Authorizing Cannabis for Medical Purposes
The legalization of cannabis for recreational purposes came into effect with the Cannabis Act in October 2018, and patients continue to have access to cannabis for therapeutic purposes. The Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations. Patients can obtain cannabis for medical purposes when a physician or nurse practitioner provides a “medical document” , authorizing its use, and determining the daily dried cannabis dose in grams.
With the authorization, patients have the choice whether to (a) buy directly from a federally licensed producer; (b) register with Health Canada to produce a limited amount for personal consumption; (c) designate someone to produce it for them; or (d) buy cannabis at provincial or territorial authorized retail outlets or online sales platforms, if above the legal age limit.
While acknowledging the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief, physicians remain concerned about the serious lack of clinical research, guidance and regulatory oversight for cannabis as a medical treatment. There is insufficient clinical information on safety and efficacy for most therapeutic claims. There is little information around therapeutic and toxic dosages and knowledge on interactions with medications. Besides the need for appropriate research, health practitioners would benefit from unbiased, accredited educational modules and decision support tools based on the best available evidence.
The Canadian Medical Association has consistently expressed concern with the role of gatekeeper that physicians have been asked to take as a result of court decisions. Physicians should not feel obligated to authorize cannabis for medical purposes.
Physicians who choose to authorize cannabis for their patients must comply with their provincial or territorial regulatory College's relevant guideline or policy. They should also be familiar with regulations and guidance, particularly:
Health Canada’s Information for Health Care Practitioners – Medical Use of Cannabis (monograph, summary and daily dose fact sheet),
the Canadian Medical Protective Association’s guidance;
the College of Family Physicians of Canada’s preliminary guidance Authorizing Dried Cannabis for Chronic Pain or Anxiety; and
the Simplified guideline for prescribing medical cannabinoids in primary care, published in the Canadian Family Physician.
The CMA recommends that physicians should:
Ensure that there is no conflict of interest, such as direct or indirect economic interest in a licensed cannabis producer or be involved in dispensing cannabis;
Treat the authorization as an insured service, similar to a prescription, and not charge patients or the licensed producer for this service;
Until such time as there is compelling evidence of its efficacy and safety for specific indications, consider authorizing cannabis only after conventional therapies are proven ineffective in treating patients’ conditions;
Have the necessary clinical knowledge to authorize cannabis for medical purposes;
Only authorize in the context of an established patient-physician relationship;
Assess the patient’s medical history, conduct a physical examination and assess for the risk of addiction and diversion, using available clinical support tools and tests;
Engage in a consent discussion with patients which includes information about the known benefits and adverse health effects of cannabis in its various forms (e.g., edibles), including the risk of impairment to activities such as driving and work;
Advise the patient regarding harm reduction strategies and the prevention of accidental exposure for children and other people;
Document all consent discussions in patients' medical records;
Reassess the patient on a regular basis for its effectiveness to address the medical condition for which cannabis was authorized, as well as for addiction and diversion, to support maintenance, adjustment or discontinuation of treatment; and
Record the authorization of cannabis for medical purposes similar to when prescribing a controlled medication.
The Cannabis Regulations provide some consistency with many established provincial and territorial prescription monitoring programs for controlled substances. Licensed producers of cannabis for medical purposes are required to provide information to provincial and territorial medical licensing bodies upon request, including healthcare practitioner information, daily quantity of dried cannabis supported, period of use, date of document and basic patient information. The Minister of Health can also report physicians to their College should there be reasonable grounds that there has been a contravention of the Narcotic Control Regulations or the Cannabis Regulations.
Approved by CMA Board February 2015
Latest update approved by CMA Board in February 2020
COMPLEMENTARY AND ALTERNATIVE MEDICINE
This statement discusses the Canadian Medical Association's (CMA) position on complementary and alternative medicine (CAM). CAM, widely used in Canada, is increasingly being subject to regulation. The CMA's position is based on the fundamental premise that decisions about health care interventions used in Canada should be based on sound scientific evidence as to their safety, efficacy and effectiveness - the same standard by which physicians and all other elements of the health care system should be assessed. Patients deserve the highest standard of treatment available, and physicians, other health practitioners, manufacturers, regulators and researchers should all work toward this end. All elements of the health care system should "consider first the well-being of the patient."1 The ethical principle of non-maleficence obliges physicians to reduce their patient's risks of harm. Physicians must constantly strive to balance the potential benefits of an intervention against its potential side effects, harms or burdens. To help physicians meet this obligation, patients should inform their physician if the patient uses CAM.
CAM in Canada
CAM has been defined as "a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine."i This definition comprises a great many different, otherwise unrelated products, therapies and devices, with varying origins and levels of supporting scientific evidence. For the purpose of this analysis, the CMA divides CAM into four general categories:
* Diagnostic Tests: Provided by CAM practitioners. Unknown are the toxicity levels or the source of test material, e.g., purity. Clinical sensitivity, specificity, and predictive value should be evidence-based.
* Products: Herbal and other remedies are widely available over-the-counter at pharmacies and health food stores. In Canada these are regulated at the federal level under the term Natural Health Products.
* Interventions: Treatments such as spinal manipulation and electromagnetic field therapy may be offered by a variety of providers, regulated or otherwise.
* Practitioners: There are a large variety of practitioners whose fields include chiropractic, naturopathy, traditional Chinese and Ayurvedic medicine, and many others. Many are unregulated or regulated only in some provinces/territories of Canada.
Many Canadians have used, or are currently using, at least one CAM modality. A variety of reasons has been cited for CAM use, including: tradition; curiosity; distrust of mainstream medicine; and belief in the "holistic" concept of health which CAM practitioners and users believe they provide. For most Canadians the use is complementary (in addition to conventional medicine) rather than alternative (as a replacement). Many patients do not tell their physicians that they are using CAM.
Toward Evidence-Informed Health Care
Use of CAM carries risks, of which its users may be unaware. Indiscriminate use and undiscriminating acceptance of CAM could lead to misinformation, false expectations, and diversion from more appropriate care, as well as adverse health effects, some of them serious.
The CMA recommends that federal, provincial and territorial governments respond to the health care needs of Canadians by ensuring the provision of clinical care that continually incorporates evidence-informed technological advances in information, prevention, and diagnostic and therapeutic services.2 Physicians take seriously their duty to advocate for quality health care and help their patients choose the most beneficial interventions. Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others.3 Until CAM interventions are supported by scientifically-valid evidence, physicians should not recommend them. Unless proven beneficial, CAM services should not be publicly funded. To help ensure that Canadians receive the highest-quality health care, the CMA recommends that CAM be subject to rigorous research on its effects, that it be strictly regulated, and that health professionals and the public have access to reliable, accurate, evidence-informed information on CAM products and therapies. Specific recommendations are provided below:
a) Research: Building an Evidence Base
To date, much of the public's information on CAM has been anecdotal, or founded on exaggerated claims of benefit based on few or low-quality studies. 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-informed.4 Increasingly, good-quality, well-controlled studies are being conducted on CAM products and therapies. The CMA supports this development. Research into promising therapies is always welcome and should be encouraged, provided that it is subject to the same standards for proof and efficacy as those for conventional medical and pharmaceutical treatments. The knowledge thus obtained should be widely disseminated to health professionals and the public.
b) An Appropriate Regulatory Framework
Regulatory frameworks governing CAM, like those governing any health intervention, should enshrine the concept that therapies should have a proven benefit before being represented to Canadians as effective health treatments.
i) Natural Health Products. Natural health products are regulated at the federal level through the Natural Health Products Directorate of Health Canada.
The CMA believes that the principle of fairness must be applied to the regulatory process so that natural health products are treated fairly in comparison with other health products.5 The same regulatory standards should apply to both natural health products and pharmaceutical health products. These standards should be applied to natural health products regardless of whether a health claim is made for the product. This framework must facilitate the entry of products onto the market that are known to be safe and effective, and impede the entry of products that are not known to be safe and effective until they are better understood. It should also ensure high manufacturing standards to assure consumers of the products' safety, quality and purity. The CMA also recommends that a series of standards be developed for each natural health product. These standards should include:
* manufacturing processes that ensure the purity, safety and quality of the product;
* labelling standards that include standards for consumer advice, cautions and claims, and explanations for the safe use of the product to the consumer.6
The CMA recommends that safety and efficacy claims for natural health products be evaluated by an arm's length scientific panel, and claims for the therapeutic value of natural health products should be prohibited when the supportive evidence does not meet the evidentiary standard required of medications regulated by Health Canada.7 Claims of medical benefit should only be permitted when compelling scientific evidence of their safety and efficacy exists.8
The Canadian Medical Association advocates that foods fortified with "natural health" ingredients should be regulated as food products and not as natural health products
The CMA recommends that the regulatory system for natural health products be applied to post-marketing surveillance as well as pre-marketing regulatory review. Health Canada's MedEffect adverse reaction reporting system now collects safety reports on Natural Health Products. Consumers, health professionals and manufacturers are encouraged to report adverse reactions to Health Canada.
ii) CAM Practitioners. Regulation of CAM practitioners is at different stages. The CMA believes that this regulation should: ensure that the services CAM practitioners offer are truly efficacious; establish quality control mechanisms and appropriate standards of practice; and work to develop an evidence-informed body of competence that develops with evolving knowledge.
Just as the CMA believes that natural health products should be treated fairly in comparison with other health products, it recommends that CAM practitioners be held to the same standards as other health professionals. All CAM practitioners should develop Codes of Ethics that insure practitioners consider first the best interests of their patients.
Among other things, associations representing CAM practitioners should develop and adhere to conflict of interest guidelines that require their members to:
* Resist any influence or interference that could undermine their professional integrity;9
* Recognize and disclose conflicts of interest that arise in the course of their professional duties and activities, and resolve them in the best interests of patients;10
* Refrain, for the most part, from dispensing the products they prescribe. Engaging in both prescribing and dispensing , whether for financial benefit or not, constitutes a conflict of interest where the provider's own interests conflict with their duty to act in the best interests of the patient.
c) Information and Promotion
Canadians have the right to reliable, accurate information on CAM products and therapies to help ensure that the treatment choices they make are informed. The CMA recommends that governments, manufacturers, health care providers and other stakeholders work together to ensure that Canadians have access to this information. The CMA believes that all natural health products should be labeled so as to include a qualitative list of all ingredients. 11 Information on CAM should be user-friendly and easy to access, and should include:
* Instructions for use;
* Indications that the product or therapy has been convincingly proven to treat;
* Contraindications, side effects and interactions with other medications;
* Should advise the consumer to inform their health care provider during any encounter that they are using this product.12
This information should be provided in such a way as to minimize the impact of vested commercial interests on its content.
In general, brand-specific advertising is a less than optimal way of providing information about any health product or therapy. In view of our limited knowledge of their effectiveness and the risks they may contain risks, the advertising of health claims for natural health products should be severely restricted. The CMA recommends that health claims be promoted only if they have been established with sound scientific evidence. This restriction should apply not only to advertising, but also to all statements made in product or company Web sites and communications to distributors and the public. Advertisements should be pre-cleared to ensure that they contain no deceptive messages. Sanctions against deceptive advertising must be rigidly enforced, with Health Canada devoting adequate resources to monitor and correct misleading claims.
The CMA recommends that product labels include approved health claims, cautions and contraindications, instructions for the safe use of the product, and a recommendation that patients tell physicians that they are using the products. If no health claims are approved for a particular natural health product, the label should include a prominent notice that there is no evidence the product contributes to health or alleviates disease.
The Role of Health Professionals
Whether or not physicians and other health professionals support the use of CAM, it is important that they have access to reliable information on CAM products and therapies, so that they can discuss them with their patients.
Patients should be encouraged to report use of all health products, including natural health products, to health care providers during consultations. The CMA encourages Canadians to become educated about their own health and health care, and to appraise all health information critically.
The CMA will continue to advocate for evidence-informed assessment of all methods of health care in Canada, and for the provision of accurate, timely and reliable health information to Canadian health care providers and patients.
i Working definition used by the National Center for Complementary and Alternative Medicine of the U.S. National Institutes of Health.
1 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004.
2 Canadian Medical Association. Policy resolution GC00-196 - Clinical care to incorporate evidence-based technological advances. Ottawa (ON): The Association; 2000. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
3 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
4 Canadian Medical Association. CMA statement on emerging therapies [media release]. Ottawa (ON): The Association; 2010. Available: www.facturation.net/advocacy/emerging-therapies.
5 Canadian Medical Association. CMA statement on emerging therapies [media release]. Available: www.facturation.net/advocacy/emerging-therapies.
6 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa (ON): The Association; 1998.
7 Canadian Medical Association. Policy resolution GC08-86 - Natural health products. Ottawa (ON): The Association; 2008.
8 Canadian Medical Association. Policy resolution GC10-100 - Foods fortified with "natural health" ingredients. Ottawa (ON): The Association; 2010. Available:
9 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 7. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
10 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 11. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
11 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
12 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
What do we mean by "personal information"?
Throughout this policy, we discuss "personal information," and it is important from the outset to set out what we mean by this term. "Personal information" is information that reveals a distinctive trait about yourself and helps others identify you. Some personal information such as your business address may be found in the public domain by accessing publications like telephone or professional directories. The focus of this policy is personal information collected, used and disclosed by the CMA that is NOT in the public domain.
What types of personal information does the CMA collect and use?
Primarily, the CMA collects and uses personal information about its members. CMA also has personal information about individuals who purchase CMA products and services, attend CMA sponsored events and seminars and submit manuscripts to CMA publications. The CMA assigns a personal identifier called a "CMA ID" to each member or purchaser of a CMA product or service so that you can use this number when contacting the CMA, ordering CMA products and publications or registering for the cma.ca Web site.
The CMA collects personal information directly from individuals or receives it from one of its provincial or territorial medical associations ("PTMAs") or subsidiaries, the CMA group of subsidiary companies, including our primary financial services company, MD Physician Services Inc.
-If you are a CMA member, you might have provided on an application form or will provide to the CMA or a PTMA or a CMA subsidiary, personal information like your home address, date of birth and gender. If you are both a client of one or more of CMA's financial subsidiaries and a CMA member, the fact of your client status, but not detailed financial information, will be known to CMA. A circumscribed and limited number of CMA employees, all of whom receive enhanced privacy training and sign specific undertakings, will have access to more detailed MD PS information such as frequency of meetings about your MD client status (but still not specific financial transactional details) in order to perform statistical analysis.
- If you have attended an event organized through CMA's Meetings and Travel Department, you might have provided us with credit card data as well as information about certain travel preferences and food sensitivities.
- If you have purchased a CMA product (e.g., classified advertising) or attended a CMA seminar (e.g., Physician Manager Institute), you provided us with personal contact information such as your name and address. We might also have collected credit card information if you chose to pay for the product or service by this method.
- If you have submitted a manuscript for publication in a CMA journal, you provided us with contact information, financial disclosure and competing interests data and the manuscript itself.
Why does the CMA collect and use personal information?
The CMA will collect and use only the personal information necessary to achieve the following purposes or one consistent with them:
1. to determine an individual's eligibility for membership in the CMA or to serve as a potential contributor to a CMA publication
2. to determine an individual's eligibility to benefit from the services of one of CMA's subsidiaries or its preferred third-party suppliers
3. to provide and to communicate information about CMA member benefits and services (e.g., the delivery of publications and travel reservations, financial services, advocacy, etc.)
4. to develop and to market products and services tailored to the interests of CMA members and the purchasers of CMA products and services
5. to update contact information in the CMA database
6. to assist the CMA PTMAs and CMA's subsidiaries with the maintenance of their membership and client contact information
7. to provide individuals with the opportunity to benefit from supporting the Canadian Medical Foundation which provides CMA members and others with valuable educational programs and services
8. to conduct surveys and research studies of the physician population in order to analyze for statistical and research purposes such issues as the demographics of physician human resources
9.to engage members and physicians in CMA's policy development process
10.to broadcast urgent health alerts of national significance
When and to whom does the CMA disclose personal information?
The CMA does not sell personal information. The CMA will only disclose your personal information to an organization for a purpose outlined in this policy, unless we obtain your consent for a new purpose. For example, one purpose identified above is maintaining up-to-date membership and client contact information. The CMA and its subsidiariesshare a core data field for the purposes of updating addresses and confirming membership status.
