The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy.
The Canadian Medical Association (CMA) is the national organization representing over 80,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease.
Why this matters to Canada's physicians
The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians.
CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2
In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change.
The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection.
The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease.
Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada.
1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014.
2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518.
3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014.
4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's Notice of proposed order to amend the schedule to the Tobacco Act1, from October 14, 2014, on the restriction of the use of additives.
Canada's physicians 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.
Flavoured tobacco products include candy or fruit flavoured products including cigarillos, water pipe tobacco, smokeless tobacco and blunt wraps. They come in flavours that are appealing to youth such as chocolate, mint, cherry, peach, or strawberry. Flavouring makes the tobacco products more palatable to youth and young adult smokers because they have a lower tolerance for irritation and an underdeveloped taste for tobacco smoke.2 Menthol is a long standing and common flavour used in cigarettes and is used to reduce the harshness of cigarette smoke. It is the most popular flavour among youth. Almost three out of 10 Canadian youth who smoked cigarettes in the last 30 days (29 per cent) reported smoking menthol cigarettes.3
Tobacco Use and Youth
While tobacco use has declined in Canada we must remain vigilant in our efforts to reduce smoking rates. Today 16 per cent of Canadians continue to smoke on a regular basis and physicians are particularly concerned about the smoking prevalence among young adults and youth with 20 per cent of those aged 20-24, and 11 per cent of youth aged 15-19 currently smoking on a regular basis. 4
Flavoured tobacco products, with their appeal to young Canadians are a major threat to the health and well-being of our youth. A recent report, Flavoured Tobacco Use: Evidence from Canadian Youth based on the 2012/13 Youth Smoking Survey, shows that young people are using flavoured tobacco products at high levels. Results show that 50 per cent of high school students in Canada who used tobacco products in the previous 30 days used flavoured tobacco products.5
Previous Amendments Regarding Flavouring Agents
The CMA supported efforts of the federal government in 2009 to limit the addition of flavouring agents to tobacco products through the 2010 Act to Amend the Tobacco Act. But the Act did not cover all tobacco products and it excluded menthol as a flavouring agent. Manufacturers have been able to modify the weight and packaging of their products to technically comply with the Act while they continue to market flavoured products.
It is the CMA's position that the federal government has an important role in smoking cessation and prevention among youth. The CMA supports the proposed extension of the prohibitions on the use of certain flavouring additives in relation to the manufacture and sale of little cigars to cigars weighing more than 1.4 g but less than 6 g.
The CMA remains very concerned that these amendments do not ban menthol flavouring in tobacco products. To that end, the CMA recommends that Health Canada extend its prohibition on flavouring additives to include a ban on the addition of menthol in all tobacco products.
1 Health Canada. Notice of proposed order to amend the schedule to the Tobacco Act. October 14, 2014. Accessed at: http://www.hc-sc.gc.ca/hc-ps/consult/_2014/tobacco-act-loi-tabac/index-eng.php
2 Carpenter CM, Wayne GF, Pauly JL, Koh HK, Connolly GN. New cigarette brands with flavors that appeal to youth: Tobacco marketing strategies: Tobacco industry documents reveal a deliberate strategy to add flavors known to appeal to younger people. Health Affairs 2005;24(6):1601-1610.
3 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
4 Canadian Tobacco Use Monitoring Survey 2012 , accessed at http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2012-eng.php.
5 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
Minaker L, Manske S, Rynard VL, Reid JL & Hammond D. Tobacco Use in Canada: Patterns and Trends, 2014 Edition - Special Supplement: Flavoured Tobacco Use. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo.
Canadian Medical Association 2
November 10, 2014
On behalf of its more than 82,000 members and the Canadian public, CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery.
The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 51 national medical organizations.
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Health Committee for its study on e-cigarettes.
Electronic cigarettes, or e-cigarettes, which replicate the act and taste of smoking, but do not contain tobacco, are growing rapidly in popularity. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid, mainly propylene glycol. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine. Flavourings are also added with the intention of boosting their appeal to young people. Issues have been identified with labelling of e-cigarettes, where upon inspection, there have been contaminants, and nicotine has been detected in products labeled without nicotine.1 Users are generally able to modify the contents of e-cigarettes, with the addition of other substances, including marijuana.
Originally most e-cigarette manufacturers were small entrepreneurial companies; now, however, all major transnational tobacco companies are also producing e-cigarettes and competing for a share in the market.
There are little data on Canadian use. In the U.S., one in five adult smokers has tried them, according to the Centers for Disease Control and Prevention2.
Current Regulatory Status
Health Canada issued a warning in 20093 about the potential dangers and the fact that e-cigarettes had not been fully evaluated for safety, quality and efficacy. The sale of e-cigarettes containing nicotine is currently illegal in Canada under the Food and Drugs Act regulations4 though they can still be purchased in the US or over the Internet. However, those that do not make any health claim and do not contain nicotine may legally be sold in Canada under the same regulation. Health Canada is considering additional regulatory measures but none have yet been introduced. Some municipal jurisdictions are also considering regulation changes.
Internationally, regulation of e-cigarettes is just beginning, and approaches vary. A few countries - such as Brazil, Norway and Singapore - have banned them outright. France plans to regulate e-cigarettes in the same way as tobacco products, and the US Food and Drug Administration is considering a similar approach. On the other hand, Britain will regulate e-cigarettes as non-prescription drugs starting in 2016.5
Current evidence is insufficient to estimate the health effects of e-cigarettes. There are both defenders and opponents, though their arguments are based largely on opinion since e-cigarettes are only beginning to undergo rigorous clinical testing.6
Proponents, including some health officials and groups, say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease.7 Some believe they serve a useful purpose as a harm reduction tool or cessation aid, although marketing them as such is not permitted since that claim has never been approved by Health Canada.
Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the e-cigarettes may contain other toxic ingredients such as nitrosamines, a carcinogen. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to use of tobacco by people who might otherwise have remained smoke-free.8 The use of flavouring agents and attractive packaging could entice children and youth, and survey data in some countries has shown that teens are increasingly experimenting with e-cigarettes.
