Excisão tipo 2 do colo uterino na tabela de procedimentos, medicamentos, órteses/próteses e materiais especiais do SUS / Excision type 2 of the uterine cervix in the table of procedures, medicines, orthoses / prosthetics and special materials of the SUS

Tomando como base a Portaria SAS/MS nº 497, de 09 de maio de 2016, que aprova as Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero e estabelece nova nomenclatura para os procedimentos relacionados ao rastreamento dessa neoplasia maligna, solicitam-se as alterações de nome, descrição e atributos de procedimentos e a inclusão de um novo procedimento na Tabela de Procedimentos, Medicamentos e OPM do SUS. A constatação de que alguns termos têm sido usados indistintamente para procedimentos excisionais diferentes motivou a inclusão de uma classificação de tipos de excisão em função de cada tipo de ZT [zona de transformação] na nova nomenclatura colposcópica recomendada pela IFCPC [International Federation for Cervical Pathology and Colposcopy] a partir de 2011. No Brasil, também se observa certa confusão. O termo CAF (Cirurgia de Alta Frequência), introduzido no final dos anos 1980, serviu para popularizar o método de excisão da ZT com JEC [junção escamo-colunar] visível e até o primeiro centímetro do canal. Esse termo foi utilizado em material para orientação profissional preparado pela ABPTGIC [Associação Brasileira de Patologia do Trato Genital Inferior e Colposcopia] e mantido nas diretrizes brasileiras de 20064. Todavia, o termo CAF passou a ser utilizado indistintamente para biópsias e, com a disseminação de técnicas de conização por eletrocirurgia, tornou-se muito difícil saber qual o procedimento realizado quando havia o relato de uma mulher ter sido submetida a uma CAF. Para disciplinar o uso desses termos, o Ministério da Saúde definiu, em 2010, que o tratamento excisional ambulatorial deveria ser chamado de EZT [excisão da zona de transformação]. Qualquer outra abordagem que tenha por objetivo retirar a ZT endocervical era denominada conização, independente do método utilizado para sua realização (por eletrocirurgia, por laser ou bisturi convencional). A Inclusão de procedimento Consiste na retirada da zona de transformação ectocervical e parcialmente endocervical, por meio da cirurgia de alta frequência e com profundidade máxima de 1,5 a 2,0 cm. Possui objetivo terapêutico, sendo realizado ambulatorialmente, sob anestesia local e visão colposcópica. Recomendada para o tratamento de lesões pré-invasivas diagnosticadas por biópsia prévia ou como parte do método "ver e tratar" quando a zona de transformação está completamente visível, mas tem componente endocervical (junção escamo-colunar completamente visível, mas situada na endocérvice ­ zona de transformação tipo 2). Ressalta-se que esta solicitação visa a adequar os procedimentos tabelados às novas descrições adotadas nas Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero, de 2016, e permitir melhor codificação e informação sobre casos atendidos e os procedimentos realizados para o tratamento cirúrgico resultante do rastreamento do câncer do colo do útero no Sistema Único de Saúde. A inclusão do novo procedimento não traz impacto financeiro, pois trata-se de duplicação do procedimento 04.09.06.008-9, para especificar a profundidade intermediária da retirada da zona de transformação (de 1,5 a 2,0 cm), ficando esse procedimento relativo à profundidade de até 1,0 cm e o procedimento 04.09.06.003-8, a 2,0 a 2,5 cm, classificação que melhor orienta a conduta terapêutica subsequente e o prognóstico dos casos. Na data de 06/10/2016, em sua 49ª Reunião ordinária, os membros da CONITEC presentes na reunião do plenário deliberaram pela incorporação do procedimento "Excisão Tipo 2 do Colo Uterino" na Tabela de Procedimentos, Medicamentos, Órteses/Próteses e Materiais Especiais do SUS. A recomendação será encaminhada para decisão do Secretário. Foi assinado o Registro de Deliberação nº 216/2016. A Portaria Nº 39, de 30 de novembro de 2016 - Torna pública a decisão de incorporar o procedimento "Excisão Tipo 2 do Colo Uterino" na Tabela de Procedimentos, Medicamentos, Órteses/Próteses e Materiais Especiais, no âmbito do Sistema Único de Saúde - SUS.

Utilisation de l'imagerie par résonance magnétique en présence de douleurs musculosquelettiques chez les personnes adultes du Québec: Indications justifiant le recours à l'IRM en présence de douleurs musculosquelettiques / Use of magnetic resonance imaging in the presence of musculoskeletal pain in adults in Quebec: Indications justifying the use of MRI in the presence of musculoskeletal pain

INTRODUCTION: La douleur d'origine musculosquelettique (DMS) est un problème de santé très commun qui englobe une vaste gamme d'affections touchant les os, les ligaments, les tendons, les muscles et les articulations. Ces douleurs parfois importantes peuvent restreindre le fonctionnement physique et porter significativement atteinte à la qualité de vie. Les causes des DMS sont multiples. L'imagerie médicale est souvent utilisée parmi les différents examens médicaux pour investiguer la cause de ces douleurs. L'imagerie par résonance magnétique (IRM) est indiquée et constitue l'instrument de choix dans plusieurs situations cliniques lors de DMS. On attribue à cet outil diagnostique de plus en plus d'indications cliniques validées par des données probantes. De plus, l'IRM remplace parfois des interventions plus effractives et plus coûteuses. Toutefois, au regard des constats découlant de diverses publications scientifiques, il existe actuellement une controverse quant à une possible surutilisation de l'IRM lors du diagnostic et du suivi des patients souffrant de DMS. La situation québécoise en la matière n'est pas connue. C'est dans ce contexte que le ministère de la Santé et des Services sociaux (MSSS) a mandaté l'Institut national d'excellence en santé et en services sociaux (INESSS) pour qu'il documente cette problématique et formule des recommandations afin d'optimiser l'utilisation de l'IRM dans les cas de DMS. Pour éclairer les décideurs et les cliniciens sur cette question, l'INESSS publie un avis en trois volets: i. Un portrait de l'utilisation globale de l'IRM, au Québec, et une analyse comparative avec les provinces canadiennes et autres pays ou territoires similaires; ii. Une synthèse des lignes directrices relatives aux demandes d'IRM lors de DMS; iii. Une revue des stratégies et outils pour favoriser une utilisation optimale de l'IRM. MÉTHODE: Chaque volet utilise une méthode qui lui est propre pour repérer et analyser les données probantes et contextuelles. Ces analyses et revues (systématiques ou narratives) sont réalisées selon les normes de pratique édictées. Les méthodologies respectives à chacun des volets sont décrites en détail dans les documents associés. Des représentants des parties prenantes (Comité de suivi) et des experts (Comité consultatif) ont accompagné l'INESSS à différentes étapes de la production scientifique. L'équipe de projet de l'INESSS, accompagnée par le Comité consultatif, a élaboré les recommandations qui ont été ensuite soumises pour avis au Comité de suivi. Puis, le rapport préliminaire des résultats a été envoyé en révision scientifique externe. RÉSULTATS: Pour identifier les recommandations basées sur les données probantes scientifiques, les chercheurs ont réalisé une revue des guides de « bon usage ¼ en imagerie. Les critères de sélection étaient les suivants : documents publiés entre 2010 et 2016; de production originale; qui reposent sur une analyse systématisée de la littérature; qui incluent dans le processus un groupe interdisciplinaire de professionnels; et qui formulent les recommandations lors de consensus formels d'experts ou lors de conférences de consensus. Cinq guides provenant respectivement des États-Unis, de la France, du Royaume-Uni, de l'Australie et du Canada ont servi d'assise à l'analyse comparative des recommandations. Afin de s'assurer que les recommandations étaient en adéquation avec la littérature la plus récente, l'INESSS a effectué une recherche exhaustive des revues systématiques et des guides de pratique clinique. Les chercheurs ont repéré 53 documents pertinents. Ils ont ciblé les indications cliniques propres à la lombalgie, à la cervicalgie, à la gonalgie et à la douleur à l'épaule qui conjointement, représentent près des trois quarts du volume des IRM réalisées dans le cadre des DMS. Globalement, les recommandations en rapport à l'IRM étaient somme toute homogènes. Il fait consensus que les indications cliniques relatives à une IRM se basent sur une évaluation clinique bien menée. Les anomalies à l'IRM sont très fréquentes chez les sujets asymptomatiques et toute attribution de causalité doit forcément être faite après corrélation avec les signes et les symptômes cliniques. Les recommandations élaborées dans le cadre de ces travaux sont le reflet de recommandations consensuelles provenant de guides internationaux. Les quelques discordances présentes ont été résolues à l'aide de la revue complémentaire de la littérature et de la consultation d'experts. Les recommandations cliniques détaillées se retrouvent dans le document associé au volet 2. Un total de 37 situations cliniques sont couvertes. CONCLUSION: Le portrait de l'utilisation de l'IRM pour les DMS, au Québec, confirme une utilisation en croissance de l'imagerie par résonance magnétique. La comparaison avec d'autres régions ou pays montre que l'utilisation québécoise n'est pas l'une des plus élevées et qu'il y a probablement place à un gain de productivité pour certaines des installations existantes. Par contre, aucune donnée ne peut servir à se prononcer sur la pertinence des examens. Les indications cliniques sont en grande majorité consensuelles entre les guides de bon usage internationaux. Les experts québécois sont en congruence avec celles-ci et des outils cliniques sont proposés. Des stratégies organisationnelles pour optimiser la pertinence de l'IRM, la plus prometteuse est l'ordonnance électronique, accompagnée du soutien à la décision clinique. Les équipes interdisciplinaires spécialisées en DMS constituent une piste d'intérêt dont l'évaluation est à approfondir. Les stratégies financières et de gouverne ont été mises en œuvre dans d'autres pays ou régions, mais leurs répercussions sont variables quant à l'efficience de l'IRM dans les DMS. Dans les stratégies auprès des professionnels, l'utilisation de l'audit-rétroaction n'a pas eu d'effet statistiquement significatif pour optimiser la pertinence de l'imagerie dans les DMS, mais les initiatives d'amélioration de la qualité qui y ont recours sont prometteuses. L'efficacité des stratégies auprès des patients est à surveiller dans la littérature et dans les expériences en cours au Québec. Puisque le contexte de mise en œuvre a une importance majeure dans l'efficacité des stratégies et des outils, il est suggéré de recourir à une approche graduelle qui comprend un suivi des résultats pour le Québec. Des indicateurs de suivi de la pertinence existent, mais la faisabilité d'en implanter dans la province dépend des systèmes d'information. De tels indicateurs devront être élaborés pour le Québec, de pair avec les outils cliniques informatisés. RECOMMANDATIONS: Plusieurs pistes d'optimisation de la pertinence de l'IRM, la force de leur preuve et leurs limites ont été soulevées dans le présent avis. L'opinion des experts du Comité consultatif et des parties prenantes du Comité de suivi sur les données disponibles et le contexte québécois a été prise en compte et permet à l'INESSS de recommander que: 1) le MSSS: -conçoive un formulaire standardisé de prescription de l'IRM (intégrant les indications pertinentes) relatif aux douleurs musculosquelettiques pour les médecins référents; -pilote et évalue des systèmes d'ordonnance électronique avec soutien à la décision clinique pour l'imagerie (les systèmes pilotés doivent idéalement permettre l'exploitation des données colligées); -explore l'évaluation de la pertinence et de la faisabilité d'implanter, au Québec, des équipes interdisciplinaires spécialisées en DMS dans un continuum de soins relatifs aux douleurs musculosquelettiques. 2) les CISSS / CIUSSS: -se dotent de moyens pour soutenir des activités d'amélioration de la qualité avec audit-rétroaction aux milieux cliniques sur la pertinence de l'IRM dans les cas de DMS. 3) les fédérations médicales (FMOQ, FMSQ) et les programmes universitaires: -mettent sur pied des activités novatrices et des outils de formation et de maintien des compétences en douleurs musculosquelettiques dans un contexte de pertinence des interventions.(AU)

INTRODUCTION: Musculoskeletal pain (MSP) is a very common health problem that encompasses a vast array of conditions that affect the bones, ligaments, tendons, muscles and joints. It is sometimes severe and can limit physical functioning and significantly impair quality of life. There are many causes of MSP. Medical imaging is one of the different medical examinations for investigating the cause of such pain, and it is often used for this purpose. Magnetic resonance imaging (MRI) is indicated and is the instrument of choice in several clinical situations involving MSP. This diagnostic tool is being granted an increasing number of evidence-based clinical indications. Furthermore, MRI is sometimes used in place of more invasive and more expensive procedures. However, based on observations from various scientific publications, there is currently some debate over the possible overuse of MRI in the diagnosis and follow-up of patients with MSP. The situation in Québec in this regard is not known. It was in this context that the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d'excellence en santé et en services sociaux (INESSS) to document this problem and to make recommendations for optimizing the use of MRI in cases of MSP. To enlighten decision-makers and clinicians about this matter, INESSS is publishing an evaluation in three parts: i. A description of the overall use of MRI in and a comparative analysis with the Canadian provinces and other, similar territories or countries; ii. A summary of the guidelines for ordering an MRI for MSP; iii. A review of the strategies and tools to promote the optimal use of MRI. METHOD: Each part uses its own methodology to identify and analyze the evidence and contextual data. These analyses and reviews (systematic and narrative) were carried out in accordance with the prescribed standards of practice. The respective methodologies for the different parts are described in detail in the related documents. Stakeholder representatives (Monitoring Committee) and experts (Advisory Committee) supported INESSS at different stages of its scientific production. Supported by the Advisory Committee, INESSS's project team developed recommendations, which were then submitted to the Monitoring Committee for its opinion. Subsequently, the preliminary report was sent for external scientific review. RESULTS: A review of systematic reviews and health technology assessment (HTA) reports was conducted to identify effective tools and strategies to promote appropriate imaging. The information was supplemented by a brief review of the grey literature from comparable jurisdictions to identify initiatives of interest. Among the organizational strategies evaluated, computerized physician order entry (CPOE) shows a moderate level of evidence in the imaging literature. It can be effective in influencing. the appropriateness and volume of imaging orders, especially when certain implementation conditions are present: CPOE in an integrated-care system, CPOE with integrated clinical decision support, and audit and feedback in the implementation of these tools. Clinical decision support tools, such as appropriateness criteria reminders on a standardized order form, are promising. The implementation strategy depends, among other things, on the clinical setting (hospital or ambulatory) and its level of computerization. Another organizational strategy identified is the creation of interdisciplinary MSP teams to support primary care physicians. Their role is to triage cases requiring a consultation or specialized examinations, to quickly perform a clinical evaluation of the patient's musculoskeletal system, to facilitate access to effective treatments, and to improve efficiency (including access to advanced imaging). The United Kingdom has built on these teams in its health -care system. They include health professionals with advanced training in MSP (physiotherapists, occupational therapists, primary care physicians with an interest in MSP, and others). These teams have been presented in the literature as a promising avenue for accessing timely and appropriate care and, indirectly, for appropriate imaging, and this strategy should be explored in greater depth. Financial and governance strategies are mainly illustrated by initiatives in Australia, Ontario and the United States. Financial strategies in the United States and Ontario have been implemented to limit coverage for certain examinations or the fees paid for them. Ontario uses a multifaceted intervention for low back pain that combines the aspect of differentiated remuneration, training for professionals and access to interdisciplinary teams. The impact of this project is being assessed. In the United States, the legal framework and the accreditation of imaging clinics are used to guide referral practice ethics. The objective of the Australian initiative in the area of governance was three-fold: an increase in private imaging resources accredited for coverage by the public plan, a reevaluation of fees to prevent an incentive effect, and more stringent requirements with regard to examination appropriateness and to quality and safety criteria. During the midpoint evaluation, the initiatives aimed at improving imaging order appropriateness proved more difficult to implement than expected and had not yielded the desired efficiency gains, while at the same time, there had been a large increase in the number of examinations due to the opening up of coverage in private-sector imaging. Implementation strategies aimed at health professionals, such as audit and feedback and educational materials as isolated interventions, have not been shown to be statistically effective in the case of imaging, but they could have a clinically significant impact in multifaceted interventions. Medical education initiatives aimed at equipping physicians to field patient requests have not been found to have an impact on imaging utilization, but initiatives for training physicians to view differently the role of imaging in evaluating a patient are underway and should be followed. In the studies consulted, implementation strategies aimed at patients (media campaign) have not been shown to have a meaningful effect on behaviours in the medium term. Strategies aimed at better informing patients and including them in the approach to ensure appropriateness should be explored. In the diagnostic area of interest here, the literature supports the implementation of tailored strategies in health-care facilities, and there are several promising avenues: reminders, CPOE and interdisciplinary MSP teams. CONCLUSION: The overview of the use of MRI in MSP in Québec confirms that its use is growing. A comparison with other jurisdictions shows that this use is not one of the highest and that there is probably room for increased productivity at certain existing facilities. However, there are no data for commenting on the appropriateness of these examinations. For the vast majority of the clinical indications, there is a consensus among the international appropriate use guidelines. Experts in Québec are in agreement with these indications, and clinical tools have been proposed. Of the organizational strategies for optimizing MRI appropriateness, the most promising one is CPOE with clinical decision support. Interdisciplinary MSP teams are an avenue of interest that warrants further evaluation. Financial and governance strategies have been put in place in other jurisdictions, but their impact on the efficiency of MRI in MSP varies. In implementation strategies targeting health professionals, the use of audit and feedback has not had a statistically significant impact on optimizing imaging appropriateness in MSP, but quality improvement initiatives that use audit and feedback are promising. The effectiveness of implementation strategies targeting patients should be monitored in the literature and in the ongoing initiatives in Québec. Since the implementation context is of great importance for the effectiveness of strategies and tools, a gradual implementation approach with results monitoring is recommended for the strategies proposed for Québec. Indicators for monitoring appropriateness do exist, but the feasibility of implementing them in Québec depends on the information systems. These indicators should be developed for Québec, together with CPOE. RECOMMENDATIONS: Several ways to optimize MRI appropriateness were raised during the discussion. In light of the available data and the Québec context, INESSS recommends: 1) That the MSSS: -Create a standardized MRI order form (with the relevant indications) for musculoskeletal pain for referring physicians; -Pilot and evaluate CPOE with clinical decision support for imaging (ideally, these systems should permit the use of collected data); -Explore the assessment of the appropriateness and feasibility of setting up interdisciplinary MSP teams in a continuum of MSP care. 2) That CISSSs and CIUSSSs: -Institute the means to support quality improvement activities with audit and feedback in their clinical facilities on the appropriateness of MRI in MSP. 3) That the medical federations (the FMOQ and FMSQ) and university programs: -Set up innovative activities and training and maintenance-of-compet ence tools for musculoskeletal pain in a context of intervention appropriateness.(AU)

Utilisation de l'imagerie par résonance magnétique en présence de douleurs musculosquelettiques chez les personnes adultes du Québec: Stratégies et outils favorisant une utilisation optimale de l'IRM / Use of magnetic resonance imaging in the presence of musculoskeletal pain in adults in Quebec: Strategies and tools for optimal use of MRI

INTRODUCTION: La douleur d'origine musculosquelettique (DMS) est un problème de santé très commun qui englobe une vaste gamme d'affections touchant les os, les ligaments, les tendons, les muscles et les articulations. Ces douleurs parfois importantes peuvent restreindre le fonctionnement physique et porter significativement atteinte à la qualité de vie. Les causes des DMS sont multiples. L'imagerie médicale est souvent utilisée parmi les différents examens médicaux pour investiguer la cause de ces douleurs. L'imagerie par résonance magnétique (IRM) est indiquée et constitue l'instrument de choix dans plusieurs situations cliniques lors de DMS. On attribue à cet outil diagnostique de plus en plus d'indications cliniques validées par des données probantes. De plus, l'IRM remplace parfois des interventions plus effractives et plus coûteuses. Toutefois, au regard des constats découlant de diverses publications scientifiques, il existe actuellement une controverse quant à une possible surutilisation de l'IRM lors du diagnostic et du suivi des patients souffrant de DMS. La situation québécoise en

INTRODUCTION: La douleur d'origine musculosquelettique (DMS) est un problème de santé très commun qui englobe une vaste gamme d'affections touchant les os, les ligaments, les tendons, les muscles et les articulations. Ces douleurs parfois importantes peuvent restreindre le fonctionnement physique et porter significativement atteinte à la qualité de vie. Les causes des DMS sont multiples. L'imagerie médicale est souvent utilisée parmi les différents examens médicaux pour investiguer la cause de ces douleurs. L'imagerie par résonance magnétique (IRM) est indiquée et constitue l'instrument de choix dans plusieurs situations cliniques lors de DMS. On attribue à cet outil diagnostique de plus en plus d'indications cliniques validées par des données probantes. De plus, l'IRM remplace parfois des interventions plus effractives et plus coûteuses. Toutefois, au regard des constats découlant de diverses publications scientifiques, il existe actuellement une controverse quant à une possible surutilisation de l'IRM lors du diagnostic et du suivi des patients souffrant de DMS. La situation québécoise en la matière n'est pas connue. C'est dans ce contexte que le ministère de la Santé et des Services sociaux (MSSS) a mandaté l'Institut national d'excellence en santé et en services sociaux (INESSS) pour qu'il documente cette problématique et formule des recommandations afin d'optimiser l'utilisation de l'IRM dans les cas de DMS. Pour éclairer les décideurs et les cliniciens sur cette question, l'INESSS publie un avis en trois volets: i. Un portrait de l'utilisation globale de l'IRM, au Québec, et une analyse comparative avec les provinces canadiennes et autres pays ou territoires similaires; ii. Une synthèse des lignes directrices relatives aux demandes d'IRM lors de DMS; iii. Une revue des stratégies et outils pour favoriser une utilisation optimale de l'IRM. MÉTHODE: Chaque volet utilise une méthode qui lui est propre pour repérer et analyser les données probantes et contextuelles. Ces analyses et revues (systématiques ou narratives) sont réalisées selon les normes de pratique édictées. Les méthodologies respectives à chacun des volets sont décrites en détail dans les documents associés. Des représentants des parties prenantes (Comité de suivi) et des experts (Comité consultatif) ont accompagné l'INESSS à différentes étapes de la production scientifique. L'équipe de projet de l'INESSS, accompagnée par le Comité consultatif, a élaboré les recommandations qui ont été ensuite soumises pour avis au Comité de suivi. Puis, le rapport préliminaire des résultats a été envoyé en révision scientifique externe. RESULTS: A review of systematic reviews and health technology assessment (HTA) reports was conducted to identify effective tools and strategies to promote appropriate imaging. The information was supplemented by a brief review of the grey literature from comparable jurisdictions to identify initiatives of interest. Among the organizational strategies evaluated, computerized physician order entry (CPOE) shows a moderate level of evidence in the imaging literature. It can be effective in influencing the appropriateness and volume of imaging orders, especially when certain implementation conditions are present: CPOE in an integrated-care system, CPOE with integrated clinical decision support, and audit and feedback in the implementation of these tools. Clinical decision support tools, such as appropriateness criteria reminders on a standardized order form, are promising. The implementation strategy depends, among other things, on the clinical setting (hospital or ambulatory) and its level of computerization. Another organizational strategy identified is the creation of interdisciplinary MSP teams to support primary care physicians. Their role is to triage cases requiring a consultation or specialized examinations, to quickly perform a clinical evaluation of the patient's musculoskeletal system, to facilitate access to effective treatments, and to improve efficiency (including access to advanced imaging). The United Kingdom has built on these teams in its health -care system. They include health professionals with advanced training in MSP (physiotherapists, occupational therapists, primary care physicians with an interest in MSP, and others). These teams have been presented in the literature as a promising avenue for accessing timely and appropriate care and, indirectly, for appropriate imaging, and this strategy should be explored in greater depth. Financial and governance strategies are mainly illustrated by initiatives in Australia, Ontario and the United States. Financial strategies in the United States and Ontario have been implemented to limit coverage for certain examinations or the fees paid for them. Ontario uses a multifaceted intervention for low back pain that combines the aspect of differentiated remuneration, training for professionals and access to interdisciplinary teams. The impact of this project is being assessed. In the United States, the legal framework and the accreditation of imaging clinics are used to guide referral practice ethics. The objective of the Australian initiative in the area of governance was three-fold: an increase in private imaging resources accredited for coverage by the public plan, a reevaluation of fees to prevent an incentive effect, and more stringent requirements with regard to examination appropriateness and to quality and safety criteria. During the midpoint evaluation, the initiatives aimed at improving imaging order appropriateness proved more difficult to implement than expected and had not yielded the desired efficiency gains, while at the same time, there had been a large increase in the number of examinations due to the opening up of coverage in private-sector imaging. Implementation strategies aimed at health professionals, such as audit and feedback and educational materials as isolated interventions, have not been shown to be statistically effective in the case of imaging, but they could have a clinically significant impact in multifaceted interventions. Medical education initiatives aimed at equipping physicians to field patient requests have not been found to have an impact on imaging utilization, but initiatives for training physicians to view differently the role of imaging in evaluating a patient are underway and should be followed. In the studies consulted, implementation strategies aimed at patients (media campaign) have not been shown to have a meaningful effect on behaviours in the medium term. Strategies aimed at better informing patients and including them in the approach to ensure appropriateness should be explored. In the diagnostic area of interest here, the literature supports the implementation of tailored strategies in health-care facilities, and there are several promising avenues: reminders, CPOE and interdisciplinary MSP teams. CONCLUSION: The overview of the use of MRI in MSP in Québec confirms that its use is growing. A comparison with other jurisdictions shows that this use is not one of the highest and that there is probably room for increased productivity at certain existing facilities. However, there are no data for commenting on the appropriateness of these examinations. For the vast majority of the clinical indications, there is a consensus among the international appropriate use guidelines. Experts in Québec are in agreement with these indications, and clinical tools have been proposed. Of the organizational strategies for optimizing MRI appropriateness, the most promising one is CPOE with clinical decision support. Interdisciplinary MSP teams are an avenue of interest that warrants further evaluation. Financial and governance strategies have been put in place in other jurisdictions, but their impact on the efficiency of MRI in MSP varies. In implementation strategies targeting health professionals, the use of audit and feedback has not had a statistically significant impact on optimizing imaging appropriateness in MSP, but quality improvement initiatives that use audit and feedback are promising. The effectiveness of implementation strategies targeting patients should be monitored in the literature and in the ongoing initiatives in Québec. Since the implementation context is of great importance for the effectiveness of strategies and tools, a gradual implementation approach with results monitoring is recommended for the strategies proposed for Québec. Indicators for monitoring appropriateness do exist, but the feasibility of implementing them in Québec depends on the information systems. These indicators should be developed for Québec, together with CPOE. RECOMMENDATIONS: Several ways to optimize MRI appropriateness were raised during the discussion. In light of the available data and the Québec context, INESSS recommends: -That the MSSS: -Create a standardized MRI order form (with the relevant indications) for musculoskeletal pain for referring physicians; -Pilot and evaluate CPOE with clinical decision support for imaging (ideally, these systems should permit the use of collected data); -Explore the assessment of the appropriateness and feasibility of setting up interdisciplinary MSP teams in a continuum of MSP care. 1) That CISSSs and CIUSSSs: -Institute the means to support quality improvement activities with audit and feedback in their clinical facilities on the appropriateness of MRI in MSP. 2) That the medical federations (the FMOQ and FMSQ) and university programs: -Set up innovative activities and training and maintenance-of-compet ence tools for musculoskeletal pain in a context of intervention appropriateness.(AU)

Summary: use of class 3b and class 4 lasers and intense pulsed light sources for cosmetic procedures in non-medical settings

INTRODUCTION: Body image has always preoccupied people across time and cultures. Today, the search for beauty can be fulfilled with high-power technologies that are relatively easy to use, such as Class 3b and Class 4 lasers and intense pulsed light (IPL) sources. Lasers are devices that amplify light, emitting it in a narrow, coherent optical beam; the beam produced is near-monochromatic, the particles all move in the same direction, and the waves are in phase with one another. Intense pulsed light is based on different physical and technological principles. Unlike lasers, IPL sources emit polychromatic light (non-coherent, between 500 and 1,200 nm), and selected wavelengths are obtained by means of filters. These technologies are used for various cosmetic purposes and applications, including some that clearly come under activities reserved to physicians, while others fall into the grey areas surrounding medicine. Based on the definitions of the different fields of medical activity and on the laws and regulations governing the practice of medicine, this report has limited its scope to examining laser and IPL procedures that do not require medical diagnosis and that may be performed in Québec by operators other than physicians or health professionals, without medical supervision. This report does not purport to determine what does and does not lie within the scope of medicine. Rather, it focuses on the risks inherent in these technologies and on the qualifications required to use them, by taking hair removal as a base case and by dealing more briefly with skin resurfacing and tattoo removal, without ruling on the field of activity to which these practices belong. RESEARCH METHODS: Medline (National Library of Medicine) via PubMed and the Cochrane Library were searched. The grey literature was also examined to take into account the contextual aspects that prompted the request for this report, especially the legal and regulatory provisions framing the use of lasers and IPL by non-physician operators in various countries and regions. In addition, local experts were consulted to validate the contextual evidence and the applicability of the ensuing recommendations. These experts are key actors in the following organizations: Association des dermatologistes du Québec; Collège des médecins du Québec; Comité sectoriel de la main-d'œuvre des services de soins personnels [sector committee on personal services workers]; Ministère de l'Éducation, du Loisir et du Sport; Ministère de l'Emploi et de la Solidarité sociale; and Ministère de la Santé et des Services sociaux. CONCLUSION: Analysis of the scientific and contextual evidence leads to these findings: Class 3b and Class 4 lasers and IPL sources are high-power technologies entailing risks for operators and their customers. The use of these technologies leads to adverse effects that, although minor and transient for the most part, may in some cases be serious; however, scientific evidence does not allow us to determine their frequency or severity, or to link them with the types of professionals using them. Some cosmetic procedures may overlap with activities reserved to physicians when these. procedures are applied to areas of the skin with an underlying medical condition or with the risk of complications requiring medical expertise. Current Canadian safety standards regulate the sale and importation of these devices and their use in health-care facilities, and the safe use of lasers is governed by laws and regulations intended to protect workers' health and safety in all work settings. However, Québec has no law or regulation to protect the health and safety of the public undergoing laser or IPL procedures in non-medical settings. The use of Class 3b and Class 4 lasers and IPL sources is widespread in beauty care centres, but the specific types of devices used are not known. There is no professional order regulating the practice of estheticians or other types of personnel working in the personal services sector and likely to use laser or IPL devices, and the Office des professions du Québec has already denied the application by the Association des électrolystes du Québec to establish a professional order. The Comité sectoriel de la main-d'œuvre des services de soins personnels and the Ministère de l'Éducation, du Loisir et du Sport have already developed their own non-mandatory vocational training programs in laser hair removal, but these programs do not cover other cosmetic laser applications or the use of IPL. The Act respecting Workforce Vocational Training and Qualification (R.S.Q., c. F-5) could fill this regulatory gap in part by standardizing the required occupational skills, establishing vocational training and qualification programs, and determining occupational eligibility requirements for laser or IPL operators working in non-medical settings. In light of these findings, this report is not able to rule either on the safety of laser or IPL procedures by non-physician operators working without medical supervision or on the scope of activities that could be authorized to them in the Québec context. However, given that these technologies present hazards and may lead to adverse effects that are potentially serious when used for cosmetic procedures, and given that there is a serious possibility of interference with the field of medicine, AETMIS has reached the following conclusions, which define the major issues to be dealt with: The boundary between the procedures restricted to the field of medicine and the cosmetic procedures that may be performed by non-physician operators must be clearly established.

Health care technology at home: Issues in organization and delivery in Québec

INTRODUCTION: Most industrialized countries have initiated health care system reforms that are aiming to in-crease the number and scope of health services delivered on an ambulatory basis and at the pa-tient's home. In Québec, this shift is called the "virage ambulatoire". Traditional home health-care services include case management, nursing, personal care, home support (or homemaking), occupational and physical therapies, social work counseling, nutrition counseling, and respiratory therapy. More complex forms of clinical treatments at home are emerging, such as IV therapy, life support/ventilator assistance systems, cancer therapy, palliative care, and ser-vices for persons with AIDS or Alzheimer's dis-ease [CIHI, 2003a]. This report is mainly con-cerned with these latter forms of interventions, i.e. high-tech home care. Technology, we argue, cannot simply be seen as one of several factors driving change in home care, but should be viewed as a pervasive component of a new model of care. The aim of this report is to iden-tify the organizational issues associated with an increased use of health care technology at home and provide recommendations regarding the de-velopment of such services in Québec. This report is organized in six parts. First, we present the rationale for this investigation and describe the methods and data sources. Second, we summarize the features of home health care service developments in Canada and present four problems raised by the increased use of technol-ogy at home. Third, we describe in greater detail the prevalence and patterns of the use of tech-nology in home care services as provided by Québec local community health centres (CLSCs), and highlight potential barriers and opportunities in the expansion of such services. Fourth, we synthesize the organizational, social, ethical, and legal dimensions of technology-enhanced home care from a review of the inter-national literature. Fifth, we analyze how such dimensions could be addressed in the delivery and evaluation of home care services, referring specifically to the Québec health care reform. Finally, in conclusion, we formulate recommen-dations and identify the actors whose decisions and actions might be influenced by this report. TECHNOLOGY AT HOME IN QUÉBEC: A study was conducted in 1999-2001 by the first author of this report (PL) and her colleagues at Université de Montréal. The aim of the research was to identify the organizational, technical, and human factors influencing the use of certain technologies at home by CLSCs. A mail-back survey was sent to CLSCs; the response rate was close to 70%. Almost all responding CLSCs had been involved in the provision of home IV ther-apy. The two most common modes of IV deliv-ery were gravity (81.3% of CLSCs) and pro-grammable pumps (97.9%), whereas the mechanical delivery system was used less fre-quently (58.9%). Oxygen therapy was the second most frequent home care service provided by CLSCs (with fixed concentrators: 83.5% of CLSCs). The provision of services related to parenteral nutrition was limited but still signifi-cant (26.6%). A large proportion of CLSCs (78.1%) indicated that they had been involved in the delivery of peritoneal dialysis care. A major-ity of CLSCs had been involved in the provision of anticoagulant therapy services (87.9%), while a third (35.6%) had been involved in the delivery of IV chemotherapy. Despite the abundant litera-ture underscoring the rapid growth of home telecare, the use of various information technology -based home monitoring services was infrequent. ISSUES IN ORGANIZATION AND DELIVERY: Introducing sophisticated technologies into the home setting has created new types of patients, new treatment possibilities, new roles and re-sponsibilities for providers and caregivers, new ethical dilemmas, and new areas of accountabil-ity. Part 4 of the report is an attempt to clarify and summarize issues that are often entangled both in the literature and in practice. Organiza-tional dimensions of technology-enhanced home care are intimately linked to the characteristics of the home care delivery model, and to the par-ticular needs of patients in terms of care, tech-nology, and support. Social dimensions of the use of technology at home refer to the capacity of the patients and their relatives to maintain sat-isfying relationships, to engage in leisure activi-ties, to raise a family, to carry out social roles, to be employed and earn an income, and to live without discrimination. Several factors suggest that issues of legal liability in home care will in-crease [Kapp, 1995a]: home care is becoming increasingly high-tech; patients are being dis-charged "quicker and sicker"; and the coordina-tion of care provided by various professionals is becoming more complex (making it increasingly difficult to control legal risks). CONCLUSION: Current challenges in the organization and deliv-ery of home care call for immediate policy ac-tions. Sophisticated technology is changing the nature of health systems across industrialized countries, and one of its most significant devel-opments is the use of complex equipment in the patient's home. The use of such equipment often requires the clinical and technical expertise of secondary and tertiary level care providers, as well as a keen understanding of home care pa-tients' needs­an expertise that CLSC home care program staff have developed for particular clientele over the last two decades in Québec. One critical challenge, for the next decade, will be to bring these two types of expertise together in or-der to provide specialized home care that re-mains meaningful for the patients and their rela-tives, while being effective from clinical and organizational perspectives. In this endeavour, coordination among individual care providers and among health organizations is key, as is building the technical and clinical competence of providers, patients, and caregivers. Each of our four recommendations addresses a particular facet of the 'home care problem'. While a global vision of home care should help structure the fu-ture of this service in Québec, regional leader-ship is required to support and implement organ-izational incentives that will enable effective coordination between hospitals and CLSCs or the réseaux locaux de services in which they are now integrated.