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NEWSFor the recordOntario to adopt patient-based funding of hospitals March 11, 2010 Health care will gobble up 70% of every Ontario tax dollar within 12 years, from a current level of 46%, the province’s Liberal government asserted in its Mar. 8 Speech from the Throne. To rein in those skyrocketing costs, Premier Dalton McGuinty’s government is proposing to make hospitals compete for health care funding and focus their services on surgeries and treatments that they can do cheaper than their rivals. The speech argued that a “money-will-follow-the-patient” model of funding hospitals would yield efficiencies. But critics contend that system will compromise the availability of medical services in rural and remote areas, while shifting the focus of health care facilities towards increasing patient volume at the expense of quality of care (CMAJ 2008. DOI:10.1503/cmaj.080594. The Throne Speech also proposed to appoint an expert panel to “provide recommendations on clinical practice guidelines. It will ensure that future investments get results and improve patient health.” The government also said it will overhaul the Public Hospitals Act “to create a hospital system that taps into the expertise of community partners and all health care professionals.” The latter is much needed, says Tom Closson, president of the Ontario Hospital Association. “It is a very old piece of legislation. It hasn’t be updated to reflect the changes in the way health care is interprofessional today.” Currently, hospital care doesn’t link enough to primary care and home care, Closson says. “It needs to be well-connected to the rest of the health care system in order to be an efficient, high quality system.” Closson also indicated that his association will swing firmly behind the move toward patient-based funding of hospitals: “We’ve supported it for a while.” The association also supports the creation of an expert panel to improve patient care. Evidence isn’t being used consistently enough around the system and there is a greater need for the use of best practices, Closson says. “It’s an excellent package to provide more affordable and higher quality health care for patients. The recommendations will achieve efficiency in system.” While the long-term reforms are introduced, Ontario’s hospitals will continue to grapple with short-term financial challenges. They’re now mulling cuts to programs, services and staff in fiscal 2010/11 as a result of Health Minister Deb Matthews December 2009 demand that facilities provide budget plans based on a zero, 1% and 2% increase in hospital funding (CMAJ 2010. DOI:10.1503/cmaj.109-3154). — Kat Guerin, Ottawa, Ont. Facilities and employment status affect mental health readmissions March 9, 2010 Most hospital readmissions for mental health occur within 30 days after discharge, according to a report from the Canadian Institute for Health Information. Readmissions are more common in general, rather than psychiatric, hospitals and are more typical for the unemployed, said the report, Depression in Ontario: What Predicts a First Mental Health Rehospitalization? The type of hospital — general or psychiatric — in which an individual is hospitalized for the first time could affect whether there’s a readmission, CIHI said in the report (http://secure.cihi.ca/cihiweb/products/depression_in_ontario_aib_2010_e.pdf). The study found that individuals admitted to a general hospital were more likely to be readmitted within 30 days. Unemployed patients were 1.4 times more likely to be readmitted within 30 days, while employment status had no significant impact on a patient’s readmission past the 30-day mark. In the report, out of the 3500 individuals admitted for depression between Apr. 1, 2006, and Mar. 31, 2008, 19% were readmitted within one year. Risk factors including socio-demographic status, treatment, clinical and discharge environment all play a role in the tendency of psychiatric readmission. Individuals with a higher severity level of depression at the time of their discharge were 64% more prone to readmission within the 30-day period. A diagnosis of depression tagged with another disorder, such as anxiety, was more likely to result in a later readmission. “The presence of a comorbid anxiety disorder makes the treatment of depression more difficult than a diagnosis of depression alone,” the report stated. “A lack of support with managing illness” in an individual’s discharge environment was proven to be a significant factor in readmissions 31 to 365 days after the initial hospitalization, the report added. Continued social support in the form of help managing daily activities, stressers, and illness “may reflect diminishing follow-up care,” and avoid readmission in the long run, the authors said. — Kat Guerin, Ottawa, Ont. Decade of action for road safety March 4, 2010 In a bid to reduce the spiraling problem of road traffic death and injury, the UN General Assembly has declared 2011 to 2020 the “Decade of Action for Road Safety” and asked the World Health Organization (WHO) to develop interventions. WHO estimates that 1.3 million people die and 50 million are injured annually in road traffic collisions. The majority of those occur in low- and middle-income countries and the toll will rise to 2.4 million a year, making road traffic collisions the fifth leading cause of death in the world, unless action is taken, WHO says in a draft action plan proposed in response to the November 2009 global ministerial conference on road safety (www.who.int/roadsafety/Decade_of_action.pdf). “Road traffic injuries can be prevented,” the draft states. “Experience suggests that an adequately funded lead agency and a national plan or strategy with measureable targets are crucial components of a sustainable response to road safety. Effective interventions include incorporating road safety features into land-use and transport planning; designing safer roads and requiring independent road safety audits for new construction projects; improving the safety features of vehicles; effective speed management; setting and enforcing laws requiring use of seat-belts, helmets and child restraints; setting and enforcing blood alcohol concentration limits for drivers; and improving post-crash care for victims of road crashes.” But “political will and funding levels are far from commensurate with the scale of the problem,” the draft plan adds. — Wayne Kondro, CMAJ Transport agency to examine airline pet travel policies March 2, 2010 The Canadian Transportation Agency says people with allergies to household pets can be considered persons with disabilities and may therefore be entitled to air travel without having to share cabin space with dogs, cats and other pets, except for service animals such as seeing-eye dogs. Such pet allergies constitute a disability under the World Health Organization’s International Classification of Functioning, Disability and Health, the agency said in a decision favoring applications by Katherine Covell and Sarah Daviau against Air Canada, and by Dr. J. David Spence against Air Canada, Air Canada Jazz and WestJet (www.otc-cta.gc.ca/decision-ruling/drv.php?type=d&no-num=66-AT-A-2010&lang=eng). The three applicants suffered “activity limitations” as a result of their exposure to cat allergens, the decision stated. “The Agency is of the opinion that, provided the evidence establishes that the applicant experiences an allergic reaction that is significant enough to result in an inherent difficulty in executing a task or action (such as impaired breathing), this is sufficient to demonstrate the existence of an activity limitation. With respect to participation restrictions, the evidence must establish that, as a result of the applicant's activity limitation (i.e., allergic reactions) when exposed to cats, he/she cannot travel in the same manner as passengers without cat allergies.” Once an obstacle to the mobility of someone with a disability has been established, “the onus then shifts to the respondent transportation service provider to prove, on a balance of probabilities, that the obstacle is not undue by demonstrating that reasonable accommodation has been provided, meaning up to the point of undue hardship,” the decision added. To that end, the agency said it will examine airlines’ pet policies to see if they constitute an obstacle to mobility and issue a ruling (CMAJ 2009: DOI:10.1503/cmaj.109-3045). The transportation agency’s decision added that “as part of this examination, the Agency will determine appropriate accommodation for the applicants, which will be based on effectiveness of potential solutions. Should the Agency find that an obstacle exists, it will assess whether the obstacle is undue.” — Wayne Kondro, CMAJ American physicians working fewer hours February 25, 2010 The average number of hours worked per week by physicians in the United States declined to 51 hours from 54.9 hours between 1996 and 2008, while mean physician fees, adjusted for inflation, decreased by 25% between 1995 and 2006, according to a new study. The decline is equivalent to the loss of 36 000 doctors, concluded a research team headed by Douglas O. Staiger, an economist at Dartmouth College in Hanover, New Hampshire (JAMA 2010;303[8]:747-53). “Our results have implications for how reform efforts and market forces may affect the future physician workforce,” the authors write. “Our findings are consistent with the possibility that economic factors such as lower fees and increased market pressure on physicians may have contributed, at least in part, to the recent decrease in physician hours. Further reductions in fees and increased market pressure on physicians