Decision aids for people facing health treatment or screening decisions.

BACKGROUND: Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES: To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS: We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA: We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS: Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS: This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS: Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Strategies for involving patients and the public in scaling initiatives in health and social services: A scoping review.

BACKGROUND: Scaling in health and social services (HSS) aims to increase the intended impact of proven effective interventions. Patient and public involvement (PPI) is critical for ensuring that scaling beneficiaries' interests are served. We aimed to identify PPI strategies and their characteristics in the science and practice of scaling in HSS. METHODS: In this scoping review, we included any scaling initiative in HSS that used PPI strategies and reported PPI methods and outcomes. We searched electronic databases (e.g., Medline) from inception to 5 February 2024, and grey literature (e.g., Google). Paired reviewers independently selected and extracted eligible reports. A narrative synthesis was performed and we used the PRISMA for Scoping Reviews and the Guidance for Reporting Involvement of Patients and the Public (GRIPP2). FINDINGS: We included 110 unique reports out of 24,579 records. In the past 5 years, the evidence on PPI in scaling has increased faster than in any previous period. We found 236 mutually nonexclusive PPI strategies among 120 scaling initiatives. Twenty-four initiatives did not target a specific country; but most of those that did so (n = 96) occurred in higher-income countries (n = 51). Community-based primary health care was the most frequent level of care (n = 103). Mostly, patients and the public were involved throughout all scaling phases (n = 46) and throughout the continuum of collaboration (n = 45); the most frequently reported ethical lens regarding the rationale for PPI was consequentialist-utilitarian (n = 96). Few papers reported PPI recruitment processes (n = 31) or incentives used (n = 18). PPI strategies occurred mostly in direct care (n = 88). Patient and public education was the PPI strategy most reported (n = 31), followed by population consultations (n = 30). CONCLUSIONS: PPI in scaling is increasing in HSS. Further investigation is needed to better document the PPI experience in scaling and ensure that it occurs in a meaningful and equitable way. PATIENT AND PUBLIC CONTRIBUTION: Two patients were involved in this review. They shared decisions on review questions, data collection instruments, protocol design, and findings dissemination. REVIEW REGISTRATION: Open Science Framework on 19 August 2020 (https://osf.io/zqpx7/).

Implementation of an integrated primary care prevention and management program for chronic low back pain (LBP): patient-reported outcomes and predictors of pain interference after six months.

BACKGROUND: Integrated primary care programs for patients living with chronic pain which are accessible, interdisciplinary, and patient-centered are needed for preventing chronicity and improving outcomes. Evaluation of the implementation and impact of such programs supports further development of primary care chronic pain management. This study examined patient-reported outcomes among individuals with low back pain (LBP) receiving care in a novel interdisciplinary primary care program. METHODS: Patients were referred by primary care physicians in four regions of Quebec, Canada, and eligible patients received an evidence-based interdisciplinary pain management program over a six-month period. Patients were screened for risk of chronicity. Patient-reported outcome measures of pain interference and intensity, physical function, depression, and anxiety were evaluated at regular intervals over the six-month follow-up. A multilevel regression analysis was performed to evaluate the association between patient characteristics at baseline, including risk of chronicity, and change in pain outcomes. RESULTS: Four hundred and sixty-four individuals (mean age 55.4y, 63% female) completed the program. The majority (≥ 60%) experienced a clinically meaningful improvement in pain intensity and interference at six months. Patients with moderate (71%) or high risk (81%) of chronicity showed greater improvement in pain interference than those with low risk (51%). Significant predictors of improvement in pain interference included a higher risk of chronicity, younger age, female sex, and lower baseline disability. CONCLUSION: The outcomes of this novel LBP program will inform wider implementation considerations by identifying key components for further effectiveness, sustainability, and scale-up of the program.

Evidence on Scaling in Health and Social Care: An Umbrella Review.