There has also been a dramatic increase in cases of nicotine overdose by ingestion or through dermal contact, particularly in children.9 The number of these incidents seems to be rising in countries that monitor poisonings.
The World Health Organization recently released a report on the health impacts of electronic nicotine delivery systems (ENDS) use which incorporates the 2013 deliberations and scientific recommendations by the WHO Study Group on Tobacco Product Regulation. It concludes that "ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants." The report says that it is possibly less toxic for the smoker than conventional cigarettes but it is unknown by how much.10 This report suggests that governments should have the following regulatory objectives:
* impede the promotion and uptake of e-cigarettes with nicotine by non-smokers, pregnant women and youth;
* minimize potential health risks to e-cigarette users and non-users;
* prohibit unproven health claims from being made about e-cigarettes; and
* protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.11
Given the absence of solid evidence of harms or benefits, CMA recommends that:
1. E-cigarettes containing nicotine should not be authorized for sale in Canada.
2. The sale of all e-cigarettes should be prohibited to Canadians younger than the minimum age for tobacco consumption in their province or territory.
3. Smoke-free policies should be expanded to include a ban on the use of e-cigarettes in areas where smoking is prohibited.
4. Research on the potential harms and benefits of electronic cigarette use should be supported.
1 Institut national de santé publique du Québec (INSPQ). (Mai 2013). La cigarette électronique: état de situation. Available : http://www.inspq.qc.ca/pdf/publications/1691_CigarElectro_EtatSituation.pdf
2 Centers for Disease Control and Prevention. About one in five U.S. adult cigarette smokers have tried an electronic cigarette. Centers for Disease Control and Prevention Press Release. February 28, 2013 Available: http://www.cdc.gov/media/releases/2013/p0228_electronic_cigarettes.html (accessed October 31, 2014)
3 Health Canada. Health Canada Advises Canadians Not to Use Electronic Cigarettes (archived). Available: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2009/13373a-eng.php (accessed October 31, 2014)
4 Health Canada. Notice - To All Persons Interested in Importing, Advertising or Selling Electronic Smoking Products in Canada. Available: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/pol/notice_avis_e-cig-eng.php (accessed October 31, 2014)
5 Kelland, K. & Hirschler, B. Insight - No smoke, plenty of fire fuels e-cigarettes. Reuters. June 13, 2013. http://uk.reuters.com/article/2013/06/13/uk-ecigarettes-insight-idUKBRE95C0F720130613 (accessed October 31, 2014)
6 Non-Smokers Rights Association. Product Regulation: The Buzz on E-Cigarettes. Available: http://www.nsra-adnf.ca/cms/page1385.cfm (accessed October 31, 2014)
7 Weeks, C. Could e-cigarettes save smokers' lives? Some health advocates think so. The Globe and Mail April 29, 2013. Retrieved from http://www.theglobeandmail.com/life/health-and-fitness/health/could-e-cigarettes-save-smokers-lives-some-health-advocates-think-so/article11583353/?cmpid=rss1
8 Toronto Public Health. E-cigarettes in Toronto. Staff report to the Toronto Board of Health. August 1, 2014. Available: http://www.toronto.ca/legdocs/mmis/2014/hl/bgrd/backgroundfile-72510.pdf (accessed October 31, 2014).
9 Centers for Disease Control and Prevention. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes - United States, September 2010-February 2014. Morbidity and Mortality Weekly Report, 63(13): 292-293. April 4, 2014. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_w (accessed October 31, 2014).
10 World Health Organization. Electronic nicotine delivery systems. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Sixth session Moscow, Russian Federation, 13-18 October 2014. Provisional agenda item 4.4.2. Available: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf?ua=1
The Canadian Medical Association (CMA) wishes to commend the multi-party group of Members of Parliament who have come together to form the Parliamentary Committee on Palliative and Compassionate Care.
The challenge we face today in caring for our aging population is only going to get greater. Statistics Canada has projected a rapid increase in the proportion of seniors in the population. The first wave of the baby boom generation turns 65 next year. By 2031, seniors will account for roughly one-quarter of the population, nearly double the 13.9% observed in 2009.1
Canadians are clearly concerned about their ability to cope with future health care expenses, either their own or those of their parents. Respondents to the CMA's 2010 Annual National Report Card on Health Care survey anticipate a range of implications associated with our aging population:
* 29% reported that they will likely alter their retirement plans (e.g., work longer) to help pay for their own future costs or those of their parents;
* Almost one in five (19%) anticipates moving their parents into their own home and supporting them financially; and
* One in six (16%) anticipates paying for their parents to live in a nursing home.2
The CMA believes that the federal government could play a key role in allaying Canadians' concerns about the future by leading negotiations with the provinces and territories and taking direct action on extending access along the continuum of care. These actions should focus on three priority areas:
* Increasing access by all Canadians to affordable prescription drugs;
* Supporting informal caregivers; and
* Increasing access to palliative care at the end of life.
If nothing is done to extend Medicare to cover more of the continuum of care, it will erode over time as a national program. When the Canada Health Act (CHA) was passed in 1984, physician and hospital services represented 57% of total health spending; this had declined to 42% as of 2009.3 While there is significant public spending beyond CHA-covered services (more than 25% of total spending) for programs such as seniors' drug coverage and home care, these programs are not subject to the CHA principles and coverage across the provinces and territories varies significantly.
Access to Prescription Drugs
The federal government missed an excellent opportunity to modernize Medicare in July 2004 when Premiers called on it to upload responsibility for drug programs. The Premiers stated that "a national pharmaceutical program should immediately be established. The federal government should assume full financial responsibility for a comprehensive drug plan for all Canadians, and be accountable for the outcomes."4
The federal government did not give this offer even fleeting consideration. Instead, the September 2004 10-Year Plan to Strengthen Health Care contained a watered-down version of the First Ministers' 2003 commitment to ensure that all Canadians would have reasonable access to catastrophic drug coverage by the end of 2005/06.
