Canadian Jurisdictions Research Articles

Artificial Intelligence–Assisted Colonoscopy for Detecting Polyps, Adenomas, Precancerous Lesions, and Colorectal Cancer

What Is the Issue? Colorectal cancer is 1 of the most common cancers globally. In Canada, it is estimated that more than 25,000 people will be diagnosed with colorectal cancer in 2024 and that more than 9,000 people will die of it. To reduce the incidence and mortality of colorectal cancer, screening programs across various jurisdictions in Canada have implemented screening strategies involving routine fecal testing and colonoscopy. While colonoscopy is often considered the gold standard for colorectal cancer screening, missed polyps remain a challenge with this modality. In recent years, many artificial intelligence (AI)–enabled polyp detection systems have been developed for use during colonoscopy. A review of the clinical and cost-effectiveness of these systems could help clarify their potential role in clinical practice. What Did We Do? To inform decisions regarding the use of AI-assisted colonoscopy, we conducted a rapid review to identify and summarize evidence that compared the clinical and cost-effectiveness of AI-assisted colonoscopy to conventional colonoscopy and among different AI-assisted colonoscopy systems. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings. What Did We Find? We found 1 health technology assessment (HTA), 3 systematic reviews (SRs), and 1 randomized controlled trial (RCT) that evaluated the clinical and cost-effectiveness of AI-assisted colonoscopy for detecting polyps, adenomas, precancerous lesions, and colorectal cancer. AI-assisted colonoscopy may improve clinical outcomes compared to conventional colonoscopy, including adenoma detection rates, the number of adenomas detected per procedure, and adenoma miss rates, although it may also lead to longer withdrawal times. However, not all studies included in this report demonstrated statistically significant differences between the groups for each of these outcomes. The included RCT allocated participants to receive AI-assisted colonoscopy with either Deep-GI or CAD EYE, but the authors did not perform statistical testing to compare the outcomes between these 2 treatment groups. Findings from 6 economic evaluations summarized in the HTA suggest that AI-assisted colonoscopy is likely to be cost-effective or dominant — meaning it is less costly and more effective — compared to conventional colonoscopy. We did not find any studies on the relative cost-effectiveness of different AI-assisted colonoscopy systems that met our selection criteria for this review. None of the included studies reported long-term outcomes, such as colorectal cancer incidence and mortality; therefore, the impact of AI-assisted colonoscopy on these outcomes is unknown. What Does This Mean? AI-assisted colonoscopy may improve clinical outcomes and be more cost-effective than conventional colonoscopy for detecting polyps, adenomas, precancerous lesions, and colorectal cancer. The clinical and cost-effectiveness of different types of AI-assisted colonoscopy systems compared to each other is unknown. Clinicians and decision-makers can use the evidence summarized in this review to inform decisions regarding the implementation of AI-assisted colonoscopy.

How can digital citizen science approaches improve ethical smartphone use surveillance among youth: Traditional surveys versus ecological momentary assessments.

Ubiquitous use of smartphones among youth poses significant challenges related to non-communicable diseases, including poor mental health. Although traditional survey measures can be used to assess smartphone use among youth, they are subject to recall bias. This study aims to compare self-reported smartphone use via retrospective modified traditional recall survey and prospective Ecological Momentary Assessments (EMAs) among youth. This study uses data from the Smart Platform, which engages with youth as citizen scientists. Youth (N = 77) aged 13-21 years in two urban jurisdictions in Canada (Regina and Saskatoon) engaged with our research team using a custom-built application via their own smartphones to report on a range of behaviours and outcomes on eight consecutive days. Youth reported smartphone use utilizing a traditional validated measure, which was modified to capture retrospective smartphone use on both weekdays and weekend days. In addition, daily EMAs were also time-triggered over a period of eight days to capture prospective smartphone use. Demographic, behavioural, and contextual factors were also collected. Data analyses included t-test and linear regression using Python statistical software. There was a significant difference between weekdays, weekends and overall smartphone use reported retrospectively and prospectively (p-value = <0.001), with youth reporting less smartphone use via EMAs. Overall retrospective smartphone use was significantly associated with not having a part-time job (β = 139.64, 95% confidence interval [CI] = 34.759, 244.519, p-value = 0.010) and having more than two friends who are physically active (β = -114.72, 95%[CI] = -208.872, -20.569, p-value = 0.018). However, prospective smartphone use reported via EMAs was not associated with any behavioural and contextual factors. The findings of this study have implications for appropriately understanding and monitoring smartphone use in the digital age among youth. EMAs can potentially minimize recall bias of smartphone use among youth, and other behaviours such as physical activity. More importantly, digital citizen science approaches that engage large populations of youth using their own smartphones can transform how we ethically monitor and mitigate the impact of excessive smartphone use.

