Delivery Of Health Care In Canada Research Articles

Perceived Access to Health Care of Indigenous Peoples in Canada with Rheumatoid Arthritis and their First-Degree Relatives.

There are complex and interrelated factors that lead to inequitable healthcare delivery in Canada. Many of the factors that underlie these inequities for Canada's geographically dispersed Indigenous Peoples remain underexamined. A cohort of 831 First Nations (FN) individuals from urban and remote communities were recruited into a longitudinal study of rheumatoid arthritis (RA) risk from 2005-2017. Data from each participant's initial enrollment visit was assessed using a survey that captured concerns with health care access. We found that remote participants with RA reported poor access compared to remote First-Degree Relatives (FDR, p<0.001), this difference was not observed for urban RA participants. We observed substantial differences based on sex; Females perceived access to care to be more difficult than males in both urban and remote cohorts (p<0.001). We also observed that male participants with RA reported poor access to care compared to male FDR. Importantly, access to care in remote communities appeared to improve over the duration of the study (p=0.01). In a logistic regression analysis, female sex, remote location, and older age were independent predictors of poor access to care. Predictors of poor access in participants with RA were also female sex, remote location and older age. FN peoples living in remote communities, particularly those with an established RA diagnosis, report more problems accessing healthcare. Sex-based inequities exist, with FN females reporting greater difficulties in accessing appropriate healthcare, irrespective of RA diagnosis. Addressing these sex-based inequities should be a high priority for improving healthcare delivery.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project

IntroductionPrivatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some...

Infection Prevention and Control for 2019 Novel Coronavirus (2019 nCoV) in Acute Healthcare Settings: The Canadian Response

Background: Severe acute respiratory coronavirus virus 2 (SARS-CoV-2), able to cause pneumonia in humans, was discovered in Wuhan, Hubei Province, China. Investigations related to transmissibility are ongoing, but human-to-human transmission involving healthcare workers providing patient care and close contacts of infected patients have been confirmed. Infection control procedures are necessary to prevent transmission during delivery of health care in healthcare settings. Public health in Canada is a shared responsibility among municipal, provincial, territorial, and federal governments. Significant public health events require coordination between all levels of government and a consistent approach across jurisdictions. The objective of this summary is to describe the Public Health Agency (PHAC)’s Infection Prevention and Control (IPC) guideline on SARS-CoV-2. Methods: The PHAC’s interim guideline for infection prevention and control of 2019-nCoV in acute healthcare settings was informed by the currently limited evidence available, and adapted to the context of healthcare delivery in Canada. The guideline is based upon Canadian guidance developed for previous coronavirus outbreaks (eg, SARS and MERS), as well as the World Health Organization (WHO)’s interim guidance. Technical advice was provided by the National Advisory Committee on Infection Prevention and Control (NAC-IPC) of the Government of Canada. Interjurisdictional collaboration and decision making between multiple authorities and levels of government was facilitated using PHACs federal/provincial/territorial (FPT) Public Health Response Plan for Biological events (Fig. 1). Results: In the absence of effective drugs or vaccines, IPC strategies to prevent or limit SARS-CoV-2 transmission in healthcare settings include the following: prompt identification of signs, symptoms and exposure criteria, implementation of appropriate IPC measures (eg, contact and droplet precautions, patient isolation, N95 respirator plus eye protection when performing aerosol-generating medical procedures on a person under investigation), and etiologic diagnosis. Guideline recommendations are informed by collective expert interpretation of available evidence. Recommendations cover all relevant areas including screening and assessment, public health surveillance and notification, laboratory testing and reporting, respiratory hygiene, hand hygiene, patient placement and flow, management of visitors, use of personal protective equipment, environmental cleaning and discontinuation of precautions. Conclusions: This guideline is an ever-changing document. Changes in recommendations provided may be warranted with new evidence, changes in WHO guidelines, or other identified concerns. FPT governments continue to work collaboratively to ensure that Canada is ready to respond to public health events and is prepared to protect the health of Canadians. Opportunities for international collaboration on IPC products, as well as knowledge exchange and mobilization, continue to thrive.Funding: NoneDisclosures: None

