Les systèmes de santé canadiens sont responsables d’environ 4,6 % des émissions nationales de gaz à effet de serre ainsi que de 200 000 tonnes d’autres polluants, et les retombées environnementales des salles d’opération sont considérables. Dans le présent guide de pratique clinique, nous émettons des recommandations concrètes visant à accroître la durabilité environnementale des salles d’opération. MÉTHODES : Ce guide de pratique clinique a été réalisé par le groupe Best Practice in Surgery (Pratique exemplaire en chirurgie) de la University of Toronto, avec la collaboration de représentantes et représentants nationaux. Nous avons respecté les principes de l’outil Appraisal of Guidelines for Research and Evaluation — Health Services (AGREE-HS), du processus ADAPTE, ainsi que du Guidelines International Network (GIN). En raison de la nature des données probantes, nous avons conçu une grille de classification fondée sur le triple bilan (personnes, planète, profits), et nous n’avons pas évalué la qualité des études. Le guide repose sur 24 revues rapides, et nous avons suivi un processus Delphi modifié pour parvenir à un consensus. De plus, nous avons demandé une révision externe dans divers hôpitaux de tout le Canada. Nous présentons ici 21 recommandations visant à accroître la durabilité environnementale des salles d’opération. Nous les avons regroupées en 4 catégories, soit réduire, réutiliser, recycler et repenser. La catégorie « réduire » vise la diminution des déchets par un tri adéquat, de même que par une réduction des déchets pharmaceutiques, des instruments dans les plateaux chirurgicaux et les trousses chirurgicales sur mesure, et de la consommation énergétique non nécessaire. Nous y formulons également des recommandations visant la réduction des émissions associées à l’anesthésie par inhalation. La catégorie « réutiliser » porte sur le remplacement des articles à usage unique (comme les dispositifs médicaux, les textiles et les contenants pour objets tranchants) par des substituts réutilisables. La catégorie « recycler » concerne des recommandations relatives aux programmes de recyclage classiques et spécialisés. Enfin, la catégorie « repenser » regroupe des stratégies pour lesquelles les données probantes directes sont rares, mais qui sont jugées essentielles à la durabilité à long terme, notamment les dons, la friction des mains à l’alcool et les politiques d’achats écologiques. INTERPRÉTATION : Les activités des salles d’opération alourdissent considérablement le fardeau environnemental des systèmes de santé canadiens, et l’application de ces recommandations peut contribuer à en réduire le poids.
Le cancer est la principale cause de décès au Canada et a des répercussions majeures sur la santé de la population et l’économie au pays. Nous avons voulu fournir des estimations à jour de l’incidence du cancer et de la mortalité due au cancer pour mettre en évidence les progrès réalisés et les domaines où il faut planifier et sensibiliser. MÉTHODES : Nous avons estimé les cas, les décès et le taux d’incidence normalisé selon l’âge (TINA) et le taux de mortalité normalisé selon l’âge (TMNA) en 2026, en fonction de la population canadienne type de 2021, par sexe et province ou territoire. Nous avons utilisé les données du Registre canadien du cancer (jusqu’à 2022) et celles de la Base canadienne de données de l’état civil — décès (jusqu’à 2023). Nous avons modélisé l’incidence et la mortalité au moyen de la trousse du logiciel Canproj. RÉSULTATS : Au Canada, on estime qu’en 2026, 254 100 personnes recevront un diagnostic de cancer et que 87 900 mourront de cette maladie. Dans l’ensemble, le TINA (591,4 pour 100 000) et le TMNA (200,0 pour 100 000) devraient diminuer par rapport aux années précédentes. On estime que les cancers du poumon, du sein, de la prostate et le cancer colorectal devraient représenter 47 % de tous les nouveaux cas. Le TINA pour tous les types de cancer combinés devrait être de 16 % plus élevé chez les hommes que chez les femmes (642,2 c. 553,9 pour 100 000) et le TMNA, de 36 % plus élevé (235,8 c. 172,8 pour 100 000). Des résultats notables ont été observés dans les taux de cancer spécifiques selon le sexe. INTERPRÉTATION : Les taux d’incidence et de mortalité due au cancer normalisés selon l’âge devraient diminuer au Canada; cependant, le nombre de nouveaux cas et le nombre de décès devraient demeurer à des niveaux élevés, compte tenu de la croissance et du vieillissement de la population ainsi que des effets différentiels prévus selon le sexe. Ces résultats indiquent qu’il faut continuer d’investir et de faire preuve de diligence pour poursuivre les progrès importants dans la lutte contre le cancer face aux changements démographiques en cours.