Temporal and regional trends in Canada for the epidemiology and management of diabetic foot ulcers.

Diabetic foot ulcers (DFUs) are a common downstream consequence of diabetes and pose significant concern to the health of affected individuals. There are currently limited data available that detail the epidemiology and inpatient burden of DFUs in Canada. This study aims to provide updated data on the epidemiological and economic burden of DFUs in Canada between 2015 and 2019. Using the Canadian Institute for Health Information Patient Cost Estimator the authors estimated, as the primary outcome, the number of DFU inpatient cases in Canada, the associated financial burden of these admissions on the Canadian healthcare system, physician compensation, and average patient length of hospitalisation. This analysis covered 12 Canadian jurisdictions and was stratified by age, sex, province and geographical region. The secondary outcome was to highlight temporal trends in the public health burden of DFUs by computing the average annual percentage change (AAPC; the weighted average of several annual percentage changes over multiple years) using Joinpoint (Surveillance Research Program National Cancer Institute, US) regression analysis. The total number of cases, average length of hospitalisation and physician costs across Canada were highest for patients over ≥60 years of age. By region, the total number of cases and standardised physician costs were highest in Central Canada, followed by Western Canada, and subsequently Eastern and Northern Canada. In 2019, there were >1800 patients with DFUs admitted to Canadian acute care hospitals. Despite having the lowest number of inpatient admissions, Northern Canada had the highest associated inpatient costs, followed by Central, then Western and, lastly, Eastern Canada. Overall, mean inpatient costs remained stable over time across all age groups (AAPC 0.61; 95% confidence interval: -1.87-3.15), with an average cost of >$10,000 CAD per case. Average physician cost across all jurisdictions was approximately $1000 CAD per case, with the mean hospitalisation time being nine days. The findings of this study emphasise the dynamic nature of the economic and epidemiological DFU burden in Canada, underscoring the need for targeted interventions, multidisciplinary care and evidence-based resource allocation for the optimal management of diabetes and DFUs.

Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review

Background: This scoping review examines the risk factors considered in assessing the dangerousness of individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canadian administrative courts. This review aims to identify the factors used by mental health review boards during annual case reviews to guide decisions on detention or release. Methods: Using a scoping review approach following PRISMA guidelines, this study analyzed research across multiple databases to identify relevant studies focusing on risk assessment for NCRMD cases. Results: The findings indicate that five primary categories of risk factors—historical, clinical, behavioral, legal, and miscellaneous—are influential in the decision-making process. Historical factors, such as past violence and early psychiatric contacts, are critical in predicting future risk. Clinical factors, including psychiatric diagnosis and treatment adherence, are key to evaluating current and potential future risks. This study reveals variability in the application of standardized risk assessment tools, highlighting a need for more consistent practices across Canadian jurisdictions. Conclusion: This review concludes that, while a multifaceted approach to risk assessment is essential for balancing public safety with individual rehabilitation, further research is needed to refine these processes and establish more uniform standards for managing NCRMD cases in forensic psychiatry.