Policy Points More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations. The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases. Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally. CONTEXT: Scaling of effective innovations in health and social care is essential to increase their impact. We aimed to synthesize the evidence base on scaling and identify current knowledge gaps. METHODS: We conducted an umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We included any type of review that 1) focused on scaling, 2) covered health or social care, and 3) presented a methods section. We searched MEDLINE (Ovid), Embase, PsycINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstracts (ProQuest), Academic Search Premier (EBSCO), and ProQuest Dissertations & Theses Global from their inception to August 6, 2020. We searched the gray literature using, e.g., Google and WHO-ExpandNet. We assessed methodological quality with AMSTAR2. Paired reviewers independently selected and extracted eligible reviews and assessed study quality. A narrative synthesis was performed. FINDINGS: Of 24,269 records, 137 unique reviews were included. The quality of the 58 systematic reviews was critically low (n = 42). The most frequent review type was systematic review (n = 58). Most reported on scaling in low- and middle-income countries (n = 59), whereas most first authors were from high-income countries (n = 114). Most reviews concerned infectious diseases (n = 36) or maternal-child health (n = 28). They mainly focused on interventions (n = 37), barriers and facilitators (n = 29), frameworks (n = 24), scalability (n = 24), and costs (n = 14). The WHO/ExpandNet scaling definition was the definition most frequently used (n = 26). Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers). CONCLUSIONS: The evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions. Our study highlights knowledge gaps around methodology and research infrastructures to facilitate equitable North-South research relationships. Common efforts are needed to ensure scaling expands the impacts of health and social innovations to broader populations.

Evaluating the impact of continuing professional development courses on physician behavioral intention: a pre-post study with follow-up at six months.

BACKGROUND: Continuing professional development (CPD) for health professionals includes educational activities to maintain or improve skills. We evaluated the impact of a series of CPD courses by identifying factors influencing physicians' intention to adopt targeted behaviors and assessing self-reported behavior adoption six months later. METHODS: In this pre-post study, eligible participants attended at least one in-person course at the Fédération des Médecins Spécialistes du Québec annual meeting in November 2019. Before and afterwards, participants completed CPD-REACTION, a validated questionnaire based on Godin's integrated model for health professional behavior change that measures intention and psychosocial factors influencing intention. We used Wilcoxon signed-rank test to compare pre- and post-course intention scores and linear regression analyses to identify factors influencing intention. We also compared the post-course intention scores of participants reporting a behavior change six months later with the scores of those reporting no behavior change six months later. Qualitative data was collected only six months after courses and responses to open-ended questions were analyzed using the Theoretical Domains Framework. RESULTS: A total of 205/329 course attendees completed CPD-REACTION (response rate 62.3%). Among these participants, 158/329 (48%) completed the questionnaire before CPD courses, 129/329 (39.2%) only after courses and 47/329 (14.3%) at 6 months. Study population included 192 physicians of whom 78/192(40.6%) were female; 59/192(30.7%) were between 50 and 59 years old; and 72/192 (37.5%) were surgical specialist physicians. Mean intention scores before (n = 158) and after (n = 129) courses were 5.74(SD = 1.52) and 6.35(SD = 0.93) respectively. Differences in mean (DM) intention before and afterwards ranged from - 0.31(p = 0.17) to 2.25(p = 0.50). Multivariate analysis showed that beliefs about capabilities (ß = 0.15, p = 0.001), moral norm (ß = 0.75, p < 0.0001), and beliefs about consequences (ß = 0.11, p = 0.04) influenced post-course intention. Post-course intention was correlated with behavior six months later (DM = 0.63; p = 0.02). Qualitative analysis showed that facilitators to behavior adoption after six months were most often related to the TDF domains of beliefs about capabilities. Most frequent barriers to adoption related to lack of resources. CONCLUSIONS: Overall, scores for intention to adopt targeted behaviors increased after the courses. CPD providers could increase participants' intention by including interventions that emphasize beliefs about capabilities, moral norm and beliefs about consequences.

Tools for assessing the scalability of innovations in health: a systematic review.

BACKGROUND: The last decade has seen growing interest in scaling up of innovations to strengthen healthcare systems. However, the lack of appropriate methods for determining their potential for scale-up is an unfortunate global handicap. Thus, we aimed to review tools proposed for assessing the scalability of innovations in health. METHODS: We conducted a systematic review following the COSMIN methodology. We included any empirical research which aimed to investigate the creation, validation or interpretability of a scalability assessment tool in health. We searched Embase, MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library and ERIC from their inception to 20 March 2019. We also searched relevant websites, screened the reference lists of relevant reports and consulted experts in the field. Two reviewers independently selected and extracted eligible reports and assessed the methodological quality of tools. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. RESULTS: We identified 31 reports describing 21 tools. Types of tools included criteria (47.6%), scales (33.3%) and checklists (19.0%). Most tools were published from 2010 onwards (90.5%), in open-access sources (85.7%) and funded by governmental or nongovernmental organizations (76.2%). All tools were in English; four were translated into French or Spanish (19.0%). Tool creation involved single (23.8%) or multiple (19.0%) types of stakeholders, or stakeholder involvement was not reported (57.1%). No studies reported involving patients or the public, or reported the sex of tool creators. Tools were created for use in high-income countries (28.6%), low- or middle-income countries (19.0%), or both (9.5%), or for transferring innovations from low- or middle-income countries to high-income countries (4.8%). Healthcare levels included public or population health (47.6%), primary healthcare (33.3%) and home care (4.8%). Most tools provided limited information on content validity (85.7%), and none reported on other measurement properties. The methodological quality of tools was deemed inadequate (61.9%) or doubtful (38.1%). CONCLUSIONS: We inventoried tools for assessing the scalability of innovations in health. Existing tools are as yet of limited utility for assessing scalability in health. More work needs to be done to establish key psychometric properties of these tools. Trial registration We registered this review with PROSPERO (identifier: CRD42019107095).

Effects of the scope of practice on family physicians: a systematic review.

BACKGROUND: Family medicine is a branch of medicine that manages common and long-term illnesses in children and adults. Family physicians in particular play a major role and their scope of practice is expected to impact patient and population. However, little is known about its impact on physicians. We aimed to assess the effects of scope of practice on family physician outcomes. METHODS: We performed a systematic review that we reported using PRISMA guidelines. For the inclusion criteria, any study exploring an association between the scope of practice and physician outcomes was considered. Three bibliographic databases Medline, Embase, and ERIC were consulted through OVID interface from their respective inceptions to November, 2020. Two reviewers independently selected studies, extracted data and assessed the risk of bias of studies using appropriate tools. We conducted data synthesis using a narrative form. GRADE was used for evaluating quality of cumulative evidence. RESULTS: In total, we included 12 studies with 38,732 participants from 6927 citations identified. Eleven of them were cross-sectional, and one was a cohort study with acceptable methodological quality. We found that: 1) family physicians with diverse clinical and nonclinical activities significantly improve their job satisfaction (p<0.05); 2) family physicians with a variety of clinical practices significantly improve their competences and health status (p<0.05); 3) family physicians who perform clinical procedures (mainly extended to gynecological procedures) significantly improve their psychosocial outcomes (e.g., job satisfaction) (p<0.05); and 4) some associations are not statistically significant (e.g., relation between variety of practice settings and outcomes). We observed that the evidence available has a very low level. CONCLUSIONS: Our findings suggest that the scope of practice may be favorably associated with some family physician outcomes but with a very low level of evidence available. Based on these findings, healthcare system managers could monitor the scope of practice among family physicians and encourage future research in this field. SYSTEMATIC REVIEW REGISTRATION: Our protocol was registered under the number CRD42019121990 in PROSPERO.

Sex and gender analysis in knowledge translation interventions: challenges and solutions.

Sex and gender considerations are understood as essential components of knowledge translation in the design, implementation and reporting of interventions. Integrating sex and gender ensures more relevant evidence for translating into the real world. Canada offers specific funding opportunities for knowledge translation projects that integrate sex and gender. This Commentary reflects on the challenges and solutions for integrating sex and gender encountered in six funded knowledge translation projects. In 2018, six research teams funded by the Canadian Institutes of Health Research's Institute of Gender and Health met in Ottawa to discuss these challenges and solutions. Eighteen participants, including researchers, healthcare professionals, trainees and members of the Institute of Gender and Health, were divided into two groups. Two authors conducted qualitative coding and thematic analysis of the material discussed. Six themes emerged, namely Consensus building, Guidance, Design and outcomes effectiveness, Searches and recruitment, Data access and collection, and Intersection with other determinants of health. Solutions included educating stakeholders on the use of sex and gender concepts, triangulating perspectives of researchers and end-users, and participating in organisations and committees to influence policies and practices. Unresolved challenges included difficulty integrating sex and gender considerations with principles of patient-oriented research, a lack of validated measurement tools for gender, and a paucity of experts in intersectionality. We discuss our findings in the light of observations of similar initiatives elsewhere to inform the further progress of integrating sex and gender into the knowledge translation of health services research findings.

Access and quality of health care in Canada: Insights from 1998 to the present.

This article reviews perceptions of Canada's public and health professionals regarding access and quality of healthcare. Principal data sources were 13 sequential Health Care in Canada (HCIC) surveys, from 1998 to 2018. Over time, the data series reveals that an increasing majority of the public report receiving quality care, rising from a national average of 53% in 2002 to 61% in 2018. Regionally, the variation in quality care has been relatively narrow, ranging from 52% in the Atlantic and Prairie provinces to 65% in Ontario in 2018. Professionals' ratings for delivery of quality care in 2018 were slightly higher than the public, averaging 65% and ranging from 58% among nurses to 72% and 74% among physicians and administrators. Despite the favourable ratings received for quality of healthcare, a persistent and growing issue in all regions of the country is concern around timely access to care. In 1998, 4% of the public rated prolonged wait times as a concern; in 2018, 43% rated it as their greatest concern. Regionally, the variation in 2018 ranged from 34% in the Atlantic provinces to 49% in Alberta. This concern about timely access involves all major components of healthcare delivery and is anticipated to worsen. Proposals to improve timely access have been suggested, with interdisciplinary, team-based care being the most strongly supported proposal. The Canadian Medicare system is currently recognized as a valued component of our national identity. However, sub-optimal access continues to undermine quality of care. In the absence of improved access, healthcare quality and outcomes will also remain sub-optimal.

Support for teams, technology and patient involvement in decision-making associated with support for patient-centred care.

OBJECTIVE: Patient-centred care is recommended to transform healthcare delivery to improve the quality and safety of healthcare. This study aimed to assess the determinants of support for attributes of patient-centred care (PCC) from Canadian public and professionals' perspectives. DESIGN: A national population-based survey, the Health Care in Canada Survey. SETTING: Canada. PARTICIPANTS: One-thousand Canadian adults, 101 doctors, 100 nurses, 100 pharmacists and 104 administrators, randomly selected from online panels based on multiple source recruitment. INTERVENTION: None. MAIN OUTCOME MEASURE: Support for PCC, assessed using a summary score across seven items. RESULTS: Of 1000 Canadian public adults surveyed, 51% were female, 74% were living with another person, and 62% had at least one chronic condition. Only 18% of health professionals were working in teams. Multivariable regression models showed that work in teams (0.24, 95%CI: 0.20, 0.28), use of e-technology (0.29, 95%CI: 0.17, 0.42), and patient older age (0.59, 95%CI: 0.32, 0.86) and involvement in decision-making (0.42, 95%CI: 0.30, 0.55) were significantly associated with higher support for PCC while lower adherence to medications (-0.81, 95%CI: -1.16, -0.47) was associated with a decreased support for attributes of PCC. CONCLUSIONS: The findings confirmed that perceptions of requiring health professionals to work in teams and the use of technology in healthcare are associated with support for PCC from both the public and health professionals. Programs to accelerate the implementation of healthcare teams supported by information and communication technologies are needed to deliver PCC, particularly for individuals living with chronic conditions.

Canada's Evolving Medicare: Patient-Centred Care.

Canada's universal healthcare program, medicare, continues to evolve. An area of care that has gained increasing attention over the past several years is the general concept and specific components of patient centricity in healthcare delivery. This paper compares key measures of patient-centred care practices recorded in the 2013 and 2016 Health Care in Canada (HCIC) surveys, with the most recent preferences of the public and health professionals obtained in the 2018 HCIC survey, including priorities for improved future care. Timely access and caring care were the public's top-supported components of patient-centred care in the 2013 and 2016 HCIC surveys. In the 2018 HCIC survey, the Canadian public's overwhelming choice as the top-priority component of patient-centred care continued to be care readily and timely accessed, provided in a caring and respectful environment and based on need versus the ability to pay. In contrast, the public's lesser-supported option in all surveys was measurement and stakeholder feedback of actual care and outcomes. Among professionals in 2018, timely access and caring care were also rated as the top characteristics of patient-centred care, followed by care supported by research and expert opinion. Also similar to the public, Canadian healthcare professionals in 2018 rated measurement and feedback of delivered care and outcomes at the bottom of their support list. When the public and professionals were asked in the 2018 survey to prioritize their implementation choices for enhanced patient-centred care going forward, both stakeholder groups chose timely access as their first priority. Measurements and feedback of care and outcomes were rated at the lower end of choices in both groups in 2018. In summary, among key stakeholders, healthcare that is not readily and timely accessed remains the perceived greatest impediment to achievement of patient-centred care in contemporary Canadian medicare. The continued reality of undue delay in accessing healthcare in Canada is disturbing. A companion risk going forward is that all other components of patient-centred care will retreat to a level of irrelevance. Measurement and feedback of care, particularly its timeliness of access and outcomes, are necessary to monitor progress, stimulate innovation and ensure the success of Canadian medicare. Things can be better.

Medicare's Evolution: National Pharmacare and Shared Leadership.

Repeated Health Care in Canada (HCIC) surveys over the past two decades have consistently reported that the adult public and clinical and administrative health professionals consider medicare to be successful in terms of quality of care, despite a growing concern that timely access to care remains challenging. These key stakeholders have also recently signalled that major change strategies are likely necessary for continuing success. In the 2018 survey, both the public and professionals ranked highest the creation of a national comprehensive pharmacare plan, entirely funded by the federal government, or with federal funding for those not currently covered by existing pharmaceutical plans. The majority of the public and health professionals in 2018 were also remarkably concordant regarding preferred leadership for designing, instituting and managing a national pharmacare program. The public's priority, supported by 50% of the adult population, was shared leadership involving governments, medical academia and the pharmaceutical/biotech industries, followed by government leadership at 33%. Among professionals, preference for shared leadership averaged 60% and governmental leadership averaged 33%. Based on these data, restriction of pharmacare's leadership exclusively to any single stakeholder raises concern of a critical lack of support for success. A coalition of governments, research hospitals/health authorities and the pharmaceutical/biotech industry - the highest-ranked candidates as potential leaders - would likely provide the best chance to garner the majority of public support and enhance the chances of success in the short and long terms. In summary, the addition of universal pharmacare to medicare's existing healthcare portfolios is an attractive strategy to advance Canadian healthcare and outcomes. The federal government has taken the initial step. Recruitment of additional leaders sharing aspiration, inspiration and experience to optimize pharmacare's development and measure its outcomes is needed. Things can be better.

Non-Adherence to Prescribed Therapies: Pharmacare's Existential Challenge.

Pharmacare, a recently proposed addition to Canada's universal medicare program, has become a prominent topic in the public discourse, but funding and leadership have not been established. Repeated Health Care in Canada (HCIC) surveys of the adult public and a broad spectrum of health professionals reveal very strong support for a national system that is easy to access and covers all prescribed pharmaceuticals. Although the practical details of universal pharmacare remain to be established, there is strong support among the public and professionals as well as increasing federal government interest in moving forward and ultimately implementing pharmacare. At the same time, HCIC surveys indicate that a high percentage of patients do not take their medications as directed, both for acute and chronic illnesses. The data suggest that pharmacare's success will be severely challenged by this. Of the four major challenges preventing usual care from being the best care - suboptimal access, non-diagnosis, non-prescription and non-adherence - risk from some form of non-adherence is often ranked first by care professionals. The most commonly reported reasons for non-adherence in clinical settings are patients' forgetfulness and how they feel in the moment on any given day. Costs of therapy, lack of understanding or poor knowledge transfer between prescribers and patients regarding therapeutic risks and benefits are rarely cited causes for poor adherence. These findings from the 2018 HCIC survey are not new. They are very consistent with measurements in the 2016 and other previous HCIC surveys. They do, however, raise practical challenges for the creation and ongoing management of universal pharmacare. Specifically, a patient-centred care component designed to improve non-adherence to prescribed therapies is needed. Ideally, it should include a measurement and feedback component on adherence that shares data with and between patients, health professionals and payers. Things can be better.

Age, gender, and current living status were associated with perceived access to treatment among Canadians using a cross sectional survey.

BACKGROUND: Access, particularly timely access, to care is the Canadian public's most important healthcare concern. The drivers of perceived appropriateness of access to care among patients with at least one chronic health condition (CHC) are not, however, well defined. This study evaluated whether personal characteristics, self-reported health status and care received were associated with patients' perception of effective access in managing a chronic illness. METHODS: The study population (n = 619) was drawn from a representative sample of the adult Canadian population who reported having ≥1 CHC in the 2013-2014 Health Care in Canada survey. Ordinal regression, with the continuation ratio model, was used to evaluate association of perceived level of access to treatment with socio-demographic factors, perceived health status and care utilization experience. RESULTS: Factors most closely associated with patients' satisfaction with care access were: age, sex, current cohabitation, care affordability, and availability of support and information to help manage their CHCs. Individuals, particularly females, < 35 years, currently living alone, with poor access to professional support or information and who feel affordability of care has worsened over the past five years were more likely to report a poorer level of treatment access. CONCLUSIONS: Individuals living alone, who are younger, and women may be especially susceptible to lower perceived access to care of CHCs and a sense of pessimism about things not getting better. Further evaluation of the reasons behind these findings may help develop effective strategies to assist these populations to access the care they need.

Healthcare in Canada: Choices Going Forward.

The overarching purpose of serial Health Care in Canada (HCIC) surveys of the adult Canadian public and a broad spectrum of healthcare professionals over the past two decades has been the development of an evidence-based map to inform strategic and clinical decisions to improve care and outcomes for Canadians. Recent surveys reveal a growing concern that medicare may require complete rebuilding or major strategic repairs. On the other hand, a majority of stakeholders perceive continuing underlying quality in our clinical care and look forward to both system- and patient-centred initiatives to improve future care. Currently, the most strongly supported strategic improvement target among the public and professional caregivers is enhanced availability of less expensive prescription medications. With regard to practical implementation of this strategy, the public's (39%) and healthcare professionals' (39-54%) preference was institution of a nation-wide pharmacare plan, funded by a federal tax. There was also pan-stakeholder concordance around the two least favoured potential strategies: increasing taxes and shifting money from other funded services. In terms of improving clinical care, the public and all professional groups were also concordant in most strongly supporting increases in home and community care services, disease prevention/wellness education and use of non-physician care providers and electronic health records. There was also remarkable concordance regarding who is most responsible for implementing these preferred innovations: research hospitals/health authorities, government funding agencies and pharmaceutical/biotech industries. In summary, contemporary Canadian public and health professionals agree on key strategic and practical priorities to improve future care and outcomes. Moreover, they concur on who should lead their implementation. This public/professional concordance supporting evidence-driven choices and leadership for improving care is not common. It is, however, an opportunity, providing a call to arms for other stakeholders, particularly governments and industry, to recognize the opportunity and their leadership expectations and to act upon them. Things can be better.

Public and Professional Insights on End-of-Life Care: Results of the 2016 Health Care in Canada Survey.

A new dimension has been added to Canadian Medicare ߝ exemption from prosecution for physicians, nurse practitioners and assistants providing medical assistance in dying for competent and informed adult patients with a grievous and irremediable medical condition causing intolerable physical or psychological suffering, irreversible decline in capabilities and reasonably foreseeable natural death. To define stakeholders' perceptions on all contemporary end-of-life care options, we analyzed data from the 2016 Health Care in Canada Survey comprising representative samples of the adult public (n = 1,500), physicians (n = 102), nurses (n = 102), pharmacists (n = 100), administrators (n = 100) and allied health professionals (n = 100). Among the public, enhanced pain management, hospice/palliative care and home/family care were all supported at, or above, the 80th percentile; medically assisted death was supported by 70%. Among all professionals, hospice/palliative care, pain management and home care garnered >90% support; support for medically assisted death ranged from 58% (physicians) to 79% (allied professionals). In terms of priority to implement available options, medically assisted death was rated first by 46% of the public, overall, and by 69% of the sub-group who strongly supported it, followed by enhanced pain management (45%) and home care (42%). Among professionals, top implementation priorities (range: 57ߝ61%) were: enhanced pain management, hospice/palliative care and home care support. Priority for medically assisted death ranged between 25% and 41%, although among professionals who strongly supported it, it was their top priority (52%). When asked to balance patients' right to access assisted death, versus some professionals' reluctance to provide it, 42% of the public and the majority of professionals thought providers should be allowed to opt out if they referred patients to another willing provider. And many professionals perceive some risk of either legal or regulatory reprisal if they assist in patients' deaths. In summary, there is substantial contemporary support for all components of end-of-life care among all stakeholders. However, non-lethal care modalities remain generally preferred, perhaps, at least in part, because medical professionals have a pervasive concern of going in harm's way by participating in assisted death, or by refusing. Things can be better.

Patient-Centred Care in Canada: Key Components and the Path Forward.

Canadians' health and its care continue to evolve. Chronic diseases affect more than 50% of our aging population, but the majority of public and professional stakeholders retain a sense of care quality. An emergent issue, however, is generating an increasingly wide debate. It is the concept of patient-centred care, including its definition of key components, and efficacy. To advance the evidence base, the 2013-2014 and 2016 Health Care in Canada (HCIC) surveys measured pan-stakeholder levels of support and implementation priorities for frequently proposed components of patient centricity in healthcare. The public's highest rated component was timely access to care, followed by perceived respect and caring in its delivery, with decisions made in partnership among patients and professional providers, and within a basic belief that care should be based on patients' needs versus their ability to pay. Health professionals' levels of support for key components largely overlapped the public's levels of support for key components, with an additional accent on care influenced by an evidence base and expert opinion. In terms of priority to actually implement enhanced patient-centred care options, timely access was universally dominant among all stakeholders. Caring, respectful care, also retained high implementation priority among both the public and professionals, as did care decisions made in partnership, and, among professionals, care driven by research and expert opinion. Low priorities, for both the public and professionals, were the actual measurements of patient-centred care delivery and its impact on outcomes. In summary, there is remarkable concordance among all stakeholders in terms of favoured interventions to enhance patient-centred care, namely, timely access, caring, partnering and communicative delivery of evidence-based care. Unfortunately, the lack of contemporary imperative around the value of measuring and reporting actual use and outcomes of favoured interventions means uncertainty of their efficacy will persist for the foreseeable future. Things can be better.

Searching for Best Direction in Healthcare: Distilling Opportunities, Priorities and Responsibilities.

Canada's health and its care are evolving. Evidence from serial Health Care in Canada surveys of the public and health professionals over the last two decades reveal a persistent sense of care quality, despite an aging population, decreasing levels of good and excellent health, increasing prevalence of chronic illnesses; and sub-optimal access to timely and patient-centred care. Stakeholders are, however, somewhat pessimistic and many sense complete rebuilding, or major changes, may be necessary. To improve access, the primary health concern of all Canadians - increasing medical and nursing school enrolment, and requiring professionals to work in teams - have attracted increasingly high support from both the public and professionals. However, physicians' support lags behind that of nursing, pharmacy and administrative colleagues; and, currently, only a minority of patients and professionals are actively involved in team care programs. Another example in which high levels of support may not necessarily translate into priority implementation of promising interventions is the realm of patient-centred care. The public and all professionals report a very high level of general support for care provided in a caring and respectful manner. However, while the public rank it second in implementation priority, following timely access, the majority of professionals rank it only fourth. By contrast, there is remarkable pan-stakeholder concordance around interventions to improve the overall health system, with the majority of public and professional stakeholders rating the creation of national supply systems as their top priority to expedite the clinical and cost efficiency of new treatments. There is a similar pan-stakeholder concordance around priority of responsibility to drive innovations, the top three being: federal/provincial governments; research hospitals/regional health authorities; and the pharmaceutical industry. In summary, Canadians are at a healthcare crossroads. Population health is decreasing, chronic diseases are increasing and desire for timely access to patient-centred, team-delivered and technology-supported care remain top concerns. Despite some disconnects between theoretical support for, and priority to implement, promising innovations, there is universal support to optimize resources to make things better. And there is concordance around the leadership best suited to lead innovation. Things can be better.

Predictors of perceived asthma control among patients managed in primary care clinics.

OBJECTIVE: To estimate the extent to which symptom status, physical activity, beliefs about medications, self-efficacy, emotional status, and healthcare utilization predict perceived asthma control over a period of 16 months among a primary care population. METHODS: The current study is a secondary analysis of data from a longitudinal study that examined health outcomes of asthma among participants recruited from primary care clinics. Path analysis, based on the Wilson and Cleary and International Classification of Functioning, Disability and Health frameworks, was used to estimate the predictors of perceived asthma control. RESULTS: The path analysis identified initial perceived asthma control asthma (ß = 0.43, p < 0.0001), symptoms (ß = 0.35, p < 0.0001), physical activity (ß = 0.27, p < 0.0001), and self-efficacy (ß = 0.29, p < 0.0001) as significant predictors of perceived asthma control (total effects, i.e., direct and indirect), while emotional status (ß = 0.08, p = 0.03) was a significant indirect predictor through physical activity. The model explained 24 % of the variance of perceived asthma control. Overall, the model fits the data well (χ (2) = 6.65, df = 6, p value = 0.35, root-mean-square error of approximation = 0.02, Comparative Fit Index = 0.999, and weighted root-mean-square residual = 0.27). CONCLUSION: Initial perceived asthma control, current symptoms status, physical activity, and self-efficacy can be used to identify individuals likely to have good perceived asthma control in the future. Emotional status also has an impact on perceived asthma control mediated through physical activity and should be considered when planning patient management. Identifying these predictors is important to help the care team tailor interventions that will allow individuals to optimally manage their asthma, to prevent exacerbations, to prevent other respiratory-related chronic disease, and to maximize quality of life.

Contributions and Challenges of Non-Professional Patient Care: A Key Component of Contemporary Canadian Healthcare.

The Canadian public is aging. Population levels of excellent, or very good, health are decreasing, and the prevalence of chronic diseases is increasing. Timely access to caring and respectful care from health professionals, with supporting information transfer, are key qualities in patients' sense of centricity and hope for best outcomes. Data from the 2013-2014 Health Care in Canada (HCIC) survey reveal, however, that 38% of such patients do not always, or often, access this support. The lack of timely access may be one underlying driver for non-professional caregivers to contribute to the care, as well as the personal and financial management, of family members or friends with chronic disease. Previous HCIC surveys, in 2005, 2006 and 2007, reported non-professional caregivers' prevalence in the adult public at 21, 23 and 26%, respectively, compared with 19% in the 2013-2014 survey. In all the surveys, a notable feature of non-professional care providers has been their universality of contribution, across age, sex, geography and time. Caregivers pay, however, a price. They have a lower level of self-related health, a higher incidence of chronic illness and net-negative impacts on relationships, career and finances, including use of personal savings (53%) and necessity of quitting their job (12%). Conversely, they infrequently claim available tax (12%) or compassionate care (11%) benefits. Interestingly, non-professional caregivers work in team-care settings with health professionals more frequently (29%) than patients in the general population with chronic illnesses (18%). Nonetheless, their current levels of always, or often, receiving assisting support (46%) and information (53%) from health professionals are lower than the respective results reported by the general public (65% and 68%). In conclusion, non-professional patient care in Canada is a common, longstanding and not-for-profit enterprise. It is more likely driven by altruistic caring or sense of duty that balance, or overwhelm, its associated personal, medical and financial burdens. In the short term, practical opportunities for enhancement include broader recognition of caregivers' contributions, their improved access to professional support and communication and wider use of available governmental financial support. All are likely to enhance both patient-centred care and lessen the practical burdens of caregivers. Things can be better.