Although brain and heart conditions share overlapping risk factors and commonly co-occur, current cardiac and neurologic clinical guidelines are typically produced within specialty silos. The objective of this guideline from a Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) panel is to expand on current cardiovascular guidelines to include evidence from the neurologic and mental health literature, with specific recommendations for providers managing comorbid brain and heart conditions. The guideline development panel comprised an Executive Steering Committee; 10 expert subgroups to develop research questions and draft recommendations for specific brain-heart conditions; an Evidence Review Team to ensure the rigour and consistent application of the methodology; and an Implementation Committee to facilitate uptake of the recommendations by clinicians and into electronic medical records. The McMaster Evidence Review and Synthesis Team supported the literature searches and critical appraisal. A panel of people with lived experience of specific conditions and caregivers provided input on patient values and perspectives throughout the guideline development process. Our consensus process followed the Appraisal of Guidelines for Research and Evaluation II framework. We used an established evidence appraisal approach to determine the level of evidence and strength of each recommendation, and adhered to the Guidelines International Network's principles for managing competing interests. We developed 11 recommendations for the management of joint brain and heart diseases. Key recommendations include screening for cognitive decline in atrial fibrillation and depression in coronary artery disease; treatment of depression in coronary artery disease, cognitive impairment in hypertension, and dyslipidemia in stroke; and vaccination to prevent stroke, myocardial infarction, and dementia. We also recommend shared decision-making, including the use of evidence-based decision aids, to support patients with heart-brain diseases. We sought to produce an implementable and actionable guideline for patients with brain and heart comorbidity. It is primarily targeted to primary care providers, but also relevant to help address and individualize subspeciality care and for interprofessional teams caring for patients with joint brain and heart diseases.
In Nunavik, the Inuit lands in Quebec, the incidence of tuberculosis has been rising and is currently 1000 times that seen among non-foreign-born Quebec residents. To inform tuberculosis policies aligned with Inuit self-determination, we sought to explore Nunavimmiut (Inuit of Nunavik) experiences with tuberculosis care. We undertook a community-based participatory action research project in an Indigenous research methodology (IRM) framework. From 2022 to 2023, Indigenous researchers (First Nations and Inuit) conducted interviews and focus groups with Nunavimmiut about tuberculosis and health care experiences. We also interviewed health care workers. In our data analyses, we used constructivist grounded theory integrated with IRM to identify constructs. Findings derived from Nunavimmiut-reported perspectives and experiences informed calls for policy and service changes. We interviewed 156 Inuit (37% aged ≤ 35 yr, 61% women), in 5 Nunavik communities and in Montréal, and 21 health care workers. Nunavimmiut shared a strong desire to protect individual and community health, which they reported was undermined by under-resourced health services. Contemporary tuberculosis care itself was identified as a source of hardship, with contributing factors including displacement outside of community, isolation, directly observed therapy, fear of coercive measures, and threat of culturally unsafe experiences in health care settings. Information gaps undermined agency and caused heightened anxiety and stigma related to tuberculosis. The rarity of the Inuktitut language in health services contrasted with its predominance in community life. Health care workers echoed these concerns. Recommendations by Nunavimmiut for improving tuberculosis care were grouped into 7 calls to action: increasing Inuit control over services and data; providing person-centred care; increasing local services to minimize displacement; using community-wide screening, adapted locally; training and hiring more Inuit health care workers; reducing stigma; and implementing Inuit-led cultural safety training for health care workers. Nunavimmiut reported experiencing program-centred tuberculosis care, requiring Inuit to adapt to services that are shaped by resource scarcity. By contrast, Inuit recommended person-centred tuberculosis care that is supportive and responsive to community needs. Changes will necessitate reconciliation- and decolonization-aligned policy changes and increased resources.