Aging in Place

What Is the Issue? Canada is experiencing an important demographic transition toward an increasingly diverse aging population with an increased need for care and support during the later stages of life. Despite older adults’ strong preferences to live in their home or community for as long as possible, health systems are challenged to keep up with growing demands for home care, community care and support services to support conditions to age in place, when appropriate. What Did Canada’s Drug Agency Do? Canada’s Drug Agency prepared an Evidence Assessment report that identified and described the current context of aging and hinderances to aging in place in Canada, considerations relevant to aging in place for equity-deserving groups, strategies and initiatives intended to address unmet needs and improve outcomes, and systemic considerations related to implementing initiatives supporting aging in place. The Health Technology Expert Review Panel (HTERP) used the Canada’s Drug Agency Evidence Assessment report to inform deliberations and to develop objective, impartial, trusted pan-Canadian guidance for decision-makers when considering evidence-informed aging-in-place initiatives to support equitable aging in place in jurisdictions in Canada. What Is HTERP’s Position on Aging in Place? Everyone has the right to age with dignity. Aging is a normal part of life and may be accompanied by changes in health status and/or abilities to complete everyday self-care tasks. Older adults comprise a heterogenous population with a continuum of health care needs and risks, including people living with vitality, those with moderately complex care issues, and those with complex care issues. Health and social systems were originally designed to meet the less complex acute care needs of a younger population and operate largely in silos. They cannot adequately or proactively address the continuum of needs of many older adults and their caregivers. Aging in place is a dynamic and complex experience that occurs within a larger context that is not limited to health systems. Older adults’ autonomy and preferences for care are realized by the active role of informal unpaid caregivers. The population of older adults in Canada is diverse with varying needs, risks, and cultural norms and values related to aging in place. Barriers to aging in place may disproportionately affect members of equity-deserving groups that experience multiple and often intersecting historical, social, cultural, medical, structural, institutional, and environmental barriers to care and support. There must be equity in access to safe, appropriate, and ongoing care to support dignity in living in a place of one’s choosing for older adults as they age. What Is HTERP’s Guidance to Support Aging in Place? foster a system that prioritizes integrated models of care to address current and future unmet needs and bridge gaps in and between services identify interventions that are aligned within an integrated model of care and are responsive to the unique and complex needs of older adults and their unpaid caregivers ensure culturally appropriate and equitable opportunities for positive outcomes standardize core measures or indicators to guide data collection, analysis, use, and reporting that support robust evaluation and cross-jurisdictional comparisons of interventions.

Canadian Medical Imaging Inventory 2022–2023: SPECT and SPECT-CT

SPECT is a nuclear imaging technique that provides 3D information on functional and molecular processes in the body. SPECT has been integrated with CT to combine the imaging strengths of both modalities in SPECT-CT. In total, 331 SPECT-CT units in 10 provinces and 210 SPECT units operating in 9 provinces were identified by the Canadian Medical Imaging Inventory (CMII) in its 2022–2023 national survey. There are no SPECT-CT and SPECT units operating in Yukon, Northwest Territories, and Nunavut. Canada has 8.3 SPECT-CT units per million people and 5.3 SPECT units per million people. The greatest density of units per million people for SPECT-CT is in Newfoundland and Labrador and the greatest density for SPECT are in Alberta and New Brunswick. The combined volume of SPECT-CT and SPECT exams conducted in 2022–2023 has decreased by approximately 37.5% since 2015, which is attributed to the gradual decommissioning of SPECT units and replacement of these technologies with other imaging modalities. SPECT-CT is primarily used for oncology exams, followed by cardiology exams and musculoskeletal exams. SPECT is primarily used for cardiology exams, followed by oncology and musculoskeletal exams. On average, SPECT-CT and SPECT units operate approximately 42 hours per week across jurisdictions in Canada that have capacity.

Chronic pain and accidental acute toxicity deaths in Canada, 2016-2017.

