Choosing Wisely Canada campaign associated with less overuse of thyroid testing: Retrospective parallel cohort study.

OBJECTIVE: To assess the effectiveness of a Choosing Wisely Canada (CWC) initiative to improve thyroid-stimulating hormone (TSH) test ordering for patients with no identified indication for this test. DESIGN: Retrospective parallel cohort study using routinely collected electronic medical record (EMR) data. The CWC initiative included supporting primary care leads in each participating family health team, providing education on better test ordering, and allowing adaptation appropriate to each local context. SETTING: Toronto, Ont, and surrounding areas. PARTICIPANTS: Family physicians contributing EMR data to the University of Toronto Practice-Based Research Network and their patients aged 18 or older. MAIN OUTCOME MEASURES: Proportion of adult patients with a TSH test done in a 2-year period (2016 to 2017) in the absence of EMR data with an indication for TSH testing; proportion of TSH test results in the normal range for those patients; and change in the rate of TSH screening in sites participating in the CWC initiative compared with sites not participating. RESULTS: A total of 150 944 patients (51.7% of studied adults) had no identified indication for TSH testing; 33.4% of those patients were seen by physicians in the family health teams participating in the CWC initiative. Overall, 35.1% of all patients with no identified indication had at least 1 TSH test between January 1, 2016, and December 31, 2017. The 119 physicians participating in the CWC initiative decreased their monthly rate of testing by 0.23% from 2016 to 2017, a relative reduction of 13.2%. The 233 physicians not participating decreased testing by 0.04%, a relative reduction of 1.8%. The monthly difference between the 2 groups was 0.19% (95% CI -0.02 to -0.35 P = .03), a relative difference of 11.4%. The TSH testing decreased for almost all CWC patient subgroups. More than 95% of patients tested in both groups had TSH results in the normal range. CONCLUSION: This study found high rates of TSH testing without identified indications in the practices studied. A CWC initiative implemented in primary care was effective in reducing TSH testing.

Guideline for referral of patients with suspected colorectal cancer by family physicians and other primary care providers.

OBJECTIVE: The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of colorectal cancer (CRC) in their patients. COMPOSITION OF THE COMMITTEE: Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network, the members of the Ontario Colorectal Cancer Screening Advisory Committee, and the members of the Cancer Care Ontario Gastrointestinal Cancer Disease Site Group. METHODS: This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations. REPORT: Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of CRC within the Canadian context. CONCLUSION: The judicious balancing of suspicion of CRC and level of risk of CRC should encourage timely referral by FPs and primary care providers. This guideline might also inform indications for referral to CRC diagnostic assessment programs.

Systematic review of clinical features of suspected colorectal cancer in primary care.

OBJECTIVE: To systematically review the diagnostic accuracy of clinical features associated with colorectal cancer (CRC) presenting in primary care. DATA SOURCES: MEDLINE and EMBASE were searched for studies in primary care that provided information on clinical features predictive of CRC. Positive predictive values were used to guide the determination of clinical features associated with increased risk of CRC. STUDY SELECTION: Systematic reviews or primary studies that provided possible clinical features predictive of CRC were included. SYNTHESIS: Clinical features of patients presenting in primary care that are associated with increased risk of CRC, listed in descending order of association, included palpable rectal or abdominal mass; rectal bleeding combined with weight loss; iron deficiency anemia; rectal bleeding mixed with stool; rectal bleeding in the absence of perianal symptoms; rectal bleeding combined with change in bowel habits; dark rectal bleeding; rectal bleeding and diarrhea; and change in bowel habits. Being male and increasing age were also, in general, associated with increased risk of CRC. CONCLUSION: Recognition of clinical features associated with increased risk of CRC by FPs might help with earlier identification and referral among patients presenting in primary care. This review might help inform providers and CRC diagnostic assessment programs about indications for assessment and further investigation.

Guideline for referral of patients with suspected lung cancer by family physicians and other primary care providers.

OBJECTIVE: The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of lung cancer in their patients. COMPOSITION OF THE COMMITTEE: Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network and from among the members of the Cancer Care Ontario Lung Cancer Disease Site Group. METHODS: This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations. REPORT: Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of lung cancer within the Canadian context. CONCLUSION: Earlier identification and referral of patients with lung cancer might ultimately help improve lung cancer morbidity and mortality. These guidelines might also be of value for informing the development of lung cancer diagnostic programs and for helping policy makers to ensure appropriate resources are in place.

