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Policies that advocate for the medical profession and Canadians


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Aboriginal health

https://policybase.cma.ca/en/permalink/policy811
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Population health/ health equity/ public health
Resolution
GC90-95
That the Canadian Medical Association take action to support aboriginal peoples in those areas of social, political and economic life that would improve the health of their communities.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Population health/ health equity/ public health
Resolution
GC90-95
That the Canadian Medical Association take action to support aboriginal peoples in those areas of social, political and economic life that would improve the health of their communities.
Text
That the Canadian Medical Association take action to support aboriginal peoples in those areas of social, political and economic life that would improve the health of their communities.
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Aboriginal health care

https://policybase.cma.ca/en/permalink/policy809
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC90-93
That the Canadian Medical Association encourage physicians to expand contacts with their local aboriginal communities, on both a community and professional level, in order to address aboriginal health care issues.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC90-93
That the Canadian Medical Association encourage physicians to expand contacts with their local aboriginal communities, on both a community and professional level, in order to address aboriginal health care issues.
Text
That the Canadian Medical Association encourage physicians to expand contacts with their local aboriginal communities, on both a community and professional level, in order to address aboriginal health care issues.
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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
Documents
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Age to operate dirt bikes, all-terrain vehicles and snowmobiles

https://policybase.cma.ca/en/permalink/policy11685
Last Reviewed
2018-03-03
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-25
The Canadian Medical Association calls on governments to prohibit anyone under age 16 from operating dirt bikes, all-terrain vehicles and snowmobiles.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-25
The Canadian Medical Association calls on governments to prohibit anyone under age 16 from operating dirt bikes, all-terrain vehicles and snowmobiles.
Text
The Canadian Medical Association calls on governments to prohibit anyone under age 16 from operating dirt bikes, all-terrain vehicles and snowmobiles.
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Antimicrobial Resistance (AMR)

https://policybase.cma.ca/en/permalink/policy14079
Date
2019-03-02
Topics
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Policy document
Date
2019-03-02
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Antimicrobials (which include antibiotics) are a precious public resource and an essential tool for fighting infections in both humans and animals. Their importance to human medical, nutritional and economic security cannot be understated. Yet globally, antimicrobials are losing their effectiveness more quickly than new such drugs, treatments and therapies are being identified and introduced to market.1 Over time, this dynamic has eroded the human antimicrobial arsenal, placing the lives and futures of an unacceptable number of people at risk. Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria, viruses, fungi and parasites come into contact with antimicrobial drugs, such as antibiotics, antivirals, antifungals, antimalarials and anthelmintics, and undergo changes. The drugs are rendered ineffective and cannot eradicate infections from the body. AMR is an international challenge that threatens to reverse over a century of progress in public health, health care and human development attributable to antimicrobial use. Indeed, the effects of AMR are already being felt across Canada’s health care system. Currently, Canada’s dedicated investment in solutions to militate against encroaching AMR in the AMR and antimicrobial stewardship (AMS) fields (both federally and provincially/territorially) can only be viewed as wholly inadequate to address the scope of the problem and the risks it poses for the health of Canadians. Therefore, to: (1) promote awareness of AMR; (2) incentivize investment in AMR mitigation strategies; and (3) support the mobilization of an effective suite of more clinically effective management/treatment practices and policies, the following target audience recommendations are offered.a a All the policy recommendations made in this document are not meant to be interpreted as clinical practice guidelines. Any individual who suspects they may have an infection should promptly consult a physician. 2 Key AMR principle — the “One Health” approach a) The complexity of AMR underscores the need for coordinated action known as the “One Health” approach. The term implies integrated strategies that span the human, animal/agricultural and environmental sectors. Thus, cooperation across a wide variety of stakeholders is necessary to address the collective nature of AMR. These stakeholders include governments, health professionals, private and public partners, and the public at large. b) The One Health approach will require attention and investment in the following domains: (1) surveillance of antimicrobial prescribing and usage; (2) infection prevention and control practices that mitigate the spread of resistant pathogens; (3) stewardship programs and practices that educate health professionals, the public, and the private sector and nudge each into more appropriate patterns of supply and demand; and (4) a program of innovation, research and development focused on diagnostics, vaccines and alternative treatments to reduce reliance on antimicrobials. This includes the development of novel antimicrobials that expand the currently available arsenal. c) Given the global dimensions of AMR, a successful One Health approach will require ambitious investments in global AMR mitigation. Given that health infrastructure and resources are limited in low- to middle-income countries, the impacts of AMR will primarily be felt in those settings. Recommendations 1. Physicians and allied health professionals Should: a) Be aware that AMR is a serious public health crisis. b) Know that various Canadian prescribing aides/guidelines are available to assist physicians in choosing appropriate antibiotics and improving practice (e.g., Choosing Wisely Canada). c) Know that using antibiotics appropriately can help combat AMR and that diagnosis and laboratory testing play a key role. This includes only prescribing antibiotics for conditions that are clinically infectious and of a non-viral nature. Viral infections are the greatest source of antibiotic misuse. d) Consider delayed prescriptions and/or prioritize follow-up for patients when diagnosis is initially undifferentiated or when symptoms worsen, progress or are prolonged. e) Know that prevention of infections through hand hygiene, vaccination and appropriate use of antibiotic prophylaxis is evidence based and effective f) Know that durations of therapy and dosage rates for treating many infections change with time and that you should prescribe antimicrobials for the shortest effective duration (using the narrowest spectrum possible). 