Multiple Canadian jurisdictions have reported a pattern of chronic pain among people who died from substance-related acute toxicity. This study examined the prevalence and characteristics of those with chronic pain using data from a national study of people who died of accidental acute toxicity. A cross-sectional analysis of accidental substance-related acute toxicity deaths that occurred in Canada between 1 January 2016 and 31 December 2017 was conducted. The prevalence of pain and pain-related conditions were summarized as counts and percentages of the overall sample. Subgroups of people with and without a documented history of chronic pain were compared across sociodemographic characteristics, health history, contextual factors and substances involved. From the overall sample (n = 7902), 1056 (13%) people had a history of chronic pain while 6366 (81%) had no documented history. Those with chronic pain tended to be older (40 years and older), unemployed, retired and/or receiving disability supports around the time of death. History of mental health conditions, trauma and surgery or injury was significantly more prevalent among people with chronic pain. Of the substances that most frequently contributed to death, opioids typically prescribed for pain (hydromorphone and oxycodone) were detected in toxicology more often among those with chronic pain than those without. Findings underscore the cross-cutting role of multiple comorbidities and unmanaged pain, which could compound the risk of acute toxicity death. Continued prioritization of harm reduction and regular patient engagement to assess ongoing needs are among the various opportunities for intervention.

Cutaneous Melanoma Mortality-to-Incidence Ratio and Its Association With Socioeconomic and Healthcare Factors in Canada: A National Ecological Study.

The mortality-to-incidence ratio (MIR) can be used to approximate healthcare inequities and is helpful to understand/compare cancer survival between geographic regions/jurisdictions. We investigated cutaneous melanoma (CM) outcomes through MIR analysis in Canadian jurisdictions and census divisions (CDs) between 1992 and 2016. Data were obtained from the national databases from 1992 to 2016 for all Canadian jurisdictions, except Quebec. Age-standardized overall and median MIRs were calculated per province per year, while crude MIRs were calculated for CDs. Generalized linear regression models were conducted to study the effect of province and year on MIR, while a mixed effect regression model was used to determine how healthcare and socioeconomic factors affect MIR, while accounting for possible clustering effects (eg, year and province). We identified 106,015 CM cases and 20,570 CM deaths between 1992 and 2016. National MIR from 1992 to 2016 demonstrated a significant linear decrease (P value < .0001). The national median MIR was 15.4 (ie, 0.154 × 100), whereby Manitoba (19.9), Ontario (19.5), Saskatchewan (18.5), British Columbia (16.1), and Newfoundland and Labrador (15.9) demonstrated higher MIRs than the Canadian average. CDs with the highest MIRs were commonly identified in the southern regions of provinces. No healthcare or socioeconomic factors were found to be significantly associated with higher MIR at the provincial level. MIRs have decreased at the national and provincial levels in recent decades, which is reassuring. Higher MIRs were noted in select rural CDs and in the Canadian territories, reinforcing the importance of proper dermatological care in all parts of the country.

An update on the status of direct testing for Treponema pallidum subspecies pallidum for the laboratory diagnosis of syphilis in Canada

Background: In Canada, the recent resurgence of infectious syphilis and rising rates of congenital syphilis have renewed interest in direct detection methods for the laboratory diagnosis of syphilis. The Canadian Public Health Laboratory Network (CPHLN) has previously published a series of guidelines for the diagnosis of syphilis in Canada, including the use of direct tests. In the decade since those guidelines were published, laboratory practice has changed. Methods: This systematized review combined a literature search (MEDLINE) of methods for direct detection of Treponema pallidum with an informal survey of current testing practices in Canadian public health laboratories. Results: Direct testing methods have favourable performance characteristics for detection of early syphilis and congenital cases. Although no government licensed commercial nucleic acid amplification test (NAAT) for syphilis is available in Canada, laboratory-developed tests have been implemented in multiple Canadian jurisdictions. Clinical specimens with the highest yield of positive NAAT results for syphilis include genital ulcers, skin lesions, and oral swabs from primary and secondary syphilis patients. For investigation of congenital syphilis, nasopharyngeal, placenta, umbilical cord, blood, and skin lesions are specimens of choice for direct detection of T. pallidum by NAAT. Conclusions: This update on the status of direct testing highlights the importance of NAAT for the detection of T. pallidum, the reduced role of microscopy-based methods, and the emergence of DNA and genome sequencing as tools for phylogenetic analysis and molecular epidemiology.

