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Health Canada consultation on proposed vaping products promotion regulations

https://policybase.cma.ca/en/permalink/policy14128
Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Since 1867, the Canadian Medical Association has been the national voice of Canada’s medical profession. We work with physicians, residents and medical students on issues that matter to the profession and the health of Canadians. We advocate for policy and programs that drive meaningful change for physicians and their patients The Canadian Medical Association (CMA) appreciates this opportunity to respond to the notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada’s proposed Vaping Products Promotion Regulations “that would (1) prohibit the promotion of vaping products and vaping product-related brand elements by means of advertising that is done in a manner that can be seen or heard by young persons, including the display of vaping products at points of sale where they can be seen by young persons; and (2) require that all vaping advertising convey a health warning about the health hazards of vaping product use.” Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always, and will continue to support, strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on governments in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. Introduction It is imperative that the regulations concerning the promotion of vaping products be tightened sooner rather than later. While the CMA views Health Canada’s proposed regulations as a step in the right direction, they should only be considered as the start of extensive regulatory, policy and public health work required to effectively address the harms associated with vaping. Vaping is not without risks. Evidence continues to grow about the hazards associated with the use of e-cigarettes, especially for youth and young adults. The emergence of e-cigarette, or vaping, product use-associated lung injury (EVALI) in the United States and to a lesser extent in Canada, illustrates the danger these products can pose. The Centers for Disease Control and Prevention (CDC) reported that as of January 7, 2020 that there were 2,602 cases of hospitalized EVALI or deaths (57 so far) reported by all 50 states, the District of Columbia, and 2 U.S. territories (Puerto Rico, and the U.S. Virgin Islands). In an update published in the CDC’s Morbidity and Mortality Weekly Report, “younger age was significantly associated with acquiring THC-containing and nicotine-containing products through informal sources.” The report concludes with this warning: “Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.”3 In Canada, as of January 7, 2020, 15 cases of severe pulmonary illness associated with vaping have been reported to the Public Health Agency of Canada. A recent public opinion survey conducted by the Angus Reid Institute (ARI) indicates that Canadians are growing more concerned about the safety of vaping as more information on the potential harms becomes available. The survey found that the number of people saying that vaping does more harm than good rose from 35% in 2018 to 62% in 2019.5 Further, 17% of parents with children under 19 said their child either vaped or had tried it; 92% of those parents considered vaping harmful.5 Significant to this discussion is the fact that 90% of respondents support “banning advertisements of vaping products in areas frequented by young people. This includes areas such as bus shelters or parks, and digital spaces like social media.”5 As public unease continues to rise, the need for further tightening of regulations becomes vital. Unfortunately, the federal government is still behind the curve when it comes to the proliferation of vaping and the vaping industry. Health Canada will have to step up surveillance and enforcement if tightening of the regulations is to be effective. This brief will address the planned regulations as well as discuss important issues not covered such as nicotine levels and flavours. We have expressed concerns about these topics in previous consultations and will be reiterating them here. Promotion of Vaping Products The CMA appreciates Health Canada’s intent to tighten the regulations but this proposal is not sufficient, and we must reiterate our long-held position that the restrictions on the promotion of all vaping products and devices be the same as those for tobacco products. , The proposed regulations provides the vaping industry with too much latitude in their promotion activities to ensure youth are protected. As we noted in our response to Health Canada’s consultation on The Impact of Vaping Products Advertising on Youth and Nonusers of Tobacco Products, the advertisements that have been permitted to this point seem to have managed to find their way to youth, even if they are not directed at them, as has been asserted.7, We recommended vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. The CMA stands by that recommendation.7 The methods used by the vaping industry in the past succeeded in attracting more and more youth and young adults and it will no doubt continue efforts to find novel approaches for promoting their products, including the use of popular social media channels. , , , Indeed, “JUUL’s™ advertising imagery in its first 6 months on the market was patently youth oriented. For the next 2 ½ years it was more muted, but the company’s advertising was widely distributed on social media channels frequented by youth, was amplified by hashtag extensions, and catalyzed by compensated influencers and affiliates.”10 The vaping industry’s efforts to circumvent marketing restrictions in other jurisdictions are evident in view of some recent developments. A US study outlines an e-cigarette marketing technique that involves the promotion of scholarships for students. The study found 21 entities (manufacturers, e-cigarette review websites, distributors) offering 40 scholarships, ranging in value from $300 to $5000 (US).13 Most of the scholarships required “an essay submission, with most listing prompts related to e-cigarettes or eliciting information about the benefits of vaping.”13 The authors suggest “that prohibitions on e-cigarette scholarships to youth are also needed, as many of these scholarships require youth under the age of 18 years (for whom use of e-cigarettes are illegal) to write positive essays about vaping.”13 Health Warnings The CMA reiterates, yet again, its position that all health warnings for vaping products and devices should be similar to those presently required for tobacco packages in Canada.6, The need for such cautions is important in that we still do not understand fully the effects vaping can have on the human body. Harms More research is needed into the potential harms of using electronic cigarettes to understand the long-term effects users may face. , , The proposed health warnings are not strong enough in light of the research and knowledge that has emerged to date about the harms caused by e-cigarettes. For example, a recent US study highlighted the potential link between e-cigarette use and depression. It found “a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use.”18 As the authors note, “the potential mental health consequences may have regulatory implications for novel tobacco products.”18 Further, with respect to respiratory issues, a US study found that “use of e-cigarettes appears to be an independent risk factor for respiratory disease in addition to all combustible tobacco smoking.” The authors also don’t recommend the use of e-cigarettes as a smoking cessation tool because “for most smokers, using an e-cigarette is associated with lower odds of successfully quitting smoking.”19 Nicotine Levels Nicotine levels and flavours are not addressed in this consultation. However, the CMA considers these issues to be vital in the effort to protect youth and young adults from the harms associated with e-cigarettes and will therefore provide comment in effort to speed movement toward resolving these problems. The CMA remains very concerned about the rising levels of nicotine available through the vaping process. They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.” Hammond et al noted in their 2019 study that “JUUL® uses benzoic acid and nicotine salt technology to deliver higher concentrations of nicotine than conventional e-cigarettes; indeed, the nicotine concentration in the standard version of JUUL® is more than 50 mg/mL, compared with typical levels of 3-24 mg/mL for other e-cigarettes.”9 The salts and flavours available to be used with these devices reduce the harshness and bitterness of the taste of the e-liquids with some of the competition delivering even higher levels of nicotine. The CMA called on Health Canada to restrict the level of nicotine in vaping products to avoid youth (and adults) from developing a dependence.20 Health Canada set the maximum level at 66 mg/ml while a European Union (EU) directive of 2014 indicates the level should not exceed 20 mg/ml. , Nicotine, among other issues, “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment. , Utilizing the EU level as an interim measure until more scientific research is available to determine an optimal level is acceptable. Flavours On December 5, 2019, the Government of Nova Scotia became the first province or territory to announce it would institute a ban on sale of flavoured e-cigarettes and juices, as of April 1, 2020. The CMA recommends that flavours banned to reduce the attractiveness of vaping to youth as much as possible; others share this sentiment.6,7, Flavours are strong factors in attracting youth, especially when coupled with assertions of lower harm. Their success in doing so is evidenced by the rise in the rates of vaping among youth.9, A recent US study found that “perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes may lead to e-cigarette use progression among youth never tobacco users. Determining the factors (including e-cigarette marketing and specific e-cigarette flavors) that lead to perceived ease of using flavored e-cigarettes would inform efforts to prevent and curb youth e-cigarette use.” The CMA recommends that flavours be banned to reduce the attractiveness of vaping to youth as much as possible. Recommendations 1. The CMA recommends that vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. 2. The CMA reiterates its position that all health warnings for vaping products and devices should be similar to those for tobacco packages. 3. The CMA believes that the European Union 2014 directive indicating the nicotine concentration not exceed 20 mg/ml should be adopted as an interim measure until more scientific research is available to determine an optimum level. 4. CMA recommends flavours be banned to reduce the attractiveness of vaping to youth as much as possible.
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Climate governance in Quebec: For a better integration of the impact of climate change on health and the health care system

https://policybase.cma.ca/en/permalink/policy14130
Date
2020-02-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2020-02-05
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) and its Quebec office are pleased to provide this submission to the Committee on Transportation and the Environment on Bill 44: An Act mainly to ensure effective governance of the fight against climate change and to promote electrification. The CMA maintains that governance of the fight against climate change will not be effective unless it integrates the health impacts on the Quebec population. Physicians in Quebec, across Canada, and around the world have a unique role to play in helping advance government and public understanding of the health consequences of climate change and in supporting the development of effective public health responses. The CMA’s submission provides recommendations to better prepare and mitigate the impacts of a changing climate on people’s health and the health care system in Quebec. How Climate Change Affects Health The World Health Organization has identified climate change as the biggest threat to global health. 1 In Canada, the immediate health effects of climate change are a growing concern. In this century, Canada will experience higher rates of warming in comparison to other countries around the world. Northern Canada, including northern Quebec (Nunavik), will continue to warm at more than triple the global rate. These warming conditions will lead to an increase in extreme weather events, longer growing seasons, melting of the permafrost, and rising sea levels.2 Physicians are at the front lines of a health care system that is seeing growing numbers of patients experiencing health problems related to climate change, including heat-related conditions, respiratory illnesses, infectious disease outbreaks and impacts on mental health. For example, the heat wave in southern Quebec in 2018 was linked to over 90 deaths.3 Examples of the extent of this issue include:
The number of extremely hot days is expected to double or triple in some parts of Canada in the next 30 years and will lead to an increase in heat-related impacts (e.g., heat stroke, myocardial infarction, kidney failure, dehydration, stroke).4
Air pollution contributes to approximately 2,000 early deaths each year in Quebec by way of heart disease, stroke, lung cancer, and respiratory disease (such as aggravated asthma).5
An increase in vector-borne diseases such as Lyme disease has increased significantly in Quebec, with the number of cases increasing from 125 in 2014 to 338 in 2018.6
Extreme weather events are increasing in frequency, intensity and duration across Quebec and can negatively impact mental health (e.g., anxiety, depression and post-traumatic stress disorder),7 as well as place additional strain on the health care system.