3 g) Consider the potential side effects of antibiotics (including C. difficile and allergic reactions) in prescribing and when counselling patients as to their potential side effects. h) Engage in conversations with patients about antimicrobials regarding: i. their appropriate use; ii. their potential risks; iii. when to delay, begin or end an antimicrobial prescription (e.g., delayed prescriptions); and iv. when to seek medical reassessment if symptoms worsen or persist. i) Ask your local hospital or specialty organization about educational initiatives related to antibiotic prescribing. j) Collaborate where possible with colleagues in other prescribing professions to reduce unnecessary antimicrobial use. 2. Patients and the Canadian public Should: a) Be aware that AMR is a significant problem that is linked to the inappropriate use of antimicrobials like antibiotics. Therefore, commit to only taking antibiotics if they are prescribed and only as directed by an authorized health professional. i. Never share, or use, the antibiotics of others as it may contribute to AMR and have serious consequences for your health. b) Consider that your expectations about antimicrobials may unduly pressure physicians, and other prescribers, to provide you a prescription when an antimicrobial would not be appropriate or helpful. c) Engage in a conversation with prescribers about: i. whether an antimicrobial is necessary; ii. the risks associated with taking an antimicrobial; iii. whether there are simpler and safer options to pursue; and iv. when you should take further actions if your symptoms worsen or do not improve. d) Rather than keeping antimicrobials in your medicine cabinet, throwing them in the garbage/toilet or sharing them with family or friends, practise a One Health mindset. Dispose of all unused and expired antimicrobials at your local pharmacy. This will limit the spread of resistance and prevent antimicrobials from finding their way into the environment. e) Help limit resistance by staying up to date with all recommended vaccinations, and practise good hand hygiene. f) If you or a family member have had personal experiences with AMR, consider sharing them with local politicians (provincial/territorial and federal). 3. Governments (federal, provincial/territorial) Should: 4 a) (Including internationally) immediately make substantial, long term, coordinated and directly dedicated financial investments in AMR and AMS. Specific areas to prioritize include: i. AMR and AMS awareness campaigns targeted to the public; ii. campaigns that support health professionals to incorporate AMS principles into their everyday practice; iii. detailed, and integrated, action plans based on clear metrics of success and that address the needs of communities, primary care practitioners, patients and health care organizations (including long-term care facilities); iv. practical surveillance of antimicrobial resistance, purchasing, prescribing and use that maximizes the opportunity to respond to changing landscapes; v. studying in detail the links, and associated risks, between animal health and agricultural practices and human health; vi. scaling up local AMS initiatives at the provincial/territorial and national health care delivery levels; vii. pharmaceutical development pipelines and non-pharmacological treatment options for AMR infections; viii. inexpensive, accurate and timely point-of-care diagnostic tests (usable in the community, at the bedside or in a clinic) to optimize prescribing; and ix. fostering clinical research, development and innovation in the fields of AMR and AMS. b) Scale up coordination between federal and provincial/territorial AMR and AMS activities. c) Hold regular, high-level meetings of ministers of health, agriculture and finance (both federally and provincially/territorially) to discuss the implications of unchecked AMR and how best to mobilize public finances to address it. d) Strongly consider an arms-length, national-level taskforce to address AMR and AMS. e) Strengthen the roles of the chief public health officer and the provincial/territorial chief medical officers in addressing AMR and AMS. f) Undertake a timely review of the Canadian Antimicrobial Resistance Surveillance System (CARRS) with an emphasis on: i. scaling up the system; ii. standardizing all AMR reporting metrics across the country; and iii. injecting adequate resources into AMR surveillance and tracking antimicrobial usage rates. g) Establish a permanent review body on infectious disease, including pharmacists, microbiologist and other experts, to evaluate the forthcoming Pan-Canadian Action Plan on AMR and release regular progress reports. 5 4. Health care institutions and organizations Should: a) Implement strategic AMR plans that are coordinated, cross-departmental and adopted institution wide. These should be premised on: i. standardized and comprehensive reporting metrics for AMR and antimicrobial usage; ii. tailored infection prevention and control programs to screen for and effectively prevent new AMR infections; iii. improving public and professional awareness of AMR organization wide; iv. improving conservation measures such as prescribing practices (audit and feedback, incentives programs, etc.); and v. supporting and incentivizing appropriate prescribing of antimicrobials. b) Evaluate whether existing policies and procedures, diagnostics and testing capacities, and multidisciplinary and organizational cultures are strategically geared toward combatting AMR. c) Where possible, develop collaborations with other local health institutions, clinical researchers and community, public and private partners to promote AMS. 5. Accreditation and regulatory bodies Should: a) Regularly review and establish meaningful criteria for accreditation, ethical codes and regulatory practice standards surrounding AMR and AMS so that practitioners and health institutions can be informed, supported and kept up to date on emerging AMR trends, practices and issues. b) Adopt profession-specific mandatory requirements for AMR and AMS (proper credentialing and training, regular updating of knowledge and competence for prescribing antimicrobials, appropriate data collection regarding antimicrobial usage, etc.) as part of credentialing. c) Work to promote, support and enhance existing AMS practices and programs. d) Collaborate with health institutions, professional health associations and other accreditation and regulatory bodies to implement AMS goals/plans. 6. Colleges and faculties for medicine and allied health professions Should: a) Promote and support more educational resources for AMS and AMR, throughout the continuum of education (undergraduate, postgraduate and continuing education). i. Topics for these resources should include (1) awareness of AMR and AMS, (2) appropriate diagnostic testing, (3) strategies to minimize antimicrobial use and (4) personal prescribing practices. b) Promote and support research on AMR and the implementation and dissemination of effective AMS strategies. 6 1 Public Health Agency of Canada. Tackling antimicrobial resistance and antimicrobial use: a pan-Canadian framework for action. Ottawa: Public Health Agency of Canada; 2017. Available: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/drugs-health-products/tackling-antimicrobial-resistance-use-pan-canadian-framework-action/tackling-antimicrobial-resistance-use-pan-canadian-framework-action.pdf (accessed 2018 Aug 10). BACKGROUND TO CMA POLICY Antimicrobial Resistance See also CMA Policy Antimicrobial Resistance PD19-08 OVERVIEW The world is at the tipping point of a post-antibiotic era. “Worldwide, we are relying more heavily on antibiotics to ensure our medical, nutritional, and economic security; while simultaneously causing the decline of their usefulness with overuse and ill-advised use.” It is estimated that the world’s use of antimicrobials increased by 65% between 2000 and 2015 — mainly in low- to middle-income countries. Dr. Margaret Chan, the former head of the World Health Organization (WHO), described antimicrobial resistance (AMR) as a slow-moving tsunami for public health. Other experts have characterized AMR as a looming “antibiotic apocalypse,” warning that all countries “will face disastrous consequences if the spread of AMR is not contained.” Others are now calling AMR the “climate change” of health care. According to the UK’s review on AMR, an estimated 10 million people globally will die annually by 2050, and AMR will surpass cancer to become the leading cause of death. AMR occurs when “microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). … As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.” Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs.” “Nightmare bacteria,” as they have been dubbed, are bacterial strains that no conventional antimicrobial can effectively treat; their incidence is on the rise. AMR represents a unique challenge for the medical profession as it is estimated that as many as 50% of current antibiotic prescriptions are either inappropriate or unnecessary. In addition, taking an antimicrobial involves potentially considerable exposure to side effects or risk. At stake are many currently routine, and lifesaving, forms of medical treatment. Critically, these include many medications for currently treatable bacterial infections, and many forms of surgery (including cesarean delivery), radiation therapy, chemotherapy and neonatal care.4 THE UNDERLYING DYNAMICS OF AMR AMR is driven by a complex set of interlocking factors. These include: (1) increased global travel and medical tourism; (2) inappropriate, and unnecessarily high, use of antimicrobials in the agrifood sector; (3) poor medical prescribing practices; (4) inadequate implementation of infection prevention and control measures; (5) lack of knowledge, inappropriate expectations and misuse of antimicrobials on the part of the general public; (6) availability of poor-quality antimicrobials; (7) lack of access to rapid, affordable and accurate rapid diagnostic tools and infrastructure; (8) inadequate and underused surveillance data from AMR surveillance systems; (9) international travel rates; and (10) low commercial interest in, or support for, new antimicrobial research and development. To make progress on AMR, we need to carefully think about how to address its various drivers. Antimicrobial stewardship (AMS) is a term describing coordinated efforts, at any program level, to: (1) promote the appropriate use of antimicrobials; (2) improve patient outcomes; (3) reduce microbial resistance and preserve the effectiveness of antimicrobials; and (4) decrease the spread of infections caused by multidrug-resistant organisms. AMS efforts are based on the “One Health” approach. These include: (1) surveillance; (2) conservation of existing AM effectiveness; (3) innovation through research and development; and (4) infection prevention and control. Fundamentally, AMR can be thought of as a collective action problem, similar in character to the problem of climate change.3, While all stakeholders have a role to play in combatting AMR, each has very different resources, abilities and perspectives on AMR. Canada and much of the developed world have the luxury of health infrastructures, finances and regulatory frameworks that can make AMR mitigation possible. But in low- to middle-income countries — places where antibiotics might be the only real health care available — the very discussion of AMS can be perceived as threatening. Simply put, this illustrates the fact that solutions to AMR need to mobilize and leverage a collective strategy that is as broad and as connected as possible. To be successful, these solutions will need to do so in a manner that acknowledges the local reality of health care delivery. Global investment in antimicrobial research and development is underwhelming, a dynamic described as a “drying up” of the pharmaceutical pipeline.8 This is evidenced by the recent large-scale withdrawal of major pharmaceutical companies from antimicrobial research and development, reflecting the lack of profitability in this area. On the pharmaceutical side, there are clear barriers to companies investing in the development of novel antimicrobials. Underlying factors include: (1) 10-year timelines, and an estimated minimum $1 billion price tag for development; (2) high development failure rates for new antimicrobials; (3) the inevitable emergence of resistance to any newly developed antimicrobial; (4) antimicrobials being offered at relatively cheap dosage rates over shorter durations of use; and (5) the need to preserve the efficacy of any antimicrobial’s future use, which limits their economic viability.8 WHAT ARE THE CANADIAN CONTEXTS? AMR is already a major costly public health challenge in both the US and Canada. AMR infections are clearly linked to poorer health outcomes, longer hospital stays and higher mortality rates.3 The Public Health Agency of Canada (PHAC) estimates that roughly 18,000 hospitalized Canadians contract drug-resistant infections per year. The Canadian Patient Safety Institute estimates that 8,000 Canadian patients die annually with an AMR-related infection. It is estimated that close to 23 million antibiotic prescriptions are written annually for patients in Canada, the approximate equivalent to 1.6% of the population being on an antimicrobial on any given day. An action plan in Canada is being developed by PHAC. On the surface, the action plan appears comprehensive in that it outlines a One Health approach.10 However, despite commitments to take comprehensive, measurable action on AMS, Canadian leadership on AMR has historically lagged because of a lack of concrete coordination between PHAC and the provinces and because it has been challenging to implement local initiatives systemically. Previous shortcomings were highlighted in the Auditor General of Canada’s 2015 report and again in a 2017 issue brief by HealthCareCAN.18 Although efforts continue and the action plan is set for release at some point in 2019, concerns remain that: (1) the scope of coordinated efforts with the provinces and territories requires an interest in cooperation that may not exist between the two levels of government; (2) relative to the scope of the problem, sufficient and dedicated resources won’t be allocated; and (3) efforts on the industrial and agricultural fronts may not be sufficiently coordinated with AMR efforts for human health. In the spring of 2018 the House of Commons Standing Committee on Health (HESA) released a report outlining 10 recommendations for action on AMR in Canada. Although the federal government “accepted” most of the committee’s recommendations, no meaningful (and dedicated) AMR funding has been announced in advance of the action plan’s launch. Indeed, the federal government’s response to the HESA report sought to downplay the need for either urgent action or additional resources. This was done by pointing to nominal federal AMR efforts over the span of more than a decade. It should be noted that a small number of excellent localized AMS initiatives exist and have begun yielding promising local AMS results in Canada. AMR and AMS champions such as Choosing Wisely Canada, Do Bugs Need Drugs, and the Association of Medical Microbiology and Infectious Disease Canada have long argued that with proper resourcing, localized initiatives can be scaled up to a systemic level of application within provincial health care systems. GLOBALLY, WHERE DOES AMR STAND? Urgent action is required at an international level to combat AMR. Although AMR remains a complex public health challenge, the benefits of AMS are clear. The preservation of these precious resources will save lives and can positively affect both quality of care and health care delivery costs.7,14 Globally, many higher income nations and, increasingly, middle-income countries have now developed AMR/AMS action plans. Like the situation in Canada, these emerging and existing global action strategies remain largely unimplemented. Initial cash infusions into the AM drug development pipeline are beginning to emerge.8 Despite this, experts warn that such investments are too short term and wholly inadequate to address the scope of the looming AMR crisis.8, This reflects the many complexities that exist in the implementation of AMR action plans, owing in large part to: (1) a general lack of resources or prioritization; (2) complacency about AMR as a pressing public health concern; (3) difficulties in generalizing local AMS efforts; (4) coordination between sectorial actors; and (5) a lack of tangible AMR metrics and evidence. If AMS gains are to be made in low- and middle-income countries, the impact of limited resources in those settings will need to be considered.13 Realistically these countries will require various forms of monetary incentives and assistance to be able to effectively adopt AMR programs. If such support is not provided, human health rights will be affected and global AMS efforts will be undermined. Finally, there are now well-established calls for an international model, even a treaty, to be implemented on AMR/AMS.12,
Documents
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Breast-feeding of infants in Canada

https://policybase.cma.ca/en/permalink/policy8531
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-28
The Canadian Medical Association recommends that governments develop and implement a comprehensive plan to promote and support breast-feeding of infants in Canada.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-28
The Canadian Medical Association recommends that governments develop and implement a comprehensive plan to promote and support breast-feeding of infants in Canada.