In addition to a core data field for the purposes of updating addresses and confirming membership status, CMA shares with its wholly owned subsidiary, MDPS, information about a member's participation in CMA activities and products such as Physician Manager Institute events. MDPS, as the most highly rated provider of CMA products and services, is seeking to have a better understanding and appreciation of physicians' relationship and interaction with CMA. Knowledge of an individual's participation in CMA events and activities provides this complete or "integrated" picture. If a CMA member objects, a note will be entered in the database.
If you are both a CMA member and a client of a CMA subsidiary company, when you inform us of an address change, with your permission, this information will be changed for both organizations.
The CMA might also disclose personal information to third parties or to organizations or companies that are not CMA-affiliated companies or Divisions if these organizations have contracted or partnered with the CMA to help us provide products and services or do research. For example, the CMA might out-source the mailing list function for one of its publications or work with the Canadian Post-MD Education Registry to study physician resource planning.
We may, in certain instances, contract with a third party service provider located in other countries such as the United States. Your information may be processed and stored in the United States and the United States governments, courts or law enforcement or regulatory agencies may be able to obtain disclosure of your information under a lawful order made in that country. If you would like more information about the jurisdictions in which we our service providers may operate please contact us as noted in the What if you have a question... section of this policy.
Within the CMA itself, your personal information in the form of interactions with the CMA will be shared amongst CMA departments. This will enable CMA to have a better understanding of your interests and activities such that CMA might tailor its product and service offerings to your interests. For example, if a member has completed a number of Physician Manager Institute courses, we might send him or her information about our Physician Leadership Credential Program. If a member objects to a particular disclosure of an activity, for instance a particular CME course, a note will be entered into the database
What if you object to CMA's collection, use or disclosure of personal information?
The CMA seeks to respect and honour your privacy and communication preferences. For instance, if you indicate to the CMA that you do not wish to receive certain publications, participate in surveys or receive information about new or specific benefits and services such as communications from CMA's subsidiaries, your preference will be noted and you will no longer receive correspondence from us on these issues. Please contact the CMA Member Service Centre at 888-855-2555 to make such a request.
You may also at any time, subject to restrictions required by law, object to the CMA's collection, use or disclosure of personal information. You need only provide the CMA with reasonable notice in writing of your intention and the details of your objection. For instance, if you do not wish to have contact and demographic information shared with the Canadian Medical Foundation, we will respect your choice.
Please note, however, that your objection to the disclosure of other information might mean that the CMA is unable to continue to provide you with some products or services. For example, if you object to the sharing of your CMA membership status with CMA's financial subsidiaries, then you will not be eligible to benefit from their products or services. MD Physician Services has to confirm your CMA membership status in order to offer you financial services.
It is your responsibility to contact the CMA in order to determine how an objection to the collection, use and disclosure of personal information might affect the services supplied.
How accurate is the personal information held by the CMA?
The CMA makes every reasonable effort to ensure the accuracy and currency of your personal information so that we might fulfill the purposes for which it was first collected. Your personal information is subject to change so please advise us accordingly of such changes so that we might better meet your needs.
How do you access the personal information held by the CMA?
You may send a written request to the attention of the Chief Privacy Officer at 1867 Alta Vista Drive, Ottawa, Ontario, K1G 5W8or to firstname.lastname@example.org to obtain the personal information held about you by the CMA. Within a reasonable time frame, the CMA will then advise you in writing whether it has such personal information and the nature of this information unless there is the rare occurrence that the release of such information is legally prohibited. If the CMA cannot release the personal information, we will provide you with the reasons for denying access.
You may challenge the accuracy and completeness of the personal information that is maintained by the CMA. The CMA will amend personal information when an individual successfully demonstrates inaccuracy or incompleteness.
How secure is your personal information?
The CMA makes every reasonable effort to protect your personal information by implementing security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification. The CMA uses physical, organizational and technological measures as methods of protection. For instance, only a limited number of staff have access to such sensitive information as credit card numbers. Moreover, the CMA will ensure that employees are aware of the importance of maintaining the confidentiality of personal information.
How long does the CMA retain personal information?
The CMA keeps personal information as long as it is needed to fulfill the purposes identified above. When personal information is no longer required to fulfill the identified purposes, it will be safely and securely destroyed. Moreover, the CMA will retain personal information that is the subject of an access request for as long as is necessary to allow an individual to exhaust any legal remedy that is provided for in applicable federal or provincial/territorial privacy legislation.
This paper discusses the current state of the professional relationship between physicians and the health care system. A review of the concept of medical professionalism, and the tensions that can arise between the care of individual patients and a consideration of the broader needs of society, provides some basic groundwork. Our understanding of what it means to be a physician has evolved significantly over the years, and the medical profession is now being challenged to clarify the role it is willing to play in order to achieve transformation of our health care system.
We have arrived at this point due to a convergence of several factors. Regionalization of health care has led to a change in the leadership roles played by practising physicians and to the opportunities they have for meaningful input into system change. Physicians are now also less likely to be involved in hospital-based care, which has resulted in a loss of collegiality and interactions with peers. Changing models of physician engagement status and changing physician demographics have also presented new and unique issues and challenges over the past few years.
The Canadian Medical Association (CMA) suggests that its physician members and other stakeholders employ a "AAA" lens to examine the challenges and opportunities currently facing Canadian physicians as they attempt to engage with the health care system: Autonomy, Advocacy and Accountability. These important concepts are all underpinned by strong physician leadership. Leadership skills are fundamentally necessary to allow physicians to be able to participate actively in conversations aimed at meaningful system transformation.
KEY CMA RECOMMENDATIONS ARE AS FOLLOWS:
Physicians should be provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians need to be provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and must be included as valued collaborators in the decision-making process.
Physicians have to recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians must be able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians should participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care should be team based and interdisciplinary with smooth transition from one care setting to the next and funding and other models need to be in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
The concept of medical professionalism, at its core, has always been defined by the nature and primacy of the individual doctor-patient relationship, and the fiduciary obligation of physicians within this relationship. The central obligation of the physician is succinctly stated in the first tenet of the CMA Code of Ethics:
Consider first the well-being of the patient.1
Since the latter half of the 20th century, however, there has been a growing emphasis on the need for physicians to also consider the collective needs of society, in addition to those of their individual patients. As stated in the CMA Code of Ethics:
Consider the well-being of society in matters affecting health.
This shift in thinking has happened for at least two reasons. First, there have been tremendous advances in medical science that now enable physicians to do much more to extend the length and quality of life of their patients, but these advances inevitably come at a cost which is ultimately borne by society as a whole. Second, since World War II, Canadian governments have been increasingly involved in the financing of health care through taxation revenues. As a result, there have been growing calls for physicians to be prudent in their use of health care resources, and to be increasingly accountable in the way these resources are employed.
The 2002 American Board of Internal Medicine (ABIM) Foundation Charter on Medical Professionalism calls for physician commitment to a just distribution of finite resources: "While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."2 This has also been described as civic professionalism.
Lesser et al have put forward a systems view of professionalism that radiates out from the patient-physician relationship to broader interactions with members of the health care team, the training environment and to the external environment, dealing with payers and regulators and also addressing the socio-economic determinants of health.3 Understandably, given that the resources available for health care are finite, tensions will arise between the care of individual patients and the collective needs of society, and these tensions can at times be very difficult to resolve for individual medical practitioners.
As stated in the CMA policy Medical Professionalism (Update 2005):
Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. 4
Over time the delivery, management and governance of health care have become more complex, and as a result the health care sector now accounts for roughly one in 10 jobs in Canada. There are more than two dozen regulated health professions across Canada, as well as numerous professional managers employed in various capacities, many of whom have had little or no exposure to the everyday realities of the practice of clinical medicine. Notwithstanding the acknowledgement of the very real and important need for inter-professional collaboration and teamwork, inevitably this creates competition for influence in the health care system.
The CMA 2005 update of its policy on medical professionalism acknowledges the need for change.
While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.
Now, physicians are being challenged to clarify exactly what it is that they are prepared to do in order to advance the much-needed transformation of our health care system, and how they will partner with patients, other care providers and the system in order to achieve this common goal. This provides a significant opportunity for physicians to continue their leadership role in the health care transformation initiative in the interests of their patients, while at the same time redefining their relationship with the system (understood in this context as health care administrators, governments and their representatives, health districts, health care facilities and similar organizations) in order to ensure that they have a meaningful and valued seat at the decision-making table, now and in the future.
The common refrain among health administrators, health ministry officials and health policy analysts for the past decade and longer has been that physicians are "not part of the health care system", that they are independent contractors and not employees, and that they are too often part of the problem and not the solution.
Over this period of time, several developments have resulted in a diminished role of physicians in clinical governance in Canada and have, to varying degrees, transformed the professional and collegial relationship between physicians and their health regions, health care facilities and communities to one that is increasingly governed by legislative fiat or regulation.
Beginning with New Brunswick in 1992, all jurisdictions except Ontario, the Yukon Territory and Nunavut have adopted a regional governance model. This change has eliminated all hospital and community services boards within a geographic region and replaced them with a single regional board. Clinical governance is now administered through a regional medical advisory committee (MAC). Some provinces such as Saskatchewan recognize the role of the district (regional) medical staff association. This has had a profound impact in reducing the number of physicians engaged in the clinical governance of health care institutions.
Another by-product of regionalization is that in virtually all jurisdictions, physicians no longer sit on governing boards. While physicians continue to serve as department heads and section chiefs within regions and/or individual hospital facilities, the level of support and financial compensation to do so varies greatly, particularly outside major regions and institutions, and there has been a lack of physician interest in such positions in some places.
In addition to a diminished presence in clinical governance, physicians are less likely to be actively involved in hospitals than they were previously. Anecdotally, many physicians, particularly in larger urban communities, describe having been "pushed out" of the hospital setting, and of feeling increasingly marginalized from the decision-making process in these institutions. Another result of the diminished engagement with hospitals has been the loss of the professional collegiality that used to be fostered through interaction in the medical staff lounge or through informal corridor consultations.
In the community setting, there have been some positive developments in terms of physician leadership and clinical governance. Ontario and Alberta have implemented new primary care funding and delivery models that promote physician leadership of multidisciplinary teams, and at least two-thirds of the family physicians in each of these jurisdictions have signed on. British Columbia has established Divisions of Family Practice, an initiative of the General Practice Services Committee (a joint committee of the BC Ministry of Health and the BC Medical Association), in which groups of family physicians organize at the local and regional levels and work in partnership with the Health Authority and the Ministry of Health to address common health care goals.
Looking ahead, regionalization is also likely to affect physicians in community-based practice. There is a clear trend across Canada to require all physicians within a region to have an appointment with the health region if they want to access public resources such as laboratory and radiology services. In the future this may also result in actions such as mandated quality improvement activities which may be of variable effectiveness and will not necessarily be aligned with the learning needs of physicians.
Physician engagement status
Traditionally physicians have interfaced with hospitals through a privileges model. This model, which has generally worked well, aims to provide the physician with the freedom to reasonably advocate for the interests of the patient.5 In this model, legislation and regulations also require that there are minimum procedures in place for renewing, restricting, and terminating privileges, and that procedures are set out to ensure that this takes place within a fair and structured framework. The hospital's MAC generally reviews physician privileges applications and recommends appointment and reappointment. The MAC thus plays an integral role in ensuring the safety of care within the region or hospital.5
There has been increasing attention recently on engaging in other types of physician-hospital relationships, including employment or contractual arrangements. This type of arrangement can vary from an employment contract, similar to that used by other professional staff such as nurses and therapists, to a services agreement whereby the physician provides medical services to the hospital as an independent contractor.5 However, there are concerns, expressed by the Canadian Medical Protective Association (CMPA) and others, that many of the procedural frameworks and safeguards found in hospital bylaws pertaining to the privileges model may not necessarily extend to other arrangements, and that physicians entering into these contractual agreements may, in some cases, find their appointment at the hospital or facility terminated without recourse. Under such arrangements the procedural fairness and the right of appeal available under the privilege model may not be available to physicians.
One relatively new approach is the appointment model, which aims to combine many of the protections associated with the privileges model with the advantages of predictability and specificity of the employment model. It generally applies the processes used to grant or renew privileges to the resolution of physician performance-related issues.5
It has been argued that changes in appointment status and relationship models can have a detrimental impact on the relationship between practitioners and health care facilities.6 While this has been reported specifically within the context of Diagnostic Imaging, the same may hold true for other specialties as well.
It should also be noted that the issues raised in this paper are applicable to all members of the profession, regardless of their current or future practice arrangements or locations.
Changing physician demographics and practice patterns
It is well recognized that physician demographics and practice patterns have changed significantly over the past several years. Much has been written about the potential impact of these changes on medicine, and their impact on patient care, on waiting lists and on the ability of patients to access clinical services.7 It is also acknowledged that "lifestyle factors," that is to say the attempt by many physicians to achieve a healthier work-life balance, may play a role in determining the type and nature of clinical practice chosen by new medical graduates, the hours they will work and the number of patients they will see.
All of these changes mean that clinical practices may have smaller numbers of patients and may be open shorter hours than in the past. Physicians are being increasingly challenged to outline their understanding of their commitment to ensuring that all patients have timely access to high quality health care within the Canadian public system, while balancing this with their ability to make personal choices that are in their best interests.
Put another way, how can we assist physicians in adjusting their clinical practices, at least to some extent, based on the needs of the population?
While there are clearly challenges and barriers to physician participation in meaningful transformation of the health care system, there are also opportunities for engagement and dialogue, particularly when the doctors of Canada show themselves to be willing and committed partners in the process. Health care transformation cannot be deferred just because it involves difficult decisions and changes to the status quo. Regardless of how we have reached the current situation, relationships between physicians and other parties must evolve to meet future needs. Physicians need to be assisted in their efforts in this regard, both by local health boards and facilities, and by organizations such as the CMA and its provincial and territorial counterparts.
Physicians, individually and collectively, need to demonstrate what they are willing to do to assist in the process and what they are willing to contribute as we move forward, and they need to commit to having the medical profession be an important part of the solution to the challenges currently facing the Canadian system.
We examine some of these challenges through the "AAA" lens of Autonomy, Advocacy and Accountability, which are underpinned by the concept of Physician Leadership.
To a large extent, physicians continue to enjoy a significant degree of what is commonly termed clinical or professional autonomy, meaning that they are able to make decisions for their individual patients based on the specific facts of the clinical encounter. In order to ensure that this autonomy is maintained, physicians need to continue to embrace the concept of clinical standards and minimization of inter-practice variations, where appropriate, while also recognizing the absolute need to allow for individual differences in care based on the requirements of specific patients. Professional autonomy plays a vital role in clinical decision-making, and it is at the heart of the physician-patient relationship. Patients need to feel that physicians are making decisions that are in the best interest of the patient, and that physicians are not unduly limited by external or system constraints. As part of this decision-making, physicians may also need to consider carefully the appropriate balance between individual patient needs and the broader societal good.
In recent years, governments have sometimes made use of the "legislative hammer" to force physicians to conform to the needs of the health system, thus undermining physicians' individual or personal autonomy. Historically, physicians have organized themselves to provide 24-hour coverage of the emergency room and other critical hospital services. This has proven increasingly challenging in recent years, particularly in the case of small hospitals that serve sparsely populated areas where there are few physicians.
Physicians need to continue to make sure that they do not confuse personal with professional autonomy and that they continue to ensure that health care is truly patient-centred. Physicians have rights but also obligations in this regard and they need to make sure that they continue to use a collaborative approach to leadership and decision-making. This includes an ongoing commitment to the concept of professionally-led regulation and meaningful physician engagement and participation in this system.
While physicians will continue to value and protect their clinical and professional autonomy, and rightly so as it is also in the best interests of their patients, they may need to consider which aspects of personal and individual autonomy they may be willing to concede for the greater good.
For example, physicians may need to work together and collaboratively with administrators and with the system to ensure that call coverage is arranged and maintained so that it need not be legislatively mandated, or imposed by regions or institutions. They may need to consider changing the way they practice in order to serve a larger patient population so that patients in need of a primary care physician do not go wanting, and so that the overall patient care load is more evenly balanced amongst colleagues. New primary care models established in Ontario and Alberta over the past decade that provide greater out-of-hours coverage are one example of such an initiative.
By working collaboratively, both individually and collectively, physicians are finding creative ways to balance their very important personal autonomy with the needs of the system and of their patients. These efforts provide a solid foundation upon which to build as the profession demonstrates its willingness to substantively engage with others to transform the system.