may, therefore, contribute to continued decreases in physician work hours in the future.” “Whatever the underlying cause, the decrease in mean hours worked among US physicians during the last decade raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630 000 in 2007, is equivalent to a loss of approximately 36 000 physicians from the workforce, had hours worked per physician not changed.” “Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce. This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult, although increases in the number of practicing physicians either through increases in the size of domestic medical school classes or further immigration of international medical graduates would mitigate those concerns. Moreover, if this trend toward lower physician hours continues, it could frustrate stated goals of health reform, http://jama.ama-assn.org/cgi/content/full/303/8/747?home" \l "REF-JOC05009-4#REF-JOC05009-4 which may require an expanded physician workforce to take on new roles and enhanced functions in a reformed delivery system.” The study, which used data culled from the US Census Bureau, indicated that while the average work week declined for all physicians, that of residents declined the most — 9.8% as compared with 5.7%. Resident hours began decreasing following the introduction of work-hour limits in 2003. — Wayne Kondro, CMAJ HIV vaccine manufacturing facility kiboshed February 23, 2010 The Canadian government and Bill & Melinda Gates Foundation have announced that they are reneging on their commitment to construct a pilot scale manufacturing facility to develop small amounts of HIV vaccine for clinical trials. None of the four not-for-profit corporations who were selected as finalists in a competition to build and operate the facility “were found to be successful in meeting the pre-established criteria,” the government said in announcing the decision on the website of the Canadian HIV Vaccine Initiative (www.chvi-icvv.gc.ca/index-eng.html). “A thorough, evidence-based review of all applications was completed,” the statement said. “This included an internal review and external review by an international expert panel.” “As part of the due diligence process, a study commissioned by the Gates Foundation to analyse current vaccine manufacturing capacity concluded that there is currently sufficient vaccine manufacturing capacity in North America and Europe to meet research needs,” it added. “After weighing all of the evidence, the Government of Canada and the Gates Foundation have decided not to proceed with the pilot-scale vaccine manufacturing facility. Other CHVI programs are unaffected by this decision and will continue to move forward. As with any initiative, we need to ensure that proposals meet application criteria and represent value for money for our respective organizations, as well as Canadian taxpayers. Capacity for scientific research is evolving globally and the Government of Canada must invest its resources where they will be most effective in the fight against HIV/AIDS.” Ottawa had committed $88 million toward construction of the pilot manufacturing facility, which was to have been the centerpiece of Canada’s $111 million contribution to the Global HIV Vaccine Enterprise, a five-year joint initiative with the Gates Foundation, which had anted-up $28 million toward accelerated development of a globally accessible HIV vaccine. Need for better data collection February 18, 2010 Canada’s lack of national data collection and storage is detrimental to improving health care quality, the Canadian Health Services Research Foundation) says in a new report. With so many variations in health care systems and services between provinces, the overall quality of Canadian health care can’t be properly assessed, monitored or improved, according to the report, Quality of Health Care in Canada: A Chartbook, (www.chsrf.ca/documents/QualityInHealthcareChartbook_EN.pdf). While some outcome measures, such as mortality rates, are available on a national basis, others are not, including critical data on adherence to evidence-based care standards. Without such data, effective quality improvement strategies can’t be developed, the report states. While some progress has been made in terms of monitoring wait times, the report also states that Canada needs more clinically driven national medical quality studies, particularly focusing on disease or specialty areas. “The lack of standardized information about health care delivery and adherence to evidence-based processes of care across the country hampers the ability to draw more conclusions about the effectiveness of health care in Canada.” The report also indicated that it is difficult to find detailed data on adverse incidents to properly gauge patient safety. The first of its kind in Canada, the report seeks to emulate similar reports in the United States, United Kingdom and Australia by analyzing six key domains of health care quality: effectiveness, access, capacity, safety, patient-centredness and equity. — Brittany Hinds, Ottawa, Ont. Doc Talk: connecting health and environmental issues online February 16, 2010 Collaboration between medical and environmental organizations has generated a new online forum called Doc Talk to explain what environmental issues mean for human health (http://beta.davidsuzuki.org/blogs/docs-talk/). The web-based education program developed by the David Suzuki Foundation and the Canadian Association of Physicians for the Environment presents physician-written articles about such environmental issues as climate change and air pollution. The initial post was penned by Dr. Warren Bell, a self-described “small-town family physician” from south central British Columbia, who wrote that Doc Talk seeks to explain the connection between human and environmental health and how both can be protected. “I once heard some years ago that we humans share 70 per cent of our genome with earthworms,” he wrote. “The notion that we share more than two-thirds of our genetic material with a small, soft creature that crawls just below the surface of the soil may be startling to some. Startling or not, it confirms that we are intimately connected to other life forms on this planet.” Bell added that he sees people in real-life circumstances, knowing that their bodies are interpenetrated with bacteria, viruses, fungi, parasites and chemicals from the environment around them. “So when I treat the patient in front of me, I am well aware that I am inevitably, and always, treating Planet Earth,” Bell concluded. — Brittany Hinds, Ottawa, Ont. Health funding in Alberta sees dramatic increase February 11, 2010 Alberta physicians will receive a healthy 8.2% increase in financial compensation under provincial Finance Minister Ted Morton’s blueprint for fiscal year 2010/11 (http://budget2010.alberta.ca/). The $253 million hike in payments to doctors and monies for medical education, to $3.3 billion, is part of an overall 6% increase in health spending, as the governing Conservative Party essentially chose to exempt health care from any measure of constraint. The overall health budget rises to $9 billion, an increase of $512million. Moreover, health spending will rise 6% in each of the next three years, and 4.5% in the two following years, so that by fiscal 2014/15, Alberta Health Services will receive $11.1 billion. The provincial deficit, meanwhile, will soar to $4.7 billion this year, of which Alberta Health Services contributed $1.3 billion in fiscal 2009/10. But the government said it would eliminate the department’s operating deficit within two years by making one-time payments of $549 million for fiscal 2009-10 and $759 million for fiscal 2010/11. Although opposition politicians and critics suggested that the government’s generosity toward health was motivated by fears that the Conservative government is losing political ground to the upstart, right-wing Wildrose Alliance Party, the government insisted it is merely listening to Albertans. “Albertans have clearly indicated that our publicly funded health-care system is a priority, and our government has responded,” Health and Wellness Minister Gene Zwozdesky said in a press release. “By providing predictable funding over the next five years, we will improve long-range planning to better meet the health needs of Albertans and accomplish our vision. We will also emphasize the ‘care’ in health care and increase the wellness agenda.” In other health measures, the government set aside $930 million for cancer therapy drugs, prescription drugs, ambulance services and specialized high cost drugs. Some $799 million was set aside for specialty services provided by oral surgeons, optometrists, podiatrists and other health professionals, as well as vaccination programs, tissue and blood services and continuing care initiatives. Of that $799 million, about $25 million was ticketed for health services in correctional facilities, which are being transferred from Solicitor General and Public Security to the health department. — Brittany Hinds, Ottawa, Ont. Health and science winners in Obama budget February 4, 2010 United States President Barack Obama’s financial blueprint for fiscal year 2010/11 has proposed a US$1 billion increase, to US$32 billion, in funding for the National Institutes of Health Research (NIH). Obama’s blueprint proposes to spend US$900.8 billion on health and human services, with the bulk of that money (US$818 billion) for Medicare and Medicaid, which cover health services for the poor and the elderly. The “discretionary” portion of the Department of Health and Human Services budget will rise to a projected $US82.8 billion in 2011, including the increase for the NIH, which received