Text
The Canadian Medical Association recommends that governments develop and implement a comprehensive plan to promote and support breast-feeding of infants in Canada.
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Canadian Injury Control Strategy

https://policybase.cma.ca/en/permalink/policy8545
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-75
The Canadian Medical Association urges the immediate implementation of a Canadian Injury Control Strategy.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Resolution
GC06-75
The Canadian Medical Association urges the immediate implementation of a Canadian Injury Control Strategy.
Text
The Canadian Medical Association urges the immediate implementation of a Canadian Injury Control Strategy.
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Child poverty in Canada

https://policybase.cma.ca/en/permalink/policy8525
Last Reviewed
2013-03-02
Date
2006-08-23
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC06-21
The Canadian Medical Association requests that the federal government adopt a rigorous strategy to eradicate child poverty in Canada.
Policy Type
Policy resolution
Last Reviewed
2013-03-02
Date
2006-08-23
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC06-21
The Canadian Medical Association requests that the federal government adopt a rigorous strategy to eradicate child poverty in Canada.
Text
The Canadian Medical Association requests that the federal government adopt a rigorous strategy to eradicate child poverty in Canada.
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Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

https://policybase.cma.ca/en/permalink/policy14165
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Homeless and vulnerably housed populations are heterogeneous and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies.2 Collectively, they face dangerous living conditions and marginalization within health care systems.3 However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices.1,4,5 Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6 Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality.7,8 For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women.7 A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people (Box 1), immigrants, older adults and people from rural communities.13,14 For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors.10 Practice navigators, peer-support workers and primary care providers are well placed to identify social causes of poor health and provide orientation to patient medical homes.16,17 A patient’s medical home is “a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns.”18 Medical care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated with other services in the health care system and the community” (https://patientsmedicalhome.ca). Primary care providers are also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19 GUIDELINE VULNERABLE POPULATIONS CPD Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH, Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD, Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD, Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW, Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD, Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA, Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777 CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199 KEY POINTS
Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person’s gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.
Harm-reduction interventions, such as supervised consumption facilities, and access to pharmacologic agents for opioid use disorder, such as opioid agonist treatment, are recommended for people who use substances. GUIDELINE CMAJ
MARCH 9, 2020
VOLUME 192
ISSUE 10 E241 However, the social and health resources available to homeless and vulnerably housed people may vary based on geographic setting, municipal resources, housing coordination, and patients’ mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities for care, patient mistrust of the health care system or limited access to health services.3 Homeless and vulnerably housed people can benefit from timely and effective health, addiction and social interventions. Our guideline provides initial steps for practice, policy and future research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values such as trauma-informed and patient-centred care, and dignity are needed to foster trust and develop sustainable therapeutic relationships with homeless and vulnerably housed people.20,21 Scope The purpose of this clinical practice guideline is to inform providers and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers. Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the many etiologies of homelessness, such as childhood trauma, the housing market, or the root causes of low social assistance rates and economic inequality. Rather, this guideline aims to reframe providers’ approach toward upstream interventions that can prevent, treat and work toward ending the morbidity and mortality associated with homelessness. A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led team.22 This process recognizes the distinct rights of Indigenous Peoples, including the right to develop and strengthen their own economies, social and political institutions; the direct links between historic and ongoing colonial policies and Indigenous homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples. Recommendations The steering committee and guideline panel members developed and approved recommendations to improve social and health outcomes for homeless and vulnerably housed people. The order of these recommendations highlights priority steps for homeless health care. We list a summary of the recommendations in Table 1 and we present our list of good practice statements in Table 2. These good practice statements are based on indirect evidence and support the delivery of the recommendations. The methods used to develop the recommendations are described later in this document. A summary of how to use this guideline is available in Box 2. Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation). Evidence summary Our systematic review (Tim Aubry, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 14 trials on permanent supportive housing (PSH).30–43 Several trials across Canada and the United States showed that PSH initiatives house participants more rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30 increase the number of people who maintain stable housing at 2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and significantly increase the percentage of days spent stably housed.41 No trials showed a significant improvement in mental health symptoms compared with standard care.30,31,33,34,41,42 Two studies found that the mental health of PSH participants did not improve as much as that of usual care participants (e.g., mean difference –0.49, 95% CI –0.85 to –0.12).30,31 The At Home/Chez Soi trial showed small improvements in quality of life for high-needs (adjusted standardized mean difference 0.15, 95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37, 95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41 Youth receiving PSH saw larger improvements in their quality of life during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24), which diminished over time (mean difference 7.29, 95% CI –1.61 to 16.18).44 No trials showed a significant improvement in substance use compared with standard care.30,33,41–43 Most trials reported no effect of PSH on acute care outcomes (e.g., number of emergency department visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found no effect of PSH on job tenure, hours of work per week or hourly wage compared with standard care.46 Participants receiving PSH may have increased odds of employment, but this depends on the severity of participant needs.46 One trial found no effect on income outcomes.46 Box 1: Indigenous homelessness Indigenous homelessness is a term used to describe First Nations, Métis and Inuit individuals, families or communities who lack stable, permanent and appropriate housing, or the immediate prospects, means or ability to acquire such housing. However, this term must be interpreted through an Indigenous lens to understand the factors contributing to this condition. These factors include individuals, families and communities isolated from their relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities as well as the legacy of colonialism and genocide.11 It is estimated that urban Indigenous people are 8 times more likely to experience homelessness than the general population.11,12 GUIDELINE E242 CMAJ
ISSUE 10 The certainty of the evidence was rated moderate, because blinding of participants and personnel was not feasible in any of the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which could introduce high risks of detection and performance biases. Income assistance
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation). Evidence summary We identified 10 trials on income-assistance interventions, including rental assistance,47–56 financial empowerment,47 social enterprise interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that income-assistance interventions have on housing stability (Gary Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020). Rental assistance increased the likelihood of being stably housed (OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with case management increased the number of days in stable housing per 90-day period compared with case management alone (mean Table 1: Summary of evidence-based recommendations Recommendations and clinical considerations Grade rating* Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system. Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those with disabilities, refugees and migrants. Strong recommendation Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or living in a low-income household Low certainty