Much of the data about physician harassment and discrimination come from self-report surveys or qualitative data. We used publicly available sources to systematically identify physician-originating sex- and gender-based harassment and discrimination reported over a 5-year period. We performed systematic searches of Canadian news outlets (Canadian Newsstream), legal decisions (Canadian Legal Information Institute), and regulatory body notifications (websites of colleges of physicians and surgeons) to identify instances of harassment and discrimination involving a physician reported from Aug. 1, 2019, to July 31, 2024, in Canada. Data extraction was performed in duplicate. We performed comparative case analysis to generate insights related to physician-originating sex- and gender-based harassment and discrimination. We found 1437 records that described 208 physician respondents involved in concerns of sex- or gender-based harassment or discrimination during the study period. Of the estimated 689 victims, 585 were women or girls (84.9%) and at least 40 were children (5.8%). Sexual-boundary violations or sexual misconduct was the most common category (n = 75, 36.1%) followed by sexual assault (n = 65, 31.3%). A police complaint occurred for 72 cases (34.6%), and 29 physicians were convicted (65.9% of trials). Comparative case analysis generated several important themes, including physicians not self-reporting criminal convictions, resulting in no practice restrictions; news media being an important mechanism for additional complainants to come forward; and a substantial proportion of physician respondents having had a previous complaint (29.8%). In our study, most victims of physician-originating sex- or gender-based harassment or discrimination in Canada were women or girls, and many physician respondents were not restricted in their practice. Gaps in remediation and monitoring of physicians with previous complaints are apparent; analysis of current regulatory practices would be more feasible if data reporting by Canadian regulatory bodies were more transparent.
Current screening tools for harmful alcohol consumption have fallen out of step with recent guidance on the health risks of alcohol. To address this gap, the Canadian Research Initiative in Substance Matters updated the screening recommendations for high-risk drinking and alcohol use disorder (AUD) in the 2023 national clinical practice guideline. Following a systematic review of literature published between Jan. 1, 2013, and Feb. 24, 2023, that examined screening tools for high-risk drinking and AUD, the updated recommendations were developed by a multidisciplinary national committee, which included people with lived and living experience. We scored the recommendations and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation tool. We used the Appraisal of Guidelines for Research and Evaluation II instrument and the Guidelines International Network's principles for disclosure of interests and management of conflicts to ensure the update met international standards for transparency, high quality, and methodological rigour. Acknowledging that time constraints are the most commonly reported barrier to universal alcohol screening, we developed 5 recommendations involving a simple screening method, to identify and address both unhealthy alcohol consumption and more serious problems related to alcohol. The recommendations include asking all patients about alcohol consumption and providing educational support to all those who drink above Canada's Guidance on Alcohol and Health's low-risk threshold. We propose a simple screening algorithm to optimize and tailor further intervention, including when to assess for possible AUD. The revised screening recommendations represent a timesaving and pragmatic approach intended to be a resource for universal screening for alcohol risks and problems. The recommendations streamline the process of identifying and addressing the health needs of those who consume alcohol in a hazardous way or may have more serious problems related to alcohol.
The COVID-19 pandemic affected the epidemiology of respiratory syncytial virus (RSV). We sought to describe tertiary care hospital admissions associated with pediatric RSV in 2022/23 in Canada and to assess pandemic-related changes. We conducted active surveillance of hospital-admitted infants and children aged 0 to 16 years at 13 Immunization Monitoring Program, Active (IMPACT) centres. We compared RSV-associated hospital admissions in 2022/23 with those in the prepandemic period (2017/18 through 2019/20). We calculated province-specific and age-stratified proportions of all-cause hospital admissions with RSV detection and age-stratified proportions of RSV-associated intensive care unit (ICU) admissions. We performed seasonal autoregressive integrated moving average (SARIMA) time-series analyses. In 2022/23, 5362 RSV-associated hospital admissions occurred, including 1260 (23.5%) ICU admissions, both more than double the prepandemic yearly averages. Overall, the median age increased from 6 (interquartile range [IQR] 1 to 20) months to 9 (IQR 2 to 27) months (p < 0.001). The proportion of RSV-associated hospital admissions among all-cause admissions increased by 3.5 percentage points (95% confidence interval [CI] 3.3 to 3.7 percentage points), to 6.8% (95% CI 6.6% to 7.0%). Whereas 41.5% of RSV-associated hospital admissions were among infants younger than 6 months, this age group accounted for 62.1% of ICU admissions. Overall, the ICU proportion remained constant; however, the odds of ICU admission among infants younger than 6 months increased (adjusted odds ratio 1.35, 95% CI 1.2 to 1.52) compared with the prepandemic period. National weekly incidence in 2022/23 peaked earlier and higher, and persisted longer than expected by SARIMA. In 2022/23, the number of RSV-associated hospital admissions and ICU admissions increased dramatically in Canadian pediatric hospitals. The greatest burden remained in infants younger than 6 months. Strategies for RSV immunization for young infants may have a substantial public health impact.