Increasing temperatures are affecting the ice roads used in winter, and other roads built on permafrost in northern Quebec, threatening food security.8 3 There are sub-populations that are more susceptible to the health-related impacts of climate change. For example, in northern Quebec, climate change is already increasing health risks from food insecurity due to decreased access to traditional foods, decreased safety of ice-based travel, and damage to critical infrastructure due to melting permafrost. For the rest of Canada, the health impacts vary by geographic region, but include a list of issues such as increased risk of heat stroke and death, increases in allergy and asthma symptoms due to a longer pollen season, mental health implications from severe weather events, and increases in infectious diseases, UV radiation, waterborne diseases and respiratory impacts from air pollution. 9 Seniors, infants and children, socially disadvantaged individuals, and people with existing medical conditions such as cardiovascular disease, are at greater risk of being affected by climate change. The susceptibility of a population to the effects of climate change is dependent on their existing vulnerabilities and their adaptive capacity. 10,11 Figure 1. Examples of Health Impact of Climate Change in Canada5 Climate Change: A Health Emergency Recent polls have demonstrated that Canadians are very concerned about climate change and its impact on health. A 2017 poll commissioned by Health Canada revealed that 79% of Canadians were convinced that climate change is happening, and of those people 53% accepted that it is a current health risk and 40% believe it will be a health risk in the future.12 As well, a 2019 poll commissioned by Abacus Data reports that Quebecers are the most anxious about climate change and think about the climate more often than people living in the rest of Canada. The same poll reports that 59% of people in Quebec believe that climate change is currently an emergency and 12% reported that it will likely become an emergency in a few years.13 These numbers are not surprising considering the intensity and frequency of extreme weather events in Quebec in recent years. The CMA believes climate change is a public health crisis. Over the past few years in Canada, there have been numerous extreme climate events, such as wildfires in British Columbia, 4 extreme heat waves in Quebec, and storm surges on the east coast. In southern Quebec, a changing climate has also increased the range of several zoonoses, including blacklegged ticks, which are vectors of Lyme disease.14 Physicians across Quebec are seeing patient outcomes affected by the changing climate and are advocating for change. The health impacts of climate change were raised at last year’s COP25 meeting in Madrid, Spain, among an international group of leading environment and health stakeholders, including the CMA. The group collectively called on governments to broaden the scope of their climate change initiatives and investments to include health care. A lack of progress in reducing greenhouse gas emissions and building adaptive capacity threatens both human lives and the viability of health systems, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. In Quebec, the research consortium Ouranos estimated in 2015 that extreme heat, Lyme disease, West Nile virus and pollen alone will cost the Quebec state an additional $609 million to $1,075 million,15 and could result in up to 20,000 additional lives lost within the next 50 years. Canada is currently not on track to meet the international targets set out by the Paris Agreement.16 The 2019 report from Lancet Countdown, the largest international health and climate research consortium, states that continued inaction on meeting the targets set out by the Paris Agreement will result in the health of a child born today being impacted negatively by climate change at every stage of its life. Recommendation 1: The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health. Hearing Health Care Professionals on Climate Change Last June, the CMA was pleased with the announcement made by the Minister of the Environment and the Fight Against Climate Change, Benoit Charette, to create a task force to ensure effective governance of the fight against climate change, including meeting Quebec’s international climate targets.17 Climate change crosses multiple sectors and requires experts from diverse backgrounds to create solutions to adapt and mitigate the impacts of climate change. Considering the overwhelming evidence of the impacts of climate change on human health, it is paramount that a health representative sits on the committee that will be advising the Minister. Physicians and health professionals have a critical role to play in advancing public understanding of the potential impacts of climate change on health and promoting appropriate actions aimed at protecting the health of Canadians. Physicians believe that what’s good for the environment is also good for human health. Protecting human health must be at the core of all environmental and climate change strategies within Quebec. 5 Recommendation 2: The CMA recommends that a health representative sit on the committee that will be advising the minister. Dedicated Funding for a Greener Health Care System The 2019 Lancet Countdown on Health and Climate Change reports that Canada has the third-highest per capita greenhouse gas emissions coming from its health care sector in the world. Health care related emissions account for approximately 4.5% of the country’s total emissions. Hospitals produce a significant proportion of health sector emissions as they are always on, are resource intensive, and have strict ventilation standards. Hospital services also produce large amounts of waste through the use of single-use items (e.g., hospital gowns and surgical supplies). To remedy this problem, the CMA recommends that experts from research, education, clinical practice, and policy work together to reduce greenhouse gas emissions and that funding be dedicated to measuring the carbon footprint of different institutions and addressing these issues. Health care providers are uniquely positioned to advocate for innovative solutions that will help reduce greenhouse gas emissions by the health sector and improve public health.18 By reducing greenhouse gas emissions from the health system, the Quebec government will better position itself to be consistent with the timelines and goals of the Paris Agreement for zero-emissions for healthcare by 2050.19 Recommendation 3: The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems. Conclusion The CMA’s submission highlights the need to better prepare and mitigate the health impacts of a changing climate, as well as the need for a health representative to advise the minister, and the allocation of funding for the greening of health systems in Quebec. Physicians are in a unique position to help the government develop strategies to mitigate the impacts of climate change and ultimately improve population health. Summary of recommendations Recommendation 1: The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health. Recommendation 2: The CMA recommends that a health representative sit on the committee that will be advising the minister. Recommendation 3: The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems. 6 1 Costello A, Abbas M, Allen A, Ball S, et al. The Lancet and University College London Institute for Global Health Commission, The Lancet, 2009;373( 9676):1693-1733. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60935-1/fulltext (accessed 2020 Jan 25). 2 Government of Canada. Canada’s Changing Climate Report. Ottawa: Government of Canada; 2019. Available: https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/energy/Climate-change/pdf/CCCR_FULLREPORT-EN-FINAL.pdf (accessed 2020 Jan 25). 3 Institut national de santé publique du Québec. Surveillance des impacts des vagues de chaleur extrême sur la santé au Québec à l’été 2018 [French only]. Québec : Institut national de santé publique du Québec; 2018. Available: https://www.inspq.qc.ca/bise/surveillance-des-impacts-des-vagues-de-chaleur-extreme-sur-la-sante-au-quebec-l-ete-2018 (accessed 2020 Jan 25). 4 Guilbault S, Kovacs P, Berry P, Richardson G, et al. Cities adapt to extreme heat: celebrating local leadership. Ottawa: Health Canada Institute for Catastrophic Loss Reduction; 2016. Available: https://www.iclr.org/wp-content/uploads/PDFS/cities-adapt-to-extreme-heat.pdf (accessed 2020 Jan 25). 5 Health Canada. Health Impacts of Air Pollution in Canada--an Estimate of Premature Mortalities. Ottawa: Health Canada; 2017. Available: https://www.canada.ca/en/health-canada/services/air-quality/health-effects-indoor-air-pollution.html (accessed 2020 Jan 25). 6 Santé et services sociaux Québec. Maladie de Lyme. Tableau des cas humains – Archives 2014 à 2018. [French only]. Available: https://www.msss.gouv.qc.ca/professionnels/zoonoses/maladie-lyme/tableau-des-cas-humains-lyme-archives/ (accessed 2020 Jan 25). 7 Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81. 8 Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4937722/pdf/IJCH-75-31127.pdf (accessed 2020 Jan 25). 9 Howard C, Buse C, Rose C, MacNeill A, Parkes, M. The Lancet Countdown on Health and Climate Change: Policy Brief for Canada. London: Lancet Countdown, Canadian Medical Association, and Canadian Public Health Association, 2019. Available: https://storage.googleapis.com/lancet-countdown/2019/11/Lancet-Countdown_Policy-brief-for-Canada_FINAL.pdf. (accessed 2020 Jan 25). 10 Canadian Medical Association (CMA). CMA Policy. Climate Change and Human Health. Ottawa: CMA; 2010. Available: https://policybase.cma.ca/en/permalink/policy9809 (accessed 2020 Jan 25). 11 Health Canada. Climate Change and Health. Ottawa: Health Canada; 2020. Available: https://www.canada.ca/en/health-canada/services/climate-change-health.html (accessed 2020 Jan 26). 12 Environics Health Research. Public Perceptions of Climate Change and Health Final Report. Ottawa: Health Canada; 2017. 13 Abacus Data. Is Climate Change “An Emergency” and do Canadians Support a Made-in-Canada Green New Deal? Ottawa: Abacus Data; 2019. Available: https://abacusdata.ca/is-climate-change-an-emergency-and-do-canadians-support-a-made-in-canada-green-new-deal/ (accessed 2020 Jan 26). 14 Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association. Available: https://storage.googleapis.com/lancet-countdown/2019/10/2018-lancet-countdown-policy-brief-canada.pdf. (accessed 2020 Jan 25). 15 Ouranos. Vers l’adaptation. Synthèse des connaissances sur les changements climatiques au Québec [French only]. Montreal: Ouranos; 2015. Available: https://www.ouranos.ca/publication-scientifique/SyntheseRapportfinal.pdf (accessed 2020 Jan 25). 16 Government of Canada. Greenhouse Gas Emissions. Ottawa: Government of Canada; 2018. Available: https://www.canada.ca/en/environment-climate-change/services/environmental-indicators/greenhouse-gas-emissions.html (accessed 2020 Jan 26). 17 Gouvernment du Québec. Press Release: Minister Benoit Charette announces an unprecedented process to develop the forthcoming Electrification and Climate Change Plan. Québec: Gouvernment du Québec; 7 2019. Available: http://www.environnement.gouv.qc.ca/infuseur/communique_en.asp?no=4182 (accessed 2020 Jan 26). 18 Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067712/pdf/pmed.1002623.pdf (accessed 2020 Jan 25). (accessed 2020 Jan 26). 19 Intergovernmental Panel on Climate Change (IPCC). Global Warming of 1.5C--Summary for Policymakers, France: IPCC; 2018. Available: https://www.ipcc.ch/sr15/ (accessed 2020 Jan 25).