Systematic review of guidelines for the management of suspected lung cancer in primary care.

OBJECTIVE: To systematically review the literature and provide an update and integration of existing peer-reviewed guidelines with recent systematic reviews and with primary studies related to the early recognition and management of lung cancer in primary care. DATA SOURCES: MEDLINE and EMBASE were searched for relevant articles. The quality of the evidence to support existing guideline recommendations, and the consistency of recommendations with updated evidence, were assessed. Applicability in a Canadian primary care setting was also evaluated. STUDY SELECTION: All studies that explored signs or symptoms of or risk factors for lung cancer in the primary care setting were included. All diagnostic studies in which symptomatic primary care patients underwent 1 or more investigations were also searched. SYNTHESIS: Recommendations were consistent among guidelines despite a paucity of supporting evidence. Updated evidence provided further support for the recommendations. Recommendations for identifying signs and symptoms of lung cancer presenting in primary care and for initial management can be adopted and applied within a Canadian primary care setting. CONCLUSION: This updated review of recommendations might help promote evidence-based practice and, ultimately, more timely management and improved prognosis for lung cancer patients. It might also assist in the development of lung cancer diagnostic assessment programs.

The impact of the early COVID-19 pandemic on healthcare system resource use and costs in two provinces in Canada: An interrupted time series analysis.

INTRODUCTION: The aim of our study was to assess the initial impact of COVID-19 on total publicly-funded direct healthcare costs and health services use in two Canadian provinces, Ontario and British Columbia (BC). METHODS: This retrospective repeated cross-sectional study used population-based administrative datasets, linked within each province, from January 1, 2018 to December 27, 2020. Interrupted time series analysis was used to estimate changes in the level and trends of weekly resource use and costs, with March 16-22, 2020 as the first pandemic week. Also, in each week of 2020, we identified cases with their first positive SARS-CoV-2 test and estimated their healthcare costs until death or December 27, 2020. RESULTS: The resources with the largest level declines (95% confidence interval) in use in the first pandemic week compared to the previous week were physician services [Ontario: -43% (-49%,-37%); BC: -24% (-30%,-19%) (both p<0.001)] and emergency department visits [Ontario: -41% (-47%,-35%); BC: -29% (-35%,-23%) (both p<0.001)]. Hospital admissions declined by 27% (-32%,-23%) in Ontario and 21% (-26%,-16%) in BC (both p<0.001). Resource use subsequently rose but did not return to pre-pandemic levels. Only home care and dialysis clinic visits did not significantly decrease compared to pre-pandemic. Costs for COVID-19 cases represented 1.3% and 0.7% of total direct healthcare costs in 2020 in Ontario and BC, respectively. CONCLUSIONS: Reduced utilization of healthcare services in the overall population outweighed utilization by COVID-19 patients in 2020. Meeting the needs of all patients across all services is essential to maintain resilient healthcare systems.

Physicians' attitudes and behaviour toward screening mammography in women 40 to 49 years of age.

OBJECTIVE: To determine family physicians' attitudes and behaviour toward screening mammography, breast self-examination, and breast awareness in women aged 40 to 49 at average risk of breast cancer. DESIGN: Cross-sectional survey. SETTING: Women's College Hospital and Sunnybrook Health Sciences Centre, both in Toronto, Ont. PARTICIPANTS: Family medicine residents, fellows, and staff physicians at 2 academic family practice health centres affiliated with the University of Toronto (n = 95). MAIN OUTCOME MEASURES: Physicians' answers to questions about offering screening mammography and promoting breast self-examination and breast awareness. RESULTS: Fifty-two completed surveys were returned (response rate 55%). Less than half of all surveyed family physicians (46%) routinely offered screening mammography to women aged 40 to 49 who were at average risk of breast cancer. Although 40% of physicians did not think breast cancer screening was necessary for women aged 40 to 49, 62% indicated that they would offer screening if their patients requested it. Physicians' reasons not to offer screening included no evidence of decreasing breast cancer deaths (63%), grade A recommendation to screen women starting at age 50 and not at age 40 (25%), and the harms of screening outweighing the benefits (19%). Physicians' reasons to offer screening included patient request (55%), personal clinical practice experience or mentors' recommendations (27%), and guideline recommendations (18%). Breast self-examination was not recommended by most physicians (74%), yet most encouraged women to practise breast awareness (81%). CONCLUSION: Many women at average risk of breast cancer are not being offered the opportunity to discuss and initiate mammographic screening before 50 years of age. While breast-self examination is not recommended, most physicians promote breast awareness.