Cancer is the leading cause of death and has major health and economic impacts on people in Canada. We sought to provide updated estimates of cancer incidence and mortality to highlight progress and areas of need for planning and awareness. We estimated cases, deaths, and age-standardized incidence (ASIR) and mortality rates (ASMR) in 2026, standardized to the 2021 Canadian standard population, by sex and province or territory. We used data from the Canadian Cancer Registry (until 2022) and the Canadian Vital Statistics Death Database (until 2023). We modelled incidence and mortality with the canproj projection package. In Canada, an estimated 254 100 people will be diagnosed with cancer and 87 900 will die from cancer in 2026. Overall, the ASIR (591.4 per 100 000) and the ASMR (200.0 per 100 000) are projected to decrease from previous years. Lung, breast, prostate, and colorectal cancers are projected to account for 47% of all new cases. The ASIR for all cancers combined is anticipated to be 16% higher among males than females (642.2 v. 553.9 per 100 000), and the ASMR 36% higher (235.8 v. 172.8 per 100 000). Notable findings in cancer-specific rates by sex were observed. Age-standardized cancer incidence and mortality rates are projected to decline in Canada; however, the numbers of new cases and deaths are expected to remain at high levels, given the growing and aging population, with differential impacts expected by sex. These findings suggest that continued investment and diligence are needed to continue the major progress in cancer control in the face of changing population demographics.
Low-value care exposes patients to unnecessary risk and wastes scarce health resources. We aimed to determine if patient- or clinician-directed nudges could reduce low-value care for low back pain in the emergency department. We conducted a 2 × 2 factorial, cluster randomized controlled trial involving patients with low back pain presenting to emergency departments. Eight emergency departments were randomized to receive patient nudges (6 electronic information posters discouraging unnecessary imaging and opioids, displayed on 55-inch screens in waiting rooms), clinician nudges (3 electronic health record alerts that provided indications for lumbar spine imaging and suggested alternatives to opioids), both patient and clinician nudges, or no nudges. The primary outcome was the proportion of encounters for low back pain with low-value care, defined as non-indicated lumbar spine imaging test, opioid prescription at discharge, or both. We calculated odds ratios (ORs), adjusted for baseline and clustering. There were 3770 encounters for low back pain during the study period. The overall baseline prevalence of low-value care was 41.6%. During the intervention period, the proportion of encounters with low-value care reduced to 36.4% with patient nudges versus 38.1% without, but the difference was not significant (adjusted OR 0.80, 95% confidence interval [CI] 0.51 to 1.27). The proportion of encounters with low-value care was 39.4% with clinician nudges versus 35.0% without (adjusted OR 1.31, 95% CI 0.84 to 2.05). We did not observe an interaction effect between the interventions (p = 0.4). The patient nudge may have reduced strong beliefs among patients in the value of imaging for low back pain. We found no important differences in secondary outcomes. Nudges - including waiting room information posters targeting patients and electronic health record alerts targeting clinicians - did not reduce low-value care in emergency departments. www.anzctr.org.au, ACTRN12623001000695.
Canada has achieved near-universal adoption of electronic health records (EHRs) and yet interoperability, the secure exchange and use of health data across different systems and settings, remains limited. We aimed to describe the current state of EHRs in 10 provincial and 3 territorial jurisdictions in Canada and evaluate the maturity of their interoperability using a structured interoperability assessment model. We conducted an environmental scan of EHR use and interoperability across all provinces and territories using Canada Health Infoway documents and structured interviews with 23 subject matter experts. Using a rigorously designed interoperability maturity model, we evaluated jurisdictions across 4 enabler dimensions (governance, legislation and standards, incentives and capacity-building, and technical infrastructure) and 4 interoperability status dimensions (community EHRs, hospital EHRs, patient portals, and system analytics). We found that, although EHR adoption was high, maturity of EHR interoperability was low and uneven across Canada. Integrated EHR health data exchange was limited, and nearly all jurisdictions lacked EHR interoperability between hospitals, community specialists, and primary care. Data exchange between primary care and specialists, and between hospitals and community settings, was heavily dependent on fax (traditional or online) or mailed letters in every jurisdiction. Patient portal contents and system-level analytics using EHR data were underdeveloped nationally. No jurisdiction was advanced in all dimensions. Although most jurisdictions showed strength in at least 1 area, they also exhibited many areas for growth. We identified 8 key barriers to interoperability, each of which can be overcome. Canada has widespread EHR adoption, but maturity of EHR interoperability and the enabling conditions required for true interoperability are low and inconsistent across jurisdictions. Strengthening governance, legislation, standards, incentives, and technical infrastructure - supported by national legislation to mandate interoperability across different EHRs - will be essential to advancing connected care across Canada and realizing widespread benefits for patients, clinicians, and health systems.
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