Progress Tracker Breast Cancer Registry: A Breast Cancer Canada initiative.

e23018 Background: Significant gaps exist in the collection of real-world evidence and validated patient-reported outcome measures (PROMs) data from individuals with breast cancer. Variations in treatment and surveillance care across regional jurisdictions present knowledge gaps across diverse populations which remain difficult to study. The PROgress Tracker Breast Cancer Registry, a large, prospective Canadian PROMs cohort study aims to identify care gaps through the lived patient experience to inform patient-centered care and new research directions. Methods: PROgress Tracker is a real-world, longitudinal, non-interventional PROMs registry directed by Breast Cancer Canada, a registered non-profit patient-led organization, and data managed by University of Calgary’s POET program. Launched in October 2023, this registry aims to enroll up to 50,000 adult Canadian participants with a histologic diagnosis of in-situ or invasive breast cancer (stage 0 through IV) within 10 years. A volunteer-led peer-to-peer support model, based in regional and provincial hubs across Canada, facilitates participant recruitment, engagement, and retention. Individuals who self-identify for study inclusion provide informed consent, demographic and socioeconomic profile, and clinical information on their breast cancer diagnosis. Every three months (and up to 10 years) a bilingual digital platform to reduce barriers to access is used to provide all PROgress Tracker participants 8 validated PROMs to capture evolving measures of self-efficacy for wellbeing, symptoms and overall global functioning. Based on treatment, up to 10 additional PROMs to assess the immediate adverse effects and long-term impacts of treatment are collected. PROgress Tracker has the additional capacity to link to external ethics-approved studies to investigate clinical outcome and healthcare utilization metrics for participants consenting to additional studies. Results: In progress. Conclusions: PROgress Tracker represents Canada’s first national PROMs breast cancer registry. Its unique design and implementation by a patient-led research organization helps fill gaps in current knowledge through longitudinal follow up of patients prior to, during, and after cancer care, and from the time from diagnosis through active treatment, long-term survivorship, and/or palliative care. The PROgress Tracker Registry will comprehensively gather the validated real-world data information rarely collected in in the traditional clinical or trial-based research setting using a novel self-enroll design and digital process. Such information is crucial to support evidence-based decision making to inform patient-centered healthcare change. This allows comparison across Canadian jurisdictions, is scalable to other jurisdictions around the world and further explores the utility of electronic PROMs data capture within a diverse patient population.

Newborn Screening for Congenital Cytomegalovirus in Canada

What Is the Issue Congenital cytomegalovirus (cCMV) infection is a leading cause of childhood hearing loss. It is estimated that 85% to 90% of newborns infected with cCMV will not show any symptoms at birth. Of those newborns with cCMV infection who are asymptomatic at birth, 10% to 15% will go on to develop long-term symptoms, including vision loss, hearing loss, and developmental delays. What Did We Do? This brief provides a summary about newborn screening for cCMV in Canada, including whether screening is available for cCMV in each province and territory, and if so, whether screening is universal or targeted using publicly available information. What Did We Find? Currently in Canada, 4 provinces (Alberta, Saskatchewan, Manitoba, Ontario) have or are implementing universal newborn screening for cCMV. Three provinces (British Columbia, New Brunswick, Nova Scotia) have province-wide targeted screening programs that offer cCMV testing to newborns who fail newborn hearing tests or who have suspected cCMV as identified by a clinician. Current clinical guidance and practice remain mixed on whether targeted or universal newborn screening is recommended, with each having a different distribution of benefits and harms. cCMV infections can be detected using blood, urine, or saliva tests. Most universal newborn screening programs use dried blood spot tests, which are likely to produce false-negative results; saliva tests have a lower number of false-negative results but can result in a higher number of false-positives. Some programs recommend additional testing using a different method (either saliva or urine) after an initial positive test as a validation. What Does This Mean? As both universal and targeted newborn screening programs have been adopted by several jurisdictions in Canada, there is wide recognition that cCMV infection is a serious health issue and that early detection is important. Moreover, there is an opportunity to generate data and evidence about test performance and program impact over time that could support future decision-making. As evidence and new test and treatment options become available, such data will help to inform the type of newborn screening approach used for cCMV.