The 2004 Accord reduced this commitment to the development of costing options for pharmaceutical coverage, as part of a nine-point National Pharmaceuticals Strategy (NPS).5 Costing options were included in the 2006 progress report of the NPS but they included estimates of the cost of catastrophic coverage wildly exceeding those of Romanow and Kirby, ranging from $6.6 billion to $10.3 billion.6 Nothing further has been heard about the NPS since stakeholder consultations were held in fall 2007.
As recently as September 2008, the provinces and territories (PTs) were still interested in federal participation in pharmaceuticals. In the communiqué from their annual meeting, the PT health Ministers called for a three-point funding formula to support a national standard of pharmacare coverage, including:
* PT flexibility and autonomy in program design;
* Prescription drug costs not to exceed 5% of net income; and
* Federal and PT governments to cost share 50/50, estimated at $2.52 billion each in 2006.7
Again there was no reaction from the federal government. Since then the PT governments have appeared to be giving up hope of federal participation in access to pharmaceuticals. At their June 2009 meeting, the western Premiers announced they would develop a joint western purchasing plan for pharmaceuticals,8 and more recently at the August 2010 meeting of the Council of the Federation, Premiers agreed to establish a pan-Canadian purchasing alliance for common drugs, medical supplies and equipment.9 Health Ministers reaffirmed this commitment at their September 2010 meeting.10 One can speculate that had the federal government taken up the Premiers' offer in 2004, many aspects of the NPS would be in place by now.
Meanwhile, access to prescription drugs presents a hardship for many Canadians. In the CMA's 2009 National Report Card survey, nearly one in six (14%) reported they had either delayed or stopped buying some prescription drugs. This ranged from more than one in five (22%) with annual incomes of less than $30,000 to just over one in 20 (7%) of those with incomes greater than $90,000.11
The wide geographic disparity in out-of-pocket drug expenditures is shown in the table below, which is compiled from Statistics Canada's 2009 Survey of Household Spending. Table 1 shows the percentage of households spending more than 3% and 5% of after-tax income on prescription drugs, by province, in the year prior to the survey.
[Note - see PDF for correct display of table information]
% of Households Spending Greater than 3% and 5% of After-tax Income
on Prescription Drugs, Canada and Provinces, 2008
Geography >3% >5%
Canada 7.6 3.0
Newfoundland and Labrador 11.6 5.4E
Prince Edward Island 13.3 5.8E
Nova Scotia 8.9 3.8
New Brunswick 9.1 4.1E
Quebec 11.6 3.3
Ontario 4.7 2.2E
Manitoba 12.0 5.2
Saskatchewan 11.5 5.9
Alberta 4.6E 2.2E
British Columbia 7.5 3.6
E - Use with caution - high coefficient of variation
Source: Statistics Canada, CANSIM Table 109-5012
Under both thresholds there is a more than two-fold variation across provinces in the incidence of catastrophic drug expenditures. At the 5% threshold the range is from 2.2% of households in Ontario and Alberta to 5.8% in PEI and 5.9% in Saskatchewan. With the growing availability of more expensive drugs, this variation is only likely to be exacerbated in the years ahead.
The federal government should negotiate a cost-shared program of comprehensive prescription drug coverage with the provincial/territorial governments.
This program should be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements:
* A mandate for all Canadians to have either private or public coverage for prescription drugs;
* Uniform income-based ceiling (between public and private plans across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income);
* Federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both;
* Group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and
* A continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs).
In negotiating this plan, consideration should be given to the following:
* Establishing a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective;
* Assessing the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies;
* Provision of adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; and
* Provision of comprehensive coverage of prescription drugs and immunization for all children in Canada.
Supporting Informal Caregivers
As the population ages, the incidence of diseases associated with dementia is projected to increase dramatically. A 2010 study commissioned by the Alzheimer Society of Canada has reported that the 2008 level of an estimated 103,728 new dementia cases is expected to more than double to 257,811 per year by 2038. Over this period, the demand for informal caregiving will skyrocket. In 2008, the Alzheimer Society reports, the opportunity cost of unpaid care giving was estimated at almost $5 billion. By 2038 this cost is expected to increase by 11-fold, to reach $56 billion, as the overall prevalence of dementia will have risen to 1.1 million people, representing 2.8% of the Canadian population.12
The burden of informal care giving extends beyond the costs related to dementia. Statistics Canada's 2007 General Social Survey has documented the extent to which Canadians are providing unpaid assistance to family, friends or other persons with a long-term health condition or physical limitation.
Nationwide, 1.4 million adults aged 45 or over living in the community were receiving care in 2007. Of this number almost one in two (46.9%) were receiving both paid and unpaid care, almost three in 10 (27.4%) were receiving unpaid care only, and just under one in five (18.8%) were receiving paid care only. This underscores the importance of the informal sector.
In terms of who was providing this care, an estimated four million Canadians were providing care, of whom one million were aged 65 or over, while almost two million (1.8) were in the prime working age range of 45 to 54. The provision of unpaid care represents a significant time commitment.
The caregivers who reported helping with at least one activity spent an average 11.6 hours in a typical week doing so. Those providing care reported significant personal consequences. One in three reported spending less time on social activities (33.7%) or incurring extra expenses (32.7%), almost one in five cancelled holiday plans (18.7%) or spent less time with their spouse (18.7%), and more than one in 10 (13.7%) reported that their health had suffered.
The 2.5 million informal caregivers who were in the paid labour force were likely to report that caregiving had had a significant impact on their jobs. Almost one in four (24.3%) reported missing full days of work and one in six (15.5%) reported reducing hours of work.
Compared to the total population, informal caregivers were more likely to report stress in their lives. Almost three in 10 (27.9%) reported their level of stress on most days to be either quite a bit or extremely stressful compared to fewer than one in four (23.2%) of the total population.13
As the demand for informal care grows, it seems unlikely that the burden of informal caregiving will be sustainable without additional support.