To paraphrase from the discussion at the CMA's General Council meeting in August 2011: Physicians need to carefully examine their individual and collective consciences and show governments and other partners that we are willing to play our part in system reform and that we are credible partners in the process.
All parties in the discussion, not only physicians, must be able to agree upon an appropriate understanding of professional autonomy if the health care system is to meet the current and future needs of Canadians.
Physician advocacy has been defined as follows:
Action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.8
This can consist of advocacy for a single patient to assist them in accessing needed funding for medications, or lobbying the government for changes at a system level. How and when individual physicians choose to undertake advocacy initiatives depends entirely on that individual practitioner, but physicians as a collective have long recognized their obligation to advocate on behalf of their individual patients, on behalf of groups of patients, and at a societal level for changes such as fairer distribution of resources and adequate pandemic planning.
Traditionally, physicians have served as advocates for their patients in a number of arenas; however, various factors such as provincial/territorial legislation, regulatory authorities, and hospital contracts have combined to make them more reluctant to take on this important role and as a result overall patient care may suffer and the patient-physician relationship may be threatened. Increasingly, hospital bylaws urge or require physicians to consult with their institution or health region before going public with any advocacy statements, and in at least one health region physicians are required to sign a confidentiality agreement. Because of this, many physicians fear reprisal when they decide to act as an advocate.
The ability to undertake advocacy initiatives is a fundamental concept and principle for Canadian physicians. Indeed, the CMA Code of Ethics encourages physicians to advocate on behalf of the profession and the public. Patients need to feel that their concerns are heard, and physicians need to feel safe from retribution in bringing those concerns forward.
A well-functioning and respectful advocacy environment is essential to health care planning. Health care is about making choices every day. Governments struggling to balance budgets should be aware that the public can accept that hard choices must and will get made - but they are less likely to be supportive if physicians and their patients do not feel that their opinions are sought and considered as part of the process.
Frontline health care providers, many of whom work in relative isolation in an office or community setting, also need to feel that they have a voice. The CMA supports the need for a forum where primary care physicians can speak with one voice (and make sure that this voice is heard and respected) in a community setting.
In addition to advocating for issues related directly to patient care, physicians, as community leaders, may also be called upon to advocate for other issues of societal importance, such as protection of the environment or social determinants of health. These advocacy undertakings can also be of great importance.
There can be a fine line between advocacy that is appropriate and is likely to affect important and meaningful change, and advocacy that others will perceive as being obstructive or counterproductive in nature. To further complicate matters, what might be seen as appropriate advocacy in one circumstance might not be in a different setting. Physicians should be clear on whose behalf they are speaking and whether they have been authorized to do so. If they have any questions about the possible medicolegal implications of their advocacy activities, they may also wish to contact their professional liability protection provider (e.g., CMPA) for advice in these instances.
Depending on the facts of the individual circumstances, physicians may need to consider other factors as well when deciding if, when and how to undertake advocacy activities. They should also be aware that their representative medical organizations, such as national specialty societies, provincial and territorial medical associations and the CMA, may be able to assist them with their initiatives in certain situations.
Physicians should not feel alone when advocating for their patients, particularly when this is done in a reasonable manner and in a way that is likely to effect meaningful and important change.
Physician accountability can be seen to occur at three levels: accountability to the patients they serve, to society and the health care system and to colleagues and peers.
Accountability to patients
The physician-patient relationship is a unique one. Based on, optimally, absolute trust and openness, this relationship allows for a free exchange of information from patient to physician and back again. Physicians often see patients at their most vulnerable, when they are struggling with illness and disease. While other health care providers make essential contributions to patient care, none maintain the unique fiduciary relationships that are at the heart of the physician's role and which are recognized by law.
Physicians are accountable to their individual patients in a number of important ways. They provide clinical services to their patients and optimize their availability so that patients can be seen and their needs addressed in a timely fashion. They follow up on test results. They facilitate consultations with other physicians and care providers and follow up on the results of these consultations when needed. They ensure that patients have access to after hours and emergency care when they are not personally available.
Physicians can also fulfill their obligation to be accountable to patients in other ways. They can participate in accreditation undertakings to ensure that their practices meet accepted standards. They can ensure, through lifelong learning and maintenance of competency activities, that they are making clinical decisions based on the best available evidence. They can undertake reviews of their prescribing profiles to ensure that they are consistent with best current standards. All of these activities can also be used to maximize consistencies within and between practices and minimize inter-practice variability where appropriate.
Accountability to society and the health care system
Physician accountability at this level is understandably more complex. In general, society and the health care system in Canada provide physicians with financial compensation, with a significant degree of clinical autonomy as reflected by professionally-led regulation, and with a high level of trust. In some cases, physicians are also provided with a facility in which to practice and with access to necessary resources such as MRIs and operating rooms.
In return, physicians agree to make their own individual interests secondary in order to focus on those of their patients, and they agree to provide necessary medical services. Accountability then can be examined based on the extent that these necessary services are provided (i.e. patients have reasonable access to these services) and also the level of quality of those services. Clearly, neither access nor quality can be considered in isolation of the system as a whole, but for the purposes of this paper the focus will be on the role of the physician.
The issue of level and comprehensiveness of service provision has been considered to some extent above under the concept of physician autonomy. Physicians as individuals and as a collective need to ensure that patients have access to timely medical care and follow up. They also need to make sure that the transition from one type of care to another (for example, from the hospital to the community setting) is as seamless as possible, within the current limitations of the system.
Collectively and individually, physicians also have an obligation to make sure that the quality of the care they provide is of the highest standard possible. They should strive for a "just culture of safety", which encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates health care providers and patients to help prevent similar events in the future.9
Thousands of articles and hundreds of books have been published on the subjects of quality assurance and quality improvement. From a physician perspective, we want to be able to have access to processes and resources that will provide us with timely feedback on the level of quality of our clinical care in a way that will help us optimize patient outcomes and will be seen as educational in nature rather than punitive. As a self-regulated profession, medicine already has strong accountability mechanisms in place to ensure the appropriate standards of care are maintained.
To ensure that physicians are able to meet their obligation to be accountable to the health care system for high quality care, the CMA has developed a series of recommendations for Continuous Quality Improvement (CQI) activities (see box below).
Physicians need to take ownership of the quality agenda. New medical graduates are entering practice having come from training systems where they have access to constant feedback on their performance, only to find themselves in a situation where feedback is non-existent or of insufficient quality to assist them in caring for their patients. While regulators and health care facilities have a legitimate interest in measuring and improving physician performance, ultimately physicians themselves must take responsibility for ensuring that they are providing their patients with the highest possible standard of care, and that mechanisms are in place to ensure that this is in fact the case.
Accountability to colleagues
Physicians are also accountable to their physician peers and to other health care providers. While much of this accountability is captured by the concept of "collegiality," or the cooperative relationship of colleagues, there are other aspects as well.
Anecdotal evidence suggests strongly that many physician leaders find themselves marginalized by their peers. They describe being seen as having "gone over to the other side" when they decide to curtail or forego their clinical practices in order to participate in administrative and leadership activities. Physicians should instead value, encourage and support their peers who are dedicating their time to important undertakings such as these. As well, physicians should actively engage with their administrative colleagues when they have concerns or suggestions for improvement. Collaboration is absolutely vital to the delivery of safe and quality care.
Physicians also need to make sure that they do everything they can to contribute to a "safe" environment where advocacy and CQI activities can be undertaken. This can mean encouraging physician colleagues to participate in these initiatives, as well as serving as a role model to peers by participating voluntarily in CQI undertakings.
Physicians are also accountable to ensure that transition of care from one physician to another occurs in as seamless a manner as possible. This includes participating in initiatives to improve the quality and timeliness of both consultation requests and results, as well as ensuring professional and collegial communications with other physicians and with all team members.
Finally, physicians need to support each other in matters of individual health and well-being. This can include support and care for colleagues suffering from physical or psychological illness, as well as assisting with accommodation and coverage for duty hours and professional responsibilities for physicians who are no longer able to meet the demands of full-time practice for whatever reason.
"You will not find a high performing health system anywhere in the world that does not have strong physician leadership."
Dan Florizone, Deputy Minister of Saskatchewan Health
As we can see from the discussion above, having strong physician leaders is absolutely critical to ensuring that the relationship between physicians and the health care system is one of mutual benefit. Physicians as a collective have an obligation to make sure that they support both the training required to produce strong physician leaders, as well as providing support for their colleagues who elect to undertake this increasingly important role.
Physicians are well-positioned to assume leadership positions within the health care system. They have a unique expertise and experience with both the individual care of patients, as well as with the system as a whole. As a profession, they have committed to placing the needs of their patients above those of their own, and this enhances the credibility of physicians at the leadership level as long as they stay committed to this important value. Leadership is not just about enhancing the working life of physicians, but is about helping to ensure the highest possible standard of patient care within an efficient and well-functioning system.
As part of their leadership activities, physicians need to ensure that they are consistently engaged with high quality and reliable partners, who will deliver on their promises and commitments, and that their input is carefully considered and used in the decision-making process. These partners can include those at the highest level of government, and must also include others such as medical regulators and senior managers. Without ensuring that they are speaking with the right people, physicians cannot optimize their leadership initiatives.
Physician leadership activities must be properly supported and encouraged. Many physicians feel increasingly marginalized when important meetings or training opportunities are scheduled when they are engaged in direct patient care activities. Non-clinician administrators have time set aside for these activities and are paid to participate, but physicians must either miss these discussions in order to attend to the needs of their patients, or cancel clinics or operating room times. This means that patient care is negatively impacted, and it presents a (sometimes significant) financial disincentive for physicians to participate. Some jurisdictions have recognized this as a concern and are ensuring that physicians are compensated for their participation.
Patients want their physicians to be more involved in policy-making decisions and this must be enabled through the use of proper funding mechanisms, reflective learning activities, continuing professional development credits for administrative training and participation, assisting in the appropriate selection of spokespersons including guidelines on how to select them, and guidelines for spokespersons on how to provide meaningful representation of the profession's views.
Physician leadership training must take place throughout the continuum of medical education, from the early days of medical school through to continuing professional development activities for those in clinical practice. Physicians with an interest in and aptitude for leadership positions should ideally be identified early on in their careers and encouraged to pursue leadership activities and training through means such as mentorship programs and support from their institutions to attend training courses and meetings where they will be able to enhance and refine their leadership skills.
There has been action on several fronts to support the organized professional development of physicians in leadership roles. Since the 1990s the Royal College of Physicians and Surgeons of Canada (RCPSC) has been implementing its CanMEDs framework of roles and competencies in the postgraduate medical training programs across Canada, and this has also been adopted by the College of Family Physicians of Canada (CFPC). The CanMEDs framework sets out seven core roles for physicians. Two that are most pertinent to the relationship between physicians and the health care system are those of manager and health advocate.10 These roles highlight the importance of physician involvement in leadership and system engagement activities, and are relevant for physicians in training as well as those in practice.
As managers, physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.
As health advocates, physicians responsibly use their expertise and influence to advance the health of individual patients, communities and populations.
A number of key enabling competencies have been identified for each role, and the RCPSC has developed a variety of resource materials to support the framework.
For almost 30 years, the CMA has been offering the Physician Manager Institute (PMI) program in order to provide training for physicians pursuing leadership and management positions. PMI is offered in "open enrolment" format in major cities across Canada, and also "in house" through longstanding associations with hospitals and health regions (e.g., Calgary zone of Alberta Health Services [AHS]). In 2010 the CMA and the Canadian Society of Physician Executives introduced the Canadian Certified Physician Executive (CCPE) Program. The CCPE is a peer-assessed credential that can be attained either through an academic route that is based on completion of PMI courses or through a practice-eligibility route based on formal leadership experience.11
The CMA also partners with several provincial and territorial medical associations to provide leadership training. Currently CMA has agreements with the Saskatchewan, Ontario and Quebec medical associations and this will extend to the four Atlantic medical associations and the Alberta Medical Association/AHS in 2012.
In addition, a number of university business schools have developed executive program offerings for health leaders. During the past decade, a number of physicians have taken up CEO positions in Canada's major academic health organizations.
Internationally, it has been recognized that physician leadership is critical to the success of efforts to improve health services.12, 13
Having well trained and qualified physicians in leadership roles is critical in making sure that physicians continue to play a central role in the transformation of the Canadian health care system. The CMA and its membership unreservedly support our physician colleagues who dedicate their time and energies to these leadership activities and the CMA will continue to play an integral part in supporting and training the physician leaders of the future.
CONCLUSION: THE CMA'S VISION OF THE NEW PROFESSIONAL RELATIONSHIP BETWEEN CANADIAN PHYSICIANS AND OUR HEALTH CARE SYSTEM
We have explored the factors that have brought us to this point, as well as the issues that must be examined and addressed to enable us to move forward. It is now time for the physicians of Canada to commit to meaningful participation in the process of transforming our health care system. This can only be achieved through the concerted efforts of all parties, including governments, health authorities, health care facilities, physicians and other health care providers. It will not be easy, and it is not likely that this transformation will take place without commitment and sacrifice on our part.
However, now is the time for physicians to demonstrate to their patients, to their colleagues and to society that they are willing to do their share and play their role in this critically important process, at this critically important time. Doing so will help them to achieve the CMA's vision of the new professional relationship between Canadian physicians and the health care system.
In this vision:
Physicians are provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians are provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and are included as valued collaborators in the decision-making process.
Physicians recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians are able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care is team based and interdisciplinary with seamless transition from one care setting to the next and funding and other models are in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
1. Canadian Medical Association. CMA Code of Ethics. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 05/20/11.
2. ABIM Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136(3): 243-6.
3. Lesser C, Lucey C, Egener B, Braddock C, Linas S, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-7.
4. Canadian Medical Association. Medical professionalism 2005 update. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 06/03/11.
5. Canadian Medical Protective Association. Changing physician : hospital relationships. Managing the medico-legal implications of change. 2011. https://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_2011_changing_physician-e.cfm. Accessed 02/07/12.
6. Thrall JH. Changing relationship between radiologists and hospitals Part 1: Background and major issues. Radiology 2007; 245: 633-637.
7. Reichenbach L, Brown H. Gender and academic medicine: impact on the health workforce. BMJ. 2004; 329: 792-795.
8. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med 2010 Jan; 85(1): 63-7.
9. Canadian Medical Protective Association. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009. http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_learning_from_adverse_events-e.cfm. Accessed 02/07/12.
10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf. Accessed 05/20/11.
11. Canadian Society of Physician Executives and Canadian Medical Association. Canadian Certifies Physician Executive. Candidate Handbook. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Leadership/CCPE/2012CCPE-Handbook_en.pdf. Accessed 05/20/11.
12. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80.
13. Imison C, Giordano R. Doctors as leaders. BMJ 2009; 338: 979-80.
GUIDING PRINCIPLES FOR PHYSICIANS RECOMMENDING MOBILE HEALTH APPLICATIONS TO PATIENTS
This document is designed to provide basic information for physicians about how to assess a mobile health application for recommendation to a patient in the management of that patient's health, health care, and health care information.
These guiding principles build on the Canadian Medical Association's (CMA) Physician Guidelines for Online Communication with Patients.1
* Mobile health applications, distinct from regulated medical devices, may be defined as an application on a mobile device that is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. The functions of these applications may include:
o The ability to store and track information about an individual or group's health or the social determinants thereof;
o Periodic educational information, reminders, or motivational guidance;
o GPS location information to direct or alert patients;
o Standardized checklists or questionnaires.2
* Mobile health applications can enhance health outcomes while mitigating health care costs because of their potential to improve a patient's access to information and care providers.3
* Mobile health applications are most commonly used on a smart phone and/or tablet. Some may also interface with medical devices.
* The use of mobile health applications reflects an emerging trend towards personalized medicine and patient involvement in the management of their health information. By 2016, 142 million health apps will have been downloaded.4 According to some industry estimates, by 2018, 50 percent of the more than 3.4 billion smartphone and tablet users worldwide will have downloaded at least one mobile health application.5
* While mobile health application downloads are increasing, there is little information about usage and adherence by patients. It is believed that many patients cease to use a mobile health application soon after downloading it.
* Distributers of mobile health applications do not currently assess content provided by mobile health applications for accuracy, comprehensiveness, reliability, timeliness, or conformity to clinical practice guidelines.6 However, mobile applications may be subjected to certain standards to ensure critical technical requirements such as accessibility, reachability, adaptability, operational reliability, and universality.
