Utilities In Canada Research Articles

Assessing the change in prevalence and characteristics of canadians utilizing chiropractic services across two time periods 2001–2010 and 2015–2018: a population-based repeated cross-sectional study

BackgroundDespite increases in musculoskeletal disorders (MSD) in Canada, evidence suggests utilization of chiropractic services has remained relatively stable over time. Understanding the extent to which chiropractors are consulted and factors associated with their utilization may suggest factors related to accessing care. We assessed the change in prevalence and characteristics of Canadians seeking chiropractic care across two time periods 2001–2010 and 2015–2018.MethodsWe used national cross-sectional data from seven cycles of the Canadian Community Health Survey between 2001 and 2018. The survey included Canadians aged 12 years and older living in private dwellings in all provinces and territories. National annual weighted prevalence and age-standardized weighted prevalence (and 95% confidence intervals) of chiropractic utilization were calculated. We calculated prevalence of chiropractic utilization stratified by demographic, socioeconomic, lifestyle and health-related variables. Crude linear trends and change in prevalence from 2001 to 2010 were assessed using linear regression models.ResultsThe national annual prevalence of Canadians consulting a chiropractor in the previous 12 months slightly increased from 11.0% (95% CI 10.8, 11.3) in 2001 to 11.4% (95%CI 11.1, 11.7) in 2010, and in those reporting receiving regular health care from a chiropractor from 7.5% (95%CI 7.2, 7.7) in 2015 to 7.9% (95%CI 7.7, 8.2) in 2018. Prevalence of utilization varied by province, highest in the Western provinces but lowest in Atlantic provinces. The age-specific prevalence of chiropractic utilization was highest in those aged 35–49 years and remained stable over time, except for slight increase in those aged 65–79 years. A higher percentage of Canadians identifying as white, Canadian-born, in the highest quintile of household income, overweight, physically active and in excellent health reported seeking chiropractic services. The most common reported chronic conditions measured in the survey among Canadians consulting chiropractors were chronic back problems, arthritis, fibromyalgia and headaches.ConclusionThe national prevalence of utilization of chiropractic services among Canadians slightly increased over time but varied by province and respondents’ socioeconomic and health characteristics. Chronic back problems were the most common reported chronic condition. This comprehensive population-based study on chiropractic utilization in Canada can be used to inform decisions concerning health human resources and access to rehabilitation care for MSD.

International comparison of hospitalizations and emergency department visits related to mental health conditions across high-income countries before and during the COVID-19 pandemic.

To explore variation in rates of acute care utilization for mental health conditions, including hospitalizations and emergency department (ED) visits, across high-income countries before and during the COVID-19 pandemic. Administrative patient-level data between 2017 and 2020 of eight high-income countries: Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US). Multi-country retrospective observational study using a federated data approach that evaluated age-sex standardized rates of hospitalizations and ED visits for mental health conditions. There was significant variation in rates of acute mental health care utilization across countries. Among the subset of four countries with both hospitalization and ED data, the US had the highest pre-COVID-19 combined average annual acute care rate of 1613 episodes/100,000 people (95% CI: 1428, 1797). Finland had the lowest rate of 776 (686, 866). When examining hospitalization rates only, France had the highest rate of inpatient hospitalizations of 988/100,000 (95% CI 858, 1118) while Spain had the lowest at 87/100,000 (95% CI 76, 99). For ED rates for mental health conditions, the US had the highest rate of 958/100,000 (95% CI 861, 1055) while France had the lowest rate with 241/100,000 (95% CI 216, 265). Notable shifts coinciding with the onset of the COVID-19 pandemic were observed including a substitution of care setting in the US from ED to inpatient care, and overall declines in acute care utilization in Canada and France. The study underscores the importance of understanding and addressing variation in acute care utilization for mental health conditions, including the differential effect of COVID-19, across different health care systems. Further research is needed to elucidate the extent to which factors such as workforce capacity, access barriers, financial incentives, COVID-19 preparedness, and community-based care may contribute to these variations. Approximately one billion people globally live with a mental health condition, with significant consequences for individuals and societies. Rates of mental health diagnoses vary across high-income countries, with substantial differences in access to effective care. The COVID-19 pandemic has exacerbated mental health challenges globally, with varying impacts across countries. This study provides a comprehensive international comparison of hospitalization and emergency department visit rates for mental health conditions across eight high-income countries. It highlights significant variations in acute care utilization patterns, particularly in countries that are more likely to care for people with mental health conditions in emergency departments rather than inpatient facilities The study identifies temporal and cross-country differences in acute care management of mental health conditions coinciding with the onset of the COVID-19 pandemic.