its largest budget hike in eight years. The budget states that NIH investments “will focus on priority areas including genomics, translational research, science to support health care reform, global health, and reinvigorating the biomedical research community. The Budget includes $6,036 million to support a range of bold and innovative cancer efforts, including the initiation of 30 new drug trials in 2011, and a doubling of the number of novel compounds in Phase 1-3 clinical trials by 2016” (www.whitehouse.gov/omb/budget/fy2011/assets/budget.pdf). It also proposes that US$222 million be spent on research and treatment of autism and that over US$3-billion be allocated to HIV/AIDS prevention and treatment. The Agency for Healthcare Research and Quality budget rose to US$611 million from US$400 million. Some $US286 million of that is ticketed for comparative effectiveness research (CMAJ 2009. DOI:10.1503/cmaj.109-3140). Obama’s budget also proposes to increase support for global health programs to US$8.5 billion in fiscal year 2010/2011 from US$7.8 billion. But critics, including the Center for Global Health Policy, said that the specific increases for many of the programs are inadequate given demand for treatment. The organization noted, for example, that Obama’s budget proposes a US$50 million cut in support for the Global Fund to Fight AIDS, Tuberculosis and Malaria. Obama’s proposals must still meet the stern test of Congress approval. — Wayne Kondro, CMAJ Inmates urge needle-exchange programs February 2, 2010 “At Nova [Institution for Women in Truro, Nova Scotia], there were mostly pills, like Valium, Oxycontins and Dilaudids. People snorted and injected the pills. About 70 percent of the prison population was using drugs, and 10 percent were injecting. I used Oxycontins and Dilaudids. I started snorting, but I progressed to injecting about a year into my sentence. It was the first time I ever injected drugs. The girls there told me the high was more intense and the drugs would work faster if I injected, and they were right. That was the start of my life on needles. I would inject drugs about twice a day. We got needles from the nurse’s station, from the dirty needle container. We would take them from there. Or someone would bring in the occasional needle. About five or six girls would share one needle. We did not clean the needle with bleach first, but we did use hot water to rinse it out. We only got one new needle every five or six months. I’ve seen a needle so used that when I injected with it, it would rip my skin off. I knew I could get HIV and hepatitis C from sharing a needle, but I didn’t think about that because I wanted to get high. After a while, I got addicted to the needle itself. We did not have access to methadone while I was at Nova. We did have access to bleach, but it was too time consuming to bleach the needles first, and the guards would always start asking questions if the bleach was gone. They would search our cell if they were suspicious. If they found a needle, we would get charged. It happened to a girl I knew. Someone told the guards this girl had a needle, so without telling her, they searched her room, found it, and charged her with possession of contraband. She was sent to Springhill Institution [in Springhill, Nova Scotia], maximum security, for a month …. Sometime in 1999, three other girls and I broke into the nurse’s station to get a box of clean needles. We got caught, and we got charged with a break-and-enter. Another six months were added to my sentence. I was diagnosed with HIV and hepatitis C in 1999, when I was in Nova. I am 100 percent sure I got infected from sharing used needles, because I didn’t have sex inside and I didn’t get tattoos. I didn’t do anything else that would put me at risk. I lost my mind when I found out. CSC put me in segregation after that, because I flipped out. They told me to take a while to think about it.” — “Kate”, 49, Halifax, Nova Scotia Such accounts are altogether the norm in Canadian prisons, according to the Canadian HIV/AIDS Legal Network. The tale is also one of dozens of first-person accounts documenting drug use or the sharing of needles inside Canadian prisons presented in the network’s latest report, Under the Skin (www.aidslaw.ca/publications). The network argues that the accounts demonstrate the need for needle-exchange programs within Canada’s prisons. But while a risk-benefit review of prison needle exchange programs conducted for the Public Health Agency of Canada indicated that such programming for injection drug users in prisons reduces the need for health care interventions, the Conservative government said sterile syringes aren’t needed to control the spread of AIDS and hepatitis C in cellblocks (CMAJ 2007.DOI:10.1503/cmaj.070018). — Wayne Kondro,CMAJ Scotland worst performer among Britain's four National Health Services January 28, 2010 Scotland has more doctors and nurses than other countries in the United Kingdom yet has the worst health outcomes, according to a report from the Nuffield Trust, a London, England-based charity that conducts research on health services (http://www.nuffieldtrust.org.uk/members/download.aspx?f=/ecomm/files/Four_Countries_Report.pdf). The report sought to examine the health impacts of political devolution of powers in 1999 to the Scottish Parliament and the assemblies of Wales and Northern Ireland, which, de facto, resulted in the emergence of four “different” National Health Services (NHS). The authors surmise that the differences in health outcomes within each of the four countries are attributable to the fact that each has pursued distinctly different policies, the most significant of which is England’s decision to offer “provider competition” in such forms as NHS trusts, NHS foundation trusts, independent sector treatment and private providers. In Scotland and Wales, by contrast, “instead of an emphasis on patients choosing between competing pluralist providers, these governments favour a publicly owned NHS run by authorities that are integrated with providers.” Among other factors which may play a role are historical differences in funding levels or individual policy measures, such as Scotland’s provision of free personal care for the elderly, or Wales decision to abolish charges for prescriptions. The report states that Scotland “appears to perform less well than anywhere else on almost every measure examined.” Those include highest levels of poor health, low rates of “activity” (outpatient appointments, inpatient admissions and day cases) and lowest rates of productivity for doctors and nurses in hospitals. By contrast, England, which spends less on health care and has fewer doctors, made good use of its resources and provided more and better health services, the report states. In the United Kingdom as a whole, health care providers enjoyed large funding increases since 1999, the report states, but this “feast” period is likely over and may soon be followed by a period of “famine.” “The Government in England used the years of ‘feast’ to reduce long waiting times, and governments in other countries may find it hard to catch up with performance in England during the years of ‘famine’,” the report states. It cautions, though, that the findings have limitations. The report “does not claim to offer a complete rounded assessment of NHS performance across the four countries, instead the aim was to report comparative longitudinal analysis of key statistics on funding, staffing, outputs, crude productivity, hospital waiting times and ambulance response times to emergency calls.” The report adds that the differences in those statistics, though, “raise troubling questions about performance, governance and accountability.” — Roger Collier, CMAJ A false pandemic? January 26, 2010 The Parliamentary Assembly of the Council Europe (PACE) will this week conduct a series of sessions on whether the pharmaceutical industry unduly influenced the World Health Organization’s decision to declare swine flu a pandemic and recommend mass vaccination campaigns. Among proposed emergency debates at the assembly’s plenary session in Strasbourgh, France, is one dealing with a resolution sponsored by Dr. Wolfgang Wodarg, chairman of the PACE Health Committee, which states that “in order to promote their patented drugs and vaccines against flu, pharmaceutical companies influenced scientists and official agencies responsible for public health standards to alarm governments worldwide and make them squander tight health resources for inefficient vaccine strategies, and needlessly expose millions of healthy people to the risk of an unknown amount of side-effects of insufficiently tested vaccines.” Another session will include a Jan. 26 public hearing into whether the WHO’s handling of pandemic (H1N1) 2009 flu was adequately transparent. Issues of transparency and conflict-of-interest erupted over the past two months after the newspaper, Danish Daily Information, disclosed documents obtained under freedom-of-information law which indicated that vaccine manufacturer GlaxoSmithKline had provided €6.3 million in 2009 to the National Institute for Health and Welfare, the lab of Dr. Juhani Eskola, a Finnish member of the WHO’s Strategic Advisory Group of Experts (SAGE), which advises the agency on vaccine use. Further reports indicated that as many as five other SAGE advisors had financial links to the pharmaceutical industry. — Wayne Kondro, CMAJ Afghanistan's "cancer of corruption" January 21, 2010 Doctors and nurses, it seems, require a relatively cheap bribe in the Islamic Republic of Afghanistan. Their services typically command “lower-end” bribes of less than US$100, well below the national average