Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Changes in adults' vaping and smoking behaviours associated with aerosol-free laws.

OBJECTIVES: Banning e-cigarette use in public places has attracted considerable debate, with governments adopting different policies. However, little is known about the outcomes of such bans. We investigated the association of banning e-cigarette use in public places and workplaces in Canadian provinces with adults' vaping and smoking behaviours. DESIGN: Difference-in-differences. SETTING: Nationally representative Canadian Tobacco Use Monitoring Survey (CTUMS) and Canadian Tobacco, Alcohol and Drugs Survey (CTADS). PARTICIPANTS: Adults aged 19 and older from CTADS 2013-2017 for e-cigarette outcomes (N=36 562) and from CTUMS/CTADS 2004-2017 for combustible cigarette outcomes (N=178 654). INTERVENTIONS: Bans on e-cigarette use in public places and workplaces in Canadian provinces. MAIN OUTCOME MEASURES: Past 30-day e-cigarette use, current combustible cigarette use, use of e-cigarettes when unable to smoke combustible cigarettes. RESULTS: After the bans, e-cigarette use in the past 30 days did not change significantly in provinces with a ban compared with provinces without a ban (0.004; 95% CI -0.025 to 0.032; p=0.783). The bans also had no impact on current combustible cigarette use (0.009; 95% CI -0.019 to 0.037; p=0.488). There is evidence of ban evasion among young people aged 19-24 who, after the bans, reported higher use of e-cigarettes when unable to smoke combustible cigarettes (0.114; 95% CI -0.023 to 0.250; p=0.092). CONCLUSIONS: Two years after implementation, the aerosol-free laws in Canada had no impacton adults' vaping and smoking behaviours. Policy efforts are urgently needed to improve the ban enforcement and to deal with discreet vaping among young adults.

Too young for Cannabis? Choice of minimum legal age for legalized non-medical Cannabis in Canada.

BACKGROUND: Choice of minimum legal age (MLA) for cannabis use is a critical and contentious issue in legalization of non-medical cannabis. In Canada where non-medical cannabis was recently legalized in October 2018, the federal government recommended age 18, the medical community argued for 21 or even 25, while public consultations led most Canadian provinces to adopt age 19. However, no research has compared later life outcomes of first using cannabis at these different ages to assess their merits as MLAs. METHODS: We used doubly robust regression techniques and data from nationally representative Canadian surveys to compare educational attainment, cigarette smoking, self-reported general and mental health associated with different ages of first cannabis use. RESULTS: We found different MLAs for different outcomes: 21 for educational attainment, 19 for cigarette smoking and mental health and 18 for general health. Assuming equal weight for these individual outcomes, the 'overall' MLA for cannabis use was estimated to be 19 years. Our results were robust to various robustness checks. CONCLUSION: Our study indicated that there is merit in setting 19 years as MLA for non-medical cannabis.

A scoping review to identify strategies that work to prevent four important occupational diseases.

BACKGROUND: Despite being largely preventable, many occupational diseases continue to be highly prevalent and extremely costly. Effective strategies are required to reduce their human, economic, and social impacts. METHODS: To better understand which approaches are most likely to lead to progress in preventing noise-related hearing loss, occupational contact dermatitis, occupational cancers, and occupational asthma, we undertook a scoping review and consulted with a number of key informants. RESULTS: We examined a total of 404 articles and found that various types of interventions are reported to contribute to occupational disease prevention but each has its limitations and each is often insufficient on its own. Our principal findings included: legislation and regulations can be an effective means of primary prevention, but their impact depends on both the nature of the regulations and the degree of enforcement; measures across the hierarchy of controls can reduce the risk of some of these diseases and reduce exposures; monitoring, surveillance, and screening are effective prevention tools and for evaluating the impact of legislative/policy change; the effect of education and training is context-dependent and influenced by the manner of delivery; and, multifaceted interventions are often more effective than ones consisting of a single activity. CONCLUSIONS: This scoping review identifies occupational disease prevention strategies worthy of further exploration by decisionmakers and stakeholders and of future systematic evaluation by researchers. It also identified important gaps, including a lack of studies of precarious workers and the need for more studies that rigorously evaluate the effectiveness of interventions.