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2020 pre-budget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14131
Date
2020-02-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2020-02-25
Topics
Population health/ health equity/ public health
Text
Primary care is the backbone of our health care system in Canada and a national priority for this government. The echoing words of the Speech from the Throne certify that the Government will strengthen health care and “Work with provinces, territories, health professionals and experts in industry and academia to make sure that all Canadians can access a primary care family doctor.” The Health Minister’s mandate letter further confirms that the Government will work “with the support of the Deputy Prime Minister and Minister of Intergovernmental Affairs, the Minister of Finance and the Minister of Seniors, to strengthen Medicare and renew our health agreements with the provinces and territories” to “ensure that every Canadian has access to a family doctor or primary health care team”. We recognize that strengthening primary care through a team-based, inter-professional approach is integral to improving the health of all people living in Canada. This belief is consistent across our alliance of four major groups: the Canadian Medical Association, the Canadian Nurses Association, the Canadian Association of Social Workers and the College of Family Physicians of Canada. There is nothing more suiting or fortunate than for a team-based approach to be wholeheartedly supported by an even larger team of teams. We commend the Government’s commitment to increasing Canadians’ access to primary care. We have a model to make it happen. The Primary Health Care Transition Fund 2, a one-time fund over four years, would provide the necessary funding to help establish models of primary care based on the Patient’s Medical Home, a team-based approach that connects the various care delivery points in the community for each patient. This model is rooted in the networking of family physicians, nurse practitioners, nurses, social workers and other health professionals as a team. This is the only way to provide comprehensive primary care to patients. It will enable a more exhaustive approach to patient care, ultimately leading to increased prevention and better health outcomes for Canadians. Consider it the main artery in meeting the needs of patients and communities. A commitment to the Primary Health Care Transition Fund 2 gives substance to the promise of building a network of care that addresses immediate health needs while connecting to ongoing social and community health services. This Fund model bolsters Canadians. It is backed by doctors, nurses, and social workers. A phalanx of Canadian care providers stand behind it. An entire country will benefit from it. INTRODUCTION RECOMMENDATION 2 In support of the federal government’s commitment to improve Canadians’ access to primary care, we recommend a one-time fund in the amount of $1.2 billion over four years to expand the establishment of primary care teams in each province and territory.
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Senior care and prevention – For a healthier Quebec: Pre-budget submission for the 2020–2021 Quebec government budget

https://policybase.cma.ca/en/permalink/policy14212
Date
2020-01-15
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2020-01-15
Topics
Population health/ health equity/ public health
Text
The CMA has always taken an interest in and a stand on various health issues affecting the medical profession and patients. Access to health care is one such issue. The CMA recently commissioned Ipsos to conduct an extensive survey on the population’s concerns regarding access to health care. The data indicates that Quebecers are the most pessimistic in the country—and this sentiment is even more pronounced when respondents think about the future. Forty percent of survey respondents are concerned about access to health care, and more than half (55%) have a negative perception of the future of the health care system, compared with 26% and 47%, respectively, for the rest of Canada.1 It also appears that Quebecers are significantly affected by the shortage of health professionals and the increase in system costs due to the aging population and the growing number of seniors with health care needs. The public’s worries are also shared by our members and physicians in Quebec, who are concerned by the fact that their patients are not receiving the care and services they need in a timely manner. The government of Quebec is making a significant investment in the health care network, a budget item that accounts for almost 50% of total program expenditures.2 The CMA applauds this effort. The CMA submission proposes certain measures that have a two-fold objective: improving the health of Quebecers and ensuring the sustainability of the health care system for future generations. The CMA submission is divided into three parts: improving support to elderly patients and caregivers; tobacco and vaping control; and reducing unnecessary examinations and treatments to optimize use of the health care system’s financial and human resources. 4 Seniors and caregivers It is no secret that Quebec’s population is aging rapidly. According to data from the Institut de la statistique du Québec cited in the Plan stratégique du ministère de la Santé et des Services sociaux, seniors are expected to make up 25% of the population in 2031 and 28% in 2066, compared with 18% in 2016.3 Although aging is not necessarily synonymous with poor health or disability, the likelihood of both of these conditions increases with age. Close to seven out of ten Quebecers aged 65 and over report two or more long-term health conditions, and 93% of these individuals take medication.4 The most common health issues among people aged 65 and over are arthritis and hypertension.5 Moreover, the incidence of cancer rises significantly with age.6 The aging population thus exerts additional pressure on a health care system that is already stretched thin. The CMA has long been lobbying the federal government to increase the Canada Health Transfer to take into account the needs of the aging population when calculating the Transfer. Consequently, the CMA supports the Quebec government’s negotiations with the federal government to secure an increase in federal health transfer payments. To ensure a sustainable health care system, it is important to invest in measures that will allow the public to maintain their health as they age, and that foster seniors’ independence—such as a healthy lifestyle, adequate nutrition and treatment adherence, where applicable. The Quebec government has already taken steps to foster the well-being of elderly persons, such as implementing the senior assistance tax credit and increasing support for home support services. The Minister Responsible for Seniors and Informal Caregivers has announced the development of a provincial policy for caregivers in 2020–2021, as indicated in the recently submitted strategic plan.3 These initiatives aimed at improving the lives of seniors and caregivers are to be commended. The CMA believes that the scope of these initiatives should be widened. Support for seniors In its economic update presented on December 3, 2018, the Quebec government announced a new tax credit for seniors over age 70. More specifically, this tax credit provides annual assistance of up to $200 per senior and $400 per couple. The CMA welcomes this initiative, but it should be noted that seniors aged 65 and overspend more than $2,200 on health care fees each year7 (health care items, medication, dental care, insurance premiums, etc.). Given that this level of spending is significant and that 60% of seniors have an annual income under $30,000,8 this tax credit appears to be insufficient for those who have to bear these additional daily health expenses. We must collectively 5 ensure that certain seniors will not have to forego treatment because they cannot afford it. Quebecers’ health care expenses have been increasing in recent years,9 and the CMA believes it is essential that this growing problem be dealt with right now. The CMA recommends that the Quebec government create an allowance for seniors aged 65 and over. This new allowance, which would be modelled after the family allowance, would provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses. The CMA also believes that the senior assistance tax credit should be extended to people ages 65 to 69. Family caregivers Like seniors’ advocacy groups, the CMA recommends greater recognition of family caregivers’ contribution to the Quebec health care system. This could take the form of a greater tax credit for caregivers offered in Quebec. Family caregivers are an integral part of the health care system, as they play an active role in enabling seniors to stay at home—which is what most seniors prefer.10 The Ministère de la Santé et des Services sociaux plans to increase home support services as part of its 2019–2023 strategic plan.10 The CMA believes that this initiative should be combined with increased assistance for family caregivers. In 2016, the demographic portrait of caregivers in Quebec indicated that 35% of Quebecers, or 2.2 million people, provided care to a senior. Of these, around 15% acted as caregivers for more than 10 hours a week. With the aging of the population set to accelerate in the coming years and decades, caregivers’ unpaid working hours will increase significantly. In Canada, according to a 2011 study, close to 80% of all assistance to recipients of long-term care was provided by family caregivers. This represents a contribution of over five billion dollars’ worth of unpaid services for the public health network.11 According to the CMA, the tax credit for caregivers is an indispensable and necessary financial contribution for these people and the seniors receiving care, but this measure in no way reflects the costs assumed by caregivers. More support should be provided to people who give their time every day, sustain financial losses and compensate for the lack of resources in the health care system. Given the indispensable role family caregivers play, the CMA recommends that the government increase the tax credit for caregivers so that it better reflects their contribution to society—and this should apply to all four types of family caregivers defined by Revenu Québec:12 6
Caregivers who take care of a senior spouse who is unable to live alone
Caregivers who house an eligible relative
Caregivers who cohabit with an eligible relative who is unable to live alone