of US$158 for most kickbacks and significantly below the grease demanded by judges, prosecutors or customs officers, which generally top US$200 and often exceed US$1000, according to a report by the United Nations Office on Drugs and Crime. The UN survey, Corruption in Afghanistan, Bribery as reported by the victims, also indicates that women pay bribes more frequently than men in the health sector and that in 74% of cases, bribes are paid to speed up procedures. In 28% of cases, they are paid to “receive better treatment” (www.unodc.org/documents/data-and-analysis/Afghanistan/Afghanistan-corruption-survey2010-Eng.pdf). Doctors were the fifth, and nurses the seventh, largest group who typically demand incentives for their services, behind police officers, municipal/provincial officials, judges and prosecutors. Members of the government squeezed into sixth place. “It is almost impossible to obtain a public service in Afghanistan without greasing a palm: bribing authorities is part of everyday life,” states the report, which surveyed 7600 Afghan citizens in 12 provincial capitals and 1600 villages between August and October 2009. It found that one out of every two Afghan adults had paid at least one kickback over the previous year, at an average US$158, or about one-third of the nation’s gross domestic product per capita (US$425). Those who paid bribes typically made payments to average of 2.4 public officials on two occasions, which translates into a staggering US$2.5 billion in grease shelled out in Afghanistan over a one year period. “The cancer of corruption is metastatic in Afghanistan. It will lead to a terminal condition, unless chemotherapy to reduce the chance of further infection (preventive measures) is combined with surgery to remove the biggest infected nodules (the key villains),” states the report. The survey also indicates that people working in the health sector are themselves not immune from having to pay bribes. In one anecdote, a respondent says: “My cousin runs a medical practice. Some expired and low quality drugs were found in his medical and a procedure was started by the Health Department. Later he bribed the head doctor and his file was clean within a day. My cousin is still selling the expired and poor quality drugs made in Pakistan, under the label of Germany and US Made.” To begin to tackle the scourge, the UN recommended the creation of a “comprehensive monitoring system on corruption,” including a sectoral analysis of the working conditions of civil servants and health workers “for the purpose of providing more in-depth and specific information and assist in identifying targeted policy measures.” — Wayne Kondro, CMAJ Flu toll on the economy January 19, 2010 Pandemic (H1N1) 2009 and seasonal influenza exacted a toll on the Canadian economy as 9% Canadians took off an average 19.6 hours of work as a result of the bugs in November 2009, Statistics Canada says. But 600 000 Canadians put in extra hours — including 10.5% of health workers, who put in a combined two million extra hours — so the net loss to the economy was 20.9 million hours, rather than 29.5 million hours (www.statcan.gc.ca/daily-quotidien/100115/dq100115c-eng.htm). Statistics Canada, which is tracking the economic impact of influenza for a three-month period on behalf of the Public Health Agency of Canada, said the blow to the economy was comparable to the 2003 power outage that hit Ontario and part of Quebec. During the blackouts, more than 26.4 million hours of work time were lost and when offset by 7.5 million overtime hours, the net economic effect was a loss of 18.9 million hours. The report says that flu-related absenteeism was highest in Newfoundland and Labrador (14.2% of works aged 15 to 69), while the lowest was in Quebec (7.6%). Some 12.4% of employees with children lost work hours, as compared with 6.9% for employees without children. — Wayne Kondro, CMAJ Hold the salt — please January 14, 2010 Voluntary salt reductions in the production of prepared foods and restaurant meals were again the preferred option over regulation as the National Salt Reduction Initiative, a United States coalition of 26 city and state agencies and 17 national health organizations spearheaded by the New York City Department of Health, unveiled guidelines aimed at curbing the average American’s salt intake by 20% within five years. The guidelines propose specific targets to reduce salt levels in 61 categories of packaged food and 25 classes of restaurant food, including two- and four-year targets for each category of food (www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml). For example, producers of grated cheeses, who now typically add 1530mg of salt to each 100g of their product would be asked to trim that to 1450 mg by 2012 and 1300 mg in 2014. Targets, though, could be applied variably by a manufacturer. A company that sells several lines of crackers could, for example, lower the salt levels in some of its lines of crackers, while making another line “extra salty,” and still meeting the sodium reduction target within its “overall cracker portfolio.” They could also simply ignore the guidelines, as they are entirely voluntary, an identical approach to that recently recommended by Health Canada’s Sodium Working Group to trim Canadian salt consumption, which Blood Pressure Canada estimates is a staggering 3500 mg of sodium per day, considerably higher than the recommended 1200 mg, (CMAJ 2009. DOI:10.1503/cmaj.109-3100). Still, the Salt Institute, the industry-funded trade association, balked at the proposed voluntary guidelines, arguing in a press release that “shaky science” underlies the proposition that a reduction in salt intake results in lower blood pressure and thereby, reduces the chances of heart attack and stroke (www.saltinstitute.org/content/download/11168/70799). Food manufacturers have long contended that requiring salt reductions for processed foods is problematic because of the impact it would have on preservation and taste of foods. But advocates argue that the proposed sodium reduction levels would not have a noticeable impact on the taste or preservability of most foods. “Consumers can always add salt to food, but they can’t take it out,” stated New York City Health Commissioner Dr. Thomas Farley in a press release. Consultations on the proposed targets will be conducted this month and final targets adopted in the spring. — Wayne Kondro, CMAJ PHAC releases new mumps guidelines January 12, 2010 Health care facilities should provide the measles-mumps-rubella vaccine to all health care workers who haven’t received two doses of mumps-containing vaccine, had a laboratory-confirmed case of mumps, “positive measles, mumps, and rubella IgG; or a valid contraindication” to the vaccine, according to new Public Health Agency of Canada (PHAC) guidelines. “A community mumps outbreak can have considerable impact on health care settings and health care capacity,” states the Guidelines for the Prevention and Control of Mumps Outbreaks in Canada, which were released by PHAC on Jan. 7 by PHAC (www.phac-aspc.gc.ca/publicat/ccdr-rmtc/10pdf/36s1-eng.pdf). “Factors contributing to the potential for mumps transmission in health care settings are as follows: the long infectious and incubation periods; a high proportion of sub-clinical and misdiagnosed cases; and a sizable population of susceptible health care workers.” Testing during the 2007 mumps outbreak in Nova Scotia indicated that people born after 1970 had lower levels of immunity because they were typically offered only one dose of mumps-containing vaccine and were not exposed to a wild mumps virus that circulated in Canada during earlier decades. The guidelines add that all patients, including health care workers, who contract mumps should be advised to “stay home (self-isolate) for 5 days from symptom onset; perform hand hygiene (wash with soap and water or use an alcohol-based hand rub) frequently; avoid sharing drinking glasses, eating utensils or any object used on the nose or mouth; and cover coughs and sneezes with a tissue or forearm.” The guidelines, which were prepared by a federal, provincial and territorial task force in response to a request from the Council of Chief Medical Officers of Health and the Canadian Immunization Committee, also recommend several improved reporting and surveillance measures. — Wayne Kondro, CMAJ Israel revamps organ donation policies January 7, 2010 Israelis who sign an organ donation card will get priority status for transplants, if they need them. Those with signed donor cards, their relatives (even if they don’t themselves sign cards) and living donors will be placed higher on the waiting list under new organ donation policies that take effect this month. But Israelis who sign organ donation cards will have to wait three years before getting bumped higher on the priority list. Dr. Jacob Lavee, director of the Heart Transplantation Unit and the deputy director of the department of cardiac surgery at the Sheba Medical Center, writes in an email that the aim is to reverse Israel’s low organ donor rates. Currently, about 10% of Israeli adults have signed organ donation cards, as compared with about 30% in many Western nations. But the rate of organ donation from Israeli patients with brain death is only 45%, as compared with 70-90% in other Western countries, Lavee says. “The idea was simply that a higher number of individuals with donor cards would hopefully lead to an increase in actual organ donation and in the meantime will answer the perceived social need to rectify the unfairness of 'free riders'," he writes. The “free-riders” are a small percentage of the Israeli public who oppose the idea of brain