, CMA and the Canadian Nurses Association updated a joint position statement first entered into in 1994 calling for environmentally responsible activity in the health-care sector. Most recently, the CMA has been an integral part of the drafting of the World Medical Association (WMA) policies on health and climate change. The WMA Declaration of Delhi on Health and Climate Change was adopted at its annual General Assembly in New Delhi, India in October 2009, The declaration calls for action in five main areas; advocacy to combat global warming; leadership-help people be healthy enough to adapt to climate change; education and capacity building; surveillance and research; and collaboration to prepare for climate emergencies. This policy is written to complement the WMA declaration. What needs to be done? Climate change may lead to significant impacts on human health. While it is unlikely that these outcomes can be avoided, there are some strategies that can be employed to help limit the negative consequences. Education and Capacity Building There is a need for greater public and health professional awareness and education about climate change in order to gain understanding of the health consequences and support for strategies to reduce green house gases and mitigate climate change effects. CMA recommends: 1. A national public awareness program on the importance of the environment and global climate change to personal health; 2. Encouraging health sciences schools to enhance their provision of educational programs on environmental health; and fostering the development of continuing education modules on environmental health and environmental health practices. Surveillance and Research There are important gaps in our knowledge on the health impacts of climate change as well as the effectiveness of various mitigation and adaptation strategies. Surveillance and reporting functions need to be strengthened to allow for greater accuracy in modeling of future impacts. CMA recommends: 3. That the federal government must address the gaps in research regarding climate change and health by undertaking studies to - quantify and model the burden of disease that will be caused by global climate change - identify the most vulnerable populations, the particular health impacts of climate change on vulnerable populations, and possible new protections for such populations; - increase the collection and accuracy of health data, particularly for vulnerable and underserved populations; - report diseases that emerge in conjunction with global climate change, and participate in field investigations, as with outbreaks of infectious diseases; and - develop and expand surveillance systems to include diseases caused by global climate change. Reducing the Burden of Disease to Mitigate Climate Change Impacts How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities. Therefore, work needs to be done to reduce the burden of diseases and improve upon the social determinants of health for vulnerable populations in Canada and globally. CMA recommends: 4. That the federal and provincial/territorial governments work together to improve the ability of the public to adapt to climate change and catastrophic weather events by - Encouraging behaviours that improve overall health, - Creating targeted programs designed to address specific exposures, - Providing health promotion information and education on self-management of the symptoms of climate-associated illness, - Ensuring physical infrastructure that allows for adaptation; 5. That the federal government develop concrete actions to reduce the health impact of climate-related emissions, in particular those initiatives which will also improve the general health of the population; 6. That the federal government support the Millennium Development Goals and support the principles outlined in the WHO Commission on the Social Determinants of Health report; and Preparing for Climate Emergencies To deal with the future burden of climate change related health issues there is a need to ensure adequate health capacity and infrastructure. Rebuilding of public health capacity globally is seen as the most important, cost-effective, and urgently needed response to climate change16. Domestically, there is a need to ensure adequate surge capacity within the health care system to be prepared for an increase in illness related to climate change effects. There is also a need to strengthen not only the health systems, but the infrastructure (i.e. housing) for vulnerable populations including Aboriginals and those in the North. CMA recommends that the federal and provincial /territorial governments work together to: 7. Strengthen the public health system both domestically and internationally in order to improve the capacity of communities to adapt to climate change; 8. Ensure adequate surge capacity within Canada's health system to handle the increase in climate change related illness; 9. Ensure the health of vulnerable populations is adequate to handle climate change related situations; 10. Develop knowledge about the best ways to adapt to and mitigate the health effects of climate change; 11. Integrate health professionals into the emergency preparedness plans of government and public health authorities so that front-line providers are adequately informed and prepared to properly manage any health emergencies. Advocacy to Combat Climate Change Finally, there is a need to take action to reduce the damaging effects of climate change. The global community needs to come together to reduce the levels of green house gases being released in the atmosphere, and focus on safer more environmentally friendly energy sources. Investments in cuts to greenhouse gas emissions would greatly outweigh their costs, and could help to reduce the future burden of climate change related illness17. CMA recommends: 12. That the government of Canada become a global leader in promoting equitable, carbon neutral economic, industrial, and social policies, and practices that fight global warming and adopt specific green house gas reduction targets as determined by the evolving science of climate change. 13. That health care professionals act within their professional settings to reduce the environmental impact of medical activities and to develop environmentally sustainable professional settings; 14. That all Canadians act to minimize individual impacts on the environment, and encourage others to do so, as well. Conclusions The CMA believes that Canada must prepare now for the potential health threat that climate change poses to its population. While many of these effects will take decades to materialize, certain populations, such as those in Canada's north, or those in low lying coastal areas, are already starting to experience the impact of climate change. A focus on education and health promotion, as well as advocacy for improved public policy and primary health care resources will be a good start in dealing with this issue. Additionally, further research and data collection is necessary to improve our understanding of climate change and the effectiveness of adaptation and mitigation strategies. Finally, the global community needs to act together to address the health and environmental impacts of climate change. By working together, in an international response, strategies can be implemented to mitigate any negative health effects of climate change. Canada's physicians believe that: What is good for the environment is also good for human health. It is past time for those of us in the health sector in Canada to engage fully in the debate and discussions within our own house, as well as in the broader body politic to ensure that protecting human health is the bottom line of environmental and climate change strategies. Bibliography 1 Currently a third of the world's population lives within 60 miles of the shoreline and 13 of 20 biggest world cities located on the coast- more than a billion people could be displaced (Costello et.al., 2009) 1 Costello, Anthony et.al. "Managing the health effects of climate change.' The Lancet Volume 373 May 16, 2009. pp.1693-1733. 2 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 3 Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf ; Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.; Friel, Sharon; Marmot, Michael; McMichael, Anthony J.; Kjellstrom, Tord & Denny Vagero. "Global health equity and climate stabilization: a common agenda." The Lancet Volume 372 November 8, 2008. pp.1677-1683. 4Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf; World Health Organization (2009) Protecting Health From Climate Change: Global research priorities. Available at: http://whqlibdoc.who.int/publications/2009/9789241598187_eng.pdf 5 Health Canada (2001) Climate Change and Health & Well-being: A Policy Primer Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/policy_primer-abecedaire_en_matiere/index-eng.php 6 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237 7 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 8 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 9 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 10 Ibid 11 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 12 Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005. 13 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 14 Field, Christopher B. et.al. (2007) North America. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter14.pdf 15 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 16 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 17 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