Caregivers who support an eligible relative whom they regularly and continuously assist in carrying out basic activities of daily living CMA recommendations The CMA recommends: 1. Expanding the senior assistance tax credit to support people who are between the ages of 65 and 69 2. Creating a seniors’ allowance to provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses 3. Increasing the tax credit for caregivers, for all types of family caregivers recognized by Revenu Québec Smoking and vaping prevention Although the government of Quebec must pay specific attention to seniors’ care to lighten the burden on the health care system, prevention is still just as important. Prevention has proven to be useful in reducing health care costs by eliminating the need for certain treatments and hospitalizations.13 Measures to control smoking and vaping fall under this category. For decades, the CMA has been promoting the benefits of a smoke-free society with the support of our physician members, who are witnesses to tobacco’s harmful effects on health. The CMA issued its first public health warning on the risks associated with tobacco use in 1954, and since then has made a significant contribution to the development of public policies related to the industry. One needs only to think of the role that the CMA played in the federal government’s decision to require that tobacco products be sold in plain packaging and standard sizes. Every government in the country has been actively committed to the fight against tobacco for years, and there has been a significant drop in tobacco use over time. However, regular tobacco use in Quebec has settled at around 15% of the population aged 12 or older.14 Unfortunately, this proportion is still too high. 7 There is another growing phenomenon among young people that we believe merits the attention of the Minister of Finance: e-cigarettes, also referred to as vaping devices. According to the Enquête québécoise sur la santé des jeunes du secondaire 2016-2017 [Quebec health survey of high school students 2016-2017], one third of youths have used e-cigarettes.15 Although these types of products do not contain tobacco, they do contain nicotine and aromatic substances that could be harmful to people’s health. The CMA recommends increasing research on the potential health consequences these devices can have on people, and the validity of claims that they are an effective means to quit smoking. We also support prohibiting e-cigarette sales to minors, enforcing strict regulation of the sale of these products and prohibiting vaping in locations where smoking is currently forbidden. We also recommend that the marketing restrictions on tobacco products be applied to vaping products and devices as well. The CMA also believes that governments would be well advised to draw inspiration from strategies that have been successful in curbing tobacco use and reducing the appeal of e-cigarettes, particularly among young people. According to the World Health Organization (WHO), a 10% increase in the price of tobacco results in a 4% to 8% drop in consumption. Taxes on vaping products could therefore have the same deterrent effect, especially among young people, who are more sensitive to price variations.16 This is why it is imperative that we do not wait for the outcome of the work carried out by the special vaping intervention group led by the Ministère de la Santé et des Services sociaux (MSSS) before taking action. CMA recommendation Effective January 1, 2020, the government of British Columbia raised the sales tax on vaping products from 7% to 20%17 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by increasing taxes on vaping and tobacco products. The right care at the right time According to data from the Canadian Institute for Health Information (CIHI), up to 30% of tests, treatments and procedures in Canada are potentially unnecessary. Unnecessary tests, treatments, and procedures not only add zero value to care, but they may also expose patients to additional risks and waste health resources.18 In 2012, as certain treatments were being overused or not adding value for patients, the CMA was a leading partner in the Choosing Wisely Canada campaign, which was launched in Quebec in 2014. This program helps health care professionals and patients engage in a dialogue about unnecessary tests and treatments and helps them make smart and effective choices to ensure quality health care. Guides and recommendations for patients and health 8 care professionals have been developed through this campaign to make them aware of overuse and overdiagnosis. The ultimate goal of Choosing Wisely is to improve the performance of the health care system. A survey indicates that almost half of physicians (48%) agree that they need more support and tools to help them determine which services are not suitable for their patients.19 The tools provided by the Choosing Wisely campaign have proven effective. The CMA believes that their use by Quebec physicians and patients is beneficial. Publicizing campaigns and developing and updating tools and recommendations require significant financial resources. Elsewhere in the country, several provinces are providing financial support to Choosing Wisely. However, Quebec ended its financial commitment in the past year. CMA recommendation Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment. Summary of CMA recommendations Senior and caregiver support The CMA is proposing three main recommendations to support seniors and their caregivers. The recommended measures are aimed at ensuring healthy aging and recognizing family caregivers’ economic and social contribution in Quebec. 1. Expand the senior assistance tax credit to support people who are between the ages of 65 and 69. 2. Create an allowance for seniors to help them manage private health care costs. 3. Increase the tax credit for caregivers, for all types of caregivers recognized by Revenu Québec. Implementation of a tax on tobacco and vaping products The government of British Columbia announced its intent to increase the sales tax on vaping products from 7% to 20%, effective January 1, 2020,20 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by heavily taxing vaping and tobacco products. 9 Contribution to the Choosing Wisely Canada program Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment. 1 Ipsos, Canadian Medical Association (CMA). Canadians are Nervous About the Future of the Health System. Ottawa: CMA; 2019. Available: https://www.cma.ca/sites/default/files/pdf/news-media/Canadians-are-Nervous-About-the-Future-of-the-Health-System-E.pdf (accessed 2020 Jan 13). 2 Gouvernement du Québec. Update on Québec’s Economic and Financial Situation. Quebec: Gouvernement du Québec; Fall 2019. Available : http://www.finances.gouv.qc.ca/documents/Autres/en/AUTEN_updateNov2019.pdf (accessed 2020 Jan 13). 3 Ministère de la Santé et des Services sociaux. Plan stratégique 2019-2023(French only). Quebec : Ministère de la Santé et des Services sociaux; December 2019. Available : https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13). 4 Institut de la statistique du Québec. Enquête québécoise sur les limitations d’activités, les maladies chroniques et le vieillissement 2010-2011(French only). Quebec : Institut de la statistique du Québec; October 2013. Available: http://www.stat.gouv.qc.ca/statistiques/sante/services/incapacites/limitation-maladies-chroniques-utilisation.pdf (accessed 2020 Jan 13). 5 Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates. Ottawa: Statistics Canada; 2019. Available: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009601&amp%3BpickMembers%5B0%5D=1.6&amp%3BpickMembers%5B1%5D=2.6&amp%3BpickMembers%5B2%5D=3.1&request_locale=en. (accessed 2020 Jan 13). 6 Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics, September 2019. Toronto: Canadian Cancer Society; September 2019. Available: https://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2019-EN.pdf?la=en-CA (accessed 2020 Jan 13). 7 Institut de la statistique du Québec. Dépenses moyennes des ménages déclarants, selon le groupe d'âge de la personne de référence, Québec, 2006 (French only). Quebec: Institut de la statistique du Québec; 2006. Available: http://www.stat.gouv.qc.ca/statistiques/conditions-vie-societe/depenses-avoirs-dettes/depenses/depdeclar_age.htm (accessed 2020 Jan 13). 8 Santé et des Services sociaux. Les aînés du Québec - Quelques données récentes (2e édition)(French only). Quebec: Santé et des Services sociaux; June 2018. Available: https://publications.msss.gouv.qc.ca/msss/fichiers/ainee/aines-quebec-chiffres.pdf (accessed 2020 Jan 13). 9 Santé et des Services sociaux. Dépenses moyennes des ménages en dollars courants, selon le poste de dépenses, ensemble des ménages, Québec, 2010-2017(French only): http://www.stat.gouv.qc.ca/statistiques/conditions-vie-societe/depenses-avoirs-dettes/depenses/tab1_dep_moy_menage.htm (accessed 2020 Jan 13). 10 Ministère de la Santé et des Services sociaux, Plan stratégique 2019-2023 [2019–2023 Strategic plan] (French only). Quebec: Santé et des Services sociaux; December 2019. Avalable: https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13). 11 Fast J, Lero D, Duncan K, et al. Employment consequences of family/friend caregiving in Canad. Population Change and Lifecourse Strategic Knowledge Cluster Research/Policy Brief, Vol. 1, No. 2 [2011], Art. 2. Edmonton: Research on Aging, Policies and Practice, University of Alberta; 2011. Available: https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1004&context=pclc_rpb (accessed 2020 Jan 13). 12 Revenu Québec. Tax Credit for Caregivers. Quebec: Revenu Québec; 2019. Available: https://www.revenuquebec.ca/en/citizens/tax-credits/tax-credit-for-caregivers/ (accessed 2020 Jan 13). 13 Public Health Agency of Canada. Investing in Prevention: The Economic Perspective. Ottawa: Public Health Agency of Canada; May 2009. Available: http://www.phac-aspc.gc.ca/ph-sp/pdf/preveco-eng.pdf (accessed 2020 Jan 13). 14 Statistics Canada. Table 13-10-0096-10 Smokers, by age group. Ottawa: Statistics Canada; 2018. Available: 10 https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009610 (accessed 2020 Jan 13). 15 Institut de la statistique du Québec. Enquête québécoise sur la santé des jeunes du secondaire 2016-2017. Résultats de la deuxième édition. La santé physique et les habitudes de vie des jeunes, Tome 3 (French only). Quebec: Institut de la statistique du Québec; December 2018. Available: https://www.stat.gouv.qc.ca/statistiques/sante/enfants-ados/alimentation/sante-jeunes-secondaire-2016-2017-t3.html(accessed 2020 Jan 13). 16 World Health Organization (WHO). Tobacco Free Initiative: https://www.who.int/tobacco/economics/taxation/en/ 17 Legislative Assembly of British Columbia, Bill 45 – 2019: Taxation Statutes Amendment Act. Geneva: WHO; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13). 18 Choosing Wisely Canada. Implementing Choosing Wisely Canada Recommendations. Toronto: Choosing Wisely Canada; 2020. Available: https://choosingwiselycanada.org/implementation/ (accessed 2020 Jan 13). 19 Canadian Medical Association, e-Panel Survey Summary: Choosing Wisely Canada (distributed to 3,864 e-Panel members and completed in November 2016): https://www.cma.ca/e-panel-survey-summary-choosing-wisely-canada. 20 Legislative Assembly of British Columbia. Bill 45 – 2019: Taxation Statutes Amendment Act. Vancouver: Legislative Assembly of British Columbia; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13).