The federal government took the positive step in 2004/05 of introducing Employment Insurance (EI) Compassionate Care Benefits for people who are away from work temporarily to provide care or support to a family member who is gravely ill and at risk of dying within 26 weeks.14 So far, however, this program has had limited uptake. In 2007/08, 5,706 new claims were paid.15 This pales in comparison to the 235,217 deaths that year (although not all of these would be candidates for this type of care).16
The federal government should implement measures within its jurisdiction, such as the use of tax credits, to support informal caregivers.
Increasing Access to Palliative Care at the End of Life
The Senate of Canada, and Senator Sharon Carstairs in particular, have provided exemplary leadership over the last 15 years in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. The Senator's 2005 report Still Not There noted that only an estimated 15% of Canadians have access to hospice palliative care and that for children the figure drops even further to just over 3%.17 The 2005 report repeated the 1995 call for a national strategy for palliative and end-of-life care. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada.
Diseases at the end of life, such as dementia and multiple chronic conditions, are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. There will be an estimated 40% more deaths a year by 2020. While the proportion of Canadians dying in hospital has been decreasing over the past decade, many more Canadians would undoubtedly prefer to have the option of hospice palliative care at the end of their lives than current capacity will permit.
In the 2004 Health Accord, First Ministers built on their 2003 Accord by agreeing to provide first dollar coverage for certain home care services by 2006, including end-of-life care for case management, nursing, palliative-specific pharmaceuticals and personal care at the end of life. Seven years later we have no comprehensive picture of the availability of end-of-life care across Canada.
The Health Council of Canada's last detailed reporting on the implementation of the 2003 Accord was in 2006. At that time, the only province to report comprehensive end-of-life care was British Columbia.18 For most other jurisdictions, end-of-life care was discussed under "next steps." Since then, the Health Council has ceased comprehensive reporting on the Accord.
In the 2007 National Physician Survey, doctors across Canada were asked to rate the accessibility of the range of services for their patients. Just one in three (32%) rated access to palliative care services as either excellent or very good.19
In 2006, the Canadian Hospice Palliative Care Association and the Canadian Home Care Association jointly issued a 35-point "gold standard" for palliative home care, covering the areas of case management, nursing care, pharmaceuticals and personal care, which they commended to governments.20
In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated, quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit, and federal inmates, and renewed research funding for palliative care.21
In 2010, the Quality End-of-Life Care Coalition of Canada (QELCC), of which the CMA is a member, released its Blueprint for Action 2010 to 2020. The four priorities are:
* Ensure all Canadians have access to high-quality hospice palliative end-of-life care;
* Provide more support for family caregivers;
* Improve the quality and consistency of hospice palliative end-of-life care in Canada; and
* Encourage Canadians to discuss and plan for end-of-life.22
This blueprint embodies the sound ideas that have emerged over the past decade.
In June 2010, Senator Carstairs released her latest report Raising the Bar, which, while acknowledging some of the achievements that have been made in palliative care, repeats her previous calls for a national role and active engagement of the federal government.23
A wide range of stakeholders either have, or should have, a significant stake in the issue of palliative care. They include patients and the organizations that advocate on their behalf, caregivers (both formal and informal), the institutional and community health sectors, and the employer/business community.
The CMA urges the federal government to collaborate with the provincial and territorial governments to convene a national conference in 2011 to assess the state of palliative care in Canada.
1 Statistics Canada. Population projections for Canada, provinces and territories 2009 to 2036. Catalogue no. 91-520-X. Ottawa. Minister of Industry, 2010.
2 Canadian Medical Association. 10th Annual National Report Card on Health Care, August, 2010. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2010/report_card/2010-National-Report-Card_en.pdf. Accessed 09/28/10.
3 Canadian Institute for Health Information. National health expenditure trends 1975 to 2009. Ottawa, 2009.
4 Canadian Intergovernmental Conference Secretariat. Premiers' action plan for better health care: resolving issues in the spirit of true federation. July 30, 2004. http://www.scics.gc.ca/cinfo04/850098004_e.html. Accessed 09/28/10.
5 Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 09/28/10.
6 Health Canada. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 09/28/10.
7 Canadian Intergovernmental Conference Secretariat. Annual Conference of Provincial-Territorial Ministers of Health. September 4, 2008. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/28/10.
8 Canadian Intergovernmental Conference Secretariat. Premiers taking action on pharmaceuticals. June 18, 2009. http://www.scics.gc.ca/cinfo09/850114004_e.html. Accessed 09/28/10.
9 Council of the Federation. Premiers protecting Canada's health care systems. http://www.councilofthefederation.ca/pdfs/PremiersProtectingCanadasHealthCareSystem.pdf. Accessed 09/28/10.
10 Canadian Intergovernmental Conference Secretariat. P/T health Ministers work together to advance common issues. September 13, 2010. http://www.scics.gc.ca/cinfo10/860578004_e.html. Accessed 09/28/10.
11 Canadian Medical Association. 9th Annual National Report Card on Health Care. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2009/report_card/Report-Card_en.pdf. Accessed 09/28/10.
12Alzheimer Society of Canada. Rising tide: the impact of dementia on Canadian society. http://www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20version.pdf. Accessed 09/28/10.
13 Statistics Canada. 2007 General Social Survey: Care tables. Catalogue no. 89-633-X. Ottawa, Minister of Industry, 2009.
14Human Resources and Skills Development Canada. Information for health care professionals: EI Compassionate Care. http://www.rhdcc-hrsdc.gc.ca/eng/publications_resources/health_care/ei_ccb.shtml. Accessed 09/28/10.
15 Human Resources and Skills Development Canada. Table 2.12 Compassionate care benefits. http://www.hrsdc.gc.ca/eng/employment/ei/reports/eimar_2009/annex/annex2_12.shtml. Accessed 09/28/10.