* Increasingly there are independent websites providing reviews of medical apps and checklists for health care professionals. However, the quality criteria used by these sites, potential conflicts of interest, and the scope and number of mobile apps assessed are not always declared by these groups.
To date, randomized controlled trials are not usually employed to assess the effectiveness of mobile health applications. Some believe that the rigorousness of this type of assessment may impede the timeliness of a mobile health application's availability.7
* Some examples of the uses of mobile health applications include tracking fitness activities to supplement a healthy lifestyle; supported self-management of health and health information; post-procedure follow up; viewing of test results; and the virtualization of interaction between patients and providers, such as remote patient monitoring for chronic disease management. Some mobile health applications may be linked to a patient profile or patient portal associated with a professional or recognized association or medical society or health care organization.
* Some mobile health applications may be an extension of an electronic medical records (EMR) platform.
* The objective of recommending a mobile health application to a patient must be to enhance the safety and/or effectiveness of patient care or otherwise for the purpose of health promotion.
* A mobile health application is one approach in health service delivery. Mobile health applications should complement, rather than replace, the relationship between a physician and patient.
* No one mobile health application is appropriate for every patient. Physicians may wish to understand a patient's abilities, comfort level, access to technology, and the context of the application of care before recommending a mobile health application.
* Should a physician recommend a mobile health application to a patient, it is the responsibility of the physician to do so in a way that adheres to legislation and regulation (if existing) and/or professional obligations.
* If the mobile health application will be used to monitor the patient's condition in an ongoing manner, the physician may wish to discuss with the patient what they should watch for and the steps they should take in response to information provided.
* Physicians are encouraged to share information about applications they have found effective with colleagues.
* Physicians who require additional information about the competencies associated with eHealth and the use of health information technologies may wish to consult The Royal College of Physicians and Surgeons of Canada's (RCPSC) framework of medical competencies, CanMEDS.8
* Physicians may wish to enter into and document a consent discussion with their patient, which can include the electronic management of health information or information printed out from electronic management platforms like mobile health applications. This agreement may include a one-time conveyance of information and recommendations to cover the elements common to many mobile health applications, such as the general risk to privacy associated with storing health information on a mobile device.
Characteristics of a safe and effective mobile health application
A mobile health application does not need to have all of the following characteristics to be safe and effective. However, the more of the following characteristics a mobile health application has, the likelier it will be appropriate for recommendation to a patient:
1. Endorsement by a professional or recognized association or medical society or health care organization
As recommended by the Canadian Medical Protective Association (CMPA), it is best to select mobile health applications that have been created or endorsed by a professional or recognized association or medical society.9 Some health care organizations, such as hospitals, may also develop or endorse applications for use in their clinical environments. There may also be mobile health applications associated with an EMR platform used by an organization or practice. Finally, some mobile health applications may have been subject to a peer review process distinct from endorsement by an association or organization.
There are a number of usability factors than can complicate the use of mobile applications, including interface and design deficiencies, technological restrictions, and device and infrastructure malfunction.
Many developers will release periodic updates and software patches to enhance the stability and usability of their applications. Therefore, it would be prudent for the physician recommending the mobile health application to also recommend to the patient that they determine if the application has been updated within the last year.
Physicians considering recommending a mobile health application to a patient may wish to ask about the patient's level of comfort with mobile health technologies, their degree of computer literacy, whether or not the patient owns a mobile device capable of running the application, and whether or not the patient is able to bear potential one-time or ongoing costs associated with use of the application.
Physicians may consider testing the application themselves beforehand to understand whether its functionality and interface make it easy to use.
3. Reliability of information
Physicians considering recommending a mobile health application may wish to understand how the patient intends to use the information, and/or review the information with the patient to understand whether it is current and appropriate.
Information presented by the mobile health application should be appropriately referenced and time-stamped with the last update by the application developer.
4. Privacy and security
In 2014, the Officer of the Information and Privacy Commissioner of Alberta assessed approximately 1200 mobile applications and found nearly one-third of them required access to personal information beyond what should be required relative to their functionality and purpose, and that basic privacy information was not always made available.10
Physicians entering into and documenting a consent discussion with their patients may wish to include the electronic management of health information in the scope of these discussions, and make a notation of the discussion in the patient's health record.
Some mobile health applications may feature additional levels of authentication for use, such as an additional password or encryption protocols. If all other factors between applications are equal, physicians may wish to recommend that patients use mobile health applications adhering to this higher standard of security.
5. Avoids conflict-of-interest
Physicians may wish to recommend that patients learn more about the company or organization responsible for the development of the application and their mandate. There is a risk of secondary gains by mobile health application developers and providers where information about patients and/or usage is gathered and sold to third parties.
A standardized conflict of interest statement may be made available through the mobile health application or on the developer's website. If so, physicians may wish to refer the patient to this resource.
Physicians who develop mobile applications for commercial gain or have a stake in those who develop applications for commercial gain may risk a complaint being made to the College on the basis that the physician engaged in unprofessional conduct if they recommend mobile health applications to their patients in the course of patient care.
6. Does not contribute to fragmentation of health information
Some mobile health applications may link directly to an EMR, patient portal, or government data repository. These data resources may be standardized, linked, and cross-referenced.
However, health information entered into an application may also be stored on a mobile device and/or the patient's home computer, or developers of mobile health applications may store information collected by their application separately. While there may be short-term benefits to using a particular mobile health application, the range of applications and developers may contribute to the overall fragmentation of health information.
If all other factors between applications are considered equal, physicians may wish to recommend mobile health applications which contribute to robust existing data repositories, especially an existing EMR.
7. Demonstrates its impact on patient health outcomes
While not all mobile health applications will have an appropriate scale of use and not all developers will have the capacity to collect and analyze data, physicians may wish to recommend mobile health applications that have undergone validation testing to demonstrate impact of use on patient health outcomes. If mobile health applications are claiming a direct therapeutic impact on patient populations, physicians may wish to recommend that their patients seek out or request resources to validate this claim.
1 Canadian Medical Association. Physician guidelines for online communication with patients. Ottawa: The Association; 2005. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD05-03.pdf?_ga=1.32127742.1313872127.1393248073
2 US Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Mobile medical applications: guidance for industry and Food and Drug Administration staff. Rockville (MD): The Administration; 2015. Available:
3 Canada Health Infoway. Mobile health computing between clinicians and patients. White paper. Toronto: The Infoway; 2014 Apr. Available: www.infoway-inforoute.ca/index.php/resources/video-gallery/doc_download/2081-mobile-health-computing-between-clinicians-and-patients-white-paper-full-report
4 iHealthBeat. 44M mobile health apps will be downloaded in 2012, report predicts. Available: www.ihealthbeat.org/articles/2011/12/1/44m-mobile-health-apps-will-be-downloaded-in-2012-report-predicts
5 Jahns R-G. 500m people will be using healthcare mobile applications in 2015. Research2guidance. Available: www.research2guidance.com/500m-people-will -be-using-healthcare-mobile-applications-in-2015/
6 Lyver, M. Standards: a call to action. Future Practice. 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
7 Rich P. Medical apps: current status. Future Practice 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
8 Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth Expert Working Group report. Ottawa: The College; 2014. Available: www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/ehealth_ewg_report_e.pdf
9 Canadian Medical Protective Association. Managing information to delivery safer care. Ottawa: The Association; 2013. Available: https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/managing-information-to-deliver-safer-care
10 Office of the Information and Privacy Commissioner of Alberta. Global privacy sweep rasies concerns about mobile apps [news release]. Available: www.oipc.ab.ca/downloads/documentloader.ashx?id=3482
The harms associated with psychoactive prescription medicinesi including sedatives and tranquilizers1, stimulants2, and analgesics, particularly opioids3, such as oxycodone, hydromorphone and fentanyl, are a significant public health and patient safety issue.
Canada has one of the highest per capita consumption of prescription opioids in the world.4 Dispensing of medications has substantially increased in Canada, although patterns vary considerably between provinces.5 In 2011, while opioid consumption for medical purposes in morphine equivalence (ME)ii was 62mg per person globally, Canada's ME was 812mg per person.6 When comparing to other developed countries, Australia's ME was 427 and Denmark's 483. In North America, about 5% of the adult population, and substantially higher rates for teens and young adults, reported non-medical opioid use in the previous year. This rate is higher than all other illegal drugs, with the exception of marijuana.7
Psychoactive medications pose significant health and safety risks. The harms include overdoses, suicides, motor vehicle accidents, relationship and employment problems, workplace accidents and exposure to blood borne pathogens and other infections when used by injection, besides addiction.
Data are not collected systematically in Canada, making it difficult to assess the harms and track the trends and impact of the introduction of policy changes. However, practitioners have seen the significant impact of these prescription drugs on their patients and to public health. Studies in Ontario show that the number of people enrolled in methadone maintenance treatment rose from about 7,800 in 2001 to over 35,000 in 2011, where opioids have surpassed heroin as the drug used.8 Opioid-related deaths nearly tripled from 2002 to 2010, according to the Office of the Chief Coroner of Ontario.9 Another study showed that other non-opioid depressants (sedatives), such as benzodiazepines, were involved in 92% of the opioid-related deaths.10
The impact is felt particularly among vulnerable populations, such as youth, seniors, First Nations and those living in poverty. In 2013, opioids were reported as the third most common drug used by students in Ontario (after alcohol and marijuana).11 Opioid addiction rates anywhere from 43% to 85% have been reported in some Indigenous communities.12 13 While accurate data on the harms of prescription medication among seniors is lacking, it is well known that the prevalence of pain is higher among older adults and that they account for a significant proportion of prescriptions.
The "high" they produce also leads to these medications being sought after for recreational purposes and, as they are legal products, they are often more easily accessible than street drugs. Surveys with youth have shown that as much as 70% of opioids have been obtained from legitimate prescriptions to family and friends (55% were shared at no cost).14 As well, because opioids have high abuse liability and addiction potential, people have resorted to illegal behaviour to obtain them, such as doctor-shopping, forging prescribers' signatures, or buying from street dealers.
Of great concern, opioid dispensing levels are strongly correlated with increased mortality, morbidity and treatment admissions for substance use.15 16 Studies in Ontario and British Columbia have replicated similar findings in the US. Many patients were prescribed these medications and developed dependence.17
Psychoactive medications are important therapeutic tools and serve legitimate purposes, when prescribed in an appropriate manner with proper assessment, and as part of a comprehensive therapeutic strategy and monitoring. Medications, such as opioids, have been essential in areas such as palliative and cancer care and have contributed to the alleviation of suffering.
Since the 1990s, opioids have been recommended for longer-term treatment of chronic non-cancer pain, and have become widely used due in part to aggressive promotion and marketing for this indication.18 19 However, there is evidence for significant pain relief in the short term but a need for more evidence regarding maintenance of pain relief over longer periods of time, or for improved physical function.20 21 22
Important contributing factors for the increase in prescriptions are also the lack of supports and incentives for the treatment of complex cases, including availability and funding for treatment options for pain and addictions. Alternate approaches to pain management require more time with the patient. In addition, there are new highly potent opioid drugs available.23 24
Canada's physicians are deeply concerned about the harms of opioids and other psychoactive prescription medications. As prescribers, they have a fundamental role in helping to ensure safe and effective use of these drugs, and the deterrence of abuse. 25 26 27 Physicians assess patients and consider whether a prescription is clinically indicated according to best practices, as well as consider whether the benefits outweigh the risks, while screening for risk factors for substance dependence and diversion. This area can be a source of tension with patients who might seek to obtain drugs through fraudulent means.28 It is also an area which causes concern to many physicians, and this could be affecting access to adequate pain management where it is needed.29
The challenge for physicians and public policymakers is how to mitigate the harms of psychoactive prescription drug use, while ensuring that patients have access to the appropriate treatment for their clinical conditions.
Comprehensive National Strategy
Canada's physicians believe that this challenge requires a complex and multifaceted solution; and to further such a solution, the CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the two legal drugs - alcohol and tobacco. This comprehensive approach is necessary, as isolated measures can have unintended consequences, such as under-medicating people that require a medical treatment or constraining people to seek illegal drugs as an option when medications are made tamper-resistant.
The federal government has created the National Advisory Council on Prescription Drug Misuse, co-chaired by the Canadian Centre on Substance Abuse, the Coalition on Prescription Drug Misuse (Alberta) and the Nova Scotia Department of Health and Wellness, in partnership with Health Canada's First Nations and Inuit Health Branch's Prescription Drug Abuse Coordinating Committee. In its 2013 report First Do No Harm: Responding to Canada's Prescription Drug Crisis30, there are nearly 60 recommendations toward the development of a strategy to combat the harms associated with psychoactive prescription medications. However, there is much still to be done.
The CMA supports collaborative efforts by the federal and provincial/territorial governments, and by health professionals and other stakeholders, to develop and implement a comprehensive national strategy. Such a strategy should include the following:
1. Improvement of Drug Safety
Health Canada, as the agency that approves prescription drugs for use and monitors their safety once on the market, has several levers by which it can control Canadians' access to drugs. One of these is the Controlled Drugs and Substances Act (CDSA) and its regulations, which govern access to illegal products and recently has included psychoactive prescription drugs.
Because of their health and safety risks, it is important that Health Canada ensures that the CDSA subjects psychoactive substances to high levels of regulatory scrutiny during both the approval process and post-approval surveillance. The Act should require manufacturers to:
* Meet stringent pre-approval requirements. For example, Health Canada could require intensive review of pre-approval clinical trial results and of product monographs by an expert impartial review committee (including addiction, pain and public health expertise); or require that the manufacturer fulfill special conditions, such as formal post-market studies, as a condition of the drugs' approval; or even require larger sample sizes or longer study periods to assess harms;
* Adhere to restrictions on the marketing of controlled medications to health professionals and the general public. The adequacy of regulations needs to be assessed in this regard.
* Develop and cover tamper-resistant formulations of psychoactive drugs of concern. Although not a standalone solution, tamper-resistant formulations can reduce the potential for manipulation to be able to use through snorting, chewing or intravenously.
2. Enhancement of Optimal Prescribing through Evidence-Based Guidance, Education and Support for Prescribers
CMA recommends that appropriate prescribing of psychoactive medications should be addressed through evidence-based guidance and education. A strategy to support optimal therapy might include:
* Support for models of care that allow a physician to spend time with complex patients.
* Ongoing development and dissemination of clinical guidance. The Canadian Guideline for Use of Opioids to Treat Chronic Non-Cancer Pain was published in the CMAJ in 2010. CMA has co-sponsored an online CME module based on this guideline. There is interest in similar guidelines for sedatives and stimulants.
* Evaluative research to support the critical review of guidelines periodically. It is essential to review data on chronic conditions for which risks might outweigh benefits.
* Relevant, unbiased and easily accessible information for prescribers, which can readily be incorporated into everyday practice. This should include clinical decision-support tools for use at the point of care, inclusive of dosing guidelines and guidance on when to seek consultation with experts. Physicians also require tools, including those that facilitate: monitoring of effectiveness and tolerance by tracking pain and physical function; screening for past and current substance use; screening for depression; tapering of problematic or ineffective doses; among others.
* Educational programs in optimal prescribing, pain management and in the management of addictions, as part of the curriculum in medical school, and residency training as well as in continuing education. Particular support is needed for those in primary care.
* Guidance for prescribers about how to deal with conflict in their practice. This would include guidance for patient-centred educational discussions on safe opiate prescribing and use and management of addictions.
* Access to expert advice if required through such means as:
o Policies or standards of practice developed by provincial regulatory colleges of physicians, which can include limitations on prescription volume, treatment period and indications.
o Communities of practice, knowledge hubs and clinical support networks that link practitioners with experts in the field, facilitating triage and supporting front line generalists. Experts can not only provide clinical information, but can provide mentorship and personal advice about best practices.
o Feedback to practitioners about their prescribing practices, particularly if potentially concerning patterns are identified. This initiative should be facilitated by collaborative work between health care professionals and their respective provincial regulatory colleges.
o Academic detailing programs, which use personalized, one-on-one techniques to deliver impartial prescribing information to practitioners.
3. Enhancement of Optimal Prescribing through Physician Regulation and Prescription Monitoring Programs
Medicine is a regulated profession, and the provincial colleges of physicians have ultimate authority and responsibility for the oversight of physician practice. The colleges have taken a leading role in educating their members about appropriate prescribing, in monitoring prescribing practices to ensure their appropriateness and taking disciplinary action when required, and through collaborating with law enforcement agencies to detect and halt criminal diversion.