death and organ donation, but who have no problem accepting a transplant when the need is their own. Patients in urgent need of a heart, liver or lung transplant will continue to top the priority list, but if two patients are on the list and one has signed an organ donation card, he or she will be given preferential status. Children under 18 and those unable to express their wishes because of physical or mental disability will retain their priority status. The new regime, which was passed into law by the Israeli Knesset, will be evaluated in two years to determine if it is having any effect on organ donation rates. — Sabrina Doyle, Ottawa, Ont. National dementia strategy urged January 5, 2010 A pan-Canadian plan is needed to allay the effects of a forthcoming epidemic that will see the number of Canadians living with Alzheimer disease and other forms of dementia leap to 1.125 million in 2038 from 500 000 in 2008, according to a study commissioned by the Alzheimer Society of Canada. A projected 257 800 new cases will be diagnosed in 2038, as compared with 103 700 in 2008. The study, commissioned from Toronto, Ontario-based risk management consultants RiskAnalytica, also estimates that the economic burden of dementia will increase to $153 billion in 2038 from $15 billion in 2008. The $153 billion would include $92.8 billion in direct costs of treating dementia (medication, staff and hospital expenses), $55.7 million in unpaid caregiver opportunity costs (wages that could have been earned by caregivers had they been in the labour force), and roughly $4.1 million in indirect costs (such as the loss of corporate profits as a result of lower levels of labour productivity). A national dementia plan would “prepare for and mitigate the burden of dementia on Canadian society and direct health expenditures towards activities that have the greatest potential to maximize quality of life, support individuals and families, make best use of our scarce health human resources, and reduce institutionalization and overall health costs,” says the report, Rising Tide: The Impact of Dementia in Canada (www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20version.pdf). The report sketches four scenarios in which the projected financial burden of dementia might be alleviated, including ones that might delay the onset of dementia through educational programming that promotes physical activity and health lifestyles. Another would bolster training and support for family caregivers, while a fourth would assign a “system navigator” to newly diagnosed dementia patients to coordinate care and “reduce caregiving time and delay admission into a long-term care facility.” The report also argues that a comprehensive national dementia strategy would have five essential components:
— Wayne Kondro, CMAJ NCAA proposes stricter guidelines for treating student-athletes who suffer concussions December 24, 2009 In the wake of growing public and parental concern about the long-term impact of sports-related head injuries, the governing body for university sport in the United States is proposing that student-athletes be prohibited from returning to the field of play for the remainder of a game or practice if they’re rendered unconscious, “have amnesia or persistent confusion.” The proposed National Collegiate Athletic Association (NCAA) rule, which must still be ratified by the association’s Playing Rules Oversight Panel, would also obligate teams to remove from the field of play all athletes who exhibit “signs, symptoms, or behaviours consistent with a concussion (such as unconsciousness, amnesia, headache, dizziness, confusion, or balance problems), either at rest or exertion,” until such time as they’ve been cleared by a physician www.ncaa.org/wps/ncaa?key=/ncaa/ncaa/ncaa+news/ncaa+news+online/2009/association-wide/safeguards+committee+acts+on+concussion-management+measures+-+ncaa+news+12-15-09.). The committee also urged that the NCAA convene a national summit this year to review policies regarding the medical management of concussions and examine prevention strategies. In contrast to the NCAA proposal to stiffen its regulations governing concussions, Canada appears to lack any manner of national standards, guidelines or regulations for head injuries suffered during university sporting events. Marg McGregor, executive-director of Canadian Interuniversity Sport, says policies regarding sports-related head injuries are the purview of members institutions. “Each of our universities have their own protocol with respect to how they manage injuries, return to game play, training and competition.” — Andrea Ozretic, Ottawa, Ont. Australia unveils incentive program to treat chronically-ill Aboriginal patients December 22, 2009 Australian doctors will pocket an extra A$500 a year for every chronically-ill Aboriginal patient they adequately treat starting in May 2010 under a new indigenous health incentive program. The program hopes to encourage better care for Aboriginal patients by rewarding health providers that meet treatment targets, stated Minister of Indigenous Health Warren Snowdon in a press release General practitioners and accredited Aboriginal health service units will receive A$1000 when they sign up to participate in the incentive program. Doctors will earn A$250 for every indigenous patient they sign to their practice, and an additional A$250 each time the patient renews their annual agreement. They’ll receive another A$250 yearly for each patient treated in accordance with a target level of care, including effective follow up monitoring and treatment. But indigenous health experts say the program will fail to deliver improved care to many Aboriginal communities, as it only extends support to health services accredited by the Royal Australian College of General Practitioners. The majority of Australia’s indigenous people receive care from Aboriginal community-controlled health services units, up to 50% of which are not accredited and are therefore ineligible for the new incentive program, states the 2008–2009 National Aboriginal Community Controlled Health Organization report (www.naccho.org.au/Files/Documents/NACCHO_AR09_Final.pdf). The report suggests the new incentive program, which will cost A$28 million over the next four years, will only serve to pay “mainstream” practices more for the limited service they already provide to Aboriginal communities. Australian Medical Association data shows that Aboriginal and Torres Strait Islander peoples die up to 17 years earlier than even the most disadvantaged of other Australians (www.ama.com.au/node/3229). They’re also three times as likely to have a major coronary as other Australians. — Lauren Vogel, Ottawa, Ont. Sepsis mortality rates remain high December 17, 2009 While overall mortality rates are dropping in Canadian hospitals, those for sepsis are essentially unchanged since 2004, according to the Canadian Institute for Health Information (CIHI). Roughly 47% of Canadian hospitals, excluding those in Quebec, had mortality rates below the expected national experience, compared to 36% in 2007, CIHI says in its most recent assessment of hospital standardized mortality ratios, HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. The ratio compares actual (observed) deaths to expected deaths, adjusting for factors that affect in-hospital mortality, such as age, sex, length of stay, and diagnosis group (http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hsmr_results_canada_e). But in a related report, In Focus: a National Look at Sepsis, CIHI said that there has been no significant improvement in either sepsis hospitalization rates or sepsis mortality rates since 2004 (http://secure.cihi.ca/cihiweb/products/HSMR_Sepsis2009_e.pdf). Approximately 1400 people worldwide die of sepsis every day. CIHI estimated that last year, 9320 patients with the disease died in Canadian hospitals. The current crude mortality rate for sepsis tops 30%, as compared with 18% for patients with stroke and 9% for people who suffered a heart attack. In 2008–2009, approximately a quarter of all patients with sepsis were diagnosed with the condition after being admitted to hospitals. CIHI found these patients were 56% more likely to die than those patients diagnosed before their admission to hospital. The study also found there’s a high economic cost associated with treating patients with sepsis, as they stay in hospital an average nine days longer than those admitted with other conditions. Almost half of all patients with sepsis are admitted to intensive care units. Quebec is not included in CIHI’s study of hospital standardized mortality rates due to historical differences in the classification systems of diagnosis and intervention, says Institute Vice-President, Research and Analysis, Jennifer Zellmer (CMAJ 2008; DOI: 10.1503/cmaj.071784). — Lauren Vogel, Ottawa, Ont. New Networks of Centres of Excellence Announced December 15, 2009 A University of British Columbia-led initiative to understand pediatric brain development is among three new Networks of Centres-of-Excellence (NCE) emerging from the latest tri-granting council/Industry Canada222 networks competition. NeuroDevNet will receive $19.5 million over the next five years for a research program focused on the genetic and environmental causes of cerebral palsy, autism spectrum disorders and fetal alcohol disorders under the networks program, which is jointly run by the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council and the Social Sciences and Humanities Research Council, along with Industry Canada. “The network will seamlessly combine lab research — studying how the brain develops and how to fix it when it develops poorly — with