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Improving Long-term Care for People in Canada

https://policybase.cma.ca/en/permalink/policy14246
Date
2020-06-01
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2020-06-01
Topics
Population health/ health equity/ public health
Text
Subject: Improving Long-term Care for People in Canada Dear Minister Hajdu and Minister Schulte, We are writing to you with recommendations for responding to the staggering effects COVID-19 has had on our health-care system, particularly in long-term care (LTC) homes across Canada. These recommendations were recently unveiled by the Canadian Nurses Association (CNA) on May 27 through a report entitled 2020 Vision: Improving Long-term Care for People in Canada (attached to this letter). We invite you to read it and consider the proposals we are bringing forward. As you know, Canada has had unacceptable rates of COVID-19-related deaths in LTC; by late April, 79% of the country’s deaths due to COVID-19 were linked to outbreaks in these homes. These tragic numbers are in part a result of decades of neglect of the LTC sector and a growing mismatch between the level of care required by people living in those settings, and the level of care available. Furthermore, the recent reports from the military deployed to Ontario and Quebec’s long-term care homes have emphasized the shocking and horrific conditions that exist in some nursing homes in Canada. We applaud the Prime Minster’s recent commitment to work closely and support the province’s efforts to improve standards of care for older people in long-term care 2 homes across the country. Moreover, further decisive action needs to be undertaken. To address the flaws COVID-19 has revealed in the support and care systems available to Canada’s older people, we recommend that your Government take immediate action on three important fronts:
The Government of Canada should immediately appoint a commission of inquiry on aging;
Federal public health leaders must work with provincial, territorial and Indigenous governments and public health leaders to review the country’s COVID-19 response and organize preparations for the next pandemic;
Federal, provincial and territorial governments must increase investments in community, home and residential care to meet the needs of our aging population. As the Prime Minister indicated last week, providing support in the short term and having broader discussions in the long term is critical. We believe many solutions can be put in place now in some long-term care homes if they had better funding, for example. In the long term, a deeper look to identify the best models for delivering better health and social services will support safe and dignified aging for every person in Canada. We recognize the challenges involved to address the issues in the support and care systems for older people in Canada. The benefits of redesigning how we provide care for older people (Canada’s largest growing demographic) and others with complex continuing care needs will go beyond improving their lives and health. A good long-term care system, in tandem with effective, well-organized community and home care, will ease pressure on the acute-care system and eliminate many of the gaps in the continuum of care that too often result in previously independent older people landing in the hospital or long-term care. Acting on these three recommendations will help to provide a solid foundation on which to build a safe and dignified future for Canada’s older people. Canada is known 3 for its humanitarian work around the world. It’s time we brought those values home, to care for the people to whom this country and each one of us owes so much. We look forward to discussing these proposals with you and your staff as soon as possible. Sincerely, Claire Betker, RN, MN, PhD, CCHN(C) President Canadian Nurses Association Michelle Pavloff, RN, BSN, MN, PhD(c) President, Canadian Association for Rural and Remote Nursing Jan Christianson-Wood, MCSW President Canadian Association of Social Workers Trina Klassen, RN, BN, ASMH, Med President Canadian Family Practice Nurses Association Tracy Thiele, RPN, MN, PhD(c)President, Florence Budden, Lori Schindel Martin, RN, PHD President Canadian Gerontological Nursing Association BN, RN, CPMHN(C) Past President Canadian Federation of Mental Health Nurses Lea Bill, RN, BScN, President Canadian Indigenous Nurses Association Sandy Buchman MD CCFP (PC) FCFP President Canadian Medical Association Ian Culbert Executive Director Canadian Public Health Association Miranda R Ferrier Francine Lemire, MD CM, CCFP, FCFP, CAE, ICD. D Executive Director & Chief Executive Officer College of Family Physicians of Canada National President Ontario Personal Support Workers Association Canadian Support Workers Association Jen Calver, RPN-GPNC(C), BAHSc (Hons), MHSc(c) Professional Advocacy Director Gerontological Nursing Association Ontario Lenora Brace, MN, NP, President NPAC-AIIPC Nurse Practitioner Association of Canada
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Recommendations for Canada’s long-term recovery plan - open letter

https://policybase.cma.ca/en/permalink/policy14262
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Re: Recommendations for Canada’s long-term recovery plan Dear Prime Minister Trudeau, We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering. We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the upcoming Speech from the Throne on September 23rd. The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and access to education. These social determinants of health contribute to and perpetuate inequality, which we see the pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery. To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are recommending below are critical and should be part of your government’s long-term recovery plan: 1. Ensure pandemic emergency preparedness 2. Invest in virtual care to support vulnerable groups 3. Improve supports for Canada’s aging population 4. Strengthen Canada’s National Anti-Racism Strategy 5. Improve access to primary care 6. Implement a universal single-payer pharmacare program 7. Increase mental health funding for health-care professionals We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our health-care system and create a safer and more equitable society. 1. Ensure pandemic emergency preparedness We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale capacity to conduct viral testing and contact tracing. 2.Invest in virtual care to support vulnerable groups The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported being satisfied.ii We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be given to deploying technology and ensuring health human resources receive appropriate training in culturally competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and Indigenous communities. 3.Improve supports for Canada’s aging population Develop pan-Canadian standards for the long-term care sector The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care, there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings, with proper accountability measures. Meet the health-care needs of our aging population Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures are necessary.v That is why we are calling on the federal government to address the rising costs of population aging by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community and home care. 4.Strengthen Canada’s National Anti-Racism Strategy Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural determinants of health have created and continue to reinforce serious health and social inequities for racialized communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s National Anti-Racism Strategy to address identified health disparities and combat racism via community-led projects. 5. Improve access to primary care Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi, almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased, interprofessional approach is integral to improving the health of all people living in Canada and the effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to Page 3 of 4 expand the establishment of primary care teams in each province and territory, with a special focus in remote and underserved communities, based on the Patient’s Medical Home visionvii. 6. Implement a universal single-payer pharmacare program People across Canada, especially those who are vulnerable, require affordable access to prescription medications that are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life. Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system offering affordable medication coverage that ensures access based on need, not the ability to pay. 7.Increase mental health funding for health-care professionals During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID- 19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports for health-care professionals is needed. We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in Canada and the health system. Sincerely, Tim Guest, M.B.A., B.Sc.N., RN President Canadian Nurses Association (CNA) president@cna-aiic.ca Tracy Thiele, RPN, BScPN, MN, PhD(c) President Canadian Federation of Mental Health Nurses (CFMHN) tthiele@wrha.mb.ca Lori Schindel Martin, RN, PhD, GNC(C) President Canadian Gerontological Nursing Association (CGNA) lori.schindelmartin@ryerson.ca E. Ann Collins, BSc, MD President Canadian Medical Association (CMA) Ann.collins@cma.ca Miranda Ferrier President Canadian Support Workers Association (CANSWA) mferrier@opswa.com Dr. Cheryl L. Cusack RN, PhD President Community Health Nurses of Canada (CHNC) president@chnc.ca Lenora Brace, MN, NP President Nurse Practitioner Association of Canada (NPAC) president@npac-aiipc.org ~ r. Cheryl Cusack, RN PhD CC.: Hon. Chrystia Freeland, Minister of Finance Hon. Patty Hajdu, Minister of Health Hon. Deb Schulte, Minister of Seniors Hon. Navdeep Bains, Minister of Innovation, Science and Industry Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet Dr. Stephen Lucas, Deputy Minister of Health Dr. Theresa Tam, Chief Public Health Officer of Canada
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Toward a Dementia Strategy for Canada: CMA Submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy10674
Date
2013-01-21
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2013-01-21
Topics
Population health/ health equity/ public health
Text