Ontario Midwives’ Attitudes About Abortion and Abortion Provision

Objective: In Ontario and across Canada, midwives do not provide pregnancy termination but provide referrals and support for clients. This differs from a number of international jurisdictions where abortion has been added to the midwifery scope of practice, resulting in safe outcomes for women and improved access to services. This study sought to survey Ontario midwives’ general attitudes towards abortion and willingness to incorporate abortion into the midwifery scope of practice. Ethics approval for the study was obtained from the Ryerson University Research Ethics Board. Methods: An Internet-based cross-sectional survey was sent to all registered midwives in Ontario via the Association of Ontario Midwives. The survey consisted of seven sections, with a total of 43 Likert scale questions, 17 general questions, and space for open-ended comments at the end of each section. Comments were coded and analyzed for common themes. Results: The survey was distributed to 523 midwives, all of the midwives registered in Ontario at the time of the study (2011). A total of 359 midwives participated, representing a response rate of 68% of all registered midwives in Ontario. The majority of respondents identified themselves as pro-choice; however, there were “limits to choice” expressed by many participants. Abortion was considered less acceptable at later gestations or for specific reasons such as gender selection or minor fetal anomalies. Study participants were divided over whether abortion should be added to midwifery scope of practice. Comfort with providing abortion services decreased as procedures were perceived to be more invasive or as requiring more medical expertise. The addition of misoprostol to Ontario midwives’ pharmacopoeia for early medical terminations was the most favoured expansion for midwifery scope of practice. Respondents were less willing to add surgical techniques to midwifery scope of practice. Midwives identified the current models of compensation and practice in Ontario, issues related to hospital integration, and opposition from clients as significant barriers to the provision of abortion services. Limited education about abortion during midwifery training and the desire for more learning opportunities were additional themes that emerged in this study. Conclusion: This is the first study in Canada about midwives’ attitudes towards abortion and the inclusion of abortion within midwifery scope of practice. Further research in other Canadian jurisdictions would be useful to examine systemic issues, barriers, and attitudes at a national level. For abortion to be included within the scope of practice of Ontario midwives, issues related to the current model of care, compensation, and supplemental education would need to be addressed. This article has been peer reviewed.

Commentary on the adoption of a test-based versus syndromic-based approach to outbreak declaration and management in hospital and institutional settings.

At present, Ontario, like most other jurisdictions in Canada, uses a syndromic-based surveillance definition for acute respiratory infection (ARI) outbreaks in institutions and public hospitals. Confirmed outbreaks are defined as either two or more ARIs in 48 hours with any common epidemiological link and at least one that is laboratory-confirmed; or three cases of ARIs occurring within 48 hours with any common epidemiological link, and not necessarily with lab confirmation. However, with the adoption of broader test-based approaches for sick patients/residents throughout the pandemic, new challenges have surfaced regarding the declaration and management of ARI outbreaks with a variety of scenarios in respiratory testing results. Decisions, including the determination of epidemiological linkage when there are discordant/negative test results, have become more complicated with the addition of virus-specific test results for every sick individual. The ARI outbreak case definition and management guidance was updated in 2018. The purpose of this commentary is to highlight epidemiological trends in ARI outbreaks in Ontario over the 2022-2023 season compared to the 2018-2019 and 2019-2020 pre-pandemic seasons. This is followed by a discussion around some of the benefits and challenges of implementing a test-based versus syndromic-based approach to ARI outbreaks.

Sociodemographic characteristics help predict Canadian urbanites' acceptability of restaurant food environment policies.