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CMA Patient Safety Policy Framework (Update 2010)

https://policybase.cma.ca/en/permalink/policy9747
Last Reviewed
2018-03-03
Date
2010-02-27
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-02-27
Replaces
CMA Patient Safety Policy Framework (2001)
Topics
Health care and patient safety
Text
CMA PATIENT SAFETY POLICY FRAMEWORK (Update 2010) BACKGROUND The CMA’s mission is to promote the highest standard of health and health care for Canadians. This means, among other things, ensuring that the health care system is safe for patients and providers and effective in achieving good health outcomes for individuals and society. Unfortunately, studies published in recent years have raised concern that health care is not as safe as it could be; data collected by researchers in various countries has shown that there are unacceptably high levels of preventable adverse events, as high as 16% in one study of adverse events associated with hospital admissions. A study conducted by G. R. Baker, P.G. Norton et al, “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” showed an adverse event rate of 7.5 per 100 hospital admissions. (1) This suggests that of the nearly 2.5 million hospital admissions yearly in Canada, approximately 185,000 are associated with an adverse event and 70,000 of those possibly preventable. These studies have focused attention on health care error and adverse events, but patient safety requires that participants in the health care system are constantly aware of the risks present in the system, and that risks are addressed proactively - preferably before an adverse event occurs. If a preventable adverse event does occur, it provides an opportunity to learn about and correct sources of error. The CMA considers that a national patient safety strategy, aimed at building a culture of safety, is a priority. This Policy Framework has been developed to provide a clear statement of the CMA’s views on the principles that should underpin a patient safety strategy and to ensure clear support and direction for CMA members and staff involved in patient safety initiatives. PRINCIPLES The Health Care System Outcomes Errors and adverse events are inevitable in any complex system and more complex systems are more prone to errors. Nevertheless, studies have demonstrated an unacceptably high level of preventable adverse events associated with management of health care. 1. Patient safety initiatives should aim to improve health outcomes for patients by minimizing the rate of preventable adverse events and improving the management of events when they occur. Quality 2. Patient safety is one aspect of quality health care; activities relating to patient safety should result in a net increase in the quality of health care. Systemic factors 3. Patient safety initiatives should recognize that error and adverse events occur because of qualities of the system within which individuals operate. A primary concern of initiatives should be to prevent future errors by addressing the system rather than blaming and punishing individuals. Accountability The Canadian public has a reasonable expectation that health care will not result in avoidable injury. 4. Patient safety initiatives should support the accountability of the health sector, including providers, funders and regulators, to patients and the wider public for the safety of health care. Participants in Health Care Patients as partners 5. Patient safety initiatives should promote the role of patients as partners in the provision of safe care, including the prevention and management of adverse events. 6. Patient safety initiatives should encourage and anticipate the full and appropriate disclosure to patients of relevant information that is material to their health and healthcare, including information about adverse events or effects. Professional responsibility and support With a very few exceptions, health care is delivered by competent, caring professionals who are striving to achieve a good outcome for patients. 7. Patient safety initiatives should recognize the responsibility of professionals for achieving and maintaining the standard of their own practice. 8. Patient safety initiatives, while responding appropriately to adverse events, should be sensitive to the professional role and personal well being of individual physicians and other health care providers. Learning and Collaboration 9. Patient safety initiatives should promote and reflect teamwork, communication and collaboration at all levels. 10. Patient safety initiatives should support learning from one’s own experience and the sharing of knowledge so that it is possible to learn from the experience of others. Legal and Regulatory Environment 11. Patient Safety initiatives should promote a legal and regulatory environment that supports open communication and effective management of adverse events. 12. The protection afforded to the opinions expressed within quality assurance committees must be upheld Evidence Base and Evaluation Patient safety initiatives should be based on sound evidence. Patient safety initiatives should contain provision for appropriate evaluation. Patient safety initiatives should contain provision for broad dissemination of findings. PATIENT SAFETY INITIATIVE AREAS Building a culture of safety in Canadian health care will require the collaboration of many different groups and organizations. The CMA can play a leadership role within this larger group and within its own constituency of over 70,000 physicians. In some instances, it will be the CMA’s role to advocate for initiatives that can be delivered only by another provider or through a consortium; in other instances, CMA can assume sole responsibility for taking action. The CMA has identified that, as priorities, it will support: Advocacy for changes to legislation and regulation that would remove disincentives for health care providers to share information about adverse events. Raising awareness of patient safety and changing attitudes towards risk, error and adverse events within the health care community. Developing and providing resources such as clinical practice guidelines and information technology systems that have been shown to standardize practice and reduce adverse events. Reporting systems that collect and aggregate data on risks so that good practices can be developed and shared. Education and training for health care professionals and managers to provide them with the conceptual and practical tools to introduce change into their practice and organizations. Advocacy for, and development of, an agenda for patient safety research in Canada. The involvement of government at all levels in supporting and committing resources to initiatives for improved patient safety. GLOSSARY Adverse event – any unintended injury or complication that is caused by health care management rather than the patient’s disease and that leads to prolonged hospital stay, morbidity or mortality. Adverse events do not necessarily result from error, for example a toxic reaction to a drug in a patient without apparent risk factors for the reaction. Error – the failure of a planned action to be completed as intended (“error of execution”) or the use of a wrong plan to achieve an aim (“error of planning”). An error may not result in an adverse event if the error does not result in harm or is intercepted. Risk – the chance of injury or loss as defined as a measure of the probability and severity of an adverse effect to health, property, the environment or other things of value. (1) G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert J. Reid, Sam Sheps, and Robyn Tamblyn. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Can. Med. Assoc. J., May 2004; 170: 1678 - 1686.