The CMA recommends that federal and provincial regulations regarding controlled substances recognize the established authority of physician regulatory colleges for the oversight of the medical profession.
While prescription monitoring programs (PMPs) exist in most provinces, they vary considerably in terms of quality, the nature of the information they require, whether health care practitioners have real-time access, and the purpose for which the data are collected. Standardization of monitoring systems across Canada according to best practices can contribute to addressing the harms associated with psychoactive prescription medication by:
* Allowing health care practitioners to identify previous or concomitant prescriptions of controlled medications with more than one practitioner at the time the prescription is requested or filled;
* Deterring interprovincial or jurisdictional fraud, by allowing health care practitioners to identify other prescriptions at the time the prescription is requested or filled; and
* Improving professional regulatory bodies' capacity for oversight and intervention by establishing a mechanism for real-time monitoring.
The CMA recommends that all levels of government work with one another and with health professional regulatory agencies to develop a pan-Canadian system of real-time prescription monitoring. As a first step, the CMA recommends the establishment of consistent national standards for prescription monitoring.
PMPs should be compatible with existing electronic medical and pharmacy record systems and with provincial pharmaceutical databases. Participation in prescription monitoring programs should not impose an onerous administrative burden on health care providers. PMPs should not deter physicians from using controlled medications when necessary.
CMA also recommends that Health Canada ensure that its legislative framework be used to facilitate and support the advancement of e-health, specifically e-prescribing. Electronic health records can help individual physicians or pharmacists identify potential diversion and double prescriptions, at the point where a prescription is written or filled. The electronic health record also facilitates the sharing of information among health professionals, and could minimize the potential administrative burden.
PMPs should conform to privacy laws, protecting patient confidentiality while enabling the sharing of necessary information. The CMA strongly recommends that Health Canada undertake a privacy impact assessment of the regulatory framework for controlled prescription drugs, and share the results with stakeholders.
4. Increase in Access to Treatment for Pain
Chronic pain affects many aspects of a person's life including their ability to work, their emotional, mental and physical health, and their quality of life. Pain costs Canada an estimated $60 Billion dollars per year; more than the cost of heart disease, cancer and diabetes.31 CMA has endorsed a national strategy for pain, developed and proposed by the Canadian Pain Coalition and Canadian Pain Society,32 which addresses four target areas: awareness and education; access; research; and ongoing monitoring.
Experts believe that improved access to specialized pain treatment could reduce inappropriate use of pain medications. Current best practices in pain management include:
* Care by an interprofessional team that could include physiotherapists, occupational therapists, psychologists and other health professionals;
* Recommendation of non-pharmaceutical interventions such as therapy for trauma and social pain, social supports and coping strategies;
* Appropriate pharmaceutical prescription options, covered by provincial formularies; and
* A focus on patient participation and empowerment.
However, specialized pain treatment programs are in short supply. Wait times are greater than one year at more than one third of publicly funded inter-professional treatment programs.33 In many parts of Canada, particularly rural and remote areas, such programs are not available. In addition, while physician visits are covered by the public health care system, services provided by other health professionals are more likely to be either covered by private health benefits or paid out of pocket, and are therefore beyond the means of many Canadians. These factors may result in heavier reliance on prescription medication as treatment for chronic pain.
The CMA recommends that all partners work to improve and promote access to specialized treatment programs for pain management, and that investments be made in research about options for treatment.
5. Increase in Access to Treatment for Addiction
Access to addiction treatment is very limited and, when available, is primarily comprised of detox or the substitution treatments with methadone or Suboxone(r) (buprenorphine and naloxone). As addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry by definition, which manifests along biological, psychological, social and spiritual dimensions, treatment must address all those areas rather than just one or another.34
The CMA supports the enhancement of access to options for addiction treatment that address different needs. Treatment programs must be coordinated and patient-centred, and address physical, psychological, social and spiritual circumstances. For example, it is important that addiction programs be culturally relevant for Indigenous communities.
Treatment programs must also be integrated within the health care system and be adequately funded to meet evidence based, best-practice guidelines.
CMA also supports the development and dissemination of practice tools and guidelines to help physicians assess the addiction potential of a patient receiving psychoactive medications, and to assist in managing patients who have addiction and related problems and complications.
6. Increase in Information through Epidemiological Surveillance
One of the challenges in dealing with prescription drug abuse, which can reflect hazardous (episodic) use, harmful (regular) use or addiction, is the incompleteness of our knowledge of the extent of the problem. Countries, such as the US and France, are able to monitor psychoactive drug use, while in Canada we still rely on unsystematically collected or locally limited data. The creation of a national surveillance system that supports the collection of systematic, standardized information would:
* Permit the thorough assessment of the problem, with the development and monitoring of indicators;
* Support the early detection of diversion or inappropriate prescribing behaviour;
* Support the establishment of best practices to address crucial issues;
* Identify research priorities; and
* Evaluate the impact of the implementation of strategies.
Sources of information should include PMPs, coroner's investigations, emergency room admissions, and poison control data, among others.
7. Prevention of Deaths due to Overdose
Overdose deaths have increased dramatically over the past ten years. The risk of harm from overdose may be compounded if recreational users are afraid to call for emergency assistance for fear of facing criminal charges. Opioid death and complications overdoses can be prevented with appropriate medication and prompt emergency response. The CMA recommends the:
* Creation and scaling up of community-based programs that offer access to naloxone and other opioid overdose prevention tools and services. Training should be made available to health workers, first responders, as well as opioid users, families and peers about the prevention of overdose fatalities.35
* Improvement of access to naloxone to reverse opioid overdoses. This should include the prescription of naloxone to high risk individuals and third parties who can assist a victim experiencing an opiate-related overdose.
* Enactment of Good Samaritan laws by all levels of government in order to protect callers from criminal charges if they call emergency services to report an overdose. 36 37
8. Provision of Information for Patients and the Public
Awareness programs that provide accurate information to patients and the general public are important, and could include:
* Information on the benefits and harms of psychoactive prescription medication use, and signs of dependence and overdose. This should include the risk of dependence and addiction associated with the use of opiates for the treatment of acute and chronic pain.
* Messages aimed at the prevention of problematic drug use among young people and other populations at risk.
* Information regarding safe medication storage and disposal, and reducing access to medications from family and friends. CMA supports national prescription drug "drop off" days, and recommends that patients be educated about the importance of routinely returning unused prescription drugs to the pharmacy.
The CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based. This strategy should include:
* That Health Canada require that manufacturers meet stringent pre-approval requirements, adhere to restrictions on the marketing of controlled medications to health professionals and the general public, and develop formulations of psychoactive drugs of concern that are tamper-resistant.
* Support for optimal prescribing through evidence-based guidance, education and supports, such as clinical guidance, clinical decision-support tools, educational programs, expert advice, and supportive models of care.
* The enhancement of optimal prescribing through physician regulation and the development of a pan-Canadian system of real-time prescription monitoring programs, compatible with electronic medical and pharmacy record systems, based on national standards.
* Increased access to specialized pain management and treatment, according to best practices, with investments in research.
* The enhancement of access to options for addiction treatment that address different needs, and the support for the development and dissemination of practice tools and guidelines.
* The creation of a national surveillance system that supports the collection of systematic, standardized information to better inform and track policy changes.
* The creation and scaling up of community-based programs that
* Offer access to opioid overdose prevention tools and services, including the improvement of access to medication to reverse opioid overdoses (naloxone) and the enactment of Good Samaritan laws by all levels of government.
* The provision of accurate information to patients and the general public, including safe medication storage and disposal.
i Psychoactive drugs are substances that, when taken, have the ability to change an individual's consciousness, mood or thinking processes (WHO, 2004). Psychoactive prescription drugs include sedatives (such as benzodiazepines and barbiturates), stimulants (such as amphetamines), and opioids (such as oxycodone, hydromorphone, morphine and fentanyl). [World Health Organization (2004) Neuroscience of psychoactive substance use and dependence. Available at: http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf]
ii Comprises six main opioids: fentanyl, hydromorphone, methadone, morphine, oxycodone and pethidine.
1 Canadian Centre on Substance Abuse. Prescription sedatives and tranquilizers. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Sedatives-and-Tranquilizers-2013-en.pdf
2 Canadian Centre on Substance Abuse. Prescription stimulants. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Stimulants-2013-en.pdf
3 Canadian Centre on Substance Abuse. Prescription opioids. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Canadian-Drug-Summary-Prescription-Opioids-2013-en.pdf
4 International Narcotics Control Board. Narcotics drugs: estimated world requirements for 2013; statistics for 2011. New York: United Nations; 2013.
5 Fischer B, Jones W, Murray K, et al. Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010. Pharmacoepidemiol Drug Saf. 2011;20:1269-77.
6 United Nations Office on Drugs and Crime. World drug report 2014. New York: The Office; 2014. Available: www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf
7 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
8 Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician. 2012;15:ES191-ES203.
9 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013.
10 Dhalla IA, Mamdani MM, Sivilotti MLA, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone CMAJ. 2009;181(12): 891-6.
11 Centre for Addiction and Mental Health. Drug use among Ontario students, 1977-2013: results of the Ontario Student Drug Use and Health Survey. Toronto: The Centre; 2013. Available: www.camh.ca/en/research/news_and_publications/ontario-student-drug-use-and-health-survey/Documents/2013%20OSDUHS%20Docs/2013OSDUHS_Highlights_DrugUseReport.pdf
12 Chiefs of Ontario. Prescription drug abuse strategy: 'Take a stand.' Final report. Toronto: Chiefs of Ontario; 2010. Available: www.chiefs-of-ontario.org/sites/default/files/files/Final%20Draft%20Prescription%20Drug%20Abuse%20Strategy.pdf
13 Health Canada. Honouring our strengths: a renewed framework to address substance use issues among First Nations people in Canada. Ottawa: Health Canada; 2011. Available: http://nnadaprenewal.ca/wp-content/uploads/2012/01/Honouring-Our-Strengths-2011_Eng1.pdf
14 US Department of Health and Human Services Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville (MD): The Department; 2011. p. 25. Available: www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf
15 Gomes T, Juurlink DN, Moineddin R, et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthc Q. 2011;14(1):22-4.
16 Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438-42.
17 Brands B, Blake J, Sproule B, et al. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend. 2004;73(2):199-207.
18 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142 DOI: 10.1136/bmj.d5142.
19 Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician. 2014;17(1):E1-10.
20 Franklin GM. Opioids for chronic noncancer pain. A position paper of the American Academy of Neurology. Neurology. 2014;83:1277-84. Available: www.neurology.org/content/83/14/1277.full.pdf+html
21 Chou R, Ballantyne JC, Fanciullo GJ, et al. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10:147-59.
22 Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.
23 Fischer B, Goldman B, Rehm J, et al. Non-medical use of prescription opioids and public health in Canada. Can J Public Health. 2008;99(3): 182-4.
24 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
25 Silversides A. Opioid prescribing challenges doctors. CMAJ. 2009;181(8):E143-E144.
26 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.
27 Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160:198-213.
28 Saveland C, Hawker L, Miedema B, et al. Abuse of family physicians by patients seeking controlled substances. Can Fam Physician. 2014;60:e131-6.
29 Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians' experiences with opioid prescribing. Can Fam Physician. 2011;57(3):324-32.
30 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013. Available: www.ccsa.ca/resource%20library/canada-strategy-prescription-drug-misuse-report-en.pdf
31 Canadian Pain Strategy Initiative. Rise up against pain: the Canadian Pain Strategy. Available: http://canadianpainstrategy.ca/en/home.aspx
32 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
33 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
34 American Society of Addiction Medicine. Public policy statement: definition of addiction. 2011. Available: www.asam.org/for-the-public/definition-of-addiction
35 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
36 Follett KM, Piscitelli A, Parkinson M, et al. Barriers to calling 9-1-1 during overdose emergencies in a Canadian context. Crit Social Work. 2014;15(1):18-28. Available: http://www1.uwindsor.ca/criticalsocialwork/system/files/Follett_Piscitelli_Parkinson_Munger_2014.pdf
37 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5
THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS
Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14
Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16
The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21
Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25
THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28
Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32
Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36
These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38
To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health.
AREAS FOR ACTION
The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include:
* reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position;
* decreasing the exposure of individuals and populations to the health-damaging factors they may face;
* reducing the vulnerability of people to the health damaging conditions they face; and
* intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39
All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice.
CMA and national level initiatives
Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported.
All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need.
CMA recommends that:
1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment.
2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health.
3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians.
4. Efforts be made to educate the public about the effect of social determinants on individual and population health.
5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course.
Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44
The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school.
Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged.
Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52
CMA recommends that:
6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role
7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients.
8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians.
Leadership and research
Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored.
Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines.
Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities.
CMA recommends that:
9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges.
10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources.
11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care.
12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally.
In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1
First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57
Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available.
As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed.
Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients.
Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62
CMA recommends that:
13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design.
14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector.
15. Collaborative team-based practice be supported and encouraged.
16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
17. Physicians be cognizant of equity considerations when considering their practice design and patient resources.
18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients.
1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice.
1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm
2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf
4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf
6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
7 Khalema, N. Ernest (2005) Who's Healthy?...
8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. . Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71
11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf
12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40.
13 World Health Organization (2008) Closing the gap in a generation...
14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf
15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf
18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health...
19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf
20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf
21 World Health Organization (2008) Closing the gap in a generation...
22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq
23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf
24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples...
26 Dunn, James R. (2002) The Health Determinants Partnership...
27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf
28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121.
30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians...
31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'...
32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832.
34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124.
35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients...
36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
37 Dunn, James R. (2002) The Health Determinants Partnership...
38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf
39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf
40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192.
41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf
42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf
44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113.
45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools...
46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666.
47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119.
48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1
49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146.
50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients.
51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate...
52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36
54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf
57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1
58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health
60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
HEALTH IN ALL POLICIES
Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. This negative health status can undermine not only individual health but the productivity and prosperity of the country as well.1 As noted in the Adelaide Statement on Health in All Policies, "Good health enhances quality of life, improves workforce productivity, increases the capacity for learning, strengthens families and communities, supports sustainable habitats and environments, and contributes to security, poverty reduction and social inclusion."2
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.3 Many studies show that people low on the socio-economic scale are likely to carry a higher burden of just about any disease.4 Poverty accounts for 24% of person years of life lost in Canada (second only to 30% for neoplasms).5 These numbers demonstrate a need to rethink the way we work to improve the health of the Canadian population. While a strong health care system is vital, changes to our health system alone will not be sufficient to improve health outcomes or reduce the disparities that currently exist in disease burden and health risks.
Using health determinants as a focus means that most health promotion and prevention efforts will take place outside of the health and medical care service.6 Canadians must be supported to make the choices that keep them healthy and reduce their risks of injury and disease. However, many face barriers in their physical, social and economic environments which make these healthy choices difficult. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. As noted by the former Minister of Health and Welfare, Jake Epp, "it is not an overstatement to say that public policy has the power to provide people with the opportunities for health, as well as to deny them such opportunities... All policies having a direct bearing on health need to be coordinated."7
Improving population health and reducing inequities should be an overall objective for all governments in Canada. Not only will it help to reduce costs to the health system, it will also increase economic growth as healthier people lose fewer days of work and contribute to overall economic productivity.8 As laid out in the principles to Guide Health Care Transformation, "Coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.9"
The utilization of such an approach is not new. Governments from England to Finland to New Zealand have increasingly recognized the importance of the social determinants of health and have developed national strategies accordingly. These strategies, often referred to as 'health in all policies,' call for a whole of government approach where cross-departmental collaboration is established at the highest government level to increase the health of the population and reduce inequalities.10 The World Health Organization defines health in all policies as follows:
Health in all Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. A HiAP approach is founded on health-related rights and obligations. It emphasizes the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making.11
This approach looks at all policies that have a health impact not just those in the health sector. Policies are reviewed for their potential impact on population health and health system utilization.12
There are many ways that a HiAP approach can be implemented. Examples include:
inter-ministerial and inter-departmental committees; community consultations and Citizens' Juries; cross-sector action teams; partnership platforms; integrated budgets and accounting; Health Lens Analyses; cross-cutting information and evaluation systems; impact assessments; joined-up workforce development; and legislative frameworks.13
A Plan for Canada
Role of the Federal Government:
While the provinces and territories have constitutional authority for the majority of health system delivery, the federal government has a significant role in health: through system oversight, Canada Health Act; delivery to certain populations, Canada's Aboriginal peoples; as well as accountability and pan-Canadian initiatives for the various health systems. Additionally, the federal government has significant control over areas such as taxation, food security and agriculture, justice, transportation safety and income security (eg child tax benefits, Old- Age Security). All of these can have a marked impact on both individual and population health.