Public acceptability of policies aiming to improve the healthfulness of the restaurant food environment is key to their successful implementation. Yet, the acceptability of these policies remains ambiguous, especially across diverse population groups. This study aims to examine associations between sociodemographic characteristics and acceptability levels of three restaurant food environment policies of varying degrees of intrusiveness across 17 urban Canadian jurisdictions. Data was extracted from the THEPA survey, one of the largest and most jurisdictionally comprehensive surveys on intervention acceptability (N = 27,162). To account for potential jurisdictional differences in acceptability, for each policy, multilevel logistic regression models were developed. Results indicated that, on average, those in complete agreement with the implementation of the targeted policies represented 20.3%-26.9% of participants, depending on the policy. Acceptability varied according to policy intrusiveness, jurisdiction, and participants' sociodemographic characteristics. Women, individuals with household incomes of <$40,000/year, immigrants from a high-income country other than Canada, and Indigenous peoples were more likely to express complete agreement with all policies, versus men, participants with household incomes of $40,000-$79,999/year, Canadian-born individuals, and non-Indigenous individuals. A lower likelihood of expressing complete agreement with all policies was observed for those with a $80,000-$119,999/year household income, versus those with a $40,000-$79,999/year household income. For selected policies and models, other sociodemographic characteristics (i.e., age, education, and being born in a low-or middle-income country) predicted acceptability. The examined sociodemographic characteristics did not explain jurisdictional differences in acceptability. Understanding jurisdictional differences in acceptability merits further research. Policy implications involve engaging diverse sociodemographic groups in conversations about acceptable ways in which their restaurant food environment could be rendered more healthful.

Factors that influence scope-of-practice decisions of early-career family physicians: Focus group study in Canada.

To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions. Qualitative descriptive study. Canada. Fifty-nine early-career family physicians who were 2 to 5 years into independent practice. Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions. Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors. Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals' interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.

Willingness of Canadian community pharmacists to adopt a proactive life-course approach to vaccination services

BackgroundMost Canadian jurisdictions authorize pharmacists to administer vaccines, with differences in vaccine and patient age eligibility. Vaccination rates could be further optimized if pharmacists took a more proactive role in life-course vaccine screening and administration. Health professional vaccine fatigue following the COVID-19 pandemic may negatively impact service delivery. ObjectivesTo assess vaccine fatigue among Canadian pharmacists, understand their willingness to provide proactive life-course vaccination services and identify associated vaccine practice facilitators. MethodsOne-on-one interviews were conducted with pharmacists recruited through a national community pharmacist Facebook group. Purposive sampling was used to select a diverse sample considering gender, province, and years of practice. Online interviews were conducted using a semi-structured guide with questions about vaccination experiences, perceptions of assuming a more proactive vaccinator role for adults and children, and current level of fatigue related to offering vaccination services. Interviews were audio-recorded, transcribed, and coded independently by 2 researchers; content analysis was used to identify themes. ResultsIn spring 2023, interviews were conducted with 24 pharmacists from 5 Canadian provinces. Participants were receptive to a more proactive vaccinator role, feeling that vaccine fatigue had lessened, but strongly advocated for system and practice modifications to facilitate successful implementation. They emphasized the need for patient vaccination history access, the ability to administer all publicly funded vaccines, and fair compensation. Participants requested the development of electronic tools that connected to pharmacy systems that helped them navigate complex vaccine guidelines and clinical decision making, and the required documentation/billing. They also spoke of logistical concerns related to the incorporation of vaccination into their workflow and adequate staffing. Most participants were willing to vaccinate younger children if legislated age limits were lowered, provided they were trained and compensated appropriately. ConclusionPharmacists are interested in furthering their vaccination services offerings, including proactive screening and vaccination of young children.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond.