Assessing the role of dental insurance in oral health care disparities in Canadian adults.

This study examines the association of dental insurance with oral health care access and utilization in Canada while accounting for income and sociodemographic factors. It contributes to a baseline of oral health care disparities before the implementation of the Canadian Dental Care Plan (CDCP). This retrospective study of Canadians aged 18 to 64 years is based on data from the 2022 Canadian Community Health Survey. Multivariable logistic regression was employed to evaluate the association of dental insurance with the recency and frequency of dental visits, as well as avoidance of dental care because of cost. Overall, 65.7% of Canadians reported visiting a dental professional in the previous year: 74.6% of those with private insurance, 62.8% with public insurance, and 49.8% uninsured. Cost-related avoidance of dental care was 16.0%, 20.9%, and 47.4% for the privately insured, publicly insured, and uninsured, respectively. After adjustment, adults with private (odds ratio [OR]=2.54; 95% confidence interval [CI]: 2.32 to 2.78) and public (OR=2.17; 95% CI: 1.75 to 2.68) insurance were more likely to have visited a dental professional in the last year compared with those without insurance. Similarly, both private (OR=0.22; 95% CI: 0.20 to 0.25) and public (OR=0.22; 95% CI: 0.17 to 0.29) insurance holders showed a significantly lower likelihood of avoiding dental visits because of cost when compared with uninsured individuals. This study showed the significant association of dental insurance with access to oral health care in Canada, contributing to setting a critical benchmark for assessments of the CDCP's effectiveness in addressing oral health disparities.

Variability in pediatric and neonatal organ offering, acceptance and utilization: a survey of Canadian pediatric transplant programs and organ donation organizations.

Solid organ transplantation in children is a lifesaving therapy, however, pediatric organ donation rates remain suboptimal. We conducted a cross-sectional survey of Canadian organ donation organizations (ODOs) and pediatric transplant programs (TPs), aiming to describe policies and practices for pediatric organ allocation, acceptance, and utilization in Canada. Response rates were 82% and 83% respectively for ODOs and transplant programs comprising 7 kidney, 3 heart, 2 lung, 2 liver and 1 intestine programs. All 9 ODOs reported offering pediatric organs following death by neurological criteria (DNC), while 8 reported offering organs following death by circulatory criteria (DCC) for some organs. Variability was found across ODOs and TPs. There was little agreement on both absolute and organ-specific donor exclusion criteria between ODOs. There was further disagreement in organ specific acceptance criteria between ODOs and TPs and between TPs themselves. Notably, despite the development of pediatric donation after DCC guidelines, organs from DCC donors are excluded by many ODOs and TPs. Further variability in pediatric specific training, policies, and allocation guidelines are also documented. Significant areas for improvement in standardization in organ acceptance, offering, and allocation in pediatric donation and transplantation across Canada were identified.

The marked oscillatory pattern in prescription opioid utilization in Canada since 2000: Selected observations and questions for outcomes and policy.

The marked oscillatory pattern in prescription opioid utilization in Canada since 2000: Selected observations and questions for outcomes and policy.

Failure to consider environmental risk: The case for biodiversity impact disclosure in the electricity sector

The activities of electric utilities have a significant impact on biodiversity loss. This study examines the disclosure practices and strategies of electric utilities in Canada (N = 95). Content analysis of sustainability reports and corporate websites reveals a significant gap between the risks of biodiversity loss and the companies' commitments in this area. This study groups disclosure practices to identify three overall strategies (wait-and-see, symbolic adoption, and consequential commitment). These results contribute to the literature on biodiversity disclosure, with significant managerial and policy implications, particularly for implementing mandatory disclosure standards to ensure greater consistency in the presentation of corporate performance.