Short-Term Effects of Recreational Cannabis Legalization on Youth Cannabis Initiation.

PURPOSE: As recreational cannabis is legalized, it is critical to know the impacts of legalization on youth cannabis use. Existing research generates conflicting results and does not shed light on channels of effects. This study investigates the impacts of legalization on youth cannabis initiation and overall cannabis use prevalence. METHODS: We used Interrupted Time Series design and data from nationally-representative repeated cross-sectional Canadian surveys spanning 16 years. The primary outcomes were cannabis initiation rates and cannabis use prevalence among youths. The secondary outcomes were self-reported age of first cannabis use, ease of cannabis access, and perception of cannabis harm among youths. RESULTS: After legalization, cannabis initiation rate among youths was 2.7 percentage points (95% confidence interval: 1.7-3.7; p < .01) or 69% higher, although there was no significant increase in the overall prevalence of cannabis use. Furthermore, there was a 4-month delay in the average age of first cannabis use among youths aged 17-18 years (95% confidence interval: 2.6-5.5 months; p < .01). The legalization was associated with greater perception of cannabis harm but also easier access to cannabis. DISCUSSION: The impacts of legalization on youth cannabis use after 1 year are mixed. Although we observed an increase in cannabis initiation among youths who had never used cannabis, there was no change in the overall prevalence of cannabis use, implying a possible offsetting increase in cannabis cessation among existing users. To achieve legalization's goal of reducing youth cannabis use, policy measures are needed to curb youth cannabis access and initiation.

The experiences and needs of unpaid family caregivers for persons living with dementia in rural settings: A qualitative systematic review.

PURPOSE: Unpaid family caregivers provide extensive support for community-dwelling persons living with dementia, impacting family caregivers' health and wellbeing. Further, unpaid family caregiving in rural settings has additional challenges because of lower access to services. This systematic review examines qualitative evidence to summarize the experiences and needs of rural unpaid family caregivers of persons living with dementia. METHODS: CINAHL, SCOPUS, EMBASE, Web of Science, PsychINFO, ProQuest, and Medline were searched for articles investigating the experience and needs of rural family caregivers of persons living with dementia. Eligibility criteria were: 1) original qualitative research; 2) written in the English language; 3) focused on the perspectives of caregivers of community-dwelling persons with dementia; 4) focused on rural settings. Study findings were extracted from each article and a meta-aggregate process was used to synthesize the findings. FINDINGS: Of the 510 articles screened, 36 studies were included in this review. Studies were of moderate to high quality and produced 245 findings that were analyzed to produce three synthesized findings: 1) the challenge of dementia care; 2) rural limitations; 3) rural opportunities. CONCLUSIONS: Rurality is perceived as a limitation for family caregivers in relation to the scope of services provided but can be perceived as a benefit when caregivers experience trustworthy and helpful social networks in rural settings. Implications for practice include establishing and empowering community groups to partner in the provision of care. Further research must be conducted to better understand the strengths and limitations of rurality on caregiving.

How Do We Build the Human Capital for a True Learning Healthcare System?

Our healthcare systems depend on human capital for effectiveness. The Canadian Institutes of Health Research - Institute of Health Services and Policy Research has prioritized building capacity for "solution-oriented research and evidence-informed health care system transformation" (CIHR IHSPR 2021a: 20) as a core strategic direction. In this commentary, we articulate strategies for positioning PhD-trained scientists at the forefront of this transformation, including refreshing a competency framework that outlines the skill set required for maximum impact, exploring opportunities to expand embedded research career pathways and considering new ways to support the evolution of learning health systems. We conclude highlighting the need to modernize how real-world research impact is recognized.

Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states.

Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are being continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends or other unpaid caregivers. Ten dementia care policy programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared deductively using a comparative policy framework originally developed by Richard Rose. One aim of this research was to understand how different jurisdictions have worked to reduce the fragmentation of dementia care. Another aim is to assess, relying on the theory of smart policy layering, the extent to which these policy efforts 'patch' health system structures or add to system redundancies. We find that these programs were introduced in a manner that did not fully consider how to patch current programs and services and thus risk creating further system redundancies. The implementation of these policy programs may have led to policy layers, and potentially to tension among different policies and unintended consequences. One approach to reducing these negative impacts is to implement evaluative efforts that assess 'goodness of fit'. The degree to which these programs have embedded these efforts into an existing policy infrastructure successfully is low, with the possible exception of one program in NY.

A Quantitative Retrospective Exposure Assessment for Former Chrysotile Asbestos Miners and Millers from Baie Verte, NL, Canada.

Despite numerous studies of asbestos workers in the epidemiologic literature, there are very few cohort studies of chrysotile asbestos miners/millers that include high-quality retrospective exposure assessments. As part of the creation of the Baie Verte Miners' Registry in 2008, a two-dimensional job exposure matrix (JEM) was developed for estimating asbestos exposures for former chrysotile asbestos miners/millers. Industrial hygiene data collected between 1963 and 1994 were analysed to assess validity for use in a retrospective exposure assessment and epidemiologic study. Registered former employees were divided into 52 exposure groups (EGs) based on job title and department and mean asbestos concentrations were calculated for each EG. The resulting exposure estimates were linked to individual registrants' work histories allowing for the calculation of cumulative asbestos exposure for each registrant. The distribution of exposure for most EGs (82.6%) could be described as fitting a log-normal distribution, although variability within some EGs (55%) exceeded a geometric standard deviation (GSD) of 2.5. Overall, the data used to create EGs in the development of the JEM were deemed to be of adequate quality for estimating cumulative asbestos exposures for the former employees of the Baie Verte asbestos mine/mill. The variability between workers in the same job was often high and is an important factor to be considered when using estimates of cumulative asbestos exposure to adjudicate compensation claims. The exposures experienced in this cohort were comparable to those of other chrysotile asbestos miners/millers cohorts, specifically Italian and Québec cohorts.

Training for Impact: PhD Modernization as a Key Resource for Learning Health Systems.

The Institute of Medicine (IOM) has articulated a vision of a learning health system (LHS) as one that provides the best care at lower costs and that constantly, systematically and seamlessly improves based on data and evidence (IOM 2013). The IOM identifies the four foundational characteristics of an LHS as the real-time use of data and informatics to capture the care experience, patient-clinician partnerships, incentives aligned for value and a leadership-instilled culture of learning (IOM 2013). Although much policy research and commentary has focused on informatics and incentives, relatively less has focused on the critical question of creating a culture of learning in these systems. And although its source is debated, most management gurus agree with the adage that "culture eats strategy for breakfast" (Cave 2017), which is why a focus on the cultural dimension is critically important. Some scholars have recognized the important role of human capital - and of front-line clinicians in particular - in the LHS (Verma and Bhatia 2016). In addition to clinicians, doctorally prepared individuals, such as those with a PhD in health services and policy research (HSPR) and fields such as health economics, epidemiology and health informatics, have the potential to make significant contributions to LHSs and health system reform (Bornstein 2016; Brown and Nuti 2016; CIHR-IHSPR 2016). But having a PhD in these fields is not the same as being prepared to support progress toward an LHS. As argued in other papers, substantial change in doctoral training is needed so that graduates can contribute to their full potential and help drive real innovation within the health system (Bornstein 2016; CIHR-IHSPR 2016; Reid 2016).

Developing Competencies for Health System Impact: Early Lessons Learned from the Health System Impact Fellows.