MP44: Implementing rural advanced care community paramedics in rural and remote British Columbia: a qualitative research approach

Introduction: Community paramedicine is well-established with an increasing evidence base to support its role in improving healthcare delivery in Canada and across the world. In British Columbia (BC), the BC Emergency Health Services (BCEHS) community paramedicine program provides an avenue to expand the Advanced Care Paramedic (ACP) role in underserved rural and remote communities across the province. Methods: We undertook stakeholder consultations using purposive sampling to better understand the barriers and facilitators impacting the integration of rural advanced care community paramedics (RACCPs) in 6 BC communities and to evaluate stakeholder perspectives of the implementation and impacts of the RACCP. 18 in-depth interviews were completed with a diverse range of stakeholders. The interviews were analyzed using a qualitative descriptive approach and the Theoretical Domains Framework. Results: A number of key facilitators and barriers to implementation of the RACCP were identified. Facilitators included the RACCP bridging significant gaps in existing community-based healthcare services including palliative care, harm reduction, and home-based assessment. The RACCP also provides leadership within their communities by actively engaging in the delivery of informal and formal debriefing, mentorship, and education. Identified barriers to RACCP implementation included confusion over the scope of the RACCP role, lack of shared health data, and various regulatory challenges. Several priority areas for ongoing development were also identified including workforce planning, addressing regulatory requirements, developing a strategic and systematic activation and dispatch process, providing continuing mentorship and supports for RACCPs, and the importance for ongoing engagement with end-users to determine the impact of the RACCP role for community health services. Conclusion: This research provides a strong foundation for addressing healthcare delivery in rural and remote BC by identifying the unique challenges communities face in healthcare provision and is a leading initiative for the ongoing development of professional paramedic practice across the province.

Naturopathy Special Interest Group Research Capacity and Needs Assessment Survey.

Objectives: Despite recent shifts in regulation and recognition of the role that naturopathy plays in health care delivery in Canada, comparatively little research has been conducted regarding individuals who conduct naturopathy-related research. A survey was undertaken to better understand the needs and capacity of these individuals to conduct more research.Design, Setting, and Subjects: The Naturopathy Special Interest Group (N-SIG) of the Interdisciplinary Network of Complementary and Alternative Medicine (INCAM) Researchers created and distributed a survey of individuals interested in naturopathy-related research to assess gaps between current and desired research activity and needs for further participation.Outcome measures: Results from a previous pilot study (2014; n = 58) were used to inform the design and distribution. This study received approval and oversight from the Research Ethics Board of the Canadian College of Naturopathic Medicine.Results: The survey was completed by 201 individuals (∼5%–10% of all naturopathic doctors and naturopathy researchers in Canada). The majority (70%) had no peer-reviewed publication experience; however, 63% reported having published in a nonpeer-reviewed medium. Respondents reported differing levels of confidence in completing various components of a research project. Frequently selected obstacles included lack of time due to professional and personal obligations, as well as insufficient training, funding, and mentorship. The greatest identified needs for participation in research were mentorship/support, access to a wider degree of scientific journals, and targeted funding opportunities for CAM research. Overall, the results of this survey suggest that there is interest in further conducting naturopathy-related research in Canada. There are individuals who are already involved and have expressed skills in the area of evidence-based medicine. Mentorship, research training, resources, and critical appraisal and writing skills may be important leverage points.Conclusion: Findings from this investigation will be used to inform an agenda for naturopathy-related research and activities of the N-SIG with respect to enhancing research capacity. Other CAM groups or geographic regions could consider using similar methodology to assess capacity and needs for research participation.

The Need for an Executive Leadership Curriculum in Scientist-Clinician Training Programs.