As a result of these responsibilities the Canadian government needs to adopt a clear mandate to focus on the health of the population. Actions must be taken to provide Canadians with the ability to make healthy choices. All legislation must be subject to a health lens to determine potential health implications so as to minimize or mitigate any negative consequences and maximize opportunities for health benefits. Given the central coordinating function of Cabinet in policy setting and delivery, this would be an ideal place to incorporate a HiAP approach.
1. CMA recommends that the federal government acknowledge the relationship of the social determinants of health on the health of the population as well as the demands of the health care system and that it implement a Health in All Policies approach for all cabinet decision-making.
While Cabinet should serve as the central decision-making body for a HiAP approach, there must be formal and sustainable structures that allow timely analysis of the health consequences of policy decisions, which appropriately engage stakeholders, and which ensure that health impacts are actually considered in policy decision-making.14
Such an approach will require some form of enabling legislation as well as benefits for departments that conduct HiAP analysis. In Quebec, for example, all policies are required to undergo a review of health impacts under Section 54 of the 2002 Quebec Public Health Act.15
In addition, it is likely that a lead agency will need to be appointed to facilitate the necessary data collection/analysis to review policies. In the Netherlands health impact assessments are the responsibility of the Department of Intersectoral Policy at the Netherlands School of Public Health.16 Since 2000, the Swedish National Public Health Institute (SNIPH) has been tasked with developing methodology in strategically important areas and with supporting the application of health assessments on the central, regional and local level.17 In England, the Public Health Observatories play a key role in providing data and analysis for health impact assessments.18
A significant barriers to HiAP in Canada is the existing data infrastructure. Hundreds of major and minor publications speak to the volume of analyses undertaken on health and health systems every year in Canada. Despite this effort, Canadian policy makers and the public do not fully understand how health system vs. non-health factors contribute to the health outcomes observed or the picture of overall health. The available data tends to focus on the health care system, sickness and the measurement of sickness related risks. What is missing is a way of organizing the data which provides greater insight for planners and greater accountability for all Canadians. This capacity will need to be developed in order to properly implement a HiAP approach.
2. CMA recommends that the federal government provide the necessary enabling environment to allow for the application of a health in all policies approach in all new policy development.
As the experiences from other countries demonstrate there is some value in selecting a few Ministries to begin the process. Once selected the Ministries should be responsible for starting the process and screening any new policies. If there is a potential health impact they would then contact the centralized resource to conduct the analysis and produce a report with potential impacts and recommendations for change. This report would go back to the originating Ministry for review and modification of the policy as necessary. Changes should be highlighted and the revised policy should be sent with the health analysis report to Cabinet for final decision-making. This will help to improve the policy and will create greater awareness among all Cabinet members of the potential health implications of various policies.
3. CMA recommends that the Federal Minister of Health work with Cabinet to select appropriate Ministries to begin the implementation of the health in all policies approach.
Role of Health Care Sector:
Government is not the only group with a role in HiAP. The health sector, including Canada's physicians can work to ensure that the policy environment promotes health. By working with governments at all levels, physicians can uses their vast knowledge and expertise to provide evidence regarding potential health implications, and promote the development of evidence-informed decision making. In addition, they can work with partners both within and outside of the health sector to advocate as necessary for policy improvements.19
4. CMA recommends that physicians and other health care providers use their knowledge and expertise to support governments in the development of evidence-informed policy which promotes the health of the population.
Investments in the health system will only go so far in improving the health of the population. Population health approaches must tackle the wider social determinants of health. To do so the government must consider health in all the policies that it develops.
1 Reeves, Richard A Liberal Dose? Health and Wellbeing - the Role of the State: An Independent Report. 2010. Available: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111695.pdf
2 World Health Organizatio. Adelaide Statement on Health in All Policies: moving toward a shared governance for health and well-being. Geneva:The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed 2015 Apr 16).
3 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
4 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto :The Health Determinants Partnership; 2002 Available: http://en.healthnexus.ca/sites/en.healthnexus.ca/files/resources/widening_income_equalities.pdf (accessed 2015 Apr 16)
5 Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Statistics Canada.Health Rep. 2002:13(Supplement): 10.
6 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38:115-120.
7 Epp, J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Available: www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1986-frame-plan-promotion/index-eng.php
8 Munro, D Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. Ottawa: Conference Board of Canada; 2008.Available: www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
9 Canadian Medical Association, Canadian Nursese Association. Principles for Health Care Transformation in Canada. Ottawa: The Associations; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-13.pdf
10 St-Pierre L. Governance Tools And Framework For Health In All Policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
11 World Health Organization, Government of South Australia. Adapted from WHO Working Definition prepared for the 8Th Global Conference on Health Promotion, Helsinki, 10-14 June 2013.
12 Ollila E, Baum F, Pe ña S. Introduction to health in all policies and the analytical framework of the book. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 1. Finland: Ministry of Social Affairs and Health; 2013. Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf.
13 World Health Organization, Government of South Australia. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Geneva: The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed October 18, 2014)
14 Rudolph, L, Caplan J, Mitchell C, et al. Health in All Policies: Improving Health Through Intersectoral Collaboration. Washington(DC): Institute of Medicine. Available: www.phi.org/uploads/application/files/q79jnmxq5krx9qiu5j6gzdnl6g9s41l65co2ir1kz0lvmx67to.pdf (accessed October 21, 2014).
15 National Collaborating Centre for Healthy Public Policy. Implementation of Sectin 54 of Quebec's Public Health Act. Quebec: The Centre; 2012. Available at: www.ncchpp.ca/docs/Section54English042008.pdf
16 Wright, J, Parry J, Scully EInstitutionalizing policy-level health impact assessment in Europe: Is coupling health impact assessment with strategic environmental assessment the next step forward? Bull World Health Orga. 2005;83(6):472-7
17 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38(2):115-20
18 St-Pierre L. Governance Tools And Framework for health in all policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
19 Leppo K, Tangcharoensathien V. The health sector's role in HiAP. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 14. Finland: Ministry of Social Affairs and Health; 2013.
Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. (accessed October 18, 2014)
The Canadian Medical Association (CMA) supports the promotion of healthy lifestyles in order to improve individual health and well-being and the overall health status of the population. Healthy lifestyles refer to patterns of individual practices and personal behavioural choices that are associated with optimal health. Two of the most important behaviours to create or maintain optimum health are healthy eating and physical activity.
For many Canadians, their diet and physical activity levels can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy lifestyle.1 Childhood obesity research tells us that overweight and obese children are more likely to stay the same into adulthood.2 To reverse this trend, determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. Healthy lifestyles are central to successful aging and improving the likelihood of recovery after poor health.3
This policy paper discusses the importance of physical activity and healthy eating, and the role that individuals and families, schools, workplaces, communities, the food industry and all levels of governments can play in promoting healthy lifestyles. We know that collaborative action is required to make it easier for Canadians to incorporate healthy eating and physical activity into their daily lives - to make the healthy choice the easy choice.
What are the health impacts of unhealthy diets and physical inactivity
Diet is the leading risk factor for death, disability and life-years lost; being estimated to cause over 65,000 deaths and 864,000 life years lost in Canada in 2010.4
Unhealthy diet has been consistently linked with cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and some cancers,5 which constitutes the majority of the disease burden in Canada. An estimated 80% of hypertension, which affects over 7 million Canadians, is directly or indirectly attributed to unhealthy diet.6
An estimated 60% of Canadian adults and close to one-third of children are overweight or obese, largely caused by unhealthy diets.7 Overweight and obesity (and the lifestyle choices associated with them) are contributors to more than 18 chronic conditions.8 This includes diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer.
Obesity is a public health issue not unique to Canada as the rates are increasing worldwide. Obesity is generally attributed to the fact that, as a society, we are increasing our calorie intake while at the same time burning less energy in physical activity. While it is difficult to determine how many deaths are directly attributable to obesity, we know that obesity often co-exists with other risk factors such as the lack of physical activity.
Exercise is one of the top modifiable risk factor for chronic disease.9 Regular physical activity is associated with a reduced risk of cardiovascular disease, some types of cancer, diabetes, obesity, hypertension, bone and joint diseases, and depression.10 The risk for many of these conditions is reduced by 20 - 40% in adults with the highest levels of physical activity compared to those with the lowest levels of physical activity. Recent research has shown that a sedentary lifestyle is associated with higher risk for chronic conditions such as obesity, diabetes and cancer independent of physical activity levels.11
According to the most recent Canadian Health Measures Study physical activity levels for children and youth are low with 6 out of 10 waking hours devoted to sedentary pursuits. Obesity is rising and physical fitness is declining.12
Canadians who do not achieve adequate levels of physical activity or eat unhealthy foods are vulnerable to preventable chronic diseases, premature death, and contribute to high health care costs. For instance, in 1999, $2.1 billion or 2.5% of the total direct health care costs were attributable to physical inactivity.13
To understand why the rates of obesity and overweight are rising, it may be helpful to look at what we already know about healthy eating and physical activity.
What we know about healthy eating
While modern science has allowed us to expand our knowledge of the impact of nutrients and food on human health we continue to be beset with illness and disease caused by the foods we consume. Having the right amount and type of food recommended in Canada's Food Guide is a first step towards healthy eating. But Canadians self-reported dietary intakes do not meet national dietary recommendations despite high reliance on public education concerning healthy eating and healthy diets. Children and adults are under-consuming the recommended servings of vegetables and fruits, an established proxy for healthy eating habits, and exceeding daily recommended intakes of sodium.14,15
As the links between nutrition and disease, and the impact on the health of our society are revealed it is more important than ever to understand what influences healthy eating behaviours. Food choices are structured by a variety of individual determinants of behaviour, ranging from one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors.
Many processed foods have become popular due to their accessibility and 'convenience factor', but these features have changed the way food and in particular these products are consumed compared to unprocessed foods: increased 'grazing', eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form.16
Growth in the production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower-income countries.17 A number of studies have shown that because less healthy foods are cheaper than healthier food, individuals from lower socioeconomic classes tend to be more dependent on unhealthy foods for nourishment.18
Other determinants for healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.19
What we know about physical activity
Canada's Physical Activity Guidelines recommend that children and youth aged 5 to 17 get at least 60 minutes of moderate-to-vigorous physical activity (MVPA) per day; and adults get 150 minutes of physical activity per week.20 In fact, about 94% of Canadian children and youth do not meet minimum physical activity guidelines.21 Furthermore, about 85% of Canadian adults do not meet the minimum guidelines. Physical activity includes but is not limited to sports and recreation. Using active transportation to get to work as well as being active at work is an alternative form of MVPA and can also lead to improved health.
For most Canadians, the average day is spent on passive activities such as TV viewing, computer and game-console use, workplace sitting, and time spent in automobiles. Moreover, the sprawling suburban communities, in which many live, do not encourage physical activity.
Emerging research suggests that prolonged sitting time is associated with an increased health risk.22 These findings mean that one can meet the minimum physical activity guidelines and still not engage in a healthy lifestyle. Spending a few hours a week at the gym or otherwise engaged in moderate or vigorous activity doesn't seem to significantly offset the risk. Hence too much sitting is a risk distinct from too little exercise.
While further research is required to identify which methods of exercise promotions work best for individuals,23 it is clear that supportive environments and infrastructures are essential for Canadians to make physical activity part of their daily lives. CMA's policies about the Built Environment and Active Transportation support the role of the environment on our physical activity patterns.
How we can promote physical activity and healthy eating
A sedentary lifestyle is a cue for physician advice.24 Physical activity is a vital sign that may require as much attention as other traditional vital signs25 - weight, blood pressure, or smoking history. Physicians are eager to initiate these conversations, especially with patients living with chronic diseases. A message must be repeated many times in order to effect a change in lifestyle. Physicians can reiterate the medical importance of physical activity and healthy eating by reinforcing this message during each office visit, and writing the recommendation on a prescription pad.26 For instance, in British Columbia, physicians are prescribing exercise on specially-designed pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. And in Nova Scotia, physicians have been running a free provincial running program for over 10 years that benefits thousands of kids in elementary school.
Nonetheless these clinical interventions alone cannot shape healthier food consumption patterns and lifestyle choices. An obvious starting point to develop a comprehensive policy is to understand the interplay between individual and environmental determinants that influence our behaviours. In this regard, CMA has developed policies on Active Transportation and the Built Environment and Health which recognize the role of neighborhood design and alternative modes for transportation for an active lifestyle. This approach is also at the heart of the Integrated Pan-Canadian Healthy Living Strategy (PCHLS)27, approved in 2005 by all levels of government. CMA commends the efforts put in the PCHLS to prioritize healthy eating and physical activity.
What we recommend
CMA looks forward to working with others in making options for physical activity and healthy eating more available and accessible to all Canadians. The following recommendations highlight the potential contributions of the following sectors: health professionals, all levels of government, communities, workplaces, schools, the food industry and individuals and families.
CMA encourages physicians to promote healthy eating and physical activity inside and outside their office.
Physicians are lifestyle change agents and remain the preferred source of information about health for many people. Physicians, who are committed to physical activity, are role models whose advice on healthy living is more likely to be adopted.28 CMA encourages physicians to address any work-imposed limitations - such as the lack of time, motivation, or tiredness - that could also influence their own exercise and eating habits.
In clinical practice, physicians can help patients start or maintain a healthy lifestyle by:
* assessing nutrition and physical activity as part of routine assessments;
* determining the factors that influence individual patient's nutrition and physical activity levels;
* assessing patient's readiness to change and tailoring interventions and support to their current situation;
* providing an exercise prescription to encourage physical activity to maintain or improve health status, and
* working in inter-professional teams to provide patient education with other health care providers such as dieticians.
Medical students and residents, while reporting a high level of importance for exercise prescription concede a low level of expertise in this area upon graduation.29,30,31 As knowledge develops, physicians and other health professionals should be kept updated and encouraged to incorporate the most effective interventions into their practices. The CMA encourages the development of continuing medical education courses on issues related to physical activity and healthy eating.
Within the healthy living approach, there are multiple opportunities to extend the role of physicians into the community as observed in Nova Scotia, British Columbia and Edmonton area. Physicians can establish strong community norms for a healthy lifestyle by:
* establishing and reinforcing healthy food policies in hospital cafeterias or at health-related meetings and conferences
* using, facilitating and advocating for the use of active transportation in their communities
* working within the community to ensure that recreation centres and other facilities are available and patients can be referred to the services most appropriate to their needs
Federal, Provincial, and Territorial Governments
CMA calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015.
In 2005, Canada's federal, provincial, and territorial governments endorsed a 10-year Healthy Living Strategy Framework, whose initial priorities included the promotion of healthy eating and physical activity. The national strategy addressed information and support for Canadians to help them make healthy choices; support for physicians and other health professionals in counselling patients on healthy weight and in treating existing obesity; community infrastructures that make healthy living easier; and public policies that encourage healthy eating and physical activity. The federal and provincial / territorial governments have undertaken a number of activities in the intervening years to promote physical activity and healthy eating but much remains to be done.
CMA believes that all levels of governments have a continuous obligation to provide public guidance on healthy eating and to promulgate policies, standards, regulations and legislations that support the availability and accessibility of healthy and affordable food and beverage choices.
CMA calls on governments to improve access to nutritious food at affordable prices for all Canadians.
The price of milk, fresh produce and other healthy foods can vary greatly across Canada. In many remote areas, they are often more expensive than processed, nutrition-poor foods because of high transportation costs. Governments should implement effective programs to offset the impact of transportation costs on food prices in northern and remote communities. Even in urban areas, nutritious food may be unaffordable for people on low incomes. School meal programs, social assistance rates that take into account the cost of purchasing healthy food, access to urban farmers' markets can help to ensure that all Canadians have access to healthy foods at a reasonable price.
CMA calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
The typical Canadian child may be exposed to as many as 40,000 advertisements for food a year.32 This does not include point-of-sale promotions, such as displays of candy bars at convenience-store counters. CMA's policy on marketing of unhealthy foods and beverages to children and youth calls for a ban on marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
CMA calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food.