Assist individuals with income insecurity to identify income-support resources and access income. Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products /poverty-a-clinical-tool-for-primary-care-providers). Conditional recommendation Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs (including mental illness and/or substance use) Low certainty
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to intensive case management, assertive community treatment or critical time intervention where available. Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar with local access points and less intensive community mental health programs. Conditional recommendation Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in collaboration with a public health or community health centre for linkage to pharmacologic interventions. Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT access and options in your jurisdiction, in particular for buprenorphine. Conditional recommendation Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as public health or community health centre or local community services centre. Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.190777/-/DC1). Conditional recommendation Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited. *See Box 2 for definitions. †211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and referrals to health, human and social service organizations. GUIDELINE CMAJ
ISSUE 10 E243 difference 8.58, p < 0.004).55 Compensated work therapy was found to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No income interventions showed an effect on mental health outcomes.47,52,55,56 The impact of these interventions on substance use outcomes were mixed. Provision of housing vouchers did not affect substance use over 3 years;55 however, compensated work therapy showed immediate reductions in drug (reduction: –44.7%, standard error [SE] 12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p = 0.001), as well as the number of substance use–related physical symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found on overall quality-of-life, finances, health and social relations scores. Provision of housing vouchers resulted in higher family-relations score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to improve employment rates only when there was high fidelity to the model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54 Provision of housing vouchers had no effect on monthly income.55 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance programs after completing the study had incentives to underreport symptoms, which introduced high risk for measurement bias. Case management
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment and linkage to intensive case management, assertive community treatment or critical time intervention where available (low certainty, conditional recommendation). Evidence summary Our systematic review examined the effectiveness of standard case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa, Ottawa, Ont.: unpublished data, 2020). We included a total of 56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73 16 trials on intensive case management74–89 and 5 trials on critical time intervention.90–94 Box 2: How to use and understand this GRADE guideline (www.gradeworkinggroup.org) This guideline supplies providers with evidence for decisions concerning interventions to improve health and social outcomes for people who are homeless or vulnerably housed. This guideline is not meant to replace clinical judgment. Statements about clinical considerations, values and preferences are integral parts of the recommendations meant to facilitate interpretation and implementation of the guideline. Recommendations in this guideline are categorized according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as strong or conditional recommendations. Strong recommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is appropriate for all or almost all individuals. Strong recommendations represent candidates for quality-of-care criteria or performance indicators. Conditional recommendations indicate that most informed patients would choose the suggested course of action, but an appreciable minority would not. With conditional recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at a decision consistent with their values and preferences. Conditional recommendations should not be used as a basis for standards of practice (other than to mandate shared decision-making). Good practice statements represent common-sense practice, are supported by indirect evidence and are associated with assumed large net benefit. Clinical considerations provide practical suggestions to support implementation of the GRADE recommendation. GRADE certainty ratings High: further research is very unlikely to change our confidence in the estimate of effect. Moderate: further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate. Low: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: any estimate of the effect is very uncertain. Table 2: Good practice statements to support delivery of care Good practice statement Indirect evidence (reference) 1. Homeless and vulnerably housed populations should receive trauma-informed and personcentred care. 23–26 2. Homeless and vulnerably housed populations should be linked to comprehensive primary care to facilitate the management of multiple health and social needs. 27 3. Providers should collaborate with public health and community organizations to ensure programs are accessible and resources appropriate to meet local patient needs. 28,29 GUIDELINE E244 CMAJ
ISSUE 10 Of 10 trials on standard case management, 10 evaluated housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a time-limited residential case management in which participants in all groups accessed substantial levels of services.57 A program tailored to women reduced the odds of depression at 3 months (OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in the women’s overall mental health status (mean difference 4.50, 95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female participants receiving nurse-led standard case management compared with those receiving standard care.60 Few studies reported on substance use, quality of life, employment or income outcomes. Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are mixed. Two trials found that participants receiving the treatment reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect on episodes of homelessness or number of days homeless.66,73 Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department (mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental health outcomes, including psychiatric symptoms, substance use, or income-related outcomes between the treatment and control groups. Intensive case management reduced the number of days homeless (pooled standardized mean difference –0.22, 95% CI –0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in psychological symptoms between the treatment and control groups. However, 1 trial reported significantly greater reductions in anxiety, depression and thought disturbances after 24 months (mean difference change from baseline –0.32, p = 0.007), as well as improved life satisfaction (mean difference 1.23, p = 0.001) using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department (mean difference 19%, p < 0.05) but did not have shorter hospital stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on income received from employment; however, income received by participants through public assistance increased (e.g., mean difference 89, 95% CI 8 to 170).78,85 Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard care,95 but did not spend more days rehoused.90 Adults receiving critical time intervention showed significant improvements in psychological symptoms (mean difference –0.14, 95% CI –0.29 to 0.01).90 However, findings for children’s mental health were mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86), whereas changes for children aged 6–10 years and 11–16 years were not significant.93 There were no significant effects of critical time intervention on substance-use,90 quality-of-life90,92 or income-related outcomes.96 Two trials reported mixed findings on hospital admission outcomes; in 1 study, allocation to critical time intervention was associated with reduced odds of hospital admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of nights in hospital (p < 0.05) in the final 18 weeks of the trial.97 However, another study reported a greater total number of nights in hospital for the treatment group compared with usual care (1171 v. 912).98 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by referral to an addiction specialist, potentially in collaboration with public health or community health centre for linkage to pharmacologic interventions (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on pharmalogic interventions for opioid use disorder.99 Twenty-four reviews, which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general populations.100–123 We expanded our inclusion criteria to general populations, aware that most studies among “general populations” had a large representation of homeless populations in their samples. We did not identify any substantial reason to believe that the mechanisms of action of our interventions of interest would differ between homeless populations who use substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and hydromorphone for treatment of opioid use disorder. We found pooled all-cause mortality rates of 36.1 and 11.3 per 1000 person years for participants out of and in methadone maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to 3.86), and mortality rates of 9.5 per 1000 person years for those not receiving buprenorphine maintenance therapy compared with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific mortality rates were similarly affected, with pooled overdose mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates of 4.6 and 1.4 per 1000 person years out of and in buprenorphine maintenance therapy.116 Compared with nonpharmacologic approaches, methadone maintenance therapy had no significant GUIDELINE CMAJ
ISSUE 10 E245 effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With respect to morbidity, pharmacologic interventions for opioid use disorder reduced the risk of hepatitis C virus (HCV) acquisition (risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103 Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with reduced illicit opioid use (standardized mean difference –1.17, 95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment expanded access to treatment for patients unlikely to enrol in methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear; however, use of methadone was found to show better benefits than nonpharmacologic interventions for retention (risk ratio 4.44, 95% CI 3.26 to 6.04).110 The certainty of evidence ranged from very low to moderate, primarily because of inconsistency, high risk of bias and evidence from nonrandomized studies. Harm-reduction interventions
Identify problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community health centre or les centres locaux de services communautaires (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on supervised consumption facilities and managed alcohol programs.99 Two systematic reviews, which included 90 unique observational studies and 1 qualitative meta-synthesis reported on supervised consumption facilities.124–126 For managed alcohol programs, 1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129 Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per 100 000 person years, p = 0.048), compared with 9% in the rest of the city (Vancouver).124 There were 336 reported opioid overdose reversals in 90 different individuals within the Vancouver facility over a 4-year period (2004–2008).125 Similar protective effects were reported in Australia and Germany. Observational studies conducted in Vancouver and Sydney showed that regular use of supervised consumption facilities was associated with decreased syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter) and fostered access to broader health support.125,126 Attendance at supervised consumption facilities was associated with an increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio 1.57, 95% CI 1.02 to 2.40).125 Evidence on supervised consumption facilities was rated very low to low, as all available evidence originated from nonrandomized studies. There was a lack of high-quality evidence for managed alcohol programs. Few studies reported on deaths among clients of these programs.128 The effects of managed alcohol programs on hepatic function are mixed, with some studies reporting improvement in hepatic laboratory markers over time, and others showing increases in alcohol-related hepatic damage;129 however, this may have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with medical and social services.128 Clients experienced significantly fewer social, health, safety and legal harms related to alcohol consumption.129 Individuals participating in these programs had fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129 Cost effectiveness and resource implications Permanent supportive housing We found 19 studies assessing the cost and net cost of housing interventions.30,41,45,130–145 In some studies, permanent supportive housing interventions were associated with increased cost to the payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies, however, employed a pre–post design.135,139,141,145 Moreover, 1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased quality-adjusted life years, with an incremental cost-effectiveness ratio of US$62 493 per quality-adjusted life year.136 Compared with usual care, PSH was found to be more costly to society (net cost Can$7868, 95% CI $4409 to $11 405).138 Income assistance Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received income assistance incurred additional costs of US$58 (95% CI $4 to $111) from the perspective of the payer, US$50 (95% CI –$17 to $117) from the perspective of the health care system and US$45 (95% CI –$19 to $108) from the societal perspective. The benefit gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146 Case management Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150 Findings of these studies were mixed; the total cost incurred by clients of standard case management was higher than that of clients receiving usual or standard care61,88 and assertive GUIDELINE E246 CMAJ
ISSUE 10 community treatment,67,147 but lower compared with a US clinical case-management program that included housing vouchers and intensive case management.55 Cost-effectiveness studies using a societal perspective showed that standard case management was not cost effective compared with assertive community treatment for people with serious mental disorders or those with a concurrent substance-use disorder, as it was more expensive.67 For intensive case management, the cost of supporting housing with this program could be partially offset by reductions in the use of emergency shelters and temporary residences.41 Intensive case management is more likely to be cost effective when all costs and benefits to society are considered.41 A pre–post study showed that providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150 Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We identified only 1 study on the cost effectiveness of critical time intervention that reported comparable costs (US$52 574 v. US$51 749) of the treatment compared with the usual services provided to men with severe mental illness.96 Interventions for substance use We identified 2 systematic reviews that reported findings from 6 studies in Vancouver on the cost effectiveness of supervised consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of incident HCV infection. Clinical considerations Providers can, in partnership with directly affected communities, employ a range of navigation and advocacy tools to address the root causes of homelessness, which include poverty caused by inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the propagation of violence in homes and communities, inadequate supports for patients and families living with disabilities or going through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to the patient’s needs and demographics, taking into account access to services, personal preferences and other illnesses.152 Providers should also recognize the social and human value of accepting homeless and vulnerably housed people into their clinical practices. The following sections provide additional evidence for underserved and marginalized populations. Women A scoping review of the literature on interventions for homeless women (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156 and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused specifically on homeless and vulnerably housed women. Findings showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster care placements, allowing women to maintain the integrity of their family unit.158 As well, Housing First programs for families, critical time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress, increased self-esteem and improved quality of life for women and their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among homeless women. We suggest that providers focus on patient safety, empowerment among women who have faced genderbased violence, and improve access to resources, including income, child care and other social support services. Youth A systematic review on youth-specific interventions reported findings from 4 systematic reviews and 18 RCTs.162 Permanent supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in significant improvements in depression scores, and family-based therapies are also promising, resulting in reductions in youth substance use through restoring the family dynamic. Findings on motivational interviewing, skill building and case-management interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits. Refugee and migrant populations A qualitative systematic review on homeless migrants (Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging and access to social services, such as housing. However, employment opportunities provided a sense of independence and improved social integration. Methods Composition of participating groups In preparation for the guideline, we formed the Homeless Health Research Network (https://methods.cochrane.org/equity/ projects/homeless-health-guidelines), composed of clinicians, academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P. [chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario, Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of homelessness (herein referred to as “community scholars”180) were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the participating groups and monitored competing interests. The steering committee decided to develop a single guideline publication informed by a series of 8 systematic reviews. The GUIDELINE CMAJ
ISSUE 10 E247 steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical topic experts and community scholars who were responsible for providing contextual expertise. The steering committee also assembled a technical team, which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the responsibility to provide external review of the evidence and drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists, psychiatrists, public health professionals, people with lived experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.190777/-/DC1. Selection of priority topics We used a 3-step modified Delphi consensus method (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) to select priority health conditions for marginalized populations experiencing homelessness or vulnerable housing. Briefly, between May and June 2017, we developed and conducted a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to keep in mind 3 priority-setting criteria when considering the unique challenges of implementing health care for homeless or vulnerably housed people: value added (i.e., the opportunity for a unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e., the number of people who may have a disease or condition).181 The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care, delivering care coordination and case management, and facilitating access to adequate income. The priority marginalized populations identified included Indigenous people; women and families; youth; people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Each working group then scoped the literature using Google Scholar and PubMed to determine a list of interventions and terms relating to each of the priority-need categories. Each working group came to consensus on the final list of interventions to be included (Table 3). Guideline development We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development of this clinical guideline, including the identification of clinical questions, systematic reviews of the best available evidence, Table 3: Descriptions of priority-need interventions Intervention Description Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the provision of individualized supportive services that are tailored to participants’ needs and choices, including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing housing) with permanent supportive housing. Income assistance
Benefits and programs that improve socioeconomic status. This may include assistance that directly increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and compensated work therapy) in this category. Case management
Standard case management allows for the provision of an array of social, health care and other services with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental illness by a multidisciplinary group of health care workers in the community. This team should be available 24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case management is administered by a critical time intervention worker and is a time-limited service, usually lasting 6–9 months. Pharmacologic interventions for substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine, diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or intranasally (e.g., naloxone). Harm reduction for substance use disorders
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated alcohol to support residents with severe alcohol use disorder. GUIDELINE E248 CMAJ
ISSUE 10 assessment of the certainty of the evidence and development of recommendations.182 We conducted a series of systematic reviews to answer the following clinical question: Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions be considered for people with lived experience of homelessness? Systematic reviews for each intervention were driven by a logic model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search terms, can be found in Appendix 3, available at www.cmaj.ca/ lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and comparisons according to published a priori protocols.183–186 We used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The technical team reviewed titles, abstracts and full texts of identified citations, selected evidence for inclusion and compiled evidence reviews, including cost-effectiveness and resource-use data, for consideration by the guideline panel. The technical team collected and synthesized data on the following a priori outcomes: housing stability, mental health, quality of life, substance use, hospital admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty of evidence using the GRADE approach. Where pooling of results was not appropriate, we synthesized results narratively. In addition to the intervention and cost-effectiveness reviews, the technical team conducted 3 systematic reviews to collect contextual and population-specific evidence for the populations prioritized through our Delphi process (women, youth, refugees and migrants) (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally, we conducted 1 qualitative literature review to capture patient values and preferences, focused on the experiences of people who are homeless in engaging with our selected interventions.20 Drafting of recommendations The steering committee hosted a 2-day knowledge-sharing event, termed the “Homeless Health Summit,” on Nov. 25–26, 2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all intervention reviews were presented and discussed according to the GRADE Evidence to Decision framework.187 After the meeting, the steering committee drafted GRADE recommendations (Box 2) through an iterative consensus process. All steering-committee members participated in multiple rounds of review and revision of the drafted clinical recommendations. Guideline panel review We used the GRADE Evidence to Decision framework to facilitate the development of recommendations187–189 (Appendix 4, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190777/-/DC1). We used GRADEpro and the Panel Voice software to obtain input from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off. Good practice statements We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A good practice statement characteristically represents situations in which a large and compelling body of indirect evidence strongly supports the net benefit of the recommended action, which is necessary for health care practice.191–193 Guideline-development groups consider making good practice statements when they have high confidence that indirect evidence supports net benefit, there is a clear and explicit rationale connecting the indirect evidence, and it would be an onerous and unproductive exercise and thus a poor use of the group’s limited resources to collect this evidence. The steering committee came to a consensus on 3 good practice statements based on indirect evidence. Identification of implementation considerations We completed a mixed-methods study to identify determinants of implementation across Canada for the guideline (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost (affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019; Gatineau, Que., July 18, 2019) with relevant stakeholders in the field of homeless health to analyze our implementation data. Management of competing interests Competing interests were assessed using a detailed form adapted from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the Elsevier sample coauthor agreement form for a scientific project, contingencies and communication.195 These forms were collected at the start of the guideline activities for the steering committee, guideline panel and community scholars. All authors submitted an updated form in June 2019 and before publication. The management committee iteratively reviewed these statements and interviewed participants for any clarifications and concerns. A priori, the management committee had agreed that major competing interests would lead to dismissal. There were no competing interests declared. Implementation Our mixed-methods study (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to implement, identified the following concerns regarding implementation of this guideline. GUIDELINE CMAJ
ISSUE 10 E249 Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to PSH programs and informing their patients about the resources available in the community. The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as administrative and human resources concerns. For example, not all primary care providers work in a team-based comprehensive care model and have access to a social worker or care coordinator who can help link the patient to existing services. Furthermore, wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible recommendation. Allied health practitioners and physicians do not always agree with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients and less experience exploring social determinants of health, such as housing or income. The initial steps outlined in this guideline would come at an opportunity cost for them. Stigma attached to the condition of homelessness was recognized as an important barrier to care for homeless populations. Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to increase the housing supply, income supports and human resources. However, supervised consumption facilities, with their range of benefits, were perceived as cost-saving. Many interventions have the potential to increase health equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the initial steps and advocate on a systematic level to increase availability of services. Suggested performance measures We developed a set of performance measures to accompany this guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for income assistance over 1 year.
The proportion of eligible adults using opioids who are offered opioid agonist therapy over 1 year. Updates The Homeless Health Research Network will be responsible for updating this guideline every 5 years. Other guidelines This guideline complements other published guidelines. This current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020). The World Health Organization has developed guidelines to promote healthy housing standards to save lives, prevent disease and increase quality of life.196 Other guidelines specific to opioid use disorder exist,197,198 including 1 for “treatment-refractory” patients.199 In the United Kingdom, the National Institute for Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National Health Care for the Homeless Council in the US has adapted best practices to support front-line workers caring for homeless populations.200 How is this guideline different? This guideline distills initial steps and evidence-based approaches, to both homeless and vulnerably housed people, with the assistance of patients and other stakeholders. It also introduces a new clinical lens with upstream interventions that provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we hope that our stakeholder engagement inspires and equips future students, health providers and the public health community to implement the initial step recommendations. Gaps in knowledge Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general housed populations. As primary care expands its medical home models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in this guideline. Indeed, clinical research can refine how providers use the initial steps protocol: housing, income, case management and addiction. With improved living conditions, care coordination and continuity of care, research and practice can shift to treatable conditions, such as HIV and HCV infection, substance use disorder, mental illness and tuberculosis.203 Medical educators will also need to develop new training tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and case management. Interdisciplinary primary care research and maintenance of linkages to primary care will benefit from new homeless health clinic networks. Monitoring transitions in care and housing availability will be an important research goal for Canada’s National Housing Strategy and the associated Reaching Home program. Conclusion Homelessness has become a health emergency. Initial steps in addressing this crisis proposed in this guideline include strongly recommending PSH as an urgent intervention. The guideline also recognizes the trauma, disability, mental illness and stigma GUIDELINE E250 CMAJ
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ISSUE 10 195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid publishing conflict and a proposed agreement for co-author teams [editorial]. Biol Conserv 2014;176:277-80. 196. WHO housing and health guidelines. Geneva: World Health Organization; 2018. 197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician 2019;65:321-30. 198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in Substance Misuse. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2018;190:E247-57. 199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56. 200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8. 201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www. homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12). 202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician 2018;64:170-2. 203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content /uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1). Competing interests: Gary Bloch is a founding member, former board member and currently a clinician with Inner City Health Associates (ICHA), a group of physicians working with individuals experiencing homelessness in Toronto, which provided funding for the development of this guideline. He did not receive payment for work on the guideline and did not participate in any ICHA board decision-making relevant to this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive payment for any aspect of the submitted work. No other competing interests were declared. This article has been peer reviewed. Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie, d Wendy Muckle led the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic led the review on income, David Ponka and Eric Agbata led the review on case management, Jean Zhuo Jing Wang and Sebastian Mott led the homeless youth review, Harneel Kaur led the homeless migrant review, Christine Mathew and Anne Andermann led the homeless women review, Syeda Shanza Hashmi and Ammar Saad led medical student engagement and competency review, Thomas Piggott co-led the GRADE Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and Nicole Kozloff contributed substantially to the substance use review, and Neil Arya and Stephen Hwang provided critical policy information. All of the named authors engaged in the writing and review, gave final approval of the version of the guideline to be published, and agreed to be accountable for all aspects of the work. Funding: This guideline was supported by a peer-reviewed grant from the Inner City Health Associates, and supplemental project grants from the Public Health Agency of Canada, Employment Social Development Canada, Canadian Medical Association and Champlain Local Integrated Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the guideline. The funders had no role in the design or conduct of the study; collection, analysis and interpretation of the data; or preparation, review or final approval of the guideline. Final decisions regarding the protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee. Acknowledgements: The authors thank everyone who participated in the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members. Endorsements: Canadian Medical Association, Canadian Public Health Association, Canadian Federation of Medical Students, The College of Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to End Homelessness, Canadian Nurses Association Disclaimer: The views expressed herein do not necessarily represent the views of the funding agencies. Correspondence to: Kevin Pottie, kpottie@uottawa.ca
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Code of environmental health

https://policybase.cma.ca/en/permalink/policy731
Last Reviewed
2020-02-29
Date
1990-05-26
Topics
Population health/ health equity/ public health
Resolution
BD90-05-177
That the Canadian Medical Association develop a code of environmental health that would serve as a benchmark to judge all Canadian Medical Association activities, both internal and external.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1990-05-26
Topics
Population health/ health equity/ public health
Resolution
BD90-05-177
That the Canadian Medical Association develop a code of environmental health that would serve as a benchmark to judge all Canadian Medical Association activities, both internal and external.
Text
That the Canadian Medical Association develop a code of environmental health that would serve as a benchmark to judge all Canadian Medical Association activities, both internal and external.
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