As Canada's population ages, concern is growing about the capacity of our health care system to respond to the increased demands that will be placed on it. Of particular concern is the capacity to deal with an expected surge in the prevalence of Alzheimer's disease and other dementias, a major cause of disability in Canadians aged 65 and older. The Canadian Medical Association (CMA) shares this concern. In August 2012, CMA's General Council passed a resolution supporting the development of a national dementia strategy. Background About three quarters of a million Canadians currently live with Alzheimer's disease and other forms of dementia and cognitive impairment. People with dementia may live for years with the condition, and will eventually need round-the-clock care. Our knowledge of how to prevent dementia is limited, and we do not fully understand its causes. Though treatments are available that may delay progression of the patient's condition, there is no known cure. Dementia currently costs Canada roughly $33 billion per year, both in direct health care expenses and in indirect costs, such as lost earnings of the patient's caregivers. Since the number one risk factor for dementia is age, there is no question that with the aging of Canada's population, its prevalence will increase. The Alzheimer Society of Canada predicts that by 2031, 1.4 million Canadians will have dementia, and by 2040 the annual cost to the country will reach $293 billion. Other countries, including Australia, Norway, Netherlands, France, and the United Kingdom, have developed national strategies to address the dementia epidemic. CMA recommends strongly that Canada join this list. A national strategy could address issues of pressing concern such as * The need for research on the prevention and treatment of dementia; * The occupation of acute-care hospital beds by patients with dementia while awaiting placement in more appropriate long-term care settings. This both increases health-care costs and exacerbates Canada's waiting-list problem, blocking hospital beds which could otherwise be used for other patients. * The emotional and financial burden faced by spouses, children or other informal caregivers of patients with dementia. A Dementia Strategy for Canadians Given the terrible toll that dementia currently takes on Canadians and their health care, and given the certainty that this toll will grow more severe in coming decades, the CMA believes that it is vital for Canada to develop a focused strategy to address it. The Alzheimer Society of Canada recommends that a national dementia strategy encompass the following elements: 1. Increased investment in research on key aspects of dementia, including prevention, treatment options, and improving quality of life. 2. Increased support for informal caregivers. This should take several forms. a. Financial support. The 2011 federal budget introduced a Family Caregiver Tax Credit of up to $300 a year. However, this does not adequately reimburse the cost of a caregiver's time, which studies have shown is often much higher. b. Programs to relieve the stress experienced by caregivers; this can include education and skill-building, and the provision of respite care and other support services. 3. An emphasis on brain health and risk reduction, early diagnosis and intervention. 4. An integrated system of care facilitated by effective co-ordination and case management. 5. A strengthened dementia workforce, which includes both developing an adequate supply of specialists and improving the diagnosis and treatment capabilities of all frontline health professionals. The Government of Canada has supported similar condition-specific strategies, most recently the Canadian Cancer Strategy, initially funded in 2006 and renewed for five years beyond 2012. This strategy focuses on prevention and screening, early detection, clinical care, supporting the patient's journey, targeted research, and work with the First Nations, Inuit and Metis communities. We believe that a national strategy for dementia, bringing together partners such as the Alzheimer Society of Canada, the Canadian Institutes of Health Research (Institute of Aging), the Canadian Caregiver Coalition, and other patient and health professional groups, will enhance the ability of our health care system to respond to the coming dementia epidemic in a compassionate and cost-effective manner. In 2012, the Canadian Institutes of Health Research (Institute of Aging) and the Alzheimer Society of Canada have invested about $30 million in research. We propose that an initial investment in a National Dementia Strategy be $25 million per year for five years: $10 million for research, $10 million for caregiver support and respite care, and $5 million for knowledge transfer, partnership development and administrative support. Therefore the Canadian Medical Association recommends: That the Government of Canada fund the development and implementation of a National Dementia Strategy for an initial five-year period. The CMA is ready to work with governments, patients and their families, health professional associations and other stakeholders to make this recommendation a reality. Sources: Alzheimer Society of Canada. A New Way of Looking at Dementia in Canada. Based on a study conducted by RiskAnalytica. C. 2010 Canadian Medical Association. A More Robust Economy Through a Healthier Population. 2012-2013 pre-budget submission.
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Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis

https://policybase.cma.ca/en/permalink/policy10741
Last Reviewed
2019-03-03
Date
2013-03-02
Topics
Population health/ health equity/ public health
Resolution
BD13-05-132
The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2013-03-02
Topics
Population health/ health equity/ public health
Resolution
BD13-05-132
The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
Text
The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
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Position statement on bodychecking in youth ice hockey

https://policybase.cma.ca/en/permalink/policy10758
Last Reviewed
2020-02-29
Date
2013-05-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2013-05-25
Topics
Population health/ health equity/ public health
Text
Hockey is one of the most popular sports for Canadian children and youth. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries, particularly concussion. Studies consistently identify bodychecking as the primary mechanism associated with youth hockey injuries, including concussion. Policy to delay bodychecking until bantam league play (when participants are 13 to 14 years of age) will reduce the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from non-elite youth ice hockey. The age at which bodychecking is introduced in competitive hockey leagues must be reconsidered. Both initiatives require policy change in many provinces/territories, and must be re-evaluated prospectively in light of emerging research. More than 4.5 million Canadians are involved in ice hockey, as coaches, officials, administrators or direct volunteers, and hockey is the most popular winter sport among Canadian children and youth.[1] Hockey Canada reported over 550,000 registered players under the age of 19 in 2008, and participation rates are increasing, especially among girls and young women.[1] While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries in youth, particularly concussion. The American Academy of Pediatrics (AAP) classifies hockey as a collision sport because of unintentional and intentional body contact, including bodychecking.[2] The AAP published a policy statement on youth ice hockey in 2000, recommending that bodychecking not be allowed for children younger than 15 years of age.[3] There is passionate debate about the risk factors for injury in youth hockey and the relative merits of early or later introduction of bodychecking. Because bodychecking is not allowed in girls' or women's hockey in Canada, the present statement pertains to play in boys' and men's hockey leagues. It reviews the scientific literature on bodychecking injuries, outlines positions in the current debate and makes recommendations on when bodychecking should be introduced into the game. DEFINING BODY CONTACT AND BODYCHECKING Body contact is an individual defensive tactic designed to legally block or impede the progress of an offensive puck carrier. The defensive player moves to restrict action by the puck carrier anywhere on the ice, by skating, angling and positioning. The defensive player cannot hit the offensive player by travelling in an opposite direction to him or by physically extending toward him in an effort to initiate contact. There must be no action where the puck carrier is pushed, hit or shoved into the boards. In contrast, bodychecking is an individual defensive tactic designed to legally separate the puck carrier from the puck. The defensive player physically extends his body toward the puck carrier while moving in an opposite or parallel direction, a deliberate and forceful move not solely determined by the movement of the puck carrier.[1] Bodychecking is taught based on a four-step skill development program outlined by Hockey Canada, with progression through positioning and angling, stick checking, body contact and bodychecking skills.[4] Instruction in bodychecking includes techniques for receiving bodychecks, adhering to rules, and safe play. BODYCHECKING LEGISLATION Hockey Canada groups children and adolescents by age into six play levels: initiation (5 to 6 years of age), novice (7 to 8 years), atom (9 to 10 years), peewee (11 to 12 years), bantam (13 to 14 years), and midget (15 to 17 years). Historically, from the early 1980s until the 2002/2003 season, bodychecking was introduced at age 12 years in Canadian boys' ice hockey. In 2003, four of 13 provincial/territorial branches allowed checking for players as young as nine years old. Hockey Canada mandated the introduction of bodychecking in peewee leagues (ages 11 to 12) in 2009. Quebec has delayed bodychecking until bantam (age 14 from 1978 to 2002, then age 13 following an age change mandated nationally). THE DEBATE Despite lack of evidence, proponents of bodychecking argue that it is a fundamental skill which, learned early, may prevent future injuries. However, the evidence supports that bodychecking is the most common mechanism of injury. The Canadian Academy of Sports Medicine recommends that bodychecking be introduced only in boys' competitive hockey, and no earlier than the bantam (ages 13 to14) or midget (ages 15 to 17) level.[5] The AAP recommends a ban on bodychecking for male players younger than 15 years of age.[3] The present statement marks the first CPS position on this issue. BODYCHECKING AND INJURY Hockey is recognized as a high-risk sport. The speed of play, body contact and bodychecking all contribute to injury risk.[6][7] The injury rate is also high, with Canadian data suggesting that hockey injuries account for 8% to 11% of all adolescent sport-related injuries.[8][10] Unfortunately, serious injuries such as concussion, other brain injuries and spinal cord trauma are not uncommon in hockey.[6][11] The incidence of traumatic brain injury appears to be rising.[12][13] Ice hockey-related fatality rates are double those reported in American football, and catastrophic spinal cord and brain injury rates are almost four times higher for high school hockey players than for high school and college football players.