Brand-specific advertising is a less than optimal way to provide health information to consumers, who should be encouraged to seek out objective information sources for answers to their questions about physical activity and healthy eating. To improve the quality of information received through commercial channels, the CMA recommends that health claims made for foods be strictly regulated to ensure that they are based on the best available scientific evidence and that they are accurately communicated to consumers. Food advertisements should be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drug Act should be strengthened.
CMA recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians.
CMA encourages all levels of governments to continue to fund and support research for healthy lifestyles. There is a clear need to invest in research to strengthen the evidence base about physical activity and healthy eating, particularly on:
best measures for assessing overweight and obesity;
the effectiveness of weight management and treatment programs; and
the effect of policy interventions on healthy eating and physical activity on rates of obesity and obesity-related disease.
CMA encourages governments to continue to work with the food industry to improve the food environment in Canada.
The partnership and collaboration of food manufacturers is needed to help Canadians make healthier food choices. The food industry can work with governments to:
reduce the salt, sugar, saturated fat, trans fat and calorie content of processed foods and pre-prepared meals;
provide information about the calorie and nutrition content on restaurant menus;
restrict advertising and in-store promotion of high-sugar, high-salt, high-fat foods, particularly those aimed at children;
provide user-friendly consumer information about their products, including and accurate health and advertising claims;
improve the nutrition fact table to make it more user friendly and increase the amount of information for example, by identifying the amount of free sugars.
CMA calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour.
Communities have an important role to play to promote healthy behaviours for children, youth, and adults. They shape how many Canadians decide to live, work and play in their daily life. Through mixed-use land planning and building design, communities can create walking-friendly environments, and reduce the time people spend in cars. To achieve this, communities should consider:
developing and maintaining a community-wide network of walking and cycling paths;
zoning communities in such a way that amenities are within walking distance of homes; and
revising building codes to make stairs accessible, pleasant and safe, so that people have an alternative to taking the elevator.
Canadians are considerably more physically active in the summer than in the winter and this could have an impact on obesity trends.33 Communities could improve pathways to healthy lifestyles year-round by improving access to indoor sport and recreation facilities, especially during winter. Where possible, communities should consider partnering with schools to share the use of gymnasiums, playgrounds, fields, courts, and tracks with the public after school hours and on weekends. In doing so, communities are ensuring the best use of time and resources, but also sharing liability for the development, operation, and maintenance of the facilities.
Community food security can happen if local residents have equal access to safe, affordable and nutritious food. Communities have a role to play in advocating for healthier food options in schools and workplaces, encouraging community kitchens to teach cooking skills, and supporting local agriculture and farmers markets. This, in turn, would encourage individuals to eat more healthy foods.
CMA encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias.
Prolonged, unbroken time spent sitting in front of a screen is very common in the workplace. In addition, four out of five commuters sit daily in their private vehicles to go to work.34 As Canadians spend most of their adult life at work, it is important to reduce workplace sitting. CMA encourages employers, especially in sedentary occupational groups, to increase opportunities for physical activity. For example, employers can promote healthy behaviours by:
Building on-site fitness facilities or entering into agreements with off-site fitness centres to provide programs for their employees
Providing showers, bike racks and other amenities for employees for those who want to commute to work on foot or by bike.
Healthier food options in cafeteria and vending machines can promote and encourage healthy eating by employees.
Schools, where children spend most of their time outside of home, present an excellent opportunity to instil healthy behaviours at an early age. They could, for example, provide comprehensive nutrition education, serve nutritious food in their cafeterias and promote physical activity by providing formal instruction and informal recreation time. Schools can provide the most effective and efficient way to reach not only the children themselves, but their parents, teachers, and other community members.35
CMA encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades.
Only 26% of Canadian schools reported that they had implemented daily physical education classes for their students.36 There is some evidence that school-based physical activity can increase physical activity levels and reduce time spent watching television at home. 37 For instance, schools can promote physical activity through unstructured out-of-home play, structured sports, or active transportation (e.g. walking to school). Children who are physically active and spend less time watching television after school are less likely to become overweight before age 12.38
CMA recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch.
CMA calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people.
Fast food restaurants and convenience stores can be an important influence on children's eating habits and food choices.39 Children attending schools within a short distance of fast food restaurants eat fewer fruits and vegetable servings, and drink more soft drinks than others who did not have similar establishments within proximity.40 To encourage effective school-based nutrition interventions, it is therefore important to educate students about the nutrition value of foods, healthy food choices, and provide healthy canteens or cafeterias.
Individuals and families
CMA recommends that all Canadians work toward achieving and maintaining health by:
educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults.
Ultimately, healthy eating and physical activity require that individuals take action to make healthy choices in their lives. To inform these choices, Canadians should be supported with appropriate resource materials with consistent information about healthy eating and physical activity. For instance, many young children do not choose what they consume; their parents buy and prepare the food for them. Research suggests that mothers and children appear to have divergent attitudes towards food and mealtimes.41 In this regard, it is important for parents to be well-informed and able to explain the tangible benefits of foods and their nutritional components to their children before they reach adulthood.
What we conclude
Healthy behaviours are easier to maintain through life if acquired in childhood and encouraged by the family. Therefore Canadian families should be supported in efforts to ensure that both children and adults eat nutritiously and exercise daily. We believe there is a role for everyone in promoting healthy behaviours - including health professionals, individuals, families, schools, workplaces, communities, the food industry and all levels of governments.
Popular approaches seek to provide individuals with information and options about healthy lifestyles choices. However, individual choice is not sufficient to ensure healthy behaviours.
Many barriers to the adoption of healthy behaviours and lifestyle choices can be met through a targeted population health approach, and evidence-based policy and regulatory controls. A comprehensive change in culture and mindset, political endorsement and multifaceted strategies are needed to promote and facilitate change to improve the dietary practices and physical activity levels of Canadians.
Summary of Recommendations
1. The Canadian Medical Association encourages physicians to promote healthy eating and physical activity inside and outside their office.
2. The Canadian Medical Association calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015.
3. The Canadian Medical Association calls on governments to improve access to nutritious food at affordable prices for all Canadians.
4. The Canadian Medical Association calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
5. The Canadian Medical Association calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food.
6. The Canadian Medical Association recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians.
7. The Canadian Medical Association encourages governments to continue to work with the food industry to improve the food environment in Canada.
8. The Canadian Medical Association calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour.
9. The Canadian Medical Association encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias.
10. The Canadian Medical Association encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades.
11. The Canadian Medical Association recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch.
12. The Canadian Medical Association calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people.
13. The Canadian Medical Association recommends that all Canadians work toward achieving and maintaining health by:
* educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
* engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults.
1 Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. BMJ. 2007;329:736-9.
2 Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;(12): CD001871.
3 Shields M, Martel L. (2006). Healthy living among seniors. Ottawa: Statistics Canada; 2005. Available: www5.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=82-003-S20050009086&lang=eng (accessed 2014 Jan 20).
4 Institute for Health Metrics and Evaluation. Global burden of disease arrow diagram. Seattle (WA): The Institute; 2013. Available: www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram (accessed 2010 Mar 15)
5Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Institute of Medicine of the National Academies. A population-based policy and systems change approach to prevent and control hypertension. Report, v-173. Washington (DC): National Academies Press; 2010.
6 Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377(9775):1438-47.
7 Roberts KC, Shields M, de Groh M, et al. Overweight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2012;23(3):37-41.
8 Canadian Institute for Health Information, Public Health Agency of Canada. Obesity in Canada. Ottawa: The Agency; 2011. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php (accessed 2014 Jan 20).
9 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease study 2010. Lancet. 2012;380:2224-60.
10Colley, R, Garriguet D, Janssen I, et al. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1).
11 Statistics Canada. Directly measured physical activity of Canadian adults, 2007-2011. Health fact sheets. Ottawa: Statistics Canada; 2013.
12 Colley R, Garriguet D, Janssen I, et al. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1).
13 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada CMAJ. 2000;163(11):1435-40.
14 Statistics Canada. Fruit and vegetable consumption. Health fact sheets. Statistics Canada Cat. No. 82-625-XWE. Ottawa: Statistics Canada; 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11837-eng.htm (accessed 2013 Nov 8).
15 Garriguet D. Canadians' eating habits. Statistics Canada Cat. No. 82-003. Health Rep. 2007;18(2):17-32. Available: www.statcan.gc.ca/pub/82-003-x/2006004/article/habit/9609-eng.pdf (accessed 2013 Jul 10).
16 Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291.
17 Monteiro CA, Levy RB. A new classification of foods based on the extent and purpose of their processing. Uma nova classifi cação de alimentos baseada na extensão e propósito do seu processamento. Cad Saude Publica. 2010;26(11):2039-49.
18 World Health Organization. Obesity the "new norm": day 1 of nutrition and NCDs conference. 2013. Available: www.euro.who.int/en/health-topics/health-policy/pages/news/news/2013/07/obesity-the-new-norm-day-1-of-nutrition-and-ncds-conference
19 Raine KD. Determinants of healthy eating in Canada: an overview and synthesis. Can J Public Health. 2005;96(Suppl 3):S8-14, s18-15.
20 Canadian Society for Exercise Physiology. Canadian physical activity guidelines. Ottawa: The Society; 2011. Available: www.csep.ca/guidelines (accessed 2014 Jan 20).
21 Statistics Canada. Canadian health measures survey: directly measured physical activity of Canadians, 2007 to 2011. The Daily. Ottawa: Statistics Canada; 2013 May 30. Available: www.statcan.gc.ca/daily-quotidien/130530/dq130530d-eng.pdf (accessed 2014 Jan 20).
22 Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105-13.
23 Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2013 (1). Review.
24 Glasgow RE, Eakin EG, Fisher EB, et al. Physician advice and support for physical activity results from a national survey. Am J Prev Med. 2001;21(3):189-96.
25 Salis R. Developing healthcare systems to support exercise: exercise as the fifth vital signs. Br J Sports Med. 2011;45(6):473-4.
26 Andersen RE, Blair SN, Cheskin LJ, et al. Encouraging patients to become more physically active: the physician's role. Ann Intern Med. 1997;127(5):395-400.
27 Public Health Agency of Canada. Overview of the Pan-Canadian Healthy Living Strategy. 2010. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs-eng.php (accessed 2014 Jan 20).
28 Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92.
29 Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived Success. Teach Learn Med. 2006;18(3):215-21.
30 Connaughton AV, Weiler RM, Connaughton DP. (May-June 2001). Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116:226-34.
31 Vallance JK, Wylie M, MacDonald R. Medical students' self-perceived competence and prescription of patient-centered physical activity. Prev Med. 2009;48(2):164-6. DOI: 10.1016/j.ypmed.2008.12.006
32 The Kaiser Family Foundation. The role of media in childhood obesity. Menlo Park (CA): The Foundation; 2004 Feb. Available: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/the-role-of-media-in-childhood-obesity.pdf (accessed 2014 Mar 19).
33 Merchant AT, Dehghan M, Akhtar-Danesh N. Seasonal variation in leisure-time physical activity among Canadians Can J Public Health. 2007;98(3):203-8.
34 Statistics Canada. Commuting to work. National Household Survey. 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_1-eng.cfm (accessed 2014 Jan 20).
35 Perez-Rodrigo C. School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 2001;4(1A):131-9.
36 Canadian Fitness and Lifestyle Research Institute. Policies related to physical activities. 2011 opportunities for physical activity at school survey. 2012 Aug 14. Available: http://www.cflri.ca/sites/default/files/node/1054/files/Schools%202011%20Bulletin%2012%20-%20Policy%20EN.pdf
(accessed 2013 Sep 15).
37 Dobbins M, Husson H, DeCorby K, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD007651.
38 O'Brien M, Nader PR, Houts RM, et al. The ecology of childhood overweight: a 12-year longitudinal analysis. Int J Obes (Lond). 2007;31(9):1469-78.
39 Howard PH, Fitzpatrick M, Fulfrost B Proximity of food retailers to schools and rates of overweight ninth grade students: an ecological study in California. BMC Public Health. 2011;11(68).
40 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009;99(3):505-10.
41 Le Bigot Macaux A. Eat to live or live to eat? Do parents and children agree? Public Health Nutr. 2001;4(1A):141-6.
IMPROVING EFFICIENCY IN THE CANADIAN HEALTH CARE SYSTEM
Achieving value in health care systems is an important objective for all nations.1 Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. This policy statement puts forth recommendations for system sustainability and improving quality of care. All system stakeholders including providers, funders and patients bear responsibility to ensure the health care system is as efficient as possible. Physician input is a necessary condition for meaningful system improvement and innovation.
Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. The concept of efficiency in health care has two applications. The most common is technical efficiency, which is defined as producing maximum output for a given level of inputs, or minimizing input for a given level of output.2 The difference between actual output and the maximum achievable output may be attributed to inefficiency within the system.
The second is called allocative efficiency, which refers to optimizing resource allocation to produce maximum outputs that fulfill societal demands. Canadian research suggests that increasing technical and allocative efficiency rather than increasing spending could solve some of the current challenges regarding health care quality and sustainability. Based on a macro system-level approach to estimating efficiency among its member countries, the Organization for Economic Cooperation and Development (OECD) has estimated that all of its member countries could achieve better value from their health care spending-Canada could save 2.5% of Gross Domestic Product in public spending by 2017 if it were to become as efficient as the most efficient OECD countries.3
2. Health care inefficiencies
The various inefficiencies in the Canadian health care system may be categorized and visualized using the conceptual framework developed by Bentley et al in 2008 for the U.S. health care system 4 (see Figure 1). In Canada, no such framework exists.
The framework of Bentley et al contains three main categories of inefficiencies - clinical, operational, and administrative. Clinical inefficiencies relate to practice variation challenges including, the provision of inappropriate care. Operational inefficiencies include duplication of health care services, inefficient processes, overly expensive inputs, and errors in data collection and processing. Administrative inefficiencies may be generally thought of as excess transaction costs associated with claims payment and excess costs of administration and management over and above what is required to deliver front-line health care.
Figure 1. Typology of health care inefficiencies
Source: Adapted from Bentley et al, 2008.
2.1 Clinical Inefficiencies
Clinical waste and inefficiencies refer to services that provide marginal or no health benefit compared with less costly alternatives. This may include practice variation and the provision of inappropriate and cost-ineffective care, or the underuse of more appropriate care. There is overlap between clinical inefficiencies (e.g., providing the wrong service) with operational inefficiencies (the inefficient production of services).
The chief contributor to clinical inefficiencies or waste in the health care field is practice variation-the reduction of unwarranted care variation is the foundation of the quality movement. John Wennberg and colleagues have pioneered the main body of work in this area through their studies on small area variation in care delivery.5 Over the last quarter century, technical studies on clinical practice guidelines (CPGs) have been developed in increasing numbers to address issues of appropriateness of care and care variation.
CPGs are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances".6 CPGs should contribute to better health, enhance the quality of care by reducing practice variation, and contribute to better value and lower costs by encouraging more appropriate use of resources by care providers.7 Although there has been no systematic approach in Canada to developing and disseminating CPGs, or to ensuring the quality of the CPGs produced, various organizations have developed initiatives to tackle this issue.8
Since the early 1990s, the Canadian Medical Association (CMA) has developed and maintained a CPG Infobase, which contains roughly 1,200 guidelines.9 The uptake of CPGs is a crucial component and insufficient resources are applied to necessary clinical practice change processes. Moreover, CPGs should be distillable to actionable points-of-care recommendations suited to the intended end user (e.g., family physicians).
In January 2012, the Council of the Federation (CoF) established the Health Care Innovation Working Group, which comprises all provincial and territorial health ministers, to determine practical and innovative ways to increase the value and effectiveness of care.10 The group's CPG recommendations focused on cardiovascular disease and diabetes - two of the most prevalent and highest-costing chronic diseases in Canada (see Appendix A for list of CPGs). In accordance with the CoF, the CMA recommends:
1. Developing chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system.
2. Integrating clinical practice guidelines with electronic medical records.
3. Implementing a pan-Canadian clinical practice guidelines strategy.
4. Using evidence-informed clinical practice guidelines to evaluate patient outcomes, appropriateness, and cost-effectiveness.