The health of Canadians depends on effective leadership among health care providers to facilitate the translation of new health discoveries into clinical practice. Clinician-scientists play an important role in bridging the gap between research and clinical practice, and require effective leadership skills to advance clinical practice successfully. To accelerate the leadership development in clinician scientist trainees, with the aim of developing strong leaders in administration and health advocacy, the Leaders in Medicine (LIM) training program at the University of Calgary created an Executive Leadership Coaching Program involving three phases: 1) an evidence-based evaluation tool, the Core Values IndexTM (CVI), that was used to identify the key drivers behind how individuals can be most effective in making their contribution; 2) small group workshops to debrief the results of the CVI assessment; and 3) one-on-one executive coaching sessions to facilitate the discovery, development and deployment of individual leadership capabilities. Coaching in leadership strategies enables clinician-scientist trainees to lead, influence, manage and deliver science-based improvements into the practice of medicine. We strongly recommend that other Canadian scientist-clinician training programs consider opportunities like the ones we offer to our LIM trainees. This training has important implications for the delivery of healthcare in Canada.

Ethics and the Law.

Health care providers' interpretation of law can have intended and unintended effects on health care delivery in Canada. At times, health care providers encounter situations where they perceive the law to conflict with their sense of what is most ethically justified. In many cases, these health care providers feel especially torn because they assume that the legal requirements must dictate the decision, and cannot be explored or questioned. We challenge this assumption: the law is not as cut-and-dried as some assume; therefore, its significance to health care decisions should be carefully considered. Within a systematic ethics process, legal considerations can be a source of values and information and can create opportunities for further dialogue. This approach is justified because it appropriately reflects the relationship of the law to ethics. This way of thinking about the law and ethics also avoids potentially harmful consequences of legalistic approaches to decision-making, such as breakdowns in communication, adversarial relationships, and a reduction of ethically complex decisions to simple rule following.

High-Dose, Extended-Interval Gentamicin and Tobramycin for Pediatric Inpatients: A Survey of Canadian Hospital Pharmacists

The use of high-dose, extended-interval aminoglycosides, a common practice in adult populations, is less well established for pediatric patients. In younger populations, these drugs are often administered according to a multiple daily dosing method. To characterize prescribing practices for aminoglycosides in pediatric inpatients across Canada, with a focus on high-dose, extended-interval regimens. This study was based on an electronic survey of pharmacists representing Canadian health care delivery organizations that provided pediatric inpatient services, which was distributed in March 2015. Questions focused on demographic characteristics; indications for high-dose, extended-interval tobramycin or gentamicin; use of these regimens in patients with particular comorbidities; empiric dosing; monitoring parameters; and the extent of pharmacists' authority to independently prescribe doses and order monitoring parameters for aminoglycosides at their respective institutions. Forty-five (48%) of the 94 prospective participants responded to the survey. Of these 45 respondents, 35 (78%) indicated that their respective health regions used high-dose, extended-interval tobramycin or gentamicin in pediatric inpatients. The patient characteristics for use of such regimens were varied. The median reported doses were 10 mg/kg for pulmonary exacerbation in cystic fibrosis, 7 mg/kg for urinary tract infection, and 8 mg/kg for febrile neutropenia. Thirty-one (89%) of the 35 respondents using these regimens reported that they monitored serum levels, and 27 (77%) reported monitoring for nephrotoxicity. With regard to prescriptive authority, 7 (16%) of the 45 respondents indicated that pharmacists were authorized to independently adjust dosing at their institutions, and pharmacists at 14 (31%) of 45 sites were authorized to order monitoring parameters. High-dose, extended-interval aminoglycoside therapy was frequently used for pediatric patients across Canada, although the dosages and monitoring practices varied greatly. The information from this study can be used for cross-comparison of practice by other centres across Canada.

Call to action: Interprofessional mental health collaborative practice in rural and northern Canada.