BACKGROUND: The Health System Impact (HSI) Fellowship program provides highly qualified post-doctoral fellows studying health services and policy research (HSPR) with opportunities for experiential learning, enriched core competency development and mentorship from senior-level leaders within health system organizations. Its overall aim is to prepare post-doctoral fellows with the research and professional skills, experiences and networks to make meaningful and impactful contributions in careers in academic and applied health system settings. OBJECTIVE: This study examined whether this HSI Fellowship program has contributed to the development of enriched core competencies in HSPR. METHODS: A competency assessment tool was developed and administered to the 46 fellows and their health system and academic supervisors from the inaugural HSI Fellowship cohort. Fellows' self-assessments at baseline, three months and 12 months were analyzed, along with supervisors' assessments at three and 12 months. Descriptive analyses were used to examine competency development over time. Differences by gender and between supervisor and fellow ratings were analyzed. RESULTS: HSI fellows' self-assessments indicate that they strengthened their skills in all 10 enriched core competencies. Supervisors' assessments of the fellows' competencies also improved from baseline to 12 months. Gender differences at baseline disappeared by the 12-month assessment. CONCLUSION: The HSI Fellowship provides an opportunity to develop the full suite of enriched core competencies, particularly in competency domains that are not currently emphasized in HSPR doctoral curriculum.

Training for Health System Improvement: Emerging Lessons from Canadian and US Approaches to Embedded Fellowships.

The benefits of supporting experiential learning for improved health and societal outcomes have been recognized in many countries. A number of funding organizations have developed competitive funding opportunities to support experiential learning in health system organizations outside of the traditional university setting. AcademyHealth in the US is an early innovator that pioneered the Delivery System Science Fellowship (DSSF) and inspired Canada's creation of the Health System Impact (HSI) Fellowship program. The DSSF and HSI Fellowship have similar objectives: to improve the career readiness of doctorally prepared graduates and to build research capacity within health system organizations. However, the programs have taken different approaches to achieve these objectives and operate in different healthcare systems. This paper outlines the two models of embedded fellowships, analyzes their commonalities and differences, discusses lessons learned and suggests future directions for health services and policy research training.

Exploring Mentorship as a Strategy to Build Capacity and Optimize the Embedded Scientist Workforce.

BACKGROUND: Mentorship plays a significant role in career development in academic and applied settings, but little is documented about its role in the experiential learning of academic trainees embedded in health system organizations. The experiences of the first cohort of Canada's Health System Impact (HSI) Fellowship program can provide insights into how mentorship in this innovative type of training can work. OBJECTIVES: To understand the mentorship strategies that were used and to explore fellows' and supervisors' perspectives and experiences on the effectiveness and value of those strategies. METHODS: Data from the surveys of fellows and their supervisors and a panel rooted in the lived experience of the first HSI Fellowship cohort were used. RESULTS: Health system and academic supervisors developed a range of innovative, individualized and effective approaches for guiding their fellows, such as providing the fellow with a committee of mentors within the organization, holding regular meetings with the fellow and both the health system and the academic supervisor and leveraging their own network to expand the network and resources available to the fellow. CONCLUSION: The results suggest that engaging senior leadership in health system settings has provided positive experiences for both fellows and their mentors.

Inappropriateness of health care in Canada: a systematic review protocol.

BACKGROUND: There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions. METHODS: We will include all quantitative study designs reporting objective or subjective measurements of inappropriate health care in Canada over the last 10 years. We will search the following online databases: MEDLINE, Cochrane Central Register of Controlled Trials, EconLit, and ISI-Web of Knowledge, which contains Web of Science Core Collection-Citation Indexes, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities. We will also search grey literature sources to identify provincial and national audits of inappropriate health care. Two authors will independently screen, assess data quality, and extract data for synthesis. Study findings will be synthesized narratively. We will organize our data into three care categorizations: preventive care, acute care, and chronic care. We will provide a compendium of inappropriate health care for each care category for Canada and each Canadian province and territory, where sufficient data exists, by calculating (1) overall medians of underuse, overuse, and misuse of clinical practices and (2) the range of medians of underuse, overuse, and misuse for each clinical practice investigated. DISCUSSION: This review will result in the first-ever evidence-based compendium of inappropriate health care in Canada. We will also develop detailed reports of inappropriate health care for each Canadian province and territory. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018093495.

A fragile but critical link: a commentary on the importance of government-academy relationships.

Interactions between government and academia can be an important support to effective policy and they can also ground researchers' methods and perspectives more strongly in the realities of policy-making and politics, leading to more relevant research. If properly developed, these interactions can lead to relationships between government and academia that re-enforce evidence-informed policy and useful research. However, strong relationships require repeated interactions and strong personal connections, something that can be supported through careers that cross academia and government. Academic and public service polices that value these kinds of careers can help build strong relationships.

Development of Enriched Core Competencies for Health Services and Policy Research.

OBJECTIVE: To develop an enriched set of core competencies for health services and policy research (HSPR) doctoral training that will help graduates maximize their impact across a range of academic and nonacademic work environments and roles. DATA SOURCES/STUDY SETTING: Data were obtained from multiple sources, including literature reviews, key informant interviews, stakeholder consultations, and Expert Working Group (EWG) meetings between January 2015 and March 2016. The study setting is Canada. STUDY DESIGN: The study used qualitative methods and an iterative development process with significant stakeholder engagement throughout. DATA COLLECTION/EXTRACTION METHODS: The literature reviews, key informant interviews, existing data on graduate career trajectories, and EWG deliberations informed the identification of career profiles for HSPR graduates and the competencies required to succeed in these roles. Stakeholder consultations were held to vet, refine, and validate the competencies. PRINCIPAL FINDINGS: The EWG reached consensus on six sectors and eight primary roles in which HSPR doctoral graduates can bring value to employers and the health system. Additionally, 10 core competencies were identified that should be included or further emphasized in the training of HSPR doctoral students to increase their preparedness and potential for impact in a variety of roles within and outside of traditional academic workplaces. CONCLUSION: The results offer an expanded view of potential career paths for HSPR doctoral graduates and provide recommendations for an expanded set of core competencies that will better equip graduates to maximize their impact on the health system.

A survey of rural medical education strategies throughout the medical education continuum in Canada.

In many countries the sustainability of rural health care systems is being challenged by a shortage of rural physicians and difficulties in recruiting and retaining physicians in rural practice. Research does suggest that specific medical education strategies can be introduced to enhance rural physician recruitment and retention initiatives. The purpose of this paper is to summarize the current strategies of Canadian rural medical education programs. A survey of all Canadian medical schools was undertaken to profile specific programs and activities at the undergraduate, postgraduate, and continuing medical education/continuing professional development (CME/CPD) levels. The majority of medical schools reported either mandatory or elective rural medicine placement/learning experiences during undergraduate medical education, as well as Rural Family Medicine streams or programs as components of postgraduate medical education. The majority of medical schools reported that they provide clinical traineeships to enhance clinical competencies in rural medicine as well as CME outreach programming, including the use of telehealth or distance learning technologies. Canadian medical schools all have substantial programs covering the full range of approaches found in the literature to help recruit and retain rural physicians. Not surprisingly, the most extensive programs are found in medical schools that have a specific rural mandate.

Evaluation of and Feedback for Academic Medicine Leaders: Developing and Implementing the Memorial Method.

PROBLEM: Giving and receiving honest and helpful feedback for leadership development is a common challenge in all types of organizations but particularly in academic medicine. APPROACH: At Memorial University of Newfoundland, in 2014, a consensus emerged to develop a new method for evaluating the leadership performance of the discipline chairs, dean, and vice dean, and to provide these leaders with the evaluation results to help them improve their performance. The leaders responsible for developing and implementing this method (called the Memorial Method) decided to use a survey to obtain faculty members' perceptions about their leader's performance. Beginning in October 2014, a portion of several regular meetings of the discipline chairs with the dean and vice dean was used to develop the survey, by first discussing the broad dimensions of leadership performance, then discussing these dimensions in more detail and drafting specific questions. The resulting survey included 44 quantitative questions addressing eight leadership dimensions. In March-April 2015, the survey was administered electronically to full-time faculty members on a confidential basis. The results were compiled and reported to each discipline chair and to the dean and vice dean. OUTCOMES: In total, 144/249 faculty responded to the survey (response rate: 58%). For the various dimensions, individual chairs' mean scores ranged from 2.82 to 4.70, and overall mean scores ranged from 3.57 to 4.24. Psychometric properties of the survey suggested it was both reliable and valid. NEXT STEPS: The survey will be repeated, this time with part-time as well as full-time faculty included.

Putting research in place: an innovative approach to providing contextualized evidence synthesis for decision makers.

BACKGROUND: The Contextualized Health Research Synthesis Program (CHRSP), developed in 2007 by the Newfoundland and Labrador Centre for Applied Health Research, produces contextualized knowledge syntheses for health-system decision makers. The program provides timely, relevant, and easy-to-understand scientific evidence; optimizes evidence uptake; and, most importantly, attunes research questions and evidence to the specific context in which knowledge users must apply the findings. METHODS: As an integrated knowledge translation (KT) method, CHRSP: Involves intensive partnerships with senior healthcare decision makers who propose priority research topics and participate on research teams; Considers local context both in framing the research question and in reporting the findings; Makes economical use of resources by utilizing a limited number of staff; Uses a combination of external and local experts; and Works quickly by synthesizing high-level systematic review evidence rather than primary studies. Although it was developed in the Canadian province of Newfoundland and Labrador, the CHRSP methodology is adaptable to a variety of settings with distinctive features, such as those in rural, remote, and small-town locations. RESULTS: CHRSP has published 25 syntheses on priority topics chosen by the provincial healthcare system, including: Clinical and cost-effectiveness: telehealth, rural renal dialysis, point-of-care testing; Community-based health services: helping seniors age in place, supporting seniors with dementia, residential treatment centers for at-risk youth; Healthcare organization/service delivery: reducing acute-care length of stay, promoting flu vaccination among health workers, safe patient handling, age-friendly acute care; and Health promotion: diabetes prevention, promoting healthy dietary habits. These studies have been used by decision makers to inform local policy and practice decisions. CONCLUSIONS: By asking the health system to identify its own priorities and to participate directly in the research process, CHRSP fully integrates KT among researchers and knowledge users in healthcare in Newfoundland and Labrador. This high level of decision-maker buy-in has resulted in a corresponding level of uptake. CHRSP studies have directly informed a number of policy and practice directions, including the design of youth residential treatment centers, a provincial policy on single-use medical devices, and most recently, the opening of the province's first Acute Care for the Elderly hospital unit.

Designing exposure registries for improved tracking of occupational exposure and disease.

OBJECTIVES: Registries are one strategy for collecting information on occupational exposure and disease in populations. Recently leaders in the Canadian occupational health and safety community have shown an interest in the use of occupational exposure registries. The primary goal of this study was to review a series of Canadian exposure registries to identify their strengths and weaknesses as a tool for tracking occupational exposure and disease in Canada. A secondary goal was to identify the features of an exposure registry needed to specifically contribute to prevention, including the identification of new exposure-disease relationships. METHODS: A documentary review of five exposure registries from Canada was completed. Strengths and limitations of the registries were compared and key considerations for designing new registries were identified. RESULTS: The goals and structure of the exposure registries varied considerably. Most of the reviewed registries had voluntary registration, which presents challenges for the use of the data for either surveillance or epidemiology. It is recommended that eight key issues be addressed when planning new registries: clear registry goal(s), a definition of exposure, data to be collected (and how it will be used), whether enrolment will be mandatory, as well as ethical, privacy and logistical considerations. CONCLUSIONS: When well constructed, an exposure registry can be a valuable tool for surveillance, epidemiology and ultimately the prevention of occupational disease. However, exposure registries also have a number of actual and potential limitations that need to be considered.