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice. We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach. We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward. The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Canadian workers at risk: Removing barriers to treatment for public safety professionals (PSP)

Canadian workers at risk: Removing barriers to treatment for public safety professionals (PSP) Gregory S Anderson, from Thompson Rivers University and Helen Dragatsi, from Government of Canada speak to us about removing barriers to treatment for Canadian workers at risk. It has long been recognized that public safety personnel (PSP) experience a high risk of psychological impacts caused by traumatic events within their occupations. Such exposures have been linked to increased incidence of posttraumatic stress injuries (PTSI), including anxiety, posttraumatic stress disorder (PTSD), depressive disorders, suicide ideation, and substance abuse. In response, most Canadian jurisdictions (provinces and territories) have adopted new workers’ compensation legislative amendments that create a presumption in favor of PSP who suffer from trauma-induced mental disorders. In these situations, the mental disorder is presumed to have been caused by the responder’s employment. These presumptive clauses facilitate access to workers’ compensation for public safety professionals (PSP) who previously had the onus of proving that their psychological impairments resulted from their work.

Neighbourhood-level socioeconomic status and prevalence of teacher-reported health disorders among Canadian kindergarten children.

The evidence on the association between neighborhood-level socioeconomic status (SES) and health disorders in young children is scarce. This study examined the prevalence of health disorders in Canadian kindergarten (5-6 years old) children in relation to neighborhood SES in 12/13 Canadian jurisdictions. Data on child development at school entry for an eligible 1,372,980 children out of the total population of 1,435,428 children from 2004 to 2020, collected using the Early Development Instrument (EDI), were linked with neighborhood sociodemographic data from the 2006 Canadian Census and the 2005 Taxfiler for 2,058 neighborhoods. We examined the relationship using linear regressions. Children's HD included special needs, functional impairments limiting a child's ability to participate in classroom activities, and diagnosed conditions. The neighborhood prevalence of health disorders across Canada ranged from 1.8 to 46.6%, with a national average of 17.3%. The combined prevalence of health disorders was 16.4%, as 225,711 children were identified as having at least one health disorder. Results of an unadjusted linear regression showed a significant association between neighborhood-level SES and prevalence of health disorders (F(1, 2051) = 433.28, p < 0.001), with an R2 of 0.17. When province was added to the model, the R2 increased to 0.40 (F(12, 2040) = 115.26, p < 0.001). The association was strongest in Newfoundland & Labrador and weakest in Ontario. Our study demonstrated that the prevalence of health disorders among kindergarten children was higher in lower SES neighborhoods and varied by jurisdiction in Canada, which has implications for practice and resource allocation.

Aquaculture’s offshore frontier: learning from the Canadian courts on ocean grabbing, ocean privatization, and property as process

Many coastal nations have endorsed the Blue Economy as both an economic and environmental opportunity, despite numerous questions as to how industrial expansion into deep ocean waters might be regulated for sustainability. Aquaculture is one industry actively promoting a move offshore, with numerous offshore leases in development. Drawing on the history of aquaculture in the nearshore, and relying on a processual approach to property, we explore questions around the regulation of privatized ocean spaces: What can court cases involving aquaculture in the nearshore tell us about the role of law in promoting sustainable offshore ocean spaces? And what in turn does this suggest about extractive capitalism, the privatization of ocean spaces, and the law? We examine 46 Canadian court cases which cover a 30-year time frame and multiple Canadian jurisdictions. We argue that there are lessons here regarding the questionable ability of law to effectively regulate existing or future aquaculture operations once privatization emerges. The lessons from these Canadian court cases, taken together with a burgeoning literature on legal geography, more-than-human methodologies, and critical environmental law, suggest the varied legal dimensions of deep-sea aquaculture frontier imaginaries and highlight the real limits to regulating the extraction of resources in this perceived open space (terra nullius). We highlight crucial barriers to sustainability through what we are calling jurisdictional opaqueness in regulatory issues. The results include poor regulation and overlapping or contested jurisdictions, which relates in turn to inadequate consultation, frequent environmental problems (toxic chemicals, anoxia, salmon escapes, marine debris), and scientific disputes.