Shared within health care is needed in rural and northern Canada where residents are challenged with greater social and health disparities. Compared to their urban counterparts, Canadians in these areas experience lower socioeconomic status; higher rates of disability; higher rates of unemployment; higher mortality rates; difficulty with transportation, thereby limiting access to essential health services; and higher rates of chronic illness (Barbopoulos & Clark, 2003; Canadian Institute for Health Informatics, 2006). Downsizing of hospitals in rural and northern areas is causing outmigration of health care services to centralized urban areas, forcing rural Canadians to travel greater distances to access health care services (Canadian Collaborative Mental Health Initiative [CCMHI], 2006). A lack of access to health care is frequently noted as a key issue facing rural and northern residents (Donato, 2015; Haggarty, Ryan-Nicholls, & Jarva, 2010; McIlwraith & Dyck, 2002; Ryan-Nicholls, 2004). Shortages of mental health professionals in rural, northern, and Aboriginal communities in Canada are well documented (Kulig & Williams, 2012; McIllwariath & Dyck, 2002; Pawlenko, 2005).Interprofessional mental health collaborative practice (IMHCP) is an emerging and vital response to meet the mental health-related demands in rural and northern Canada and is an enhancement of the current Canadian health practice of Interprofessional Practice (IPP; (CCMHI, 2006; Coffey & Anyinam, 2015; Commission on the Future of Health Care in Canada [CFHC], 2002; Haggarty et al., 2010; Heath et al., 2015). IPMHC involves developing and maintaining effective interprofessional working relationships with professionals, paraprofessionals, students, mental health consumShelley ers, families, and communities to ensure optimal health outcomes (Canadian Interprofessional Health Collaborative [CIHC], 2010). Effective collaboration requires individual professionals to reframe their views from the traditional 'we know best' mind-set to a holistic approach (CCMHI, 2006; Coffey & Anyinam, 2015; Petrie, 1976). Pearce and Sims (2001) define shared as leadership that emanates from members of teams, and not simply from the appointed leaders (p. 115). It is the authors' contention that psychology must fully embrace a shared role in IMHCP in rural and northern communities, not only within clinical practice but also within professional psychology associations and regulatory bodies. We discuss the opportunities and challenges this may create and how the scholarly literature can guide our next steps.BackgroundThe Romanow Report (CFHC, 2002) continues to be one of the most influential documents in modern health care delivery in Canada. Over the past decade, recommendations from this document have led to systemwide advances in IPP and interprofessional education (IPE). In response, provincial and territorial directives have been targeting collaborative practice as one of their priorities in streamlining quality health care (Canadian Health Services Research Foundation, 2011; Coffey & Anyinam, 2015; Health Professions Regulated Advisory Council [HPRAC], 2006; Province of Nova Scotia, 2014). IPP is now an explicit expectation within most standards of practice for self-regulated health care professions in Canada and is mandated by their respective regulatory bodies (Human Resources Professionals Association, 2015). National organisations specifically designed to promote awareness and education in this field, such as the CIHC (2010), are also emerging. As well, IPE is expanding within universities across Canada, supporting multimodal opportunities for clinical simulations in IPP (Church et al., 2010; Cornish et al., 2003; Curran et al., 2012; Dalhousie University, 2015a; Donato, 2015).Yet within rural and northern communities, there remain challenges with efficiently implementing IMHCP because these large, isolated geographic areas are being serviced by low numbers of health professionals representing a small number of disciplines. …

Rural Men's Health, Health Information Seeking, and Gender Identities: A Conceptual Theoretical Review of the Literature.

Beginning as early as 2009, recent shifts in Canadian health care delivery indicate that access to health information is essential to promote and maintain a healthy population. It is important to understand how and where various populations, such as underresourced rural populations, access health information so that public health agencies can develop and deliver appropriate information with, for, and in these contexts. There is a paucity of research that specifically examines how rural Canadian men seek health information; therefore, this review aimed to conceptualize this process based on three dynamic key constructs: health patterns of rural Canadians, health information-seeking behaviors, and rural gender identities. This conceptual theoretical literature review included 91 articles at the intersection of these three constructs. Discussion focuses on how residing in a rural region influences men's health and health care access. Health information-seeking behaviors are discussed in terms of social networks and framed with a rural context. Connell's theory of masculinity provides a useful approach to dissecting how rural men's gender identities influence their health attitudes, and how such attitudes are embedded in rural social and cultural norms. Each major construct-health in rural Canada, health information seeking, and rural gender identities-is discussed to highlight how specific embodiments of masculinity may promote and inhibit men's health information-seeking and positive health behaviors.