16 Statistics Canada. Deaths 2007. The Daily, Tuesday, February 23, 2010.
17 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09.
18 Health Council of Canada. Jursdictional tables on health care renewal. Companion document to Health care renewal in Canada Measuring up? Annual report to Canadians 2006. Toronto, ON, 2007
19 College of Family Physicians of Canada. Canadian Medical Association. Royal College of Physicians and Surgeons of Canada. National Physician Survey 2007. Q25a. Please rate the accessibility of the following for your patients. http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/ENG/National/pdf/Q25/Q25aALL.only_NON.CORE.only.pdf. Accessed 09/28/10.
20 Canadian Hospice Palliative Care Association. Canadian Home Care Association. The pan-Canadian gold standard for palliative home care. http://www.chpca.net/resource_doc_library/pan-cdn_gold_standards/Gold_Standards_Palliative_Home_Care.pdf. Accessed 09/28/10.
21 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. April 2009. http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf. Accessed 09/28/10.
22 Quality End -of-life Coalition of Canada. Blueprint for action 2010 to 2020. http://www.chpca.net/qelccc/information_and_resources/Blueprint_for_Action_2010_to_2020_April_2010.pdf. Accessed 09/28/10.
23Carstairs S. Raising the bar: a roadmap for the future of palliative care in Canada. June 2010. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Raising%20the%20Bar%20June%202010%20(2).pdf. Accessed 09/29/10.
"The 2014-15 budget signals the end to a tough but necessary period of fiscal consolidation. Current expectations are for a surplus of $6.4-billion in 2015-16, plus a contingency reserve of $3-billion; there is finally some room to manoeuvre in the years ahead."
Glen Hodgson, Senior VP and Chief Economist
Conference Board of Canada - February 2014
Having emerged from the global economic downturn, now is the time for the federal government to make strategic investments that will ensure Canada's long-term economic sustainability. The ageing of Canada's population is the most pressing policy imperative of our time. As highlighted in Finance Canada's 2012 report, Economic and Fiscal Implications of Canada's Ageing Population, action to prepare for an ageing population will support the sustainability of Canada's public finances and social programs.
The CMA's recommendations for the 2014-15 federal budget focus on strategic investments in three key areas:
1. Supporting Canadian families and seniors
A) Pan-Canadian Seniors Strategy
The CMA is concerned that Canada is ill-prepared for the demographic shift already underway. By 2036, it is expected that a quarter of Canada's population will be over age 65; almost double the proportion of today. Already, patients aged 65 and older account for nearly half of Canada's health care spending. Seniors also face challenges accessing health services across the continuum of care. These challenges are getting worse, despite growing efforts to provide sustainable, high-quality health care for seniors, and despite most provinces having seniors care strategies in place.
Canadians share our concern. According to an Ipsos Reid poll commissioned by the CMA, a majority of respondents (83%) said they were concerned about their health care in their retirement years. This poll found that nine out of ten Canadians (93%) believe Canada needs a national strategy for seniors health care that integrates home care, hospitals, hospices, and long-term care facilities into the continuum.
Recommendation: The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian strategy to address the needs of the aging population.
B) Incenting savings for future continuing care needs
According to the Organization for Economic Cooperation and Development (OECD), long-term care spending in Canada averaged 1.2% of GDP over the 2006-10 period and could more than double to 2.5% by 2060. The Canadian Life and Health Insurance Association estimates there will be an unfunded long-term care liability of $590 billion over and above existing government programs as the boomer generation passes through their old age1.
Of the approaches available to address this unfunded liability, encouraging and incentivizing individuals to save for their future continuing care needs is the least demanding of public finances as compared with increased personal or business income taxes or mandatory contributions.
There has been increasing interest among Canadians with focused savings vehicles established by the federal government. There continues to be increased uptake with Registered Education Savings Plans (RESPs) to support post-secondary education. The growth in RESP assets was significant in 2011 and 2012, representing an average annual rate of 12.6%.2
There has also been increased uptake in the use of tax sheltered individual savings vehicles, such as the Tax Free Savings Account (TFSA). According to a Finance Canada report, as of 2011 there were 8.2 million individuals with a TFSA, representing 31% of tax filers, and they contributed $30.7 billion in that year. The report noted that the greatest proportionate growth in TFSA uptake was observed among those with incomes of less than $20,000, with their participation rate almost doubling from 11% in 2009 to 20% in 20113.
Recommendation: The CMA recommends that the federal government use its economic levers to encourage Canadians to save over their lifetime for future continuing and long-term care needs not covered under the Canada Health Act.
C) Promoting Healthy Ageing
The Public Health Agency of Canada (PHAC) defines healthy ageing as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life."
Such initiatives could focus on:
* Physical activity - 57% of seniors in 2008 reported being physically inactive4;
* Injury prevention - 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures are due to falls by seniors5;
* Nutrition - 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less6.
The federal government has already undertaken steps to address healthy ageing among Canada's seniors, such as 'Seniors: Active. Engaged. Informed'. In funding over 13,000 projects across Canada, the New Horizons for Seniors Program has demonstrated success in enabling new programs to achieve specific goals; this program can be harnessed to deliver projects focused on promoting healthy ageing.
Recommendation: The CMA recommends that the New Horizons for Seniors program be expanded by $5 million per year to include funding for programs promoting healthy ageing activities for Canadian seniors.
2. Ensuring the availability and access to continuing care
"When we poll CARP members, they call for leadership in helping Canadians save for retirement, get home care when they need it and get access to affordable drug."
Susan Eng, VP, Advocacy for CARP - February 2014
A) Addressing the Continuing Care Infrastructure Crisis
A major issue facing health care systems across the country is the high number of alternate level of care patients (ALC) in acute care hospitals. ALC patients-many of whom are seniors-are those who have completed the acute care phase of their treatment but remain in an acute care bed or who are admitted into a hospital bed due to the lack of more appropriate assisted living settings.