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CMA statement on emerging therapies

https://policybase.cma.ca/en/permalink/policy10352
Last Reviewed
2018-03-03
Date
26-08-2010
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
26-08-2010
Topics
Health care and patient safety
Text
CMA Statement on Emerging Therapies The CMA is keenly aware of the heart-rending suffering experienced by MS patients and the devastating impact it has on families and we recognize how desperately they are seeking treatments to alleviate their symptoms. Physicians and researchers dedicate their lives to finding new treatments to prevent and ease the suffering of patients while supporting those battling disease. Along with the physician's care and compassion, clinical research is a key weapon in the battle to manage and treat disease. The CMA believes that all medical decisions must be based upon scientific evidence. That is at the heart of our commitment to patient-centred care. The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-based. This principle is highly relevant in the case of the Canadian Institutes of Health Research (CIHR) recent recommendations. The CMA concurs with the CIHR's position on the need for an evidence-based approach to the development of clinical trials of the recently proposed condition called "chronic cerebrospinal venous insufficiency" (CCSVI). We would hope that the findings of the seven diagnostic studies that are underway will be shared and analyzed as soon as they become available, and that clinical intervention trials would be supported as indicated by the evidence and if researchers come forward with scientifically sound ethical protocols. If additional Canadian funding bodies initiate clinical research in the area, we would encourage CIHR to provide advice if requested.
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Drug testing in the workplace (Update 2001)

https://policybase.cma.ca/en/permalink/policy194
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Drug testing in the workplace (1992)
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Health and safety in the workplace continue to be areas of concern to the CMA. The CMA recommends that educational programs on the risks of drug-related impairment to health and safety in the workplace be directed toward labour, management and the public in general. Occupations for which impairment resulting from drug use may constitute a serious hazard should be identified and designated as such. The association recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds to suspect impairment of the worker. Workers holding safety-sensitive jobs should be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) being taken to the occupational health physician or, in the absence of such, to the physician of the worker's choice. The CMA is opposed to routine pre-employment drug testing. It recommends that random drug testing among employees be restricted to safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Drug testing should always be conducted in such a way as to protect confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). The idea of drug testing among workers has developed from society's concern over the relation between drug use and impairment, with resultant risks to the worker, fellow workers and the public. Education: Since prevention is the principal and ultimate objective the association recommends that educational programs on the risks of impairment to health and safety in the workplace be directed toward labour, management and the public in general. Illicit drugs are not the only ones that may cause impairment. Certain prescription drugs and even some over-the-counter medications may affect a person's ability to carry out professional functions safely; such effects may vary considerably from one person to another. Alcohol is by far the most common impairing drug implicated in accidents; in addition, the scientific literature contains a growing body of information on impairment and dangers resulting from the use and misuse of various therapeutic medications. Far less is documented or known about the role of illicit drugs in work-related accidents. Safety-sensitive occupations: In most workplaces there are occupations for which impairment may constitute a serious hazard. Such occupations should be identified and designated as such. Workers who hold such safety-sensitive jobs must accept the fact that other workers and the public need to be protected from the hazards of impairment, whether from physical or psychologic ill health or from the use of drugs (over-the-counter, prescription or illicit). Performance assessment of safety-sensitive occupations: The CMA recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds (e.g., unsatisfactory performance or observed unusual behaviour) to suspect impairment of the worker. The examining physician may recommend that some tests (including tests for the presence of certain drugs) be carried out under pre-agreed protocols. Workers holding safety-sensitive jobs must be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) they may be taking to the occupational health physician or, in the absence of such, to the physician of the worker's choice. Testing: Any discussion of drug testing must take the following into account: If a quantitative test is to be used to determine impairment a limit must be established beyond which a person is deemed to be impaired. However, since the threshold of impairment varies from one person to another this variation should be taken into account when a worker is being assessed. The tests must be valid and reliable. They must be performed only in laboratories accredited for drug testing. The tests must provide results rapidly enough to be useful in deciding whether the person should continue to work. If different testing procedures are available and the differences between the validity and reliability are not significant the least intrusive alternative should be chosen. The test should be conducted in such a way as to ensure confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). Pre-employment testing: The CMA opposes routine pre-employment drug testing for the following reasons: Routine pre-employment drug screening may not objectively identify those people who constitute a risk to society. The mass, low-cost screening tests may not be reliable or valid. The circumstances may not justify possible human rights violations. Random testing: The CMA believes that random drug testing among employees has a limited role, if any, in the workplace. Such testing should be restricted to employees in safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Role of occupational health services: Occupational health physicians must not be involved in a policing or disciplinary role with respect to employee testing. CMA recommends that employers provide a safe environment for all workers. With the help of experts such as those from national and provincial agencies dedicated to dealing with substance abuse occupational health departments should develop lists of drugs known to cause short-term or long-term impairment, including alcohol. These lists should be posted prominently in the workplace, and workers should be advised that in the event of obvious impairment those involved in safety-sensitive occupations will be asked to undergo medical assessment. If testing for drugs is indicated refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. Alcohol impairment should not be tolerated, and legislation should be considered that would set a legal blood alcohol level for safety-sensitive occupations. Breathalyzers or other detection methods could be used if alcohol impairment is suspected in a person holding safety-sensitive occupation. As stated previously, refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. These measures should be discussed with labour and management. Labour should be expected to recognize drug-related impairment as a serious health and safety issue, and management should demonstrate its concern by ensuring access to treatment, prevention and educational programs such as employee assistance programs.