Counselling Psychology in Canada

Counselling psychology in Canada has experienced tremendous growth and greater recognition within the last 30 years. However, there is little empirical research on the practice of counselling psychology in Canada and the characteristics of Canadian counselling psychologists. We administered a 74 item questionnaire to 79 counselling psychologists who were members of the Counselling Psychology Section of the Canadian Psychological Association, achieving a 35.4% response rate. The survey asked various questions organized under the headings of: Background Information, Theoretical Orientations, Professional Activities, Training and Career Experiences, and Future. Overall, these Canadian counselling psychologists seem to see the discipline as moderately different from clinical psychology and from counsellor education, and are largely satisfied with their choice of career in counselling psychology. Results further indicate that independent practice is the most common work-setting and that respondents spend a large share of their time providing individual, non-career related, counselling/psychotherapy of primarily a rehabilitative/treatment-oriented nature. A strengths-focused approach was also highly valued by the sample. The development of the field, distinctive characteristics of Canadian counselling psychology, the place of counselling psychology in the Canadian health care delivery system, credentialing, professional organizations, education and training issues, allied professions, opportunities for the field, and threats to the field are also discussed.

A Canadian Survey of Pharmacist Participation during Cardiopulmonary Resuscitation.

The participation of pharmacists on cardiopulmonary resuscitation (CPR) teams has been associated with improvements in patient outcomes secondary to lower rates of adverse drug events and higher rates of compliance with guidelines for advanced cardiac life support (ACLS). The degree to which Canadian pharmacists participate on CPR teams and the services they provide have not previously been assessed. To measure the frequency of pharmacists' involvement on CPR teams in Canadian health care delivery organizations, to characterize the services provided by these pharmacists, to identify positive predictors of participation, and, for health care delivery organizations without pharmacists on CPR teams, to determine the reasons for the lack of involvement. An electronic survey was distributed to key informants in Canadian health care delivery organizations. The survey consisted of questions about characteristics of the health care delivery organizations, pharmacists' participation and role on the CPR team, training, and barriers to implementation. The primary outcome was the percentage of health care delivery organizations with pharmacists participating on CPR teams in at least one centre within the organization. The secondary outcomes were pharmacists' activities, training, and reasons for not participating on CPR teams. Forty-three of 99 key informants responded to the survey. Twenty-nine respondents (67%) indicated that their organization had a CPR team, and 10 (23%) indicated participation by pharmacists on a CPR team. Roles reported to be performed by pharmacists during CPR events were provision of drug information, preparation and administration of medications, record-keeping, and chest compressions. Training for these pharmacists was variable: ACLS training for 4 (40%) of the 10 organizations with pharmacist participation, in-house training for 3 (30%), and no training for 2 (20%); one respondent (10%) did not report the level of training. Reasons for not having pharmacists on CPR teams included inconsistent coverage, lack of training, and staff shortages. This study characterized current pharmacist participation on CPR teams in Canadian health care delivery organizations. As evidence arises showing the impact of this practice on patient outcomes, pharmacist participation on CPR teams may become more common.

Missed Connections: The Adoption of Information Technology in Canadian Healthcare

Despite the ambitious efforts of the provincial and federal governments in Canada to implement Electronic Health Record (EHR) systems, the level of health information exchange across organizations and care settings in Canada is among the lowest in surveyed countries. Some survey findings revealed that in primary care only 12 percent of physicians are notified electronically of patients’ interactions with hospitals or send and receive electronic referrals for specialist appointments. Fewer than three in ten primary care physicians have electronic access to clinical data about a patient who has been seen by a different health organization. Certainly, progress has been made, namely in the development of the infrastructure to store and share health information, as well as some use of information technology in primary care, but the delivery of healthcare in Canada has yet to take full advantage of the major potential benefits. The aims of EHR programs include reducing duplication of, and errors in, patient records; taking advantage of information and communications technology to improve patient outcomes – by delivering patient and medication data to where and when it is needed; and saving the time of patients and providers. In Canada, there will not be any large-scale benefits from gathering masses of health data until the information is shared among providers and institutions, such as between a family physician and a hospital. Leadership is required to drive continuous change and quality improvement toward integrated care. To do so, appropriate incentives are also required. Providers and provider teams need to be held accountable for improvements to happen. One key characteristic shared by many leading healthcare jurisdictions is the incentive to improve outcomes for patients at risk, in contrast to the fee-for-service reimbursement models that create incentives for higher treatment volumes. Leaders need to set goals and incentives for improved quality of outcomes and hold institutions and clinicians accountable for achieving those goals.