[14][15] Bodychecking is the predominant mechanism of injury among youth hockey players at all levels of competition where it is permitted, accounting for 45% to 86% of injuries.[8][16]-[18] Several published studies, including two recent systematic reviews, reported on risk factors for injury (including bodychecking) in youth hockey.[19][20] Emery and colleagues conducted a systematic review of 24 studies and a meta-analysis including only studies which examined policy allowing bodychecking as a risk factor for injury. Policy allowing bodychecking was found to be a risk factor for all hockey injuries, with a summary incidence rate ratio (IRR) of 2.45 (95% CI 1.7 to 3.6). Furthermore, policy allowing bodychecking was found to be a risk factor for concussion, with a summary OR of 1.71 (95% CI 1.2 to 2.44). These data confirm that bodychecking increases the risk of all injuries and the risk of concussion specifically.[20] Nine of ten studies examining policy allowing bodychecking provided evidence to support a greater risk in bodychecking leagues.[20] The second systematic review found the RR of injury associated with policy allowing bodychecking ranged from 0.6 to 39.8; all but one of these studies found an increased risk of injuries associated with bodychecking.[19] Since the publication of these systematic reviews there have been five additional studies. A Canadian prospective cohort study compared injury rates between peewee ice hockey players in a league where bodychecking is permitted at age 11 years (Alberta) versus players in a league where bodychecking is not permitted until age 13 (Quebec).[21] During the 2007/2008 season, a validated injury surveillance system was used to capture all injuries requiring medical attention and/or time loss from hockey (ie, time between injury and return to play) in 2154 players. There was a threefold increased risk of all game-related injuries (IRR =3.26 [95% CI; 2.31 to 4.60]) and of injury resulting in >7 days time lost from sport (IRR=3.30 [95% CI; 1.77 to 6.17]) in 11- to 12- year-old peewee players from Alberta when compared with Quebec. There was also an almost fourfold increased risk of game-related concussion (IRR=3.88 [95% CI; 1.91 to 7.89]) in Alberta peewee players.[21] Further evidence was reported in a five-year cohort study (2002 to 2007) including all age groups, which demonstrated that injury risk increases 3.75 times (IRR=3.75 [95% CI; 1.51 to 9.74]) in leagues that allow bodychecking compared with those that do not.[22] A second prospective cohort study by Emery et al examined whether the introduction of bodychecking at 11 years of age (Alberta) or 13 years of age (Quebec) affected injury rates in later years (at 13 to 14 years of age).[23] During the 2008/09 season, the same injury surveillance system cited above was used to study 1971 bantam players (13- to 14-year-olds). There was no reduction in game-related injury risk (all injuries) for this age group (IRR=0.85 [95% CI 0.63 to 1.16]), of concussion specifically (IRR=0.84 [95% CI 0.48 to 1.48]), or of concussions resulting in >10 days time lost from sport (IRR=0.6 [95% CI 0.26 to 1.41]) in the Alberta league, compared with Quebec. In fact, the concussion rate found in Alberta peewee players was higher than in bantam players in either province.[22][23] Injuries to bantam players resulting in >7 days time lost from sport were reduced by 33% (IRR=0.67 [95% CI 0.46 to 0.99]) in the Alberta league, where players had had two years of bodychecking experience. However, these findings must be interpreted in light of the three- to fourfold greater injury and concussion risk among peewee players in Alberta, along with a possibly higher 'survival effect' among peewee players moving on to bantam in Quebec when compared with Alberta, where bodychecking is allowed in peewee league play. Recent retrospective studies have examined the influence of policy change based on the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) surveillance data. Injury rates among boys presenting to emergency departments in the Kingston, Ontario area both before and after the 2002 rule change to allow bodychecking in younger players, were reported. There was no change between bodychecking injury rates in 1997 to 2002 (with bodychecking introduced at 11 years of age) and 2003 to 2007 (when bodychecking was introduced at nine years of age).[24] Overall rates of injury actually declined over the later period.[24] However, this retrospective study may also be biased by stronger rule enforcement, better coaching certification and temporal declines in emergency department use for this type of injury over that period. In contrast, retrospective research of CHIRPP data from 1994 to 2004 in five Ontario hospitals examined injury risk following a rule change in 1998 that allowed bodychecking in nine- and 10-year-old hockey players. A 2.2 times greater risk of injury in atom players (9 and 10 years of age) after the rule change was reported (OR=2.2 [95% CI 1.7 to 2.84]).[25] Another retrospective study using CHIRPP data (from 1995 to 2002) compared hockey injuries in children 10 to 13 years of age playing in Ontario, where bodychecking was allowed, with data from Quebec, where bodychecking was not allowed. There was a 2.6 times greater risk of bodycheck-related injuries reported for this age group when bodychecking was allowed (OR=2.65 [95% CI 2.21 to 3.18]).[26] OTHER RISK FACTORS After policy that permits bodychecking, the most commonly investigated risk factors for injury in the scientific literature are: age, session-type (ie, a practice versus a game), level of play, player position, physical size, and a previous history of injury and/or concussion. Most studies examining age found that injury risk increased with age;[8][20][27][29] others suggest no elevated injury risk in older age groups.[30]-[33] Relative age has been examined to "describe the potential advantages (or disadvantages) that result from age differences between peers within one age group".[31] One study examining relative age among hockey players found no evidence that younger (or older) players within a grouping were at elevated injury risk.[31] Additional research supports this finding at the peewee level, where no increased risk was found in first-year players. In bantam leagues, however, there was a 40% greater risk of injury in first-year players when compared with players in their second year.[21][23] Based on session-type, injury risk is reported to be consistently higher in games than in practices, with RR estimates ranging from 2.45 to 6.32.[16][18][27][34] One study also indicated that injury rates were higher in regular season play than during preseason, postseason or tournament games.[30] In general, studies examining level of play have found that injury risks rise with increasing skill levels across all age groups.[31][35][36] However, one study reported that only peewee players in the highest skill division were at the greatest risk of injury, with no significant increase by skill level in other age groups.[8] Larger cohort studies confirmed a consistently greater risk of injury among peewee players who were more highly skilled, but this trend was not observed in the bantam age group.[21][23] When examining player position, some researchers found that forwards were at higher risk of injury than defencemen or goalies, [30][32] while others reported the relative risk of injury was 2.18 times higher for defencemen than forwards.[27] In all three studies, goalies were shown to be at much lower risk than other players. Additional research shows a consistent protective effect for goalies at both the peewee and bantam levels.[21][23] Research on player size has shown conflicting results, with some studies citing increased risk for smaller players in some age groups. Prospective Canadian data show a significantly greater risk of injury in peewee players in the lowest 25th percentile by weight, [21] though this finding was not reflected in the bantam cohort.[23] However, additional research has found lighter bantam players to be at greater risk, while other studies report a significant weight difference, at all levels, between players who sustained a bodychecking-related injury and those who did not.[16][30] Other research examining body weight as a risk factor for shoulder injuries found that heavier players were at greater risk for these injuries.[37] One study looked at height as a possible risk factor for injury and found no evidence of effect among bantam players.[16] By contrast, a history of previous injury or concussion is consistently reported as a significant risk factor for reinjury and further concussion, respectively.[20] One recent Canadian peewee cohort study showed that the risk of injury doubled for players who reported being injured within the past year (IRR=2.07 [95% CI 1.49 to 2.86]), while the risk of concussion tripled for players reporting any previous concussion (2.76 [95% CI 1.1 to 6.91]).[21] The bantam cohort also showed greater risk of reinjury and concussion in players reporting previous injury within the past year (IRR=1.39 [95% CI 1.13 to 1.71]) or any previous concussion (IRR=1.87 [95% CI 1.19 to 2.94]), respectively.[21] INJURY PREVENTION AND RISK REDUCTION Injury prevention and risk reduction programs have been implemented but have not been evaluated rigorously. The STOP (Safety Towards Other Players) program (www.safetytowardsotherplayers.com) is supported by the Ontario Minor Hockey Association (www.omha.net), and includes an education component and the "STOP patch", which is sewn on the back of players' uniforms to remind opponents not to hit from behind. A study evaluating another injury prevention program, "Fair Play", which awards points for sportsmanlike play (based on penalty minutes), suggests an approximate 60% reduction in the risk of injury (OR=0.41 [95% CI 0.11 to 1.47]) where the program is in effect, but the results were not statistically significant.