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Early childhood development

https://policybase.cma.ca/en/permalink/policy11476
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
Text
Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.1,2 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.3,4 Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. Even for those children who don't encounter these types of barriers, there can be problems in the early years. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.5 Just as children are susceptible to negative influences in early life, the period of rapid development means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.6 At the government and national level there are four main areas of action: Early childhood learning and care; Support for parents; Poverty reduction; and Data collection for early childhood development. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. While most of what is necessary for early childhood development will be done by governments and stakeholders outside of the health care system, there are opportunities for physicians to influence this important social determinant both through medical education, and clinical practice. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Background Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. The early childhood period is the most important development period in life.7 Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.8,9 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.10,11 According to research done by the Centers for Disease Control and Prevention in the adverse childhood event (ACE)a study, child maltreatment, neglect, and exposure to violence can significantly impact childhood development. The study involved a retrospective look at the early childhood experiences of 17,000 US adults and the impact of these events on later life and behaviour issues. An increased number of ACEs was linked to increases in risky behaviour in childhood and adolescence12 and to a number of adult health conditions including alcoholism, drug abuse, depression, diabetes, hypertension, stroke, obesity, heart disease, and some forms of cancer.13,14 The greater the number of adverse experiences in childhood the greater the likelihood of health problems in adulthood.15 A high level of ACEs was linked to language, cognitive and emotional impairment; factors which impact on school success and adult functioning.16 Finally, the study found a correlation between experiencing ACEs, suicide, and being the victim of or perpetrating intimate partner violence.17 Poverty is a significant barrier to healthy child development. Children who grow up in poor families or disadvantaged communities are especially susceptible to the physiological and biological changes associated with disease risk.18 Poverty is associated with a number of risk factors for healthy development including: unsupportive parenting, inadequate nutrition and education, high levels of traumatic and stressful events19, including higher rates of traumatic injuries20, poorer housing, lack of services, and limited access to physical activity.21 Children from low-income families score lower than children from high-income families on various measures of school readiness, cognitive development and school achievement22,23, and this gap increases over time with children of low-income families being less likely to attend post-secondary education and gain meaningful employment.24 Children who grow up in poverty are more likely to be poor as adults25,26 and to pass this disadvantage on to their own children.27,28 Children living in poverty have more problem behaviours such as drug abuse, early pregnancy, and increased criminal behaviour.29 Finally, economic hardship in childhood has been linked to premature mortality and chronic disease in adulthood.30 Early adverse events and poverty are serious impediments to healthy development, however, it is not just disadvantaged children that need attention. The early years are critical for all children regardless of socio-economic status. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.31 By 2030, 90% of morbidity in high income countries will be related to chronic diseases.32 These diseases are due in large part to risk factors such as smoking, poor nutrition, alcohol and drug abuse, and inadequate physical activity.33 These risk factors can be heavily influenced by the environment in which people live and can be increased by poor early childhood experiences.34,35 Health promotion and disease/injury prevention programs targeted at adults would be more effective if investments were made early in life on the origins of those diseases and conditions.36,37 Areas for Action While there is reason for concern regarding early childhood development, there is positive news as well. Just as children are susceptible to negative influences in early life, the period of rapid development also means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.38 Government and National: Early Childhood Learning and Care Research suggests that 90% of a child's brain capacity is developed by age five, before many children have any access to formal education.39 More than one quarter of Canadian children start kindergarten vulnerable in at least one area of development.40 Approximately two thirds of these deficiencies can be considered preventable. Evidence suggests that each 1% of excess vulnerability in school readiness leads to a reduction in GDP of 1% over the course of that child's life.41 Children who aren't ready for kindergarten are half as likely to read by the third grade, a factor that increases the risk of high school drop-out significantly. 42 While it is possible to intervene later to address these learning deficiencies, these interventions are less effective and much more costly.43 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.44,45 A recent analysis of 84 preschool programs in the United States concluded that children participating in effective pre-school programs can acquire about a third of a year of additional learning in math, language and reading skills.46 Since the implementation of the universal childcare program in Quebec, students in that province have moved from below the national average on standardized tests to above the average.47 In addition, effective early childhood learning programs offer a significant return on investment. Research done on US preschool programs found a return on investment of between four and seventeen dollars for every dollar spent on the program. Evidence from the Quebec universal child care program indicates that the program costs are more than covered by the increased tax revenues generated as a result of increased employment among Quebec mothers. For every dollar spent on the Quebec program, $1.05 is received by the provincial government with the federal government receiving $0.44.48 In terms of early childhood learning and care, Canada is lagging far behind - tied for last place among 25 countries in Organization for Economic Cooperation and Development (OECD) early childhood development indicators.b,49 Canada spends the least amount of money on early childhood learning and care of all countries in the OECD (0.25% of GDP)50, or one quarter of the recommended benchmark. Of this money, fully 65% is attributable to Quebec's universal daycare program.51 Canadian families face great pressures in finding affordable and accessible quality early childhood learning and care spots across the country. In Quebec 69% of children 2-4 regularly attend early childhood learning programs; outside of Quebec the number falls to 38.6%. The challenges for low-income families are even more pronounced with almost 65% of poor children 0-5 receiving no out-of home care.52 The federal government and the provinces and territories must work to bring Canada in line with other OECD countries on early childhood learning and care. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. Support for Parents A supportive nurturing caregiver is associated with better physical and mental health, fewer behavioural problems, higher educational achievement, more productive employment, and less involvement with the justice system and social services.53 Studies have demonstrated that improved parental-child relationships can minimize the effects of strong, prolonged and frequent stress, referred to as toxic stress54,55, and that the effects of poverty can be minimized with appropriate nurturing and supportive parenting.56 Parental support programs can act as a buffer for children at the same time as strengthening the ability of parents to meet their children's developmental needs.57 Caregivers who struggle with problems such as depression or poverty may be unable to provide adequate attention to their children undermining the attachment relationships that develop in early life. The relatively limited attention that is focused on addressing the deficiencies in time and resources of parents across all socio-economic groups can undermine healthy childhood development.58 One approach that has been shown to improve parental functioning and decrease neglect and child abuse is early childhood home visiting programs, sometimes referred to as Nurse Family partnerships. These programs provide nursing visits to vulnerable young mothers from conception until the children are between two and six depending on the program. The home visits provide prenatal support, educate parents about early childhood development, promote positive parenting, connect parents with resources, and monitor for signs of child-abuse and neglect.59 Results from several randomized controlled trials of these programs in the United States have shown that the program reduces abuse and injury, and improves cognitive and social and emotional outcomes in children. A 15 year follow-up study found lower levels of crime and antisocial behaviour in both the mothers and the children that participated in these programs.60 In Canada Nurse Family Partnerships were first piloted in Hamilton, Ontario. They are now undergoing a broader implementation and review in the Province of British Columbia. These programs should continue to be supported and expanded to all families who would benefit from this proven early childhood intervention. Many Canadian provinces have established community resources for parents. Alberta has recently announced plans to establish parent link centres across the province. These will deliver parenting programs, and be home to community resources and programs.61 Similar programs exist in other provinces such as the early years centres in Ontario62, and family resource centres in Manitoba.63 Early Childhood Development Centres in Atlantic Canada are combining child care, kindergarten and family supports into early childhood centres that are aligned with schools.64 While these programs can go a long way in reducing abuse and neglect, there is still a need for an overarching strategy to reduce neglect and child abuse across the country. As the ACE study in the United States clearly demonstrated, exposure to early adverse events such as family violence or neglect have troubling implications for adult health and behaviours.65 Action must be taken to ensure that avoidable adverse events are eliminated. The CMA Recommends that: 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. Poverty reduction In 1989 the Canadian government made a commitment to end child poverty by 2000. As of 2011, more Canadian children and their families lived in poverty than when the original declaration was made.66 Canada ranks 15th out of 17 peer countries with more than one in seven children living in poverty (15.1%).67 Canada is one of the only wealthy nations with a child poverty rate that is actually higher than the overall poverty rate.68 Child poverty is a provincial and territorial responsibility as well. As of 2012, only four provinces had child poverty strategies that met the guidelines put forward by the Canadian Paediatric Society.c,69 Poor children grow up in the context of poor families which means that solutions for child poverty must necessarily minimize the poverty of their parents.70 Efforts to increase the income as well as employment opportunities for parents, in particular single parents, must be part of any poverty reduction strategy.71 Programs, such as affordable child care, that allows parents to be active participants in the work force represent one approach72,73 Quebec's program of early childhood care has increased female workforce participation by 70,000 and reduced the child poverty rate by 50%.74 Addressing poverty could minimize problem areas in child development. According to a 2009 report by the Chief Public Health Officer of Canada, of 27 factors seen as having an impact on child development, 80% of these showed improvement as family income increased.75 Increasing income has the greatest impact on cognitive outcomes for children the earlier in life the reduction in poverty takes place.76 The federal government and the provinces and territories must work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children. The CMA Recommends that: 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. Data Collection for Early Childhood Development The evidence shows the importance of early childhood development for later success and health. In order to properly design effective interventions to mitigate developmental concerns, there is a need for appropriate data on early childhood health indicators and interventions. Given the variation in outcomes of children among different communities and demographic groups, there is a need for individual level data which is linked to the community level. This will allow providers and governments to develop appropriate interventions. Such an approach is being used by the Manitoba Centre for Health Policy, the Human Early Learning Partnership in British Columbia, and Health Data Nova Scotia. Researchers at these centres are creating a longitudinal data set by linking administrative data from a range of sources.77 Such data sets should be supported in all provinces and territories. Another tool being used to measure the progress of Canadian children is the Early Development Instrument (EDI). This tool is a 104 item checklist completed by teachers for every child around the middle of the first year of schooling. The checklist measures five core areas of early child development that are known to be good predictors of adult health, education and social outcomes. These include: physical health and well-being; language and cognitive development; social competence; emotional maturity; and communication skills and general knowledge.78,79 This tool has been used at least once in most of the provinces and territories with a commitment from most jurisdictions to continue this monitoring.80 While this is a good start, it gives only a snapshot of development. Ideally a monitoring system plots several points of time in development to identify trajectories of children. Ontario has introduced an enhanced well baby visit at 18 months. This clinical intervention could allow for the capture of development data at an earlier time. There is a need for more comprehensive information at the 18-month and middle childhood phases.81 The CMA Recommends that: 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. Medical Education: Given the importance of early childhood experiences on adult health there is a need for a greater understanding of the biological basis of adult diseases. The medical community needs to focus more attention on the roots of adult diseases and disabilities and focus prevention efforts on disrupting or minimizing these early links to later poor health outcomes.82 The science of early brain development and biology is rapidly evolving. There is a need to ensure that future and current physicians are up to date on this information and its implications for clinical practice.83 The Association of Faculties of Medicine and the Norlien foundation have partnered to provide funding and support for a series of e-learning tools on early brain and biological development.84 Continuing medical education does exist for some components of early childhood development and more work is underway. The Ontario College of Family Physicians has developed a CME that explores early childhood development for practitioners.85 These initiatives must be supported and expanded to all physicians who provide primary care to children and their families. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. Clinical Practice: While many of the threats to early childhood development lie outside of the hospital or medical clinic, there are a number of ways that physicians can help to address this important determinant of health within their practices. Primary care practitioners are uniquely qualified to address this fundamental population health issue,86 and can provide one important component in a multi-sectoral approach to healthy early childhood development.87 Screening and support for parents The health care system is the primary contact for many child-bearing mothers, and for many families, health-care providers are the only professionals with whom they have regular contact during the early years.88,89 According to data from the Institute for Clinical Evaluative Sciences, 97% of Ontario children aged zero to two are seen by a family physician.90 Within a patient-centred medical home, health-care providers can give support and information to parents about issues such as parenting, safety, and nutrition, and can link them to early childhood resourcesd, and other supports such as housing and food security programs. 91,92 Primary-care providers can help patients connect with public health departments who have many healthy baby and healthy child programs.93 Primary-care providers can ensure that screening takes place to identify risk factors to appropriate development.94 This screening should take place as early as the prenatal stage and continue throughout childhood. Screening should include regular assessments of physical milestones such as height, weight and vision and hearing etc. In addition, providers can identify risk factors such as maternal depression, substance abuse, and potential neglect or abuse.95 Given the negative consequences of early violence and neglect on childhood development96, this is a key role for primary-care providers. Screening for social issues such as poverty, poor housing and food insecurity should also be completed.97 A significant time for screening occurs at 18 months. This is the time for the last set of immunizations and in many cases the last time a child will have a regularly scheduled physician visit before the start of school.98 The 18 month well baby visit provides an opportunity to screen for not only medical concerns but child development as well. The enhanced 18 month well baby visite developed in Ontario combines parental observations and clinical judgment to screen for any risks a child might have.99 In Ontario, parental observation is captured through the Nipissing District Developmental Screen (NDDS). The parents complete this standardized tool and report the results to their physicians or other primary-care providers. The NDDS checklist is not meant to be a diagnostic tool but instead helps to highlight any potential areas of concern while also providing information to parents about childhood development. The 'activities for your child' section which accompanies the tool can also help reinforce the importance of development.100 As part of the visit primary-care providers fill out a standardized tool known as the Rourke Baby Record. This tool is an evidence based guide which helps professionals deliver the enhanced visit. This combined with the parental report through the NDDS, allows for a complete picture of the physical as well as the development health of the child at 18 months. Primary-care providers can use the results to discuss parenting and development and link children to specialized services, as necessary, and other community supports and resources. In Ontario early child development and parenting resource system pathways have been developed in many communities to help ensure that primary care providers can be aware of the resources and supports available for their patients.101 As was already noted, almost two thirds of vulnerabilities in readiness for school can be prevented.102 Appropriate identification through screening is a first step in correcting these issues. While the expansion of this approach is currently being reviewed in Nova Scotia, it should be implemented in all provinces and territories with appropriate compensation mechanisms and community based supports. Additionally, consideration should be made to developing screening tools for physicians outside of primary care, ie. emergency departments, who see children who might not have regular primary care physicians. The CMA Recommends that: 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. Literacy By 18 months disparities in language acquisition begin to develop.103 According to US research, by age four, children of families on welfare will hear 30 million less words than children from families with professional parents.104 This can lead to ongoing disparities in childhood learning as evidence suggests that exposure to reading and language from parents is fundamental for success in reading by children.105 Physicians and other primary-care providers can play a role in helping to reduce these disparities. They can encourage reading, speaking, singing and telling stories as part of a daily routine.f Studies have demonstrated that when physicians discuss literacy with parents and provide them with appropriate resources, such as developmentally appropriate children's books, increases in reading frequency and preschool language scores have been found.106 One program which has integrated reading and literacy into clinical practice is the 'Reach out and Read' program in the United States. This program partners with physicians, paediatricians, and nurse practitioners to provide new developmentally appropriate books to children ages 6 months through 5 years, as well as guidance for parents about the importance of reading.107,108 The success of this program has been significant with parents in the program being four to ten times more likely to read frequently with their children, and children scoring much higher on receptive and expressive language scores on standardized tests.109 Given the success of this program for American children, a similar program should be explored in the Canadian context. The CMA Recommends that: 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Conclusion The early years represent the most important time of development. The first five years can 'get under the skin' and influence outcomes throughout the life course. Negative experiences such as poverty, violence, poor nutrition, and inadequate parenting can determine behaviours as well as adult health outcomes. Effective early interventions can help to minimize or capitalize on these experiences. Government actions and supports to reduce poverty, child abuse, violence and to enable parents to care for their children are necessary. In addition, appropriate high quality early childhood learning and care programs are required for all Canadians regardless of socio-economic status. Finally, health care providers can play a role in identifying children at risk, supporting their parents to encourage healthy childhood development, and advocating for communities that ensure all Canadian children have the opportunity to grow up happy and healthy. References a The adverse childhood events are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member. http://www.cdc.gov/ace/prevalence.htm#ACED b The indicators used for the comparison include: Parental leave of one year with 50% of salary; a national plan with priority for disadvantaged children; subsidized and regulated child care services for 25% of children under 3; subsidized and accredited early education services for 80% of 4 year-olds; 80% of all child care staff trained; 50% of staff in accredited early education services tertiary educated with relevant qualification (this is the only indicator that Canada met); minimum staff-to-children ratio of 1:15 in pre-school education; 1.0% of GDP spent on early childhood services; child poverty rate less than 10%; near-universal outreach of essential child health services. UNICEF (2008) The child care transition: A league table of early childhood education and care in economically advanced countries. Available at: http://www.unicef-irc.org/publications/pdf/rc8_eng.pdf c To meet the CPS guidelines a province/territory requires anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specific targets. d For a list of some of the resources available for early childhood development across the country please see the Canadian Paediatric Society Resource Page: http://www.cps.ca/en/first-debut/map/community-resources e For more detailed information on the enhanced 18 month well baby visit please see the Canadian Paediatric Society Position statement- Williams R & J Clinton. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa, ON; 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (Accessed 2014 Jan 24). For resources available to Ontario primary-care providers please visit: http://machealth.ca/programs/18-month/default.aspx f For information and resources on early literacy please see the Canadian Paediatric Society at: http://www.cps.ca/issues-questions/literacy 1 Williams R et.al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 2 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 3 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 4 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 5 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 6 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. Available: http://media.nzherald.co.nz/webcontent/document/pdf/201347/Full-report-text1.pdf (accessed 2014 Mar 3). 7 World Health Organization. Closing the Health Equity Gap: Policy options and opportunities for action. Geneva, Switzerland; 2013. Available: http://www.paho.org/equity/index2.php?option=com_docman&task=doc_view&gid=103&Itemid (accessed 2013 Dec 20) 8 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 9 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 10 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 11 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 12 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 13 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 14 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 15 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 16 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 17 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 18 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 19 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 20 Oliver LN, Kohen DE. Neighbourhood variation in hospitalization for un intentional injury among children and teenagers. Health Rep 2010;21(4):9-17 21 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 22 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 23 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 24 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 25 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 26 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 27 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 28 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 29 Dreyer BP. To Create a Better World for Children and Families: The Case for Ending Childhood Poverty. Acad. Pediat. Vol 13 No 2. Mar-Apr 2013. Available: http://download.journals.elsevierhealth.com/pdfs/journals/1876-2859/PIIS1876285913000065.pdf (accessed 2013 Dec 10). 30 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 31 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 32 Bygbjerg IC. Double Burden of Noncommunicable and Infectious Diseases in Developing Countries. Science Vol.337 21 September 2012 pp.1499-1501. Available: http://health-equity.pitt.edu/3994/1/Double_Burden_of_Noncommunicable_and_Infectious_Diseases.pdf (accessed 2014 Mar 11). 33 World Health Organization. Global Status Report on Non-Communicable diseases 2010. Chapter 1: Burden: mortality, morbidity and risk factors. Geneva, Switzerland; 2010. Available: http://www.who.int/nmh/publications/ncd_report_chapter1.pdf (accessed 2014 Mar 11). 34 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 35 Dreyer BP. To Create a Better World for Children and Families: The Case for Ending Childhood Poverty. Acad. Pediat. Vol 13 No 2. Mar-Apr 2013. Available: http://download.journals.elsevierhealth.com/pdfs/journals/1876-2859/PIIS1876285913000065.pdf (accessed 2013 Dec 10). 36 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 37 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 38 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. Available: http://media.nzherald.co.nz/webcontent/document/pdf/201347/Full-report-text1.pdf (accessed 2014 Mar 3). 39 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 40 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 41 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 42 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 43 Heckman JJ. The Case for Investing in Disadvantaged Young Children. Available: http://heckmanequation.org/content/resource/case-investing-disadvantaged-young-children (accessed 2014 Feb 6). 44 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011. 45 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013. Available: http://ec.europa.eu/justice/fundamental-rights/files/c_2013_778_en.pdf (accessed 2013 Jan 24). 46 Yoshikawa H et al. Investing in Our Future: The Evidence Base on Preschool Education. Society for Research in Child Development & Foundation for Child Development. New York (NY); 2013. Available: http://fcd-us.org/sites/default/files/Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf (accessed 2014 Feb 6). 47 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 48 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 49 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2012 Jan 24). 50 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 51 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 52 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 53 Shonkoff JP et.al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 54 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 55 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 56 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 57 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 58 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 59 Knoke D. Early childhood home visiting programs. Centres of Excellence for Children's Well-Being. Toronto(ON); 2009. Available: http://cwrp.ca/sites/default/files/publications/en/HomeVisiting73E.pdf (accessed 2014 Mar 7). 60 Mercy JA, Saul J. Creating a Healthier Future Through Early Interventions for Children. JAMA June 3, 2009 Vol 301, No.21. 61 Government of Alberta. Alberta improves supports for families. Edmonton(AB); 2014. Available: http://alberta.ca/release.cfm?xID=356434F454042-9B0A-23FD-4AD0402F87D70805 (accessed 2014 Jan 7). 62 Ontario Ministry of Education. Ontario Early Years Centres: Frequently asked questions. Toronto (ON):N.D. Available: http://www.oeyc.edu.gov.on.ca/questions/index.aspx (accessed 2015 Jan 30). 63 Healthy Child Committee of Cabinet. Starting Early, Starting Strong: Manitoba's Early Childhood Development Framework. Government of Manitoba, Winnipeg (MB); 2013. Available: http://www.gov.mb.ca/cyo/pdfs/sess_ECD_framework.pdf (accessed 2014 Jan 10). 64 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 65 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 66 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 67 Conference Board of Canada. Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Jun 20). 68 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 69 Ibid. 70 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 71 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 72 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 73 Fauth B, Renton Z & Solomon E. Tackling child poverty and promoting children's well-being: lessons from abroad. National Children's Bureau. London (UK); 2013. Available: http://www.ncb.org.uk/media/892335/tackling_child_poverty_1302013_final.pdf (accessed 2014 Jan 10). 