The CMA supports efforts to allow Canadian seniors to remain in the community as long as possible. However, there are increasing pressures on the continuing care sector given the rise in the number of seniors with complex health and social needs. These pressures not only relate to the construction of new facilities, including assisted living units and other innovative residential models for seniors, but apply as well to the need to upgrade and retrofit existing facilities7.
Despite increasing the availability of home care, Canada will face a significant infrastructure shortage in the continuing care sector. The CMA estimates this infrastructure shortage costs the health care system about $2.3 billion a year; this cost is estimated to skyrocket as our population ages.
Recommendation: The CMA recommends the federal government deliver $2.3 billion in funding to leverage provincial/territorial strategic investment in the construction, renovation and retrofitting of assisted living units, other innovative residential models, and long-term care facilities.
B) Supporting Caregivers
The 2011 Budget introduced a new non-refundable Family Caregiver Tax Credit to provide tax relief to those who provide informal care for a dependent relative within their home. However, the credit is limited to 15% of a maximum $2,040 in expenses for 2013 or a maximum sum of $306. While this credit can be added to other tax credits, the total amount is small in relation to the burden experienced by caregivers and it remains non-refundable.
The CMA is concerned that the scarcity of financial support and programs supporting caregivers represents significant risks in relation to economic costs, lower productivity, impacts on the labour market, inefficiencies within the health care system and, most importantly, patient care.
Informal caregivers are the backbone of any health care and social care system. The work of the 1.5 to 2 million caregivers in Canada is estimated at $25-26 billion annually, while incurring $80 million dollars annually in out-of-pocket costs8. The role of informal caregivers will only increase with the move to providing more care at home.
Recommendation: The CMA recommends the federal government make the Family Caregiver Tax Credit a refundable tax credit as part of an effort to better support informal caregivers.
3. Accelerating innovation in health care through enhanced use of electronic medical records (EMRs)
"The need for innovation ..., both in terms of medical technologies and healthcare delivery systems, is one of the most pressing public policy challenges of our times."
Hon. Rona Ambrose, Health Minister - January 2014
The CMA supports prioritizing continuing the development and meaningful use of electronic medical records (EMRs).
A recent report estimates the costs of a pan-Canadian electronic health record (EHR) between $7.9 billion and $16.0 billion9 while total gross savings over a 20-year range were projected at over $82 billion. To date, approximately $2.1 billion in federal funding has been invested. Five national benefit evaluation studies have been commissioned since 2008 and these analyses estimated $7.7 billion in benefits to date as a result of this investment10.
This initial investment has resulted in digitized health care information and paper processes, and created a robust marketplace for innovation by EMR vendors. As such, the value of investments in EMRs is emerging. The 2013 National Physicians Survey11 indicated that:
* Almost 70% of medical general practitioners (GPs) and specialists now use an EMR, up from 56% in 2012 and 37% in 2009.
* 45% of GPs and 40% of specialists report increased or greatly increased efficiency due to the use of EMRs.
* 63% of GPs and 50% of specialists report the quality of patient care they provide is better or much better since they started using an EMR.
The next step in the evolution of EMRs is enhanced use. In Canada, federal investment does not extend beyond the equivalent of the first stage of the U.S. framework for Meaningful Use. There remain significant gaps in funding to achieve enhanced use of EMRs by clinicians, regional interoperability, and to structure EMR data to leverage big data analytics.
Recommendation: The CMA recommends the federal government continue to fund Canada Health Infoway (CHI) to administer remaining project funds from the $500 million allocated in 2009, and allocate an additional $500 million, to be administered by CHI, for projects to achieve enhanced use of EMRs.
1 Canadian Life and Health Insurance Association. Helping Canadians prepare for long-term care costs. CLHIA report on long-term care policy. 2014.
2 Employment and Social Development Canada. 2012 CESP Annual Statistical Review. http://www.esdc.gc.ca/eng/jobs/student/reports/statistics/cesp_2012.shtml#h2.4-h3.1
3 There is a detailed analysis of the TFSA in the 2012 Tax Expenditures and Evaluations report by Finance Canada (Pages 31-42 in http://www.fin.gc.ca/taxexp-depfisc/2012/taxexp-depfisc12-eng.pdf).
4 PHAC 2010
5 PHAC 2010
6 PHAC 2010
7 Canadian Medical Association, The Need for Health Infrastructure in Canada. Submitted to Hon. Denis Lebel, PC, MP Minister of Transport, Infrastructure and Communities. March 18, 2013.
8 Hollander, M.J, Liu, G., Chappeell, N.L. (2009). Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthcare Quarterly, 12(2), 42-59.
10 Remote Patient Monitoring (RPM) Evaluation; EMR Evaluation; Telehealth evaluation; Drug Information Systems (DIS) evaluation; Diagnostic Imaging (DI) systems evaluation
Since 2010, the Canadian Medical Association (CMA) has been calling for health care transformation in Canada to better meet the needs of Canadians. A high performing health care system must be able to respond to the changing nature of its population's health needs.
The CMA believes that seniors care is the paramount health care issue of our time. Our older population will double over the next 20 years, while the 85 and older group is set to quadruple. Currently, we spend almost half of all our health care dollars on seniors. Improving seniors' care will go a long way to fixing our health care system; this is because strategies to address the needs of this population can be leveraged to address the needs of other population groups. That is why CMA has called for the development of a Pan-Canadian Seniors Strategy as a necessary first step.
The CMA welcomes the creation of the Advisory Panel on Healthcare Innovation to better prepare health systems across the country for the above challenges and to contribute toward the sustainability of Canada's public finances and social programs. This brief identifies five important innovations that will not only benefit Canada's growing seniors population but the broader Canadian population as well.