5. Developing deployment strategies to ensure maximum use of clinical practice guidelines by physicians.
Clinical practice guidelines need regular updating as new evidence emerges. Therefore, a Pan-Canadian strategy should include a system of regular review and updating using development methods that would exclude the possibility of industry bias. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada (see below).
There is an increasing trend in health care utilization in areas such as medical procedures, drugs, and physician services.11 Questions remain about whether or not people are receiving care that is appropriate and based on the best available scientific information.12 Inappropriate care, such as the hospitalization of patients who need community-based services or prescribing antibiotics for upper respiratory infections that are likely viral in origin, is another source of clinical inefficiency, using scarce resources for marginal or no health benefit.
The CMA recently defined appropriate care as the right care, provided by the right provider, to the right patient, in the right venue, at the right time:
* "right care" is based on evidence for effectiveness and efficacy in the clinical literature, and not only implies appropriateness of use, but inappropriateness of 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;
* "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.
As a corollary to this definition, if all five components are present, high quality care has been delivered with the optimal use of resources, that is, waste has been eliminated and the best value has been obtained.
Appropriateness is primarily determined by analyses of the evidence of clinical effectiveness, safety, and other health system impacts.13 The practical application of appropriateness is made when these analyses are qualified by (a) clinician judgment, particularly in atypical circumstances14 and (b) societal and ethical principles and values, including patient preferences.
There are a number of perverse incentives that can contribute to the delivery of inappropriate care across the system. These exist at the system level (e.g., patients staying in hospitals longer than needed due to the lack of community services), as well as at the individual encounter level (changes in fee codes for insured medical services such as new consult fees to see a patient every six months). Physicians and payers such as governments need to work together to eliminate perverse incentives based on available medical evidence. Physician incentives should align with system needs. The challenge is getting governments, health authorities and provincial and territorial medical associations, and individual providers agreeing on system goals and objectives.
In the U.S., an innovative appropriateness initiative called Choosing Wisely was established in 2011 with the goal of improving care quality and reducing harm to patients by avoiding unnecessary interventions, with the added benefit of possible cost reductions.15 The initiative challenged specialty societies to identify five clinical activities in their field that are generally of little value or are potentially harmful to patients.16
In Canada, CMA's 2013 General Council called for the formation of 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. Choosing Wisely Canada was launched on April 2, 2014 with the release of eight lists produced by nine specialty societies (one list was released jointly by the CMA's Forum on General and Family Practice Issues (GP Forum) and the College of Family Physicians of Canada (CFPC)). Twelve additional medical specialty societies released lists in October 2014. The Choosing Wisely Canada campaign is endorsed and supported by over 35 national specialty societies representing a broad spectrum of physicians, as well as by all provincial medical associations, patient organizations, accrediting bodies and others (Website: www.choosingwiselycanada.org). Choosing Wisely Canada aims to promote physician-patient communication about unproductive care and conserve resources by eliminating unneeded activities. This initiative also serves as an example of the role of public education campaigns to help improve appropriate care.
The development of a Canadian version of the Choosing Wisely initiative assists in operationalizing the Institute for Healthcare Improvement's (IHI) Triple Aim concept of better care, better health, better value. Specific benefits include:
* Improving accountability by providing transparent, evidence-informed care;
* Facilitating patients to make the right care decisions;
* Enhancing physician-patient relationships: improve communication and decision-making between patients and their physician; and
* Reducing clinical inefficiencies.
The ultimate objective and impetus for adopting a Choosing Wisely initiative must be to improve patient outcomes. Cost savings to the system should occur as a byproduct. Physicians are in the best position to identify which medical services are unnecessary.
Both patients and providers need to be aware of the costs associated with each treatment option, recognizing there is a balance to strike between cost and value. To facilitate this process, the CMA recommends:
6. Making available data on the cost and cost-effectiveness of treatment options at the point of care.
7. Collecting information to evaluate cost-effective care.
8. Posting costs generated by requests for diagnostic and laboratory tests in electronic medical records.
Evaluation should take place to ensure the posting of costs is targeted to areas where it will be most effective.
2.2 Operational inefficiencies
Examples of operational waste include: undertaking tests or procedures more frequently than clinically necessary (e.g., duplication of tests); unnecessary time spent waiting for medical services or time wasted from processes that add little value; using brand drugs for patients who get equal benefit from generics; and health and cost consequences of medical errors or the use of defective medical devices.
These system inefficiencies can amount to very significant costs to the health care system, patients and the economy. For instance, lengthy waits can have serious health consequences for patient outcomes and result in the substitution of additional health care services while waiting (e.g., use of pain medication). A 2008 study calculated the economic impact of excessive wait times for five procedures (hip and knee replacement surgery, MRIs, CABG surgery and cataract surgery) in all 10 provinces. It found that, in addition to the obvious emotional, physical and financial toll endured by patients and their families, lengthy waits for these medical treatments cost Canada's economy an estimated $14.8 billion overall in 2007 in reduced economic activity by patients ($16.9 billion in 2014 dollars). This included a $4.4 billion reduction in federal and provincial government revenues.17
Notwithstanding a shortage in health care infrastructure, there is general consensus that not all hospital infrastructure is used to its fullest capacity, contributing to lengthy wait times for many patients. This can include excessive turnover time between cases or limited operating room hours that can result in the last patient of the day being unable to receive their surgery at great cost to the patient and their family. In many instances, urban hospitals must cancel surgeries due to overbooked operating room time when in smaller and rural communities, operating rooms are not fully utilized. Strategies should be explored to enable greater use of health infrastructure resources in smaller community hospitals that will serve to enhance timely access to care for patients. This would also ensure that staff had a level of activity that would maintain their skills.
There has been significant uptake of operations research and quality improvement processes to help eliminate operational waste and address unnecessary waiting by patients. To this end, CMA will continue to work with its partners in the Wait Time Alliance to identify strategies to improve timely access to care for patients across the continuum. The CMA will also study the potential health applications of the Theory of Constraints within the Canadian health care system.18
There can also be system-wide inefficiencies in the various health systems operating in the country and in terms of how health systems interact with other systems such as economic and social support systems (e.g., lack of services to address homelessness). Changes in one component of the health care system can negatively affect the efficiency in another component. For instance, cuts made to home care services can lead to a rise in the number of alternate-level-of care (ALC) patients in hospitals, increased wait times in emergency departments, and elective surgery cancelations. A more recent source of system inefficiency has been occurring due to the piecemeal adoption of electronic medical records and information systems (EMR) throughout the country. The multitude of systems adopted by different segments of the health care system has resulted in problems with system inter-operability that often exacerbate administrative and clinical inefficiencies such as preventing the electronic attachment of test results leading to the reordering of tests.
The Canadian Institute for Health Information (CIHI) developed a model to measure and evaluate "health system efficiency" within Canada. It measures the average efficiency of health systems in Canada's health regions and the factors that help explain variations in estimates of system efficiency (measured as the reduction in potential years of life lost (PYLL) from treatable causes of death). The study found that equitable access to physician care is positively associated with efficiency.19 Unfortunately, over 4 million Canadians still do not have a regular family physician.20
In addition, the CIHI study found that factors related to the social determinants of health can also affect system efficiency (e.g., missed prevention opportunities). Frequently, the health care system is relied on to address preventable health needs that are attributable to the social determinants of health (e.g., injuries or illnesses caused by lack of affordable housing or poverty). Furthermore, these factors can negatively affect the effectiveness of any treatment provided by the health care system.21
Governments and health administrators should focus on improving efficiencies where there is the highest volume of services as new models of efficiency do not always show results in low volume areas.
2.3 Administrative inefficiencies
Health programs can be funded and administered at a variety of levels: local, regional, provincial and federal, as well as through employers. According to CIHI, administration accounted for $6.3 billion, or 3.1%, of health care costs in Canada in 2011-roughly middle of the pack among OECD countries22-but this is only the cost of providing public and private health insurance programs and the costs associated with health departments'operations.11 Generally, differences in the level of health administration can be explained in part by the type of health system and financing used such as whether multiple insurance providers exist or the extent that complex funding and billing procedures are in place.23 1
In terms of other administrative costs, we do not know how Canada has evolved over time in comparison to other sectors of the economy or how we compare internationally with respect to the effectiveness of administration expenditures.1 There have been questions about the expansion and contraction of regional health authorities in Canada over the past two decades. However, Canada does not have a detailed set of health accounts that would permit such analysis. CIHI has recently begun to report the percentage of administrative services expenses (general administration, finances, human resources and communications) as a percentage of total expenses for over 600 hospitals as part of its Canadian Hospital Reporting Project (CHRP).24
One source of administrative waste is the cost of duplicate collection and recording of health information. The health sector has been slow in adopting health information technology to help reduce this form of administrative waste.
Another cause of inefficiency is the increase in administrative burden faced by Canadian physicians and their patients. A major contributor is the rise in requests for physicians to complete third party forms from insurance companies and governments (see Appendix B for a list of examples of federal health programs and related medical forms). Different definitions of concepts are frequently used in these forms, but in many instances they are asking for similar information about the same patient. Physicians are also frequently requested to complete sick notes-the CMA believes such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources.25
The cumulative effect of a physician being requested to complete several forms each day can result in significant administrative burden and take away time that physicians can spend providing direct patient care. Standardizing definitions and wording on third-party forms can save time and reduce administrative errors. Physicians fully support any efforts by the private insurance industry and governments to standardize their medical forms. In addition, consideration should be given to instances where other designated providers can be tasked with completing particular forms. Where suitable, electronic medical records (EMRs) can improve the completion and timely submission of third-party forms to the benefit of patients, providers and third-parties.
To address these administrative inefficiencies, the following actions have been recommended by CMA:
9. Federal and provincial auditors general design and implement a protocol for detailed enumeration of administrative costs within their health care systems, including tracking of these costs over time, and issue an annual public report.
10. CIHI conduct a detailed study of administrative costs of Canadian hospitals and regional health authorities and report the findings.
11. Harmonize and centralize, in electronic and written format, all administrative forms that physicians must fill out on behalf of their patients.
3. Innovating for efficiency
Since the late 1990s, the federal, provincial, and territorial governments, and other granting bodies have provided considerable funding for applied health services research to aid the implementation of pilot projects to improve the quality of care delivered in Canada. However, Canada is frequently criticized for its inability to move beyond pilot projects to full implementation. One often-cited reason is the lack of communication about promising innovations from one jurisdiction to another. Other reasons include regulatory barriers such as funding silos, and pilot project funding for a limited duration to prevent meaningful outcome evaluation. Physician input is a necessary condition for meaningful and sustained system innovation.26
The CMA supports:
12. Developing and testing innovative structures or programs to demonstrate clear evidence of improvement in health care outcomes and fiscal sustainability before wide-spread adoption into the Canadian health delivery system.
13. Developing policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
14. Creating a registry of physician-managed health care transformation projects. This registry should outline the challenges and lessons learned associated with each project for those interested in adopting similar projects.
Addressing efficiency challenges in the Canadian health care system can improve the quality, continuity, and comprehensiveness of care, while making the system more cost-effective and sustainable. Many components of the health care inefficiencies set out by Bentley et al are now being considered by governments. Physician input is a necessary condition for meaningful system improvement and innovation. Physicians should practice high quality, evidence-informed health care, and advocate for cost-effective allocation of scarce resources. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada.
Clinical Practice Guidelines (CPGs) recommended by
The Health Care Innovation Working Group of the Council of the Federation
The group recommended each province and territory work with their health authorities to adopt the following CPGs:
* The C-CHANGE guidelines for cardiovascular disease published by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE) to reduce guideline variations and confusion among care providers.
* Harmonized guidelines for diagnosis, which include:
o Laboratory testing (e.g., urine analysis, ECGs)
o Risk stratification strategies (e.g., family history, lifestyle choices, and diabetic patients).
* Harmonized guidelines for treatment, which include:
o Establishing treatment targets (e.g., limiting alcohol consumption, healthy body weight, glycemic or glucose targets)
o Health behavior interventions (e.g., balanced heart healthy diet, limiting salt intake, smoking cessation)
o Pharmacological therapy (e.g., assessment of drug and drug interactions, co-morbidities).
Examples of federal health programs and related medical forms
physicians are frequently requested to complete
* Canada Pension Plan Disability
* Disability Tax Credit
* Employment Insurance (Sickness Benefits Claim)
* Non-Insured Health Benefits (for First Nations people and Inuit)
* Veterans Disability Pension
* Compassionate Care Leave
* Exception/Limited Use Drug Request Form (to permit access to drugs not on provincial formularies)
* Interim Federal Health Program
* Canadian Adverse Drug Reaction Monitoring forms
1 Organisation for Economic Co-operation and Development. Health care systems: getting more value for money. OECD Economics Department Policy Note No. 2. Paris: The Organisation; 2010.
2 Canadian Institute for Health Information. Developing a model for measuring the efficiency of the health system in Canada. Ottawa: The Institute; 2012. Available: https://secure.cihi.ca/free_products/HS_Efficiency_Tech_Report_EN-web.pdf (accessed 2013 Apr 30).
3 Organisation for Economic Co-operation and Development. OECD economic surveys: Canada 2012. Paris: OECD Publishing; 2012. Available: http://dx.doi.org/10.1787/eco_surveys-can-2012-enOECD
4 Bentley T, Effros R, Palar K, et al. Waste in the U.S. health care system: a conceptual framework. Milbank Q. 2008;86(4):629-59.
5 Wennberg J, Gittelson A. Small area variations in health care delivery. Science. 1973;182:1102-8.
6 Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington (DC): National Academy Press; 1990. p. 38.
7 Canadian Medical Association. Handbook on clinical practice guidelines. Ottawa: The Association; 2007.
8 The Canadian Institutes of Health Research (CIHR) has launched a Strategy for Patient Oriented Research and one of its core elements is the improvement of guideline development, dissemination and uptake through support for guideline development and dissemination. Canadian Institutes of Health Research. Canada's strategy for patient-oriented research: improving health outcomes through evidence-informed care. Ottawa: The Institutes; 2011. Available: www.cihr-irsc.gc.ca/e/documents/P-O_Research_Strategy-eng.pdf (accessed 2012 Feb 22).
9 Canadian Medical Association. CMA Infobase: clinical practice guidelines (CPGs). Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2012 Feb 22).
10 Council of the Federation Working Group. From innovation to action - the first report of the Health Care Innovation Working Group. Available: www.canadaspremiers.ca/phocadownload/publications/health_innovation_report-e-web.pdf (accessed 2013 Apr 25).
11 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2013. Ottawa: The Institute; 2013. Available: https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf.
12 Canadian Institute for Health Information. Health care in Canada 2010. Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/HCIC_2010_Web_e.pdf (accessed 2014 Oct 7).
13 Canadian Medical Association. Appropriateness. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-05.pdf.
14 Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. JAMA. 2013;309(24):2559-60.
15 Siwek J. Choosing wisely: top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128-33.
16 The Good Stewardship Working Group. The "top 5" lists in primary care. Arch Intern Med. 2011;171(15):1385-90.
17 Centre for Spatial Economics. The economic cost of wait times in Canada. Ottawa: The Centre; 2008. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/EconomicReport-e.pdf (accessed 2014 Apr 14).
18 Knight A. The theory of constraints in health and social care. Aldbury (UK): QFI Consulting; 2011.
19 Canadian Institute for Health Information. Measuring the level and determinants of health system efficiency in Canada. Ottawa: The Institute; 2014 Apr. Available: https://secure.cihi.ca/free_products/HSE_TechnicalReport_EN_web.pdf (accessed 2014 Feb 5).
20 Statistics Canada. Access to a regular medical doctor, 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11832-eng.htm (accessed 2014 Jan 5).
21 Canadian Medical Association. Health care in Canada: What makes us sick? Town hall report. Ottawa: The Association; 2013 Jul. Available: www.cma.ca/Assets/assets-library/document/fr/advocacy/What-makes-us-sick_en.pdf.
22 Organisation for Economic Co-operation and Development. Guidelines to improve estimates of expenditure on health administration and health insurance. Paris: The Organisation; 2013 Dec.
23 Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: U.S. costs exceed all others by far. Health Aff (Millwood). 2014;33(9):1586-94.
24 Canadian Institute for Health Information. Canadian Hospital Reporting Project (CHRP). Available: www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001 (accessed 2014 Mar 20).
25 Canadian Medical Association. Short-term illness certificate. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf
26 Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev. 2014;92(6):104-11, 138.