74 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 75 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 76 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 77 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 78 Human Early Learning Partnership. Early Development Instrument. N.D. Available: http://earlylearning.ubc.ca/edi/ (accessed 2014 Oct 8). 79 Adamson P. Child well-being in rich countries: A comparative overview: Innocenti Report Card 11. UNICEF, Florrence, Italy; 2013. Available: http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf (accessed 2014 Jan 10). 80 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://firstwords.ca/wp-content/uploads/2014/05/Early-Years-Study-3.pdf (accessed 2014 Feb 11). 81 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 82 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 83 Garner AS et al. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129;e224. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662.full.pdf+html (accessed 2014 Feb 11). 84 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 85 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 86 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 87 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 88 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 89 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 90 The Minister of Children and Youth announces that every child will receive and enhanced 18-month visit: Family Physicians Play Key Roles in Healthy Child Development. Toronto(ON). Available: http://ocfp.on.ca/docs/cme/enhanced-18-month-well-baby-visit-key-messages-for-family-physicians.pdf?sfvrsn=1 (accessed 2012 Feb 20). 91 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 92 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 93 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 94 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 95 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21). 96 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 97 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 98 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 99 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 100 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 101 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 102 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 103 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 104 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 105 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10). 106 Ibid. 107 Reach out and Read. Reach Out And Read: The Evidence. Boston (MA); 2013. Available: https://www.reachoutandread.org/FileRepository/Research_Summary.pdf (accessed 2014 Mar 5). 108 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 109 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10).
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Firearms control (Update 2001)

https://policybase.cma.ca/en/permalink/policy183
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Firearms control (1993)
Topics
Population health/ health equity/ public health
Text
FIREARMS CONTROL (UPDATE 2001) Summary Firearms are a major cause of death and injury in Canada and account for nearly 1,400 deaths annually. The CMA has made several recommendations to governments and other bodies undertaking legislative review and public policy change. These recommendations relate to the regulation of firearms, education for the safe handling of firearms, broad-based violence prevention programs, and research and information provision. In addition, the CMA has produced guidelines to assist physicians in identifying and counselling patients at risk of violent behaviour and in reporting patients at risk. Firearms are a major cause of death and injury in Canada.. The cost to society of firearm-related injury, particularly spinal cord and head injuries, is considerable. Over the short term, policy should focus on firearms and the user. Applying stringent controls on firearms, however, may have little effect on the rates of death and injury if the underlying problems of violence in society are not addressed. In an effort to accommodate both short-term and long-term solutions the CMA recommends the following to governments and bodies undertaking legislative review and public policy change. Regulation The object of regulation should be to deter people at risk for violent or self-destructive behaviour from having easy access to firearms. A regulatory policy should address (a) the acquisition of firearms (e.g., licensing of firearms and/or users, processes to screen would-be purchasers who are at risk), b) secure firearm and ammunition storage methods and modifications to firearms that would render them less accessible to children or those acting on violent impulses and (c) severe penalties for offenses such as the use of a firearm in the commission of a crime or an act of violence, including family violence. Education Training in safe handling of firearms is strongly recommended, particularly for all first-time firearm users. Broader-based education programs aimed at the prevention of violence (e.g., in schools) may also be efficacious and should be evaluated for their impact in reducing violence. Research and information provision CMA encourages research in a number of areas, including the following. Firearm surveillance: the types of firearms or classes of ammunition disproportionately involved in intentional deaths and injuries, the circumstances surrounding a firearm incident (e.g., argument between friends, alcohol involvement) and data on injuries and deaths. Determination of behavioural or environmental risk factors for violent behaviour: the relative risk or benefit of keeping a firearm at home for protection i.e.. the scientific assessment of the deterrence effect): The effects of factors such as alcohol, drug use and family history of violence on the risk of violent death; and how accurately experts can identify people at risk. Case-control and cohort studies on gun control, crime and the antecedents of violent behaviour. Evaluation of education programs that discourage firearm-related violence or promote safe handling of firearms. Role of physicians The CMA recommends that physicians consider the following guidelines. Management of patients at risk It is not always possible to identify people at risk of violent or self-destructive behaviour; however, the CMA recommends that physicians be alert to warning signs that a patient may be at risk and manage that patient accordingly. For example, always ask depressed patients about suicidal and homicidal thoughts and plans (asking will not plant ideas); admit suicidal patients to hospital, even against their will, particularly if they do not have supportive families who can monitor them at home; have the family remove all firearms from the home of a patient at risk; and monitor the patient frequently, writing small prescriptions if medication is required. Good clinical judgement and close follow-up are perhaps the most effective ways of managing a self-destructive or violent patient. Reporting of patients at risk No specific guidelines exist for the reporting of patients at risk of violent behaviour. The physician should consider whether the risk of harm to society (or a third party) posed by a patient outweighs that patient's right to confidentiality. Counselling and public advocacy A physician may be asked for a reference for an applicant of a firearms acquisition certificate. Before providing the reference the physician should consider the applicant carefully for risk factors, recommend appropriate firearms training and caution against the concomitant use of firearms, alcohol and other drugs. A physician should become an advocate for nonviolent conflict resolution. As research accumulates about the most effective interventions for nonviolent conflict resolution the health sector may be able to draw on this research to work to reduce violence in society. Like motor vehicle and bicycle safety, firearm safety is a public health issue. The CMA holds that physicians, as advocates for the health of Canadians, can help reduce firearm-related damage and address the concomitant underlying problem of violence in society.
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