179: Integrating Developmental Services with School-Based Health Care: Feasibility, Efficacy and Relevance in a Universal Healthcare System

The School-based health center (SBHC) is an emerging model for developmental healthcare delivery in Canada. Despite access to universal healthcare, barriers such as language, cultural differences and transportation affect access for children in underserved populations in Canada. The Model Schools Pediatric Health Initiative is the first SBHC program in Ontario, Canada established to alleviate barriers inner city children face to accessing developmental care. As part of the program, pediatricians attend interdisciplinary monthly school based (school support team, SST) meetings to help identify which students require developmental assessments and then offer them through the participating SHBC. To provide an update on the Model Schools Pediatric Health Initiative SHBC program with respect to feasibility and efficacy. A retrospective chart review of all clinic users from November 2010 to January 2012 was conducted and a prospective longitudinal cross-sectional analysis was implemented from February 2012 to June 2013. Among those referred for developmental concerns, time from identification at the SST meeting to first developmental assessment at the SBHC was calculated. The feasibility metrics included the number of children who enrolled at the SBHC. The efficacy metrics included the proportion of enrolled children who attended the SBHC, the proportion of new diagnoses established, as well as wait times. In total, 1042 children enrolled at the SBHC and 443 (43%of those that enrolled) attended the SBHC. There were a total of 282 new diagnoses established at the SBHC and among these 181 (64%) were in the developmental diagnostic category. From March 2012 to April 2013, 41 students were referred for developmental assessments from the School Support Team (SST). Thirty-three assessments were completed at the time of analysis and the mean wait time from presentation at the SST to developmental assessment was 102 days. The SBHC has proven to be feasible and efficacious. This model relies on an integrated approach whereby pediatricians and school board professionals meet monthly to discuss and triage at risk students needing developmental assessments. This process allows for better understanding of school related problems and provides assessments within the school setting thereby eliminating some barriers to healthcare access. Relative to the standard of care this process is fast and efficient and creates an optimal setting to increase access to specialized developmental services for inner city children facing barriers to accessing health-care in Canada.

Alberta: Evaluation of Nursing Retention and Recruitment Programs

Retention and recruitment strategies are essential to address nursing workforce supply and ensure the viability of healthcare delivery in Canada. Knowledge transfer between experienced nurses and those new to the profession is also a focus for concern. The Multi-Employer/United Nurses of Alberta Joint Committee attempted to address these issues by introducing a number of retention and recruitment (R&R) initiatives for nurses in Alberta: in total, seven different programs that were introduced to some 24,000 nurses and employers across the province of Alberta in 2001 (the Transitional Graduate Nurse Recruitment Program) and 2007 (the remaining six R&R programs). Approximately 1,600 nurses participated in the seven programs between 2001 and 2009. Of the seven strategies, one supported entry into the workplace, two were pre-retirement strategies and four involved flexible work options. This project entailed a retrospective evaluation of the seven programs and differed from the other Research to Action (RTA) projects because it was solely concerned with evaluation of pre-existing initiatives. All seven programs were launched without a formal evaluation component, and the tracking of local uptake varied throughout the province. The union and various employers faced challenges in implementing these strategies in a timely fashion, as most were designed at the bargaining table during negotiations. As a result, systems, policy and procedural changes had to be developed to support their implementation after they became available.Participants in the programs indicated improvements over time in several areas, including higher levels of satisfaction with work–life balance, hours worked and their current practice and profession. The evaluation found that participation led to perceived improvements in nurses' confidence, greater control over their work environment, decreased stress levels, increased energy and morale and perceived improved ability to provide high-quality care. However, no formal implementation plan had been developed or made available to assist employers with implementation of the programs. The findings highlight the need for more discipline in communicating, implementing and evaluating initiatives such as those evaluated retrospectively in this project. In particular, key performance indicators, baseline data, monitoring mechanisms and an evaluation plan need to be developed prior to implementation.