Five Innovations to Improve our Health Care System
1. Supportive living models and palliative care
Canada suffers from a lack of integrated community/residential supports and palliative care models, contributing to poor patient outcomes, significant inappropriate use of health care resources, and higher health care costs. An obvious sign of this gap is the significant number of alternate-level-of care (ALC) patients-most of whom are seniors-languishing in hospitals across Canada. ALC patients are those inpatients that no longer require acute care and are waiting for placement in a more appropriate setting. According to a 2009 Canadian Institute for Health Information (CIHI) report, dementia accounted for almost one-quarter of ALC hospitalizations and more than one-third of ALC days.i Dementia is the leading cause of dependency and disability among older persons. The Wait Time Alliance (WTA) has stated that the most important action to improve timely access to specialty care for all Canadians is by addressing the issue of alternate-level-of-care (ALC) patients.ii
The creation of supportive and integrated living models particularly for the frail elderly and those with dementia would lead to improved health outcomes for these patients as well as savings to the health care system.
* Supportive living models can involve providing technology and human resources to support seniors to stay in their home. It has been estimated that tele-homecare could yield an annual reduction in approximately $540 million in inpatient costs and $23 million in emergency department visit costs.iii
* For others, particularly those with dementia, residential care models are required that can properly support their needs and provide the highest quality of life possible. A few such models are already in existence but more are required. Models include the Bruyère Village in Ottawa (http://www.bruyere.org/bruyere-village) and Saskatoon's Sherbrooke Community Centre (http://www.sherbrookecommunitycentre.ca/). CMA recommends that federal and provincial infrastructure programs allow for innovative residential care options to be eligible for funding.
* Despite the vast majority (96%) of Canadians supporting the use of palliative and hospice care in end-of-life care, only 16-30% of Canadians who are dying have access to or receive hospice, palliative and end-of-life servicesiv. This issue must be addressed immediately across the country. Currently, there is no standard palliative and hospice care model in Canada. However, there are some innovative programs around the country that are leading the way to higher quality palliative care (e.g., West Island Palliative Care Residence in Quebec). The CMA is currently preparing a report to inform health care decision makers including physicians on tools to integrate palliative and hospice care services in their respective communities. But assistance is required to implement innovative practice models across the country.
2. Integrated strategies for high-users of health care and at-risk populations
It is now recognized that a targeted approach is necessary to make substantive change to improve the health status of populations; including reducing health inequities and ensuring more appropriate access to health care resources by those citizens who have a range of socio-economic needs.
Approximately five percent of patients account for two-thirds (66 percent) of provincial health expenditures-many of whom are elderly. This picture is consistent across the country.v This high use is often due to systemic issues, such as poor integration or lack of access, rather than the choices of these patients. There is general agreement that multi-sectoral approaches are necessary that involve the integration of clinical and social care as well as other sectors to best address this population group that often has polymorbidities.
Programs are being implemented in a few provinces at the regional or provider level to try and accommodate the needs of the high-users population by coordinating and integrating care for the benefit of the patient and the family. Examples include Health Links in Ontario and the Regional Integrated Complex Patient Care Planning (RICP2) program at Vancouver Coastal Health Authority. However, funding models-particularly for inter-sectoral approaches-to support the wide-spread adoption of these approaches are rare.
In addition to the high-users are those populations that feature a high burden of illness. Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.vi Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.vii
As with the high-user group, a multi-sectoral approach is required to address the social determinants of health. While it is important for society to strive to eliminate poverty and provide adequate housing and food security, the health care sector can also contribute. Some innovative programs have been put in place such as the Well North program in the United Kingdom that is targeted at improving the health of the poorest fastest, reducing premature mortality and reducing worklessness.viii In Canada, the St. Michael's family health team has an income security specialist on their multi-disciplinary team. This individual helps patients to navigate the government's social services system, will help patients reduce expenses, complete their taxes, set up bank accounts, access free programs, budget and save for emergencies. These patients are identified through screening conducted by family physicians on the team.
There are innovative approaches being developed to address the needs of high-volume users as well as at-risk populations. As many of these innovations involve greater integration between health and the community sector and attention to issues not traditionally funded through health care payment systems, there is a need to provide access to funds to enable these innovations to continue and be spread across the country.
A targeted, integrated approach to identify communities in need is required and this must be based on reliable community data (i.e., meaningful use of patient data) which can be used to integrate resources to improve health status. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first multi-disease electronic medical records (EMR) surveillance and research system that allows family physicians, epidemiologists and researchers from across the country to better understand and manage chronic care conditions for their patients. Health information is collected from EMRs in the offices of participating primary care providers (e.g. family physicians) for the purposes of improving the quality of care for Canadians suffering from chronic and mental health conditions and three neurologic conditions including Alzheimer's and related dementias. CPCSSN makes it possible to securely collect and report on vital information from Canadians' health records to improve the way these chronic diseases and neurologic conditions are managed (http://cpcssn.ca/). Despite this innovative approach to sharing information to better manage chronic care conditions, its five-year federal funding terminates in 2015. The estimated cost of continuing the project is approximately $3 million per year.
3. Optimal prescribing
Poor prescribing can lead to poor patient outcomes and unnecessary costs to the health care system (e.g., fractured hips from falls). The evidence is clear that many seniors in Canada are exposed to inappropriate drug therapy. Data from European countries such as Denmark, , show that inappropriate prescribing can be controlled with only 5.8% of elderly patients using an inappropriate medication in a four month period in 2001. In Canada, CIHI studied senior's drug claims from public programs in four provinces from 2000 to 2006 and found that the rate of inappropriate drug use in 2005-06 varied from 25.2% in Manitoba to 31.3% in New Brunswick. The rate of regular use of such medications ranged from 12.9% in Alberta to 18.8 % in New Brunswick.
E-prescribing decreases the likelihood of adverse drug events or interactions, and provides tools to monitor both patient adherence and practitioner prescribing patterns. One component of an optimal prescribing strategy would be to provide support to provincial/territorial ministries of health to complete the implementation of drug information systems and regional e-prescribing solutions, and/or to develop an agenda to accomplish the enhanced use of electronic medical records.