[38] EDUCATION Players, parents, coaches, officials and trainers must be mindful of the potential risks of playing hockey. Hockey Canada has player development, coaching, education and safety promotion programs and resources for coaches, officials, players and parents at www.hockeycanada.ca. Concussion awareness is vital. Athletes and all those involved in their care need to know about the risks, symptoms/signs and how to manage concussive injuries. The CPS statement on concussion evaluation and management is essential reading [39], with additional information available from the Canadian Academy of Sport and Exercise Medicine (www.casm-acms.org), ThinkFirst Canada (www.thinkfirst.ca) and the US Centers of Disease Control and Prevention (www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm). CONCLUSION Studies consistently identify bodychecking as the primary mechanism of hockey-related injuries, including concussion. It is expected that delaying the introduction of bodychecking until the bantam level and restricting bodychecking to elite leagues for older age groups will reduce the risks of injury and concussion substantially. Delaying bodychecking until bantam will have a clear benefit in reducing the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from recreational youth ice hockey and the age at which it is introduced in competitive hockey leagues should be reconsidered. Both initiatives require policy change in many provinces/territories in Canada, and policy changes will need to be evaluated on a regular basis in light of emerging research. RECOMMENDATIONS The Canadian Paediatric Society recommends the following: * Eliminating bodychecking from all levels of organized recreational/non-elite competitive male ice hockey. (Grade II-2A evidence) * * Delaying the introduction of bodychecking in elite male competitive leagues until players are 13 to 14 years of age (bantam level) or older. (Grade III-C evidence)* * Implementing Hockey Canada's four-stage skill development program for bodychecking (body positioning, angling, stick checking and body contact) for all leagues. * Educating coaches and trainers, schools, and policy-makers in sport about the signs and symptoms of common hockey injuries, especially concussion. * Improving injury surveillance to better identify the risk factors for, and mechanisms of, hockey injuries. * Policies to reduce injury and promote fair play in hockey, for all age groups and league levels. Clinicians who see young hockey players in their practice should offer the following advice: * Girls and young women should continue participating in non-bodychecking leagues. * Boys should play in recreational/non-elite hockey leagues that do not allow bodychecking. * Elite male players should play in hockey leagues that introduce bodychecking later, when players are 13 to 14 years of age (bantam level) or older. * All players should adhere to fair play and a non-violent sport culture. * Parents and caregivers should learn injury prevention and risk reduction strategies, including concussion prevention, recognition and management. *The levels of evidence and strength of recommendations are based on the Canadian Task Force on Preventive Health Care (See Table 1). [40][41] TABLE 1: [SEE PDF] Levels of evidence and strength of recommendations Level of evidence Description I Evidence obtained from at least one properly randomized controlled trial. II-1 Evidence obtained from well-designed controlled trial without randomization. II-2 Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group. II-3 Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category. III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. Grade Description A There is good evidence to recommend the clinical preventive action. B There is fair evidence to recommend the clinical preventive action. C The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making. D There is fair evidence to recommend against the clinical preventive action. E There is good evidence to recommend against the clinical preventive action. F There is insufficient evidence to make a recommendation; however, other factors may influence decision-making. ACKNOWLEDGEMENTS This statement was reviewed by the Community Paediatrics and Injury Prevention Committees of the Canadian Paediatric Society. Thanks to Drs. Claire MA LeBlanc, Stan Lipnowski, Peter Nieman, Christina G Templeton and Thomas J Warshawski for their input as past members of the CPS Healthy Active Living and Sports Medicine Committee. HEALTHY ACTIVE LIVING AND SPORTS MEDICINE COMMITTEE Members: Catherine Birken MD; Tracey L Bridger MD (Chair); Mark E Feldman MD (Board Representative); Kristin M Houghton MD; Michelle Jackman MD; John F Philpott MD Liaison: Laura K Purcell MD, CPS Paediatric Sports and Exercise Medicine Section Principal authors: Kristin M Houghton MD; Carolyn A Emery PT PhD May 2013 REFERENCES 1. Hockey Canada, Annual report 2008: www.hockeycanada.ca/index.php/ci_id/55192/la_id/1.htm (Accessed July 4, 2012). 2. Rice SG; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2008;121(4):841-8. 3. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Safety in youth ice hockey: The effects of body checking. Pediatrics 2000;105(3 Pt 1):657-8. 4. Hockey Canada. Teaching checking: A progressive approach. 2002: www.omha.net/admin/downloads/Teaching%20Checking.pdf (Accessed July 4, 2012). 5. Canadian Academy of Sport Medicine. Position Statement: Violence and injuries in ice hockey. 1988. www.casm-acms.org/forms/statements/HockeyViolEng.pdf (Accessed July 4, 2012). 6. Emery CA, Risk factors for injury in child and adolescent sport: A systematic review of the literature. Clin J Sport Med 2003;13(4):256-68. 7. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med 2006;16(6):500-13. 8. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey [comment]. Am J Sports Med 2006;34(12):1960-9. 9. Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injury in Calgary and area high schools. Clin J Sport Med 2006;16(1):20-6. 10. Emery C, Tyreman H. Sport participation, sport injury, risk factors and sport safety practices in Calgary and area junior high schools. Paediatr Child Health 2009;14(7):439-44. 11. Tator CH, Carson JD, Cushman R. Hockey injuries of the spine in Canada, 1966-1996 [comment]. CMAJ 2000;162(6):787-8. 12. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clin Sports Med 2000;19(4): 693-715. 13. Kelly KD, Lissel HL, Rowe BH, Vincenten JA, Voaklander DC. Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med 2001;11(2):77-81. 14. Mueller FO, Cantu RC. Catastrophic injuries and fatalities in high school and college sports, fall 1982-spring 1988. Med Sci Sports Exerc 1990;22(6):737-41. 15. Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high school and college sports, 1982-1997: Lessons for improving safety. Phys Sportsmed 1999;27(8):35-48. 16. Brust JD, Leonard BJ, Pheley A, Roberts WO. Children's ice hockey injuries. Am J Dis Child 1992;146(6):741-7. 17. Bernard D, Trudel P. Marcotte G. The incidence, types, and circumstances of injuries to ice hockey players at the bantam level (14 to 15 years old). In: Hoerner E, ed. Safety in Ice Hockey. Philadephia: American Society for Testing and Materials, 1993:44-55. 18. Benson B, Meeuwisse WH. Ice hockey injuries. In: Maffulli N, Caine DJ, eds. Epidemiology of Pediatric Sports Injuries: Team Sports. Basel: S Karger AG, 2005:86-119. 19. Warsh JM, Constantin SA, Howard A, Macpherson A. A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med 2009;19(2):134-44. 20. Emery CA, Hagel B, Decloe M, Carly M. Risk factors for injury and severe injury in youth ice hockey: A systematic review of the literature. Inj Prev 2010;16(2):113-8. 21. Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA 2010;303(22):2265-72. 22. Darling, SR, Schaubel DE, Baker JG, Leddy JJ, Bisson LJ, Willer B. Intentional versus unintentional contact as a mechanism of injury in youth ice hockey. Br J Sports Med 2011;45(6):492-7. 23. Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ 2011;183(11):1249-56. 24. Kukaswadia A, Warsh J, Mihalik JP, Pickett W. Effects of changing body-checking rules on rates of injury in minor hockey. Pediatrics 2010;125(4):735-41. 25. Cusimano M, Taback N, McFaull S, Hodgins R, Tsegaye B; Canadian Research Team in Traumatic Brain Injury and Violence. Effect of bodychecking on rate of injuries among minor hockey players. Open Medicine 2011;5(1):e59: www.openmedicine.ca/article/view/246/389 (Accessed July 4, 2012). 26. Macpherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics;117(2):e143-7 [Erratum in Pediatrics. 2006;117(6):2334-6]. 27. Stuart MJ, Smith AM, Nieva JJ, Rock MG. Injuries in youth ice hockey: A pilot surveillance strategy. Mayo Clin Proc 1995;70(4): p. 350-6. 28. Mölsä, J, Kujala U, Myllynen P, Torstila I, Airaksinen O. Injuries to the upper extremity in ice hockey: Analysis of a series of 760 injuries. Am J Sports Med 2003;31(5):751-7. 29. Björkenheim JM, Syvähuoko I, Rosenberg PH. Injuries in competitive junior ice-hockey. 1437 players followed for one season. Acta Orthop Scand 1993;64(4):459-61. 30. Wiggins W. Implication of introducing body checking in ice hockey at different ages. OpenThesis. Lakehead University, 1998: www.openthesis.org/documents/Implication-introducing-body-checking-in-182710.html (Accessed July 4, 2012). 31. Wattie N, Cobley S, Macpherson A, Howard A, Montelpare WJ, Baker J. Injuries in Canadian youth ice hockey: The influence of relative age. Pediatrics 2007;120(1):142-8. 32. Roberts WO, Brust JD, Leonard B. Youth ice hockey tournament injuries: Rates and patterns compared to season play. Med Sci Sports Exerc 1999;31(1):46-51. 33. Williamson IJS. An epidemiological investigation of concussion in youth ice hockey. Simon Fraser University: MSc thesis, 2006. 34. Smith AM, Stuart MJ, Wiese-Bjornstal DM, Gunnon C. Predictors of injury in ice hockey players. A multivariate, multidisciplinary approach. Am J Sports Med 1997;25(4): 500-7. 35. McKay C, Emery CA, Campbell T, Meeuwisse W. The effect of premature return to play on re-injury risk in elite adolescent ice hockey and associated psychosocial predictors [Abstract]. Br J Sport Med 2008;42(6):532-3. 36. Willer B, Kroetsch B, Darling S, Hutson A, Leddy J. Injury rates in house league, select, and representative youth ice hockey. Med Sci Sports Exerc 2005;37(10):1658-63. 37. Finke RC, Goodwin Gerberich S, Madden M, et al. Shoulder injuries in ice hockey. J Orthop Sports Phys Ther 1988;10(2):54-8. 38. Brunelle JP, Goulet C, Arguin H. Promoting respect for the rules and injury prevention in ice hockey: Evaluation of the fair-play program. J Sci Med Sport 2005;8(3):294-304. 39. Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee. Identification and management of children with sport related concussion (Principal author Laura K Purcell). Paediatr Child Health 2012;17(1):31 www.cps.ca/en/documents/position/concussion-evaluation-management. 40. Canadian Task Force on Preventive Health Care, New grades for recommendations from the Canadian Task Force on Preventive Health Care for specific clinical preventive actions. CMAJ 2003;169(3):207-8. 41. Canadian Task Force. Quality of Published Evidence. www.canadiantaskforce.ca/_archive/index.html (Accessed July 19, 2012). Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.
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National Dementia Strategy

https://policybase.cma.ca/en/permalink/policy10858
Last Reviewed
2020-02-29
Date
2013-08-21
Topics
Population health/ health equity/ public health
Resolution
GC13-39
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2013-08-21
Topics
Population health/ health equity/ public health
Resolution
GC13-39
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.
Text
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.
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