Major Shifts in Acid Suppression Drug Utilization After the 2019 Ranitidine Recalls in Canada and United States.

Drug shortages are a complex global challenge, and few studies have analyzed quantitative data on their impacts. In September 2019, detection of a nitrosamine impurity in ranitidine led to recalls and shortages. We investigated the extent of the ranitidine shortage and its impacts on acid suppression drug utilization in Canada and the United States (US). We conducted an interrupted time series analysis of acid suppression drug purchases in Canada and the US from 2016 through 2021 using IQVIA's MIDAS database. We used autoregressive integrated moving average models to determine the impact of the shortage on purchasing rates for ranitidine, other histamine-2 receptor antagonists (H2RAs), and proton pump inhibitors (PPIs). Prior to the recalls, 20,439,915 ranitidine units were purchased monthly in Canada and 189,038,496 in the US on average. After the recalls started in September 2019, purchasing rates decreased for ranitidine (Canada p = 0.0048, US p < 0.0001) and increased for non-ranitidine H2RAs (Canada p = 0.0192, US p = 0.0534). One month into the recalls, purchasing rates dropped by 99% (Canada) and 53% (US) for ranitidine and increased by 128.3% (Canada) and 37.3% (US) for non-ranitidine H2RAs. PPI purchasing rates did not change significantly in either country. The ranitidine shortage led to immediate and sustained shifts inH2RA utilization in both countries, potentially affecting hundreds of thousands of patients. Our results emphasize the need for future studies of the clinical and financial implications of the shortage, and the importance of ongoing work to mitigate and prevent drug shortages.

Electric Vehicle User Behavior: An Analysis of Charging Station Utilization in Canada

For a user-centered deployment of electric vehicle supply equipment (EVSE) infrastructure, it is vital to understand electric vehicle user charging behavior. This study identifies user behavioral patterns by analyzing data from more than 7000 charging stations in Canada, comparing residential vs. public Level 2, and public direct current fast (DCFC) vs. public Level 2 charging. A novel algorithm, CHAODA, was applied to identify differences between DCFC and other Level 2 charging options. Through a multivariate and holistic methodology, various patterns emerge, identifying differences in the utilization and seasonality of different EVSE types. The study provides evidence of an “EV Duck Curve” that amplifies the baseline of the power production “Duck Curve,” confirming future challenges for grid stability. Implementations of this study can support future EVSE infrastructure planning efforts and help improve the overall service of electric vehicle supply equipment and grid stability.

Leisure jobs: Recreating family and social life in Canadian electric utility marketing, 1920–1970

<h2>Abstract</h2> This paper contributes to debates of how technological and cultural change occurs in sociotechnical transitions. I this research I apply concepts from contemporary management theory to a historical case study to make two contributions. The first is to understand historical energy transitions in a new way. The second is to show how marketing and business model innovation theory can be used to examine utility marketing practices and understand how utilities help shape changes in family and social practices. The empirical case study is framed in the context of the seemingly contradictory views about technology and housework in the twentieth century. One view is that the transformation of homes with electric power created more work for mothers as they used their appliances to achieve new standards of cleanliness and devote more time to child care. The other is that it was beyond dispute that clothes dryers saved time and that over the twentieth century, women performed fewer hours of housework and family care. To investigate the issue and more generally technological and cultural change, I examined how electric power utilities in Canada conceptualized the use of domestic customer time during scale up of the grid. The research question asks what values and jobs to be done were marketed by electric utilities during the period, beyond giving homemakers more time to run the house and more money to shop? Utilities initially sought to grow by selling power as capital and labour rationality, mirroring industrial ideals of producing more with fewer resources. As those labour savings were realized, they increasingly sold power as a means to perform the new organizational and emotional jobs of creating a more intimate, happier and child-centred family life and a more entertaining social life. In doing so, they contributed to a redefinition of family and social life, from family-as-labour to family-as-leisure. Future research builds on this historical study in applying jobs to be done, business model innovation and social tableaux frameworks to understand contemporary marketing as it seeks to realize decarbonized power grids, expansion of electricity into mobility and heating markets and changed social practices to reduce greenhouse gas emissions.

Real-World Treatment Patterns and Clinical Outcomes in Canadian Patients with AML Unfit for First-Line Intensive Chemotherapy.

Acute myeloid leukemia (AML) is a hematological malignancy that predominantly affects the elderly. Prognosis declines with age. For those who cannot tolerate intensive chemotherapy, historically established treatment options have been hypomethylating agents (HMAs), low dose cytarabine (LDAC), and best supportive care (BSC). As the standard of care evolves for those unfit for intensive chemotherapy, there is a need to understand established treatment pathways, clinical outcomes and healthcare resource utilization in Canada. The CURRENT study was a retrospective chart review of AML patients not eligible for intensive chemotherapy who initiated first-line treatment between 1 January 2015 and 31 December 2018. Data were collected from 170 Canadian patients treated at six hematology centers, of whom 118 received systemic therapy and 52 received BSC as first-line treatment. Median overall survival was 8.58 months and varied from 2.96 months for BSC to 13.31 months for HMAs. Over 80% of patients had at least one outpatient visit, and 67% of patients receiving systemic therapy and 71% of those receiving BSC had at least one admission to hospital, during their first line of therapy. A total of 96 (81.4%) patients receiving first line systemic therapy and 39 (75.0%) of those receiving first line BSC had at least one red blood cell or platelet transfusion. These findings highlight the unmet need for novel therapies for patients ineligible for intensive chemotherapy.

A survey of minimally invasive surfactant therapy in Canada.

IntroductionMinimally invasive surfactant therapy (MIST) can be used to treat neonatal respiratory distress syndrome in neonatal intensive care units (NICUs). Clinical and institutional variances in MIST utilization persist globally with little published research regarding MIST utilization in Canada. Therefore, the objective of this study was to survey MIST utilization in NICUs in Canada.MethodsAn online survey was emailed to the 33 participating centres of Canadian Neonatal NetworkTM (CNN) Evidence-based Practice for Improving Quality (EPIQ) Lung Health Group (LHG). Site demographics and surfactant therapy procedural details were categorically collected. Free text and multiple-choice questions were utilized to capture perceived barriers and individual preferences for MIST use.ResultsTwenty-eight of 33 participating members of the CNN EPIQ-LHG completed the survey between April 2021 and October 2021 (85%); 17/28 (61%) respondents reported ongoing MIST utilization at their center. Most centers that used MIST techniques administered bovine lipid extract surfactant (68%), commonly using angiocatheters (47%) and purpose-built catheters (41%). MIST was widely used for patients at 26–33 weeks gestational age (88%). Nine centres had never used MIST (32%), and 3 indicated a plan to implement MIST within the next 2 years. Common barriers to MIST use included lack of consensus amongst clinicians (78%), lack of training (56%), and lack of experience with MIST (56%).ConclusionWhile MIST is being increasingly used in Canadian NICUs, universal use is yet to be seen. Clinician inexperience and lack of consensus, formal training, and local guidelines contribute to underutilization of MIST. Training workshops, country-wide data collection, and uniform operating protocols are needed to standardize practice.

Implementation of Teledermatology in Alberta, Canada: A Report of One Thousand Cases

BackgroundTeledermatology utilizes photoimaging and background information to allow dermatologists to remotely provide a diagnosis to practitioners. ConsultDerm is an asynchronous, web-based teledermatology software that allows practitioners to submit their electronic referrals for assessment by board-certified dermatologists.ObjectiveOur study aimed to retrospectively analyze teledermatology’s utilization in Canada by using the teledermatology platform ConsultDerm.MethodsAfter implementing inclusion criteria, 1000 patients were selected, and relevant demographic and clinical information were extracted for data analysis. In addition, an online survey with pre-formulated questions was distributed to 7 dermatologists currently using the ConsultDerm platform to determine their experience in utilizing teledermatology.ResultsOf the 1000 patients, 66.5% had not received treatment prior to their teledermatology referral, and on average, patients experienced symptoms for 489.5 days prior to their referral. Diagnoses made were categorized by conditions, most common being dermatitis (37.1%), followed by acneiform conditions (10.6%), benign lesions/neoplasms (12.1%), infections (9.4%), and dyspigmentation (3.1%). Most consults originated from small population centers, and the referring practitioners were predominantly family physicians. Dermatologists utilizing the platform expressed ease of use, however, areas of improvement were identified such as increasing the quality of imaging and more detailed patient history.ConclusionThrough our analysis of 1000 cases, we identified how a teledermatology consultation could be used to assess a wide variety of cutaneous conditions, improving access for patients who may face barriers to seeing a dermatologist.

Equity in healthcare utilization in Canada's publicly funded health system: 2000-2014.

Equity in healthcare utilization is a globally accepted measurement of health system performance. In Canada, equity is included as a policy goal in the Federal health legislation that governs healthcare systems. This study used ten cycles of the Statistics Canada Canadian Community Health Survey (CCHS, n = 664,548) to examine the trends in income-related inequities in healthcare utilization in Canada from 2000 to 2014. The horizontal inequity (HI) index was used to quantify inequity in healthcare utilization for general practitioner (GP) visits, specialist physician (SP) visits and hospital admissions (HA) nationally, in urban and rural areas, and for all provinces. Nationally, GP and SP visits show pro-rich inequity, while HA demonstrates pro-poor inequity. This pattern is consistent in the provincial and urban and rural areas results. Trend analysis suggested that inequity in GP visits became more pro-poor in New Brunswick, but more pro-rich in Prince Edward Island and Quebec. Despite the inclusion of equity as a main policy goal, this study demonstrated that inequity in healthcare utilization remains a persistent issue in the Canadian healthcare system.

Performance Modeling and Simulation for Water Distribution Networks

This study develops an implementation framework for asset management strategic planning of water distribution networks to meet sustainable infrastructure, socio-political, and financial targets over the life cycle of the infrastructure. The proposed framework is comprised of three decision-making layers: (1) Visions and Values, (2) Function, and (3) Performance. The asset management strategy framework is implemented and validated by demonstrating functionality and value by using data from three water utilities in Canada. The Visions and Values layer is set to meet the needs of the water utilities' stakeholders. The Function layer uses an advanced system dynamics model to simulate and forecast the system's future behavior. The Performance layer benchmarks, compares, and graphically illustrates the situation and performance of water utilities against each other regardless of their size. Benchmarking results indicate that all three water utilities can sustainably meet the strategic targets established in the Visions and Values layer of the asset management strategy over the benchmarking period. The impact of the desired cash reserve on infrastructure and financial benchmarking performance indicators is also investigated to explore the “optimal” combination of allowable fee-hike and rehabilitation rates using the contour plots developed over the benchmarking period. The results indicate that the optimal combinations of allowable fee-hike of ~8% per year and rehabilitation rate of 1.3% per year along with a 1–4% cash reserve, depends on the network condition, will allow water utilities to have sufficient funds to meet their strategic targets. The performance modeling and simulation approach presented in this study represents a powerful tool for other utilities to develop optimal strategic and operational plans for their networks and thus better service to their stakeholders.

Patterns, trends and determinants of medical opioid utilization in Canada 2005\u20132020: characterizing an era of intensive rise and fall

BackgroundInto the 21st century, the conflation of high rates of chronic pain, systemic gaps in treatment availability and access, and the arrival of potent new opioid medications (e.g., slow-release oxycodone) facilitated strong increases in medical opioid dispensing in Canada. These persisted until post-2010 alongside rising opioid-related adverse (e.g., morbidity/mortality) outcomes. We examine patterns, trends and determinants of opioid dispensing in Canada, and specifically its 10 provinces, for the years 2005–2020.MethodsRaw data on prescription opioid dispensing were obtained from a large national community-based pharmacy database (IQVIA/Compuscript), converted into Defined-Daily-Doses/1,000 population/day for ‘strong’ and ‘weak’ opioid categories per standard methods. Dispensing by opioid category and formulations by province/year was assessed descriptively; regression analysis was applied to examine possible segmentation of over-time strong opioid dispensing.ResultsAll provinces reported starkly increasing strong opioid dispensing peaking 2011–2016, and subsequent marked declines. About half reported lower strong opioid dispensing in 2020 compared to 2005, with continuous inter-provincial differences of > 100 %; weak opioids also declined post-2011/12. Segmented regression suggests breakpoints for strong opioids in 2011/12 and 2015/16, coinciding with main interventions (e.g., selective opioid delisting, new prescribing guidelines) towards more restrictive opioid utilization control.ConclusionsWe characterized an era of marked rise and fall, while featuring stark inter-provincial heterogeneity in opioid dispensing in Canada. While little evidence for improvements in pain care outcomes exists, the starkly inverting opioid utilization have been associated with extensive population-level harms (e.g., misuse, morbidity, mortality) over-time. This national case study raises fundamental questions for opioid-related health policy and practice.

Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019.

On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. We explored the impact of this campaign on antibiotic utilization in Canada. We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.

Current Use, Capacity, and Perceived Barriers to the Use of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Canada

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is a therapeutic option for refractory cardiac arrest. We sought to perform an environmental scan to describe ECPR utilization in Canada and perceived barriers for application to out-of-hospital cardiac arrest (OHCA). MethodsThis was a national cross-sectional study. We identified all cardiovascular surgery- and extracorporeal membrane oxygenation (ECMO)-capable hospitals in Canada and emergency medical services (EMS) agencies delivering patients to those centres. We requested the medical lead from each hospital’s ECMO service and each EMS agency to submit data regarding ECMO and ECPR utilization, as well as perceived barriers to ECPR provision for OHCA. ResultsWe identified and received survey data from 39 of 39 Canadian hospital institutions and 21 of 22 EMS agencies. Of hospitals, 38 (97%) perform ECMO and 27 (69%) perform ECPR (74% of which perform ≤5 cases per year). Of the 18 (46%) sites offering ECPR for OHCA, 8 apply a formal protocol for eligibility and initiation procedures. EMS agencies demonstrate heterogeneity with intra-arrest transport practices. The primary rationale for nontransport of refractory OHCA is that hospital-based care offers no additional therapies. Perceived barriers to the use of ECPR for OHCA were primarily related to limited evidence supporting its use, rather than resources required. ConclusionMany Canadian cardiovascular surgery- or ECMO-equipped hospitals use ECPR; roughly half employ ECPR for OHCAs. Low case volumes and few formal protocols indicate that this is not a standardized therapy option in most centres. Increased application may be dependent on a stronger evidence base including data from randomized clinical trials currently underway.

Potential regulatory implications of Health Canada's new lead guideline

AbstractHealth Canada's guideline for lead in drinking water was updated in March 2019. Two new sampling protocols were introduced—random daytime and 30‐min stagnation sampling—and the maximum acceptable concentration (MAC) of lead in drinking water was decreased from 10 to 5 μg/L. This study examined the possible impacts that changes in the guideline might have on water utilities in Canada. A lead‐monitoring survey of seven drinking water distribution systems was conducted using the random daytime and 30‐min stagnation protocols. Random daytime sampling captured an estimated 45% more lead than 30‐min stagnation sampling. However, both protocols yielded samples above the new MAC: 7.5% and 5.4% of random daytime and 30‐min stagnation samples, respectively, exceeded it. These data indicate that some drinking water providers—especially those supplying systems with legacy lead plumbing—may have difficulty achieving 100% compliance with the new guideline.

Understanding early childhood education and care utilization in Canada: implications for demand and oversight

This study examined early childhood education and care (ECEC) utilization in Canada, focusing on use of unlicensed home child care (HCC) from an equity perspective. Data from the 2011 cycle of the General Social Survey (GSS) were used. Across Canada, parent responses reveal that 16.6% of children between the age of 12 months and entry to school were in unlicensed HCC. Another 24% of working parents reported having no regular form of non-parental childcare. Families with higher incomes were more likely to report using center-based care. Conversely, lower-income working parents with lower levels of education were more likely to use unlicensed HCC or report using no non-parental care at all. Comparison of parent responses in Ontario, however, where government estimates for the number of licensed and unlicensed HCC spaces are available, revealed that more parents report that their children are in licensed HCC than is possible. The lack of accurate parental reporting calls into question a key assumption of current regulatory systems, which is that parents are informed consumers of ECEC services. Given that many parents misreport the type of HCC their children use, and the equity concerns raised by the overall utilization patterns we found, we argue that governments need to take a more active role in oversight and support of HCC.

Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada.

The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.