Cancer screening practices of cancer survivors: population-based, longitudinal study.

OBJECTIVE: To describe cancer screening rates for cancer survivors and compare them with those for matched controls. DESIGN: Population-based, retrospective study with individuals linked across administrative databases. SETTING: Ontario. PARTICIPANTS: Survivors of breast (n = 11 219), colorectal (n = 4348), or endometrial (n = 3473) cancer, or Hodgkin lymphoma (HL) (n = 2071) matched to general population controls. Survivors were those who had completed primary treatment and were on "well" follow-up. The study period was 4 years (1 to 5 years from the date of cancer diagnosis). MAIN OUTCOME MEASURES: Never versus ever screened (in the 4-year study period) for breast cancer, colorectal cancer (CRC), and cervical cancer and never versus ever received (during the study period) a periodic health examination; rates were compared between cancer survivors and controls. Random effects models were used to estimate odds ratios and 95% CIs. RESULTS: Sixty-five percent of breast cancer survivors were never screened for CRC and 40% were never screened for cervical cancer. Approximately 50% of CRC survivors were never screened for breast or cervical cancer. Thirty-two percent of endometrial cancer survivors were never screened for breast cancer and 66% were never screened for CRC. Forty-four percent of HL survivors were never screened for breast cancer, 77% were never screened for CRC, and 32% were never screened for cervical cancer. Comparison with matched controls showed a mixed picture, with breast and endometrial cancer survivors more likely, and CRC and HL survivors less likely, than controls to be screened. CONCLUSION: There is concern about the preventive care of cancer survivors despite frequent visits to both oncology specialists and family physicians during the "well" follow-up period.

Daily versus every other day oral iron supplementation in patients with iron deficiency anemia (DEODO): study protocol for a phase 3 multicentered, pragmatic, open-label, pilot randomized controlled trial.

BACKGROUND: Iron deficiency anemia (IDA) accounts for the majority of anemia cases across the globe and can lead to impairments in both physical and cognitive functioning. Oral iron supplementation is the first line of treatment to improve the hemoglobin level for IDA patients. However, gaps still exist in understanding the appropriate dosing regimen of oral iron. The current trial proposes to evaluate the feasibility of performing this study to examine the effectiveness and side-effect profile of oral iron once daily versus every other day. METHODS: In this open-label, pilot, feasibility, randomized controlled trial, 52 outpatients over 16 years of age with IDA (defined as hemoglobin < 12.0 g/dL in females and < 13.0 g/dL in males and ferritin < 30 mcg/L) will be enrolled across two large academic hospitals. Participants are randomized in a 1:1 ratio to receive 300 mg oral ferrous sulfate (60 mg of elemental iron) either every day or every other day for 12 weeks. Participants are excluded if they are as follows: (1) pregnant and/or currently breastfeeding, (2) have a disease history that would impair response to oral iron (e.g., thalassemia, celiac disease), (3) intolerant and/or have an allergy to oral iron or vitamin C, (4) on new anticoagulants in the past 6 months, (5) received IV iron therapy in the past 12 weeks, (6) have surgery, chemotherapy, or blood donation planned in upcoming 12 weeks, (7) a creatinine clearance < 30 mL/min, or (8) hemoglobin less than 8.0 g/dL with active bleeding. The primary outcome is feasibility to enroll 52 participants in this trial over a 2-year period to determine the effectiveness of daily versus every other day oral iron supplementation on hemoglobin at 12 weeks post-initiation and side-effect profile. DISCUSSION: The results of this trial will provide additional evidence for an appropriate dosing schedule for treating patients with IDA with oral iron supplementation. Additional knowledge will be gained on how the dosing regimen of oral iron impacts quality of life and hemoglobin repletion in IDA patients. If this trial is deemed feasible, it will inform the development and implementation of a larger multicenter definitive trial. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03725384 . Registered 31 October 2018.

Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline.

BACKGROUND: A sizeable number of individuals who participate in population-based colorectal cancer (CRC) screening programs and have a positive fecal occult