A second component of an optimal prescribing initiative would be the development of a collaboration of content experts and professional associations to raise awareness of inappropriate prescribing among physicians and other health professionals and then to develop online educational courses and practice tools to assist at the point of care. Initially the focus might be on prescribing for seniors, but subsequently could expand to cover other priority topics such as inappropriate antibiotic use or the use of narcotics for non-cancer pain.
4. Choosing Wisely Canada - Reducing the provision of low value care
A disconcerting proportion of health care, estimated in the United States to be as much as 30%, confers little of no benefit on patients and may, through exposure to excess radiation, drug reactions, adverse events during procedures, or the worry associated with false positive tests, actually cause harm. This represents both sub-optimal quality of care and poor stewardship of scarce health care resources.
The provision of unnecessary care is driven by many elements including physician habit, lack of up-to-date clinician knowledge, patient demand, and structural or financial incentives in the health system. To counter these diverse influences the CMA partnered with the University of Toronto to launch Choosing Wisely Canada, a campaign to facilitate evidence-informed conversations between physicians and patients about the necessity of tests and treatment about low-value tests and treatment. As of October 2014, 102 recommendations have been developed by national specialty societies about clinical activities that generally should be avoided. For example, the Canadian Geriatrics Society advises physicians and patients against the use of antipsychotics as a first choice to treat behavioural and psychological symptoms of dementia as well as against the use of benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation or delirium.
Within its first year of operation the campaign enlisted over 30 national specialty societies, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, all provincial and territorial medical associations, and six large citizen groups. To date the campaign has been resourced by seed funding from the Ontario government, direct contribution from the CMA, and a modest contribution agreement from Health Canada.
If the early success of Choosing Wisely Canada is to be sustained, secure long-term funding is essential. Such resources are necessary to support the development and dissemination of materials to raise physician awareness, provide educational opportunities, make available point-of-care tools, assist with implementation at the practice level, and contribute to data collection for evaluation. The medical professional has clearly stepped forward to take ownership of the low value care challenge; they deserve federal support to ensure a successful long-term outcome.
5. National Health Care Guidance Institute
Clinical practice guidelines (CPGs) have a unique ability to enhance quality of care. The peer-reviewed literature provides robust evidence that guideline use is associated with a positive impact on both processes of care and patient outcomes. Additionally, a number of studies have reported that the application of specific CPGs result in cost-effective care, including, for example, those used in the treatment of community-acquired pneumonia, stroke prevention in primary care, traumatic brain injury, and the use of lipid-lowering drugs. Conditions such as these gain particular significance in the face of an aging population: what is the out-patient antibiotic of choice in an elderly patient with pneumonia?; in an older patient with a cardiac arrhythmia what are the comparative risks of treatment with anticoagulants versus possible cerebrovascular accident?; at what age is it no longer helpful to treat hyperlipidemia? CPGs available at the point of care provide evidence-based answers to such questions.
Internationally, national governments have recognized the value of CPGs and taken a leadership role in ensuring their quality and making them available to practitioners. Three among many examples are: United States (Agency for Healthcare Research and Quality, National Guideline Clearinghouse); United Kingdom (National Institute for Health and Clinical Excellence); and Australia (National Health and Medical Research Council, National Institute of Clinical Studies).
The challenge is that CPGs are not uniformly utilized across Canada nor do we possess a national body or systematic approach to CPG development and dissemination. There are various models that can be implemented to execute this function (e.g., full function agency, collaborative virtual agency) to perform such key functions as prioritizing areas for guideline development, maintaining a national repository and driving active dissemination. The key is having a dedicated agency that can oversee the development and dissemination of CPGs at a pan-Canadian level to improve the quality of care that Canadians receive.
Federal mechanisms to support health innovation
All health systems in Canada and elsewhere are facing the challenge to better meet the needs of their seniors' population. National governments can provide necessary direction and support. The federal government must play a leadership role on seniors care and supporting health care innovation in concert with the provinces and territories and as a system manager itself for those patients falling under federal jurisdiction (e.g., armed forces). This can begin with a First Ministers' Conference as part of the development of a Pan-Canadian Seniors Strategy.
CMA recognizes there are elements of transformation already taking place in the country across the continuum of care that are being supported by technological innovation or clinical innovation (e.g., Choosing Wisely Canada). However, in many cases, there is little funding available to fund projects beyond pilot project status or bring them up to scale, and there is very little cross-country awareness of these "pockets of excellence" due to the absence of mechanisms to share best practices.
Accordingly, CMA recommends the establishment of a National Health System Innovation Fund targeted to provinces and territories to support the adoption of health system innovations including those identified in this brief. Funding criteria should be designed to not only support the development of these innovations but to incent their adoption on a scaled-up basis.
Finally, recognizing the relationship of the social determinants of health on the demands of the health care system, the federal government should implement a requirement for all cabinet decision-making to include a health-in-all policies approach whereby all polices from tax, to transportation, to trade would undergo a health lens to ensure that negative health impacts were minimized/eliminated and positive health outcomes were supported or expanded. This would help to minimize the often unintended health consequences that arise from policies outside of the health sector.
This brief identifies five opportunities for innovating Canada's health care system by improving seniors care-the paramount health care issue of our time. Our proposed innovations would not only improve the efficient delivery of health care but more importantly the quality of care provided to all Canadians. These innovation initiatives require medical leadership at the point of care level in tandem with change at the broader system level with federal support. Together, these innovations can further contribute to the transformation of Canada's health care system-one that better meets the needs of Canadians today and into the future.
i Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa (ON): The Institute; 2009. Available: https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf
ii Wait Time Alliance, Shedding light on Canadians' total wait for care. Report card on wait times in Canada. June 2012.
iii Telehealth Benefits and Adoption: Connecting People and Providers Across Canada. Praxia and Gartner. May, 30, 2011.
iv Canadian Hospice Palliative Care Association. 2014. Fact sheet: hospice palliative care in Canada. [Accessed 11 November 2014]. Available from http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf
v Canadian Institute for Health Information. Pan-Canadian forum on high users of health care-Summary report. The Institute: 2014.
vi Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
vii CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf