Objective: Patients face significant waiting times for hip and knee total joint replacement (TJR)... more Objective: Patients face significant waiting times for hip and knee total joint replacement (TJR) in publicly funded healthcare systems. We aimed to assess how surgeon selection and reputation affect patients' willingness to wait for TJR. Design: We assessed patient preferences using a discrete choice experiment questionnaire with 12 choice scenarios administered to patients referred for TJR. Based on qualitative research, pre-and pilottesting, we characterized each scenario by five attributes: surgeon reputation, surgeon selection, waiting time to surgeon visit (initial consultation), waiting time to surgery, and travel time to hospital. Preferences were assessed using hierarchical Bayes (HB) analysis and evaluated for goodness-of-fit. We conducted simulation analyses to understand how patients value surgeon reputation and surgeon selection in terms of willingness to wait for surgeon visit and surgery. Results: Of 422 participants, 68% were referred for knee TJR. The most important attribute was surgeon reputation followed by waiting times, surgeon selection process and travel time. Patients appear willing to wait 10 months for a visit with an excellent reputation surgeon before switching to a good reputation surgeon. Patients in the highest pain category were willing to wait 7.3 months before accepting the next available surgeon, compared to 12 months for patients experiencing the least pain. Conclusions: Our findings confirm that patients value surgeon reputation in the context of wait times and surgeon selection. We suggest opportunities to reduce wait times by explicitly offering the next available surgeon to increase patient choice, and by reporting surgeon performance to reduce potential misinformation about reputation.
BACKGROUND: Recent international and national events have brought critical attention to the Canad... more BACKGROUND: Recent international and national events have brought critical attention to the Canadian public health system and how prepared the system is to respond to various types of contemporary public health threats. This article describes the study design and methods being used to conduct a systems-level analysis of public health preparedness in the province of Alberta, Canada. The project is
Summary of Background Data: In the general population, it has been estimated that 1.5% of people ... more Summary of Background Data: In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with about 13% of those being symptomatic. Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers. Objective: To summarize the current evidence on surgical treatment of Tarlov cysts. Study Design: A systematic review was completed. Methods: Nine databases were searched. Abstracts and full-texts were assessed by 2 reviewers. To be included, studies had to assess safety, efficacy, or effectiveness of treating Tarlov cysts, had to be written in English or French, and had to be a randomized, quasi-randomized, observational cohort, case control, or case series design including ≥2 participants. Logistic regression analysis was undertaken on the patient-level data collected to assess the association of patient and cyst characteristics on treatment succ...
Rationale, aims, and objectives: The objective is to understand patient views on surgeon choice ... more Rationale, aims, and objectives: The objective is to understand patient views on surgeon choice when being referred for joint replacement; do they prefer referral to the next available surgeon for a shorter waiting time or do they prefer their own choice of surgeon? What factors guide this decision and what information would patients find useful when deciding? Methods: Seven focus groups were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for hip or knee replacement surgery. The method of analysis was qualitative thematic analysis. Results: There were 50 participants, 66% female, 60% knee replacements and the average age was 66 years (SD 12). 68% were on a waiting list for surgery and 32% were undecided about surgery. Although patients varied in their views, many wanted some choice in their decision about a surgeon. If patients were in severe pain, they were more likely to accept the idea of referral to the next availab...
Key Points Question Is low-dose intradermal influenza vaccine a suitable alternative to regular d... more Key Points Question Is low-dose intradermal influenza vaccine a suitable alternative to regular dose intramuscular vaccine? Findings In this systematic review and meta-analysis including 30 studies with a total of 177 780 participants, the seroconversion rates of low doses of intradermal influenza vaccine vs the 15-µg intramuscular dose for each of the H1N1, H3N2, and B strains were not statistically significantly different. Seroprotection rates for the 9-µg and 15-µg intradermal doses were not statistically significantly different from the 15-µg intramuscular dose, except for the 15-µg intradermal dose for the H1N1 strain, which was significantly higher. Meaning These findings suggest that a low-dose intradermal influenza vaccine may be a suitable alternative to standard-dose intramuscular vaccine.
Objectives: The objective of this study was to examine the effect of measures of control and mana... more Objectives: The objective of this study was to examine the effect of measures of control and management of COVID-19, Middle East Respiratory Syndrome (MERS), and severe acute respiratory syndrome (SARS) in adults 60 years or above living in long-term care facilities. This is an update of previous work done by Rios et al. Methods: A rapid review was conducted in accordance with the Rapid Review Guide for Health Policy and Systems Research. Literature search of databases MEDLINE, Cochrane library, and pre-print servers (biorxiv/medrxiv) was conducted from July 31, 2020 to October 9, 2020. EMBASE was searched from July 31, 2020 until October 18, 2020. Titles and abstracts from public archives were identified for screening using Gordon V. Cormack and Maura R. Grossmans Continuous Active Learning (CAL) tool, which uses supervised machine learning. Results: Five observational studies and one clinical practice guideline were identified. Infection prevention measures identified in this rapi...
1ABSTRACTObjectivesTo review the literature from 2011 until March 31st, 2020 to identify the risk... more 1ABSTRACTObjectivesTo review the literature from 2011 until March 31st, 2020 to identify the risk of transmission of ARIs to healthcare workers caring for patients undergoing AGMPs compared with the risk of transmission when caring for patients not undergoing AGMPs.ResultsOnly two prospective cohort studies were identified meeting inclusion criteria. One found that performance or assistance with AGMP during the previous week was significantly associated with symptomatic influenza (adjusted OR: 2.29, 95% CI: 1.3 to 4.2). The second study found that performance of AGMP was significantly associated with clinical respiratory infections (RR 2.9, 95% CI 1.42-5.87, p<0.01), laboratory-confirmed virus or bacteria (RR 2.9, 95% CI 1.37-6.22, p=0.01), and laboratory-confirmed virus (RR 3.3, 95% CI 1.01-11.02, p=0.05). Further evidence is needed regarding what constitutes an AGMP and the risk of ARI transmission during presumed AGMPs. Organizations need to interpret these findings with cauti...
The essence of human ingenuity is creation and novel ideas that result in collective and desired ... more The essence of human ingenuity is creation and novel ideas that result in collective and desired impact. Indeed, innovation is foundational to life in a changing world. In no situation today is this more relevant than in health systems, whether they be challenged to maintain population health, threatened by impending disasters, or expected to respond to the ever-expansive demand and inexorable course of those with chronic diseases. This article discusses health system innovation and its trajectory. It focuses on clinical innovation as a means of achieving high-level performance within a learning health system model. Examples of innovation in Canada are used to illustrate successful approaches worthy of broader consideration and pan-Canadian attention.
I f you always do what you've always done, you'll always get what you have always gotten. This is... more I f you always do what you've always done, you'll always get what you have always gotten. This is true for most things in life; it is true, too, for health services and policy research graduate training. The case for modernization of training programs is strong if you track the career outcomes for graduates, as has been done for 20 years and is described in this issue. Simply put, the market has changed, but the training programs have not adapted sufficiently and are largely preparing health services and policy research graduates for tenured faculty positions, which is only one of many career paths. With about one in five graduates on this tenure-track trajectory, what about the other 80% in healthcare delivery, healthcare delivery research and the public, private and not-for-profit sectors? It is apparent that the knowledge and skills for these career trajectories have to come from experience in real-world settings, dealing with real-world issues. This cannot be passive learning but is active and experiential learning, which is an ancient concept traceable to Aristotle: learn by doing. Consider professional training, such as medicine, nursing and accounting, and ask if you would want professional services from graduates if they had never treated a patient or offered client services as part of their training. Why would being a highly qualified participant in health services and policy be any different? The papers in this issue arose from recognizing this need for training modernization and not doing what we have always done but, rather, achieving something different by training differently. The Health System Impact (HSI) Fellowship results in a new type of graduate with skills, practical experience and relationships to participate in and enable evidenceinformed health system improvement. HSI Fellowships will become the qualified leaders of the system that we are trying to create. This training program is a unique and safe opportunity to experience and to learn, analogous to a flight simulator for a career in health services and policy research. At the same time this program is evolving, the advancement of learning health systems in Canada is becoming a reality. The convergence of this training program and a shifting culture toward learning health systems augurs well for Canada' s changing and challenging health system of the future. Graduates of these programs will be important and critical
Introduction: A recent pan-Canadian survey of 48 health organizations concluded that structures, ... more Introduction: A recent pan-Canadian survey of 48 health organizations concluded that structures, processes, factors and information used to support funding decisions on new non-drug health technologies (NDTs) vary within and across jurisdictions in Canada. Objectives: The objectives of this paper were to elicit the views of key stakeholders on the following: (1) possible rationale for these findings, (2) enablers and barriers to the adoption of new NDTs, (3) approaches to optimizing the usefulness of health technology assessment (HTA) and (4) creation of a centralized pan-Canadian review process for NDTs, similar to that already in place for prescription pharmaceuticals. Methods: A one-day facilitated roundtable involving 12 purposefully selected participants who were healthcare institutional/organizational leaders, hospital-based HTA program leaders and academic experts in HTA was conducted. Results: Participants validated the survey findings and identified the following two enablers of technology adoption: (1) access to dedicated information resources and (2) inclusion of innovation in organizational priorities. Participants also identified four barriers, including the lack of (1) consistent decision-making processes within an organization, (2) agreement on what is affordable, (3) integration of HTA and procurement and (4) HTA literacy. Suggested approaches to optimizing the use of HTA focused on embedding the local context into assessments. Conclusions: Given the nature of NDT decision-making and the importance of accounting for local factors in such processes, the value of a centralized HTA review mechanism similar to that in place for drugs may be limited.
Introduction: Unlike those for publicly funded drugs in Canada, coverage decision-making processe... more Introduction: Unlike those for publicly funded drugs in Canada, coverage decision-making processes for non-drug health technologies (NDTs) are not well understood. Objectives: This paper aims to describe existing NDT decision-making processes in different healthcare organizations across Canada. Methods: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. Results: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. Conclusions: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.
Verma and Bhatia make a compelling case for the Triple Aim to promote health system innovation an... more Verma and Bhatia make a compelling case for the Triple Aim to promote health system innovation and sustainability. We concur. Moreover, the authors offer a useful categorization of policies and actions to advance the Triple Aim under the "classic functions" of financing, stewardship and resource generation (Verma and Bhatia 2016). The argument is tendered that provincial governments should embrace the Triple Aim in the absence of federal government leadership, noting that, by international standards, we are at best mediocre and, more realistically, fighting for the bottom in comparative, annual cross-country surveys. Ignoring federal government participation in Medicare and resorting solely to provincial leadership seems to make sense for the purposes of this discourse; but, it makes no sense at all if we are attempting to achieve high performance in Canada's non-system (Canada Health Action: Building on the Legacy 1997; Commission on the Future of Health Care in Canad...
In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with a... more In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with about 13% of those being symptomatic. Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers. To summarize the current evidence on surgical treatment of Tarlov cysts. A systematic review was completed. Nine databases were searched. Abstracts and full-texts were assessed by 2 reviewers. To be included, studies had to assess safety, efficacy, or effectiveness of treating Tarlov cysts, had to be written in English or French, and had to be a randomized, quasi-randomized, observational cohort, case control, or case series design including ≥2 participants. Logistic regression analysis was undertaken on the patient-level data collected to assess the association of patient and cyst characteristics on treatment success. In total, 31 studies were included in this systematic rev...
Recreational marijuana has been legalized in 11 jurisdictions; Canada will legalize marijuana by ... more Recreational marijuana has been legalized in 11 jurisdictions; Canada will legalize marijuana by July 2018. With this changing landscape, there is a need to understand the public health risks associated with marijuana to support patient-care provider conversations, harm-reduction measures and evidence-informed policy. The objective of this work was to summarize the health effects of exposure to second- and third-hand marijuana smoke. In this systematic review, we searched 6 databases from inception to October 2017. Abstract and full-text review was conducted in duplicate. Studies were included if they were human, in vivo or in vitro studies with more than 1 case reported in English or French, and reported original, quantitative data. Three outcomes were extracted: 1) cannabinoids and cannabinoid metabolites in bodily fluids, 2) self-reported psychoactive effects and 3) eye irritation and discomfort. Of the 1701 abstracts identified, 60 proceeded to full-text review; the final data s...
Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and ha... more Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and have been shown to improve waiting times, access and patient flow for preference-sensitive, scheduled services. The Winnipeg Central Intake Service (WCIS) for hip and knee replacement surgery was implemented to improve access in the Winnipeg Regional Health Authority. This paper describes the system's design/implementation; successes, challenges, and unanticipated consequences. On two occasions, during and following implementation, we interviewed all members of the WCIS project team, including processing engineers, waiting list coordinators, administrators and policy-makers regarding their experiences. We used semi-structured telephone interviews to collect data and qualitative thematic analysis to analyze and interpret the findings. Respondents indicated that the overarching objectives of the WCIS were being met. Benefits included streamlined processes, greater patient access, improve...
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, Jan 8, 2018
(1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12... more (1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12 in osteoarthritis patients undergoing total hip (THR) or knee (TKR) replacement surgery; (2) to compare distribution and anchor-based methods of assessing responsiveness. Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR and 1 year post-surgery. We assessed effect size (ES), standardized response mean (SRM), and standard error of measurement (SEM). Minimum important difference (MID) was the mean change in patients reporting somewhat better in hip or knee, health in general, and those who were satisfied with surgery (5-point scales). Responders were compared using MID versus 1 and 2SEM. The sample of 537 (50% TKR) was composed of 56% female with a mean age of 64 years (SD 10). EQ-5D-5L ES was 1.86 (THR) and 1.19 (TKR) compared to 3.00 and 2.05 for Oxford scores, respectively. MID for the EQ-5D-5L was 0.22 (THR) and 0.20 (TKR) for patients who rated their hip or knee as somewhat better. There was a wide variation in the MID and the percentage of responders, depending on the joint, method of assessment, and the outcome measure. The percent agreement of responder classification using 2SEM vs. MID ranged from 79.6 to 99.6% for the EQ-5D-5L and from 69.4 to 94.8% for the Oxford scores. Responsiveness of the EQ-5D-5L was acceptable in TKR and THR. Caution should be taken in interpreting responder to TJR based on only one method of assessment.
The aim of palliative care is to improve the quality of life of patients and families through the... more The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the "home of the patient" as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Fifty-three ...
Objectives: To describe marijuana use by Canadians and their perceptions of risk and harm. Design... more Objectives: To describe marijuana use by Canadians and their perceptions of risk and harm. Design: A cross-sectional, structured, online and telephone survey. Participants: A nationally representative sample of Canadians. Methods: This survey used random probability sampling and targeted respondents based on age, sex, region and their expected response rate. Results: Of the 20% of respondents reporting marijuana use in the past 12 months, they were more likely to be younger and male. The most common form of use was smoking, 79%. When asked about harmfulness, 42% and 41% responded that they considered marijuana more harmful than helpful to mental health and to physical health, respectively. When asked about driving under the influence, 71% responded that it was the same as alcohol. Conclusion: This research is important for health providers and policy makers seeking to maximize public health through clinical and legislative reform of non-medical use of marijuana. Résumé Objectifs : Décrire l' usage de la marijuana chez les Canadiens ainsi que leurs perceptions des risques et dommages. Conception : Sondage transversal structuré, en ligne et téléphonique. Participants : Échantillon national représentatif des Canadiens. Méthodes : Ce sondage a eu recours à un échantillonnage probabiliste aléatoire et à des répondants ciblés selon l'âge, le sexe, la région et le taux de réponse escompté. Résultats : Les 20 % de répondants qui ont indiqué avoir fait usage de la marijuana au cours des 12 derniers mois sont plus susceptibles d'être des jeunes hommes. La forme d' usage la plus courante est par l'inhalation de fumée, 79 %. Au sujet de la nocivité, 42 % et 41 % ont répondu qu'ils considéraient la marijuana plus dommageable que salutaire pour la santé mentale et la santé physique, respectivement. Au sujet de la conduite sous influence, 71 % ont répondu que c'était comme pour l' alcool. Conclusion : Cette recherche est importante pour les fournisseurs de services de santé et les responsables de politiques qui veulent maximiser la santé publique par une réforme clinique et législative de l' usage non médical de la marijuana.
Objective: Patients face significant waiting times for hip and knee total joint replacement (TJR)... more Objective: Patients face significant waiting times for hip and knee total joint replacement (TJR) in publicly funded healthcare systems. We aimed to assess how surgeon selection and reputation affect patients' willingness to wait for TJR. Design: We assessed patient preferences using a discrete choice experiment questionnaire with 12 choice scenarios administered to patients referred for TJR. Based on qualitative research, pre-and pilottesting, we characterized each scenario by five attributes: surgeon reputation, surgeon selection, waiting time to surgeon visit (initial consultation), waiting time to surgery, and travel time to hospital. Preferences were assessed using hierarchical Bayes (HB) analysis and evaluated for goodness-of-fit. We conducted simulation analyses to understand how patients value surgeon reputation and surgeon selection in terms of willingness to wait for surgeon visit and surgery. Results: Of 422 participants, 68% were referred for knee TJR. The most important attribute was surgeon reputation followed by waiting times, surgeon selection process and travel time. Patients appear willing to wait 10 months for a visit with an excellent reputation surgeon before switching to a good reputation surgeon. Patients in the highest pain category were willing to wait 7.3 months before accepting the next available surgeon, compared to 12 months for patients experiencing the least pain. Conclusions: Our findings confirm that patients value surgeon reputation in the context of wait times and surgeon selection. We suggest opportunities to reduce wait times by explicitly offering the next available surgeon to increase patient choice, and by reporting surgeon performance to reduce potential misinformation about reputation.
BACKGROUND: Recent international and national events have brought critical attention to the Canad... more BACKGROUND: Recent international and national events have brought critical attention to the Canadian public health system and how prepared the system is to respond to various types of contemporary public health threats. This article describes the study design and methods being used to conduct a systems-level analysis of public health preparedness in the province of Alberta, Canada. The project is
Summary of Background Data: In the general population, it has been estimated that 1.5% of people ... more Summary of Background Data: In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with about 13% of those being symptomatic. Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers. Objective: To summarize the current evidence on surgical treatment of Tarlov cysts. Study Design: A systematic review was completed. Methods: Nine databases were searched. Abstracts and full-texts were assessed by 2 reviewers. To be included, studies had to assess safety, efficacy, or effectiveness of treating Tarlov cysts, had to be written in English or French, and had to be a randomized, quasi-randomized, observational cohort, case control, or case series design including ≥2 participants. Logistic regression analysis was undertaken on the patient-level data collected to assess the association of patient and cyst characteristics on treatment succ...
Rationale, aims, and objectives: The objective is to understand patient views on surgeon choice ... more Rationale, aims, and objectives: The objective is to understand patient views on surgeon choice when being referred for joint replacement; do they prefer referral to the next available surgeon for a shorter waiting time or do they prefer their own choice of surgeon? What factors guide this decision and what information would patients find useful when deciding? Methods: Seven focus groups were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for hip or knee replacement surgery. The method of analysis was qualitative thematic analysis. Results: There were 50 participants, 66% female, 60% knee replacements and the average age was 66 years (SD 12). 68% were on a waiting list for surgery and 32% were undecided about surgery. Although patients varied in their views, many wanted some choice in their decision about a surgeon. If patients were in severe pain, they were more likely to accept the idea of referral to the next availab...
Key Points Question Is low-dose intradermal influenza vaccine a suitable alternative to regular d... more Key Points Question Is low-dose intradermal influenza vaccine a suitable alternative to regular dose intramuscular vaccine? Findings In this systematic review and meta-analysis including 30 studies with a total of 177 780 participants, the seroconversion rates of low doses of intradermal influenza vaccine vs the 15-µg intramuscular dose for each of the H1N1, H3N2, and B strains were not statistically significantly different. Seroprotection rates for the 9-µg and 15-µg intradermal doses were not statistically significantly different from the 15-µg intramuscular dose, except for the 15-µg intradermal dose for the H1N1 strain, which was significantly higher. Meaning These findings suggest that a low-dose intradermal influenza vaccine may be a suitable alternative to standard-dose intramuscular vaccine.
Objectives: The objective of this study was to examine the effect of measures of control and mana... more Objectives: The objective of this study was to examine the effect of measures of control and management of COVID-19, Middle East Respiratory Syndrome (MERS), and severe acute respiratory syndrome (SARS) in adults 60 years or above living in long-term care facilities. This is an update of previous work done by Rios et al. Methods: A rapid review was conducted in accordance with the Rapid Review Guide for Health Policy and Systems Research. Literature search of databases MEDLINE, Cochrane library, and pre-print servers (biorxiv/medrxiv) was conducted from July 31, 2020 to October 9, 2020. EMBASE was searched from July 31, 2020 until October 18, 2020. Titles and abstracts from public archives were identified for screening using Gordon V. Cormack and Maura R. Grossmans Continuous Active Learning (CAL) tool, which uses supervised machine learning. Results: Five observational studies and one clinical practice guideline were identified. Infection prevention measures identified in this rapi...
1ABSTRACTObjectivesTo review the literature from 2011 until March 31st, 2020 to identify the risk... more 1ABSTRACTObjectivesTo review the literature from 2011 until March 31st, 2020 to identify the risk of transmission of ARIs to healthcare workers caring for patients undergoing AGMPs compared with the risk of transmission when caring for patients not undergoing AGMPs.ResultsOnly two prospective cohort studies were identified meeting inclusion criteria. One found that performance or assistance with AGMP during the previous week was significantly associated with symptomatic influenza (adjusted OR: 2.29, 95% CI: 1.3 to 4.2). The second study found that performance of AGMP was significantly associated with clinical respiratory infections (RR 2.9, 95% CI 1.42-5.87, p<0.01), laboratory-confirmed virus or bacteria (RR 2.9, 95% CI 1.37-6.22, p=0.01), and laboratory-confirmed virus (RR 3.3, 95% CI 1.01-11.02, p=0.05). Further evidence is needed regarding what constitutes an AGMP and the risk of ARI transmission during presumed AGMPs. Organizations need to interpret these findings with cauti...
The essence of human ingenuity is creation and novel ideas that result in collective and desired ... more The essence of human ingenuity is creation and novel ideas that result in collective and desired impact. Indeed, innovation is foundational to life in a changing world. In no situation today is this more relevant than in health systems, whether they be challenged to maintain population health, threatened by impending disasters, or expected to respond to the ever-expansive demand and inexorable course of those with chronic diseases. This article discusses health system innovation and its trajectory. It focuses on clinical innovation as a means of achieving high-level performance within a learning health system model. Examples of innovation in Canada are used to illustrate successful approaches worthy of broader consideration and pan-Canadian attention.
I f you always do what you've always done, you'll always get what you have always gotten. This is... more I f you always do what you've always done, you'll always get what you have always gotten. This is true for most things in life; it is true, too, for health services and policy research graduate training. The case for modernization of training programs is strong if you track the career outcomes for graduates, as has been done for 20 years and is described in this issue. Simply put, the market has changed, but the training programs have not adapted sufficiently and are largely preparing health services and policy research graduates for tenured faculty positions, which is only one of many career paths. With about one in five graduates on this tenure-track trajectory, what about the other 80% in healthcare delivery, healthcare delivery research and the public, private and not-for-profit sectors? It is apparent that the knowledge and skills for these career trajectories have to come from experience in real-world settings, dealing with real-world issues. This cannot be passive learning but is active and experiential learning, which is an ancient concept traceable to Aristotle: learn by doing. Consider professional training, such as medicine, nursing and accounting, and ask if you would want professional services from graduates if they had never treated a patient or offered client services as part of their training. Why would being a highly qualified participant in health services and policy be any different? The papers in this issue arose from recognizing this need for training modernization and not doing what we have always done but, rather, achieving something different by training differently. The Health System Impact (HSI) Fellowship results in a new type of graduate with skills, practical experience and relationships to participate in and enable evidenceinformed health system improvement. HSI Fellowships will become the qualified leaders of the system that we are trying to create. This training program is a unique and safe opportunity to experience and to learn, analogous to a flight simulator for a career in health services and policy research. At the same time this program is evolving, the advancement of learning health systems in Canada is becoming a reality. The convergence of this training program and a shifting culture toward learning health systems augurs well for Canada' s changing and challenging health system of the future. Graduates of these programs will be important and critical
Introduction: A recent pan-Canadian survey of 48 health organizations concluded that structures, ... more Introduction: A recent pan-Canadian survey of 48 health organizations concluded that structures, processes, factors and information used to support funding decisions on new non-drug health technologies (NDTs) vary within and across jurisdictions in Canada. Objectives: The objectives of this paper were to elicit the views of key stakeholders on the following: (1) possible rationale for these findings, (2) enablers and barriers to the adoption of new NDTs, (3) approaches to optimizing the usefulness of health technology assessment (HTA) and (4) creation of a centralized pan-Canadian review process for NDTs, similar to that already in place for prescription pharmaceuticals. Methods: A one-day facilitated roundtable involving 12 purposefully selected participants who were healthcare institutional/organizational leaders, hospital-based HTA program leaders and academic experts in HTA was conducted. Results: Participants validated the survey findings and identified the following two enablers of technology adoption: (1) access to dedicated information resources and (2) inclusion of innovation in organizational priorities. Participants also identified four barriers, including the lack of (1) consistent decision-making processes within an organization, (2) agreement on what is affordable, (3) integration of HTA and procurement and (4) HTA literacy. Suggested approaches to optimizing the use of HTA focused on embedding the local context into assessments. Conclusions: Given the nature of NDT decision-making and the importance of accounting for local factors in such processes, the value of a centralized HTA review mechanism similar to that in place for drugs may be limited.
Introduction: Unlike those for publicly funded drugs in Canada, coverage decision-making processe... more Introduction: Unlike those for publicly funded drugs in Canada, coverage decision-making processes for non-drug health technologies (NDTs) are not well understood. Objectives: This paper aims to describe existing NDT decision-making processes in different healthcare organizations across Canada. Methods: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. Results: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. Conclusions: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.
Verma and Bhatia make a compelling case for the Triple Aim to promote health system innovation an... more Verma and Bhatia make a compelling case for the Triple Aim to promote health system innovation and sustainability. We concur. Moreover, the authors offer a useful categorization of policies and actions to advance the Triple Aim under the "classic functions" of financing, stewardship and resource generation (Verma and Bhatia 2016). The argument is tendered that provincial governments should embrace the Triple Aim in the absence of federal government leadership, noting that, by international standards, we are at best mediocre and, more realistically, fighting for the bottom in comparative, annual cross-country surveys. Ignoring federal government participation in Medicare and resorting solely to provincial leadership seems to make sense for the purposes of this discourse; but, it makes no sense at all if we are attempting to achieve high performance in Canada's non-system (Canada Health Action: Building on the Legacy 1997; Commission on the Future of Health Care in Canad...
In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with a... more In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with about 13% of those being symptomatic. Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers. To summarize the current evidence on surgical treatment of Tarlov cysts. A systematic review was completed. Nine databases were searched. Abstracts and full-texts were assessed by 2 reviewers. To be included, studies had to assess safety, efficacy, or effectiveness of treating Tarlov cysts, had to be written in English or French, and had to be a randomized, quasi-randomized, observational cohort, case control, or case series design including ≥2 participants. Logistic regression analysis was undertaken on the patient-level data collected to assess the association of patient and cyst characteristics on treatment success. In total, 31 studies were included in this systematic rev...
Recreational marijuana has been legalized in 11 jurisdictions; Canada will legalize marijuana by ... more Recreational marijuana has been legalized in 11 jurisdictions; Canada will legalize marijuana by July 2018. With this changing landscape, there is a need to understand the public health risks associated with marijuana to support patient-care provider conversations, harm-reduction measures and evidence-informed policy. The objective of this work was to summarize the health effects of exposure to second- and third-hand marijuana smoke. In this systematic review, we searched 6 databases from inception to October 2017. Abstract and full-text review was conducted in duplicate. Studies were included if they were human, in vivo or in vitro studies with more than 1 case reported in English or French, and reported original, quantitative data. Three outcomes were extracted: 1) cannabinoids and cannabinoid metabolites in bodily fluids, 2) self-reported psychoactive effects and 3) eye irritation and discomfort. Of the 1701 abstracts identified, 60 proceeded to full-text review; the final data s...
Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and ha... more Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and have been shown to improve waiting times, access and patient flow for preference-sensitive, scheduled services. The Winnipeg Central Intake Service (WCIS) for hip and knee replacement surgery was implemented to improve access in the Winnipeg Regional Health Authority. This paper describes the system's design/implementation; successes, challenges, and unanticipated consequences. On two occasions, during and following implementation, we interviewed all members of the WCIS project team, including processing engineers, waiting list coordinators, administrators and policy-makers regarding their experiences. We used semi-structured telephone interviews to collect data and qualitative thematic analysis to analyze and interpret the findings. Respondents indicated that the overarching objectives of the WCIS were being met. Benefits included streamlined processes, greater patient access, improve...
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, Jan 8, 2018
(1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12... more (1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12 in osteoarthritis patients undergoing total hip (THR) or knee (TKR) replacement surgery; (2) to compare distribution and anchor-based methods of assessing responsiveness. Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR and 1 year post-surgery. We assessed effect size (ES), standardized response mean (SRM), and standard error of measurement (SEM). Minimum important difference (MID) was the mean change in patients reporting somewhat better in hip or knee, health in general, and those who were satisfied with surgery (5-point scales). Responders were compared using MID versus 1 and 2SEM. The sample of 537 (50% TKR) was composed of 56% female with a mean age of 64 years (SD 10). EQ-5D-5L ES was 1.86 (THR) and 1.19 (TKR) compared to 3.00 and 2.05 for Oxford scores, respectively. MID for the EQ-5D-5L was 0.22 (THR) and 0.20 (TKR) for patients who rated their hip or knee as somewhat better. There was a wide variation in the MID and the percentage of responders, depending on the joint, method of assessment, and the outcome measure. The percent agreement of responder classification using 2SEM vs. MID ranged from 79.6 to 99.6% for the EQ-5D-5L and from 69.4 to 94.8% for the Oxford scores. Responsiveness of the EQ-5D-5L was acceptable in TKR and THR. Caution should be taken in interpreting responder to TJR based on only one method of assessment.
The aim of palliative care is to improve the quality of life of patients and families through the... more The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the "home of the patient" as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Fifty-three ...
Objectives: To describe marijuana use by Canadians and their perceptions of risk and harm. Design... more Objectives: To describe marijuana use by Canadians and their perceptions of risk and harm. Design: A cross-sectional, structured, online and telephone survey. Participants: A nationally representative sample of Canadians. Methods: This survey used random probability sampling and targeted respondents based on age, sex, region and their expected response rate. Results: Of the 20% of respondents reporting marijuana use in the past 12 months, they were more likely to be younger and male. The most common form of use was smoking, 79%. When asked about harmfulness, 42% and 41% responded that they considered marijuana more harmful than helpful to mental health and to physical health, respectively. When asked about driving under the influence, 71% responded that it was the same as alcohol. Conclusion: This research is important for health providers and policy makers seeking to maximize public health through clinical and legislative reform of non-medical use of marijuana. Résumé Objectifs : Décrire l' usage de la marijuana chez les Canadiens ainsi que leurs perceptions des risques et dommages. Conception : Sondage transversal structuré, en ligne et téléphonique. Participants : Échantillon national représentatif des Canadiens. Méthodes : Ce sondage a eu recours à un échantillonnage probabiliste aléatoire et à des répondants ciblés selon l'âge, le sexe, la région et le taux de réponse escompté. Résultats : Les 20 % de répondants qui ont indiqué avoir fait usage de la marijuana au cours des 12 derniers mois sont plus susceptibles d'être des jeunes hommes. La forme d' usage la plus courante est par l'inhalation de fumée, 79 %. Au sujet de la nocivité, 42 % et 41 % ont répondu qu'ils considéraient la marijuana plus dommageable que salutaire pour la santé mentale et la santé physique, respectivement. Au sujet de la conduite sous influence, 71 % ont répondu que c'était comme pour l' alcool. Conclusion : Cette recherche est importante pour les fournisseurs de services de santé et les responsables de politiques qui veulent maximiser la santé publique par une réforme clinique et législative de l' usage non médical de la marijuana.
Uploads
Papers by Tom Noseworthy