the clinical situation as babies develop in utero and until three years of age,” said NeuroDevNet scientific director Dan Goldowitz in a press release. “We’ll bring in basic researchers to model brain development and test interventions, we’ll involve parents so they’re aware of what we’re doing, and we’ll share best practices with clinicians. The knowledge gained will provide proof of principle and contribute to discovering diagnostics and developing therapeutics. The earlier we can diagnose and intervene with the children, the bigger the effect on developmental outcome,” the senior scientist at U.B.C.’s Centre for Molecular Medicine and Therapeutics at the Child & Family Research Institute in Vancouver, BC. Also successful in the NCE competition (which drew 38 submissions, 10 of which were invited to make full applications) was Carbon Management Canada, which received $25 million to develop technologies to rapidly “decarbonise” fossil fuel production and use, as well as Graphics, Animation and New Media Canada, which received $23.5 million to explore new media issues such as social networking, virtual museums and e-health services. The three new networks bring the total number of NCEs now being supported by the councils to 17. — Sabrina Doyle, Ottawa, Ont. Patients on the prowl December 10, 2009 British doctors should think twice before responding to amorous advances on social networking sites such as Facebook or MySpace, according to the United Kingdom’s Medical Defense Union. Even polite refusals on such social networking sites are inappropriate, the association says. “The pitfalls posed to doctors using social networking sites by inadvertently breaching confidentiality or posting unprofessional content, such as photos, have been well documented. But doctors may be less prepared for patients using sites like Facebook to ask them out on a date,” wrote Dr. Emma Cuzner, Medical Defence Union medico-legal adviser in the MDU Journal (MDU Journal 2009;25:12-13). “Some doctors have told the MDU they feel it would be rude not to reply, if only to politely refuse, but given that this is not a professional route of communication, any correspondence of this sort would clearly stray outside the doctor/patient relationship.” Cuzner warned that doctors could face investigation if they crossed the line. “They have a duty to maintain the public trust in the profession at all times, in their professional and private lives and not only when at their place of work. The organization also advised doctors to use security and privacy settings on social networking sites to prevent unsolicited propositions that may lead to liaisons. — Lauren Vogel, Ottawa, Ont. Ontario passes regulatory changes for health professionals December 8, 2009 Legislation that will provide the Ontario ministry of health with the power to appoint a supervisor who can assume the regulatory duties of health professional bodies such as the College of Physicians and Surgeons of Ontario has passed third reading and needs only to be proclaimed before coming into effect. The college had expressed concerns about the legislation (CMAJ 2009: DOI:10.1503/cmaj.109-3081) and had sought amendments during the legislative process. Some but not all, of the amendments were adopted and “somewhat improve” what was originally proposed, Kathryn Clarke, the college’s senior communications coordinator, stated in an email. The college had asked that the extraordinary step of appointing a supervisor be taken only if a college had complied with requirements under Section 5 of the Regulated Health Professions Act and if the minister “is satisfied that there is a risk to patient safety.” The latter condition with respect to patient safety was not included in the amendment, though the former was, Clarke stated. Another amendment requires that the Minister give the affected college 30 days, instead of the original 14 days, notice of the intent to appoint a supervisor. As well, the affected college can, in response to the notice, make written submissions that must be included in the minister’s recommendation’s to the Lieutenant Governor that a supervisor be appointed. Overall, “the amendments fall short of what we and many other regulators” had recommended, Clarke added. The provisions apply to all the 22 health profession regulatory bodies in the province. The legislation will also give nurse practitioners, pharmacists, physiotherapists and other health professionals the freedom to provide a wider range of services, according to a ministry press release. — Ann Silversides, CMAJ Physician pool expands December 3, 2009 Canada’s national physician pool is getting older and larger, according to the Canadian Institute for Health Information (CIHI). The report, Supply, Migration and Distribution of Canadian Physicians, 2008, indicates that the number of active physicians (that is, someone with an MD degree and a valid mailing address) increased by 8.0% over the last five years, from 60 612 in 2004 to 65 440 in 2008 (http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_2510_E&cw_topic=2510&cw_rel=AR_14_E). That tally excludes 5809 physicians who are either in the military, semi-retired, pursuing residencies, nonlicensed or requested exclusion. Including these other physicians brings the total in Canada to 71 249. The overall physician-to-population per capita ratio grew to 195 per 100 000 in 2008, from 189 in 2004. That ratio is predicted to continue to rise as the number of new medical students increased from 8236 in 2004 to 9640 in 2007. However, rising enrolment in medical schools is only part of the reason for the overall increase, though. Also contributing to the increase was a trend towards later retirement among physicians. The average age of general practitioners in Canada increased by 5.6 years, to 49.0, while the average age of specialists increased by 3.4 years, to 50.6. Meanwhile, CIHI found that 69.2% of 1667 physicians who were between the age of 70 and 74 and working in 2004 were still working in 2008, while 63% of the 643 physicians aged 75-79 in 2004 were similarly still practicing, and 47% of the 217 physicians aged 80-90 in 2004 continued to practice in 2008. An increase in the number of Canadian-trained physicians (6.6%) and an influx of foreign-trained physicians (10.4%) also contributing to a swelling of the physician ranks. The report also shows that Canadians are more likely to be treated by female physicians or by those trained in their own province. In 2008, women accounted for 52.1% of new general practitioners in Canada and 45.1% of new specialists. Some 66% of medical graduates are likely to still be practicing within the jurisdiction in which they were trained 10 years earlier. Internationally-trained physicians appear more inclined to move around the country, as only 33.8% of family physicians, and 27.9% of specialists, were working in the same place between 998 and 2008. Over that time period, Alberta and British Columbia enjoyed a net annual gain of physicians due to interjurisdictional migration, while Newfoundland and Labrador, Quebec, Manitoba and Saskatchewan experienced net losses. — Lauren Vogel, Ottawa, Ont. Prominent Canadians lobby for drug access reform December 1, 2009 Dr. James Orbinski, Stephen Lewis and Dr. Samantha Nutt are among more than 50 prominent Canadians urging federal Parliamentarians to vote today in favour of a bill that would reform legislation aimed at supplying affordable life-saving drugs to the developing world. The private member’s bill to reform Canada’s Access to Medicine Regime, which faces second reading tomorrow, would streamline the approval process for the manufacture and shipping of needed drugs, advocates say. A poll commissioned by UNICEF Canada and the Canadian HIV/AIDS Legal Network found that a majority of Canadians support the changes proposed in the bill. Reform of the regime was also supported by a petition signed by 32,000 Canadians and sponsored by the Grandmother’s Campaign, which was launched in 2006 by the Stephen Lewis Foundation to support grandmothers raising AIDS orphans in Africa. But Bill C-393, which was introduced by New Democrat Member of Parliament Judy Wasylycia-Leis (Winnipeg North) is opposed by the Conservatives, Rx&D — Canada’s Research-based Pharmaceutical Companies, and some Liberal party members of Parliament, including industry, science and technology critic Marc Garneau (Westmount–Ville-Marie). The existing legislation is “a fast, efficient and effective tool to deliver medicines in the developing world,” states an Rx&D press release dated Oct. 19. However, to date, only enough of a triple-combination HIV/AIDS drug to treat 21 000 Rwandans for one year has been shipped from Canada under the five-year-old legislation. The drugs were manufactured and shipped by the Canadian generic drug company Apotex Inc. in 2008 and 2009. President Jack Kay said the process was so lengthy and cumbersome that Apotex would not repeat its efforts under the existing law. Canada’s legislation was heralded when introduced in 2004, a year after a World Trade Organization decision that provided for mechanisms to speed availability of affordable generic drugs for public health emergencies and other public noncommercial use in designated countries. But the legislation added obstacles to the effective use of the WTO decision and as a consequence, the difficulties in arranging for the one shipment from Canada were “foreseeable,” Frederick Abbott, professor of international law at Florida State University College of Law in Tallahassee, Florida, told the Senate Banking, Trade and Commerce Committee last month. A separate private member’s bill (S-232), similar to C-393, has been introduced in