Billing Patterns of Canadian Anesthesiologists over a Decade

Purpose: Over the past decade several authors have focused on the demand for anesthesiologist services. The objective of this article is to determine the clinical work billed by Canadian anesthesiologists at different stages of practice. Methods: Ten years worth of specialist anesthesiologists' billing data from Jan 1, 1993 to Dec 31, 2002 were obtained from British Columbia (BC), Ontario (Ont), and Quebec (Que). The anesthesiologists were stratified into three age categories (<51, 51-64, and 65+). The number of unique physician - patient interactions and days with submitted billings were extracted for each anesthesiologist in each province. Results: The median number of anesthesiologists per year over the 10 year period for the <51, 51-64, and 65+ age groups were, respectively, 323, 138, and 51 in Quebec, 476, 235, and 66 in Ont and 225, 83, and 8 in BC. The median number of days with billings per year and unique physician-patient interactions was dependent on the province and lower for the 65+ age group, but were similar for the <51 and 51-64 age groups. Conclusion: The median number of days with submissions for billing by anesthesiologists is relatively constant until at least 65 years of age and then declines in each province. There is much variability in billing among anesthesiologists between and within the provinces studied. Canadian health care delivery is quite dependent on anesthesiologists 65+ despite the reduced number of days with billings and physician-patient interactions in this age group.

The Role of Nursing Leadership in Integrating Clinical Nurse Specialists and Nurse Practitioners in Healthcare Delivery in Canada

Supportive nursing leadership is important for the successful introduction and implementation of advanced practice nursing roles in Canadian healthcare settings. For this paper, we drew on pertinent sections of a scoping review of the literature and key informant interviews conducted for a decision support synthesis on advanced practice nursing to describe and explore organizational leadership in planning and implementing advanced practice nursing roles. Leadership strategies that optimize successful role integration include initiating systematic planning to develop the roles based on patient and community needs, engaging stakeholders, using established Canadian role implementation toolkits, ensuring utilization of all dimensions of the role, communicating clear messages to increase awareness about the roles in the organization, creating networks and facilitating mentorship for those in the role, and negotiating role expectations with physicians and other members of the healthcare team. Leaders face challenges in creating and securing sustainable funding for the roles and providing adequate infrastructure support.

Dialysis Delivery in Canada and the United States: A View From the Trenches

Although the general framework for health care delivery is vastly different in Canada and the United States, the framework for dialysis delivery is less divergent. However, the 2 systems have evolved very differently. Examined during the past 20 years, it is apparent that the dialysis system in the United States has undergone profound change, whereas the system in Canada is relatively stagnant. Most of the change in the United States has been positive, and this evolutionary change is expected to continue. In Canada, a system that historically has worked reasonably well is now showing severe signs of suboptimal performance that would be expected to get worse if no effort is made to improve it. This article, written from the perspective of 2 academic clinicians, tries to describe similarities and differences, identify strengths and weaknesses, and serve as a catalyst for discussions about improving both systems. Just as no dialysis treatment modality is perfect, the same can be said for dialysis delivery systems. Empirical methods to objectively evaluate the impact of change must be included in the design and implementation of new initiatives in the United States and Canada.

Health Professionals' Beliefs Related to Parental Involvement in Ambulatory Care: An International Inquiry

Changes in health care delivery in Canada and Europe, especially the shift to ambulatory care, have modified the care that children and parents receive and have prompted the need for a partnership alliance. The objectives of this exploratory study were to identify Canadian and Belgian health professionals' beliefs and attitudes towards parental involvement in their child's ambulatory care and to determine if these beliefs varied according to cultural background. Health professionals from both countries generally were in favor of parental involvement in their child's care, but are uncertain about its advantages and disadvantages. Facilitators and barriers mentioned by the health care providers were related to parents' abilities or their attitudes toward partnership, and they also expressed a need for more education on the subject. Results of this study indicate that health professionals working in ambulatory care are not fully ready to utilize parents as true partners in their interventions with children and families. Staff education is an important step towards the establishment and maintenance of a real partnership.

Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences

Objectives The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences. Methods Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 ( most) to 5 ( least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas. Results Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference. Conclusions Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both.