the Senate and passed second reading there (CMAJ 2008: DOI:10.1505/cmaj.081146 and CMAJ 2006; DOI:10.1503/cmaj.061121.) — Ann Silversides, CMAJ New HIV infections declining November 26, 2009 New cases of HIV infection have decreased by 17% since 2001, according to data in the 2009 AIDS epidemic update (http://data.unaids.org/pub/Report/2009/2009_epidemic_update_en.pdf). The publication, a joint effort by the United Nations Programme on HIV/AIDS and the World Health Organization, states that international HIV prevention programs are making a difference. “There is growing evidence of HIV prevention successes in diverse settings. In five countries where two recent national household surveys were conducted, HIV incidence is on the decline, with the drop in new infections being statistically significant in two countries (Dominican Republic and United Republic of Tanzania) and statistically significant among women in a third (Zambia),” states the report, released Nov. 24. In sub-Saharan Africa, the number of new infections has dropped about 15% over the last eight years. During the same period, infections have declined by nearly 25% in East Asia and by 10% in South and South East Asia. Although there was no decline in Eastern Europe, where the number of infections had been skyrocketing among intravenous drug users, the number of infections has stabilized. Though rates of new infections are dropping, there are more people living with HIV today (about 33.4 million) than ever before because of life-extending antiretroviral therapies. The number of AIDS-related deaths has dropped by more than 10% in the past five years. “Antiretroviral therapy coverage rose from 7% in 2003 to 42% in 2008, with especially high coverage achieved in eastern and southern Africa,” states the report. The report also suggests that integrating HIV prevention and treatment programs with general health services is a top priority and would have a substantial positive impact. For example, nearly 50% of maternal deaths in Botswana and South Africa are due to HIV, which may be in part because of “AIDS isolation.” The report suggests that efforts should be made to create a unified health approach, bringing together programs for HIV prevention, maternal and child health and tuberculosis. — Roger Collier, CMAJ Stagnant smoking rates November 24, 2009 United States residents smoke less than they did a decade ago, but declines in smoking rates have stalled in recent years, according to statistics released by the Centers for Disease Control and Prevention. Ten years ago, about a quarter of Americans smoked. Today, that percentage has dropped to about 20%. But most of the decrease occurred more than five years ago. The smoking rate in 2008 (20.6%) was only slightly lower than it was in 2004 (20.9%), according to the report, Cigarette Smoking Among Adults and Trends in Smoking Cessation — United States, 2008. These percentages are nowhere near the goal of a 12% smoking rate by 2010, as proposed in the Health People 2010 project, a nationwide health promotion and disease prevention plan established by the US Department of Health and Human Services. In 2008, people with lower levels of education were found to smoke in far greater number than people with higher educations. Of those aged 25 or above with a General Education Development (GED) certificate, 41.3% smoked, and 27.5% of people with less than a high school diploma smoked. By contrast, only 5.7% of people with graduated degrees were smokers. “Evidence-based programs known to be effective at reducing smoking should be intensified among groups with lower education, and health-care providers should take education level into account when communicating about smoking hazards and cessation to these patients,” the report states. The rate of smoking among men, at 23.1%, was higher than among women, 18.3% of whom smoked in 2008. In terms of ethnic breakdown, Asians had the lowest rate of smoking (9.9%), while American Indians/Alaska natives had the highest (32.4%). Smoking was also more common among people living below the poverty line (31.5%) than those living above it (19.6%). Smoking rates were fairly consistent among adults aged 18–24 (21.4%), 25–44 (23.7%) and 45–64 (22.6%). But among adults aged 65 or above, only 9.3% smoked. The figures in the report were based on data obtained from in-person interviews with 21,781 adults. — Roger Collier, CMAJ Baby boom down under November 19, 2009 Australia is experiencing a baby boom, with rates of fertility among women in their late 30s as high as they were during the period after World War II, according to information released by the Australian Bureau of Statistics. The figures, released Nov. 11, show that 296 600 births occurred in Australia in 2008, a 4% increase from the year before. The fertility rate (the number of children women will likely bear during their reproductive years) was 1.97, much higher than the rate of 1.73 recorded in 2001, which had prompted fears of an eventual stagnation of the country’s economy. If the rate continues to increase, as some experts predict, it will soon pass 2.0 for the first time since 1977. Women in their late 30s were most responsible for the increase in births. There were 70.9 babies born per 1000 Australian women aged 35–39, the highest rate for that age range since 1948. The highest fertility rate was recorded among women aged 30–34, at 127.8 babies per 1000 women. Overall, women in their 30s accounted for 55% of the increase in births. Younger women are having more children, too. In 2008, the fertility rate for women aged 20–24 increased for only the second time since 1990. Women aged 25–29 recorded the second highest fertility rate, at 105.8 babies per 1000 women. Fertility rates remained stagnant for women aged 45–49, the only age group not to show an increased rate. Some Australian demographers attribute the increase in fertility rates to strong economic conditions in the country, and say they expect the rates to keep rising for the next decade. — Roger Collier, CMAJ Alberta whistle-blower’s statements “untruthful,” states report November 17, 2009 Many of Dr. John O’Connor’s public statements about unusually high rates of rare cancers in Fort Chipewyan, Alberta, were inaccurate and untruthful, according to a College of Physicians and Surgeons of Alberta (CPSA) investigation report. O’Connor received considerable media attention in 2006 after claiming that people in Fort Chipewyan, a community near the Alberta oil sands, were suffering elevated rates of cancer, including a rare type called bile-duct cancer. O’Connor, who now practises in Nova Scotia, has since become a vocal antagonist of the oil sands. In 2007, three physicians working with Health Canada lodged a complaint against O’Connor with the CPSA. The physicians accused O’Connor of four things: obstructing investigations into cancer rates in Fort Chipewyan by the Alberta Cancer Board and Health Canada, making statements that caused Fort Chipewyan residents to make lifestyle choices that weren’t in their best interests, causing aboriginal communities to lose faith in public health officials and making inaccurate or untruthful statements. The CPSA conducted a two-year investigation and, as indicated in the Nov. 4 report, found that O’Connor: “failed to inform public health officials and the Alberta Cancer Board of the identities of and clinical circumstances of patients whom he’d diagnosed with various types of cancer in a timely manner”; “did not respond to multiple requests for information after he made public his concerns about the incidence of cancer in the community of Fort Chipewyan”; and “made a number of inaccurate or untruthful claims with respect to the number of patients with confirmed cancers and the ages of patients dying from cancer.” As for the allegations that O’Connor statements resulted in harm to Fort Chipewyan residents and caused them to lose faith in public health officials, the report states that the CPSA “has insufficient evidence to prove or disprove them.” The report concluded by stating that neither the CPSA nor the physicians who launched the complaint fault O’Connor for raising concerns about cancer rates in Fort Chipewyan based on his observations. Doctors are right to advocate for the communities in which they practise, the report states, but such advocacy should be fair and accurate. The report also states that “neither the CPSA nor the complainants were of the view that imposing a penalty or some other punishment on Dr. O’Connor met the public interest. However, these parties accept that making inaccurate statements or claims and failing to fulfill one’s legal and ethical obligations, are not acceptable behaviors and needed, in this instance, to be declared as such.” — Roger Collier, CMAJ Assault on salt November 12, 2009 A major “population-based” assault on excessive salt intake should be launched by the governments of all nations in the Americas in a bid to prevent deaths and illness from hypertension, heart and kidney failure, and stroke, an independent panel convened by the Pan American Health Organization urges. “Governments are justified in intervening directly to reduce population-wide salt consumption because salt additives in food are so common,” states the expert panel, which was appointed in September to develop recommendations for lower salt consumption strategies. “People are unaware of how much salt they are eating in different foods and of the adverse effects on their health. Children are especially vulnerable.” The panel’s Policy Statement – Preventing cardiovascular disease in the Americas by reducing dietary salt intake population-wide urges that standardized food labeling should become a requisite component of national salt reduction programs. It also urges that governments “initiate collaboration with relevant domestic food industries to set gradually decreasing targets, with timelines, for salt levels according to food categories, by regulation or through economic incentives or disincentives with government oversight.” Governments should also “regulate or otherwise encourage domestic and multinational food enterprise to adopt the lowest of a) best in class (salt content to match the lowest in the specific food category) and b) best in world for the national market (match the lowest salt content of the specific food produced by the company elsewhere in the world).” Industry, meanwhile, should “institute reformulation schedules for a gradual and sustained reduction in the salt content of all existing salt-containing food products, restaurant and ready-made meals to contribute to achieving the internationally recommended target or national targets were applicable. Make all new food product formulations inherently low in salt.” The World Health Organization has set less than 5g/day/person (equivalent to 2000 mg of sodium) as a dietary salt intake target by 2020. The policy statement also urges the development of national salt intake surveillance systems and various educational initiatives to promote awareness of the health benefits of low salt diets. — Wayne Kondro, CMAJ Bloom is off in wild rose country November 10, 2009 Alberta healthcare workers are being asked to forgo pay raises for the next two years in a bid to help balance the province’s books, which are in arrears by $7 billion as a consequence of the recession and a drop in oil and gas prices. But Alberta Medical Association President Dr. Chip Doig says that could be hard sell among members, who “have not seen a drop in their business expenses.” Still, Doig says the association will consult members before deciding whether to abandon the scheduled pay raises at the Premier’s request. Alberta doctors are scheduled to receive a 4.5% increase in their pay envelops in 2010, the final year of their current labour agreement with the province. Doig says physicians have told him their costs are rising, and even with the pay increase, their take-home wages will be dropping. Tom Olsen, spokesman for Alberta Premier Ed Stelmach, says the the premier has made it clear to unions that a wage increase is preferable to job losses. “His line has been jobs before salary increases and he will stick to that line.” “There is a finite amount of money. That is just fact and how that money is dispersed is now a subject for negotiation,” Olsen said, adding that Stelmach “does not want there to be massive layoffs and he is doing everything he can to mitigate that.” — Ryan Tumilty, Edmonton, Alta. Canada Pension Plan buys IMS Health November 6, 2009 The economic value of health information was underscored by yesterday’s announcement that the Canada Pension Fund and the Investment Fund TPG Capital were purchasing IMS Health for $5.2-billion. The purchase “shows that the secondary use of health information is worth a lot of money and, arguably, the data has great economic value,” says Khaled El Emam, professor with the School of Information Technology and Engineering at the University of Ottawa. Over the years, some Canadian physician organizations have expressed concern about the company’s prescription data mining operations. The Canadian Medical Association was granted intervenor status at an unsuccessful appeal of the federal Privacy Commissioner’s 2001 decision that physician prescribing information is not personal information. Only Quebec doctors can now opt out of having their prescription information sold by pharmacies to data mining firms such as IMS Health. The IMS purchase is expected to be finalized by the first quarter of 2010, pending shareholder and regulatory approval. Secondary health information “can be an economic driver,” Brogan said, noting that the provincial and federal governments don’t themselves take advantage of the health related databases that they compile. Brogan is also intrigued by how the American market will react to the purchase of of the world’s largest health data company by a Canadian government agency. The announcements did not break down the relative share of the two investors. Quebec College of Physicians board of directors issues qualified endorsement of euthanasia in exceptional circumstances November 5, 2009 People who are facing imminent and inevitable death should be provided “the most appropriate possible” care at the end of their lives, the Quebec College of Physicians board of directors says while recommending that amendments be made to the Criminal Code of Canada to allow euthanasia for terminally ill patients in certain circumstances. “Patients must know that multiple alternative last resort treatments exist, to which they or their loved ones may choose to consent or not,” the college states in a “reflection document,” Physicians, Appropriate Care and the Debate on Euthanasia, released Nov. 3. “For their part, doctors must be aware that they will not be obliged to practice euthanasia. Nevertheless, those physicians who, in certain exceptional circumstances, would accept conducting activities that could be interpreted as euthanasia must be reassured that they will not be exposing themselves to criminal sanctions if they respect the conditions of proper medical practice.” Noting that “there is nothing to be gained by medical paternalism,” the paper, which was adopted by the college’s board of directors on Oct. 16, states that society has evolved to the point where consensus decisions can be made by physicians, families and other healthcare providers in “difficult” clinical situations such as, for example, cases in which a patient did not express their wishes in advance or are not competent to do so, but there is consent from the patient’s family. “Many doctors would probably feel justified in shortening the agony of certain incompetent patients in a terminal phase and suffering from uncomfortable pain,” (www.cmq.org/en/medias/profil/commun/Nouvelles/2009/~/media/208E2B537FB144FAAE33DEB458D3AA90.ashx?110904). “A new sensitivity is clearly evident among both doctors and the public that there are exceptional situations where euthanasia could be considered by patients and their loved ones and by doctors and other caregivers as a final step necessary to assure quality care to the very end. This must be recognized in order to allow for more open discussion of all the options available at the end of a patient’s life and to clearly identify the responsibilities of all parties concerned in that regard. Although certain distinctions must be drawn (i.e., between terminating treatment, relieving pain and euthanasia, between euthanasia and assisted suicide), the question of euthanasia must be integrated as a part of appropriate end-of-life care as soon as possible. If euthanasia is to be permitted, it should certainly be within a context of care and as a medical act.” — Wayne Kondro, CMAJ Royal Society panel to study physician-assisted death November 3, 2009 The Royal Society of Canada has launched a one-year exercise to assess the pros and cons of permitting physician-assisted death. To that end, the society has appointed a six-member “Expert Panel on End-of-Life Decision Making,” chaired by Udo Schuklenk, professor of philosophy and Ontario research chair in bioethics at Queen’s University in Kingston. The expert panel has decided to “focus squarely on the questions of whether or not physician assisted suicide and/or voluntary euthanasia ought to be decriminalized in Canada,” Schuklenk stated in an email interview, adding that the panel plans widespread consultations. “We will tackle these questions by means of an in-depth review of the legal situation in the country, as well as a review of the situation clinicians, as well as terminally ill patients, face on the ground in Canada on a daily basis.” The panel will also canvas the international landscape, Schuklenk said. “A number of jurisdictions outside Canada have since decriminalized physician assisted suicide and/or voluntary euthanasia. We will evaluate the experiences made in these countries with respect to influential arguments deployed against decriminalization by opponents of voluntary euthanasia and/or physician assisted suicide.” “We may or may not issue recommendations,” Schuklenk added. The Royals Society’s governing board suggest that the panel first determine the state of current knowledge regarding end-of-life care (including “what is driving current decision-making in this area — e.g., is it economics, shortages of providers, lack of training, normative stances, etc.”). It then asks that the panel ascertain “what are the main value positions (normative stances) in play and to what extent are they actually motivating decisions?” and then finally, address substantive normative questions. Schuklenk says the expert panel plans to report back to the society within a year. Joining him on the panel are: Dr. Johannes J.N. van Delden, chair of the Ethical Commission of the Medical Council of the Royal Netherlands Academy of Arts and Sciences; Jocelyn Downie, Canada research chair in health law and policy at Dalhousie University in Halifax, Nova Scotia; Sheila McLean, International Bar Association chair of law and ethics in medicine at Glasgow University in Scotland; Dr. Ross Upshur, Canada research chair in primary care research at the University of Toronto in Ontario; and Daniel Weinstock, Canada research chair in ethics and philosophy at the University of Montreal in Quebec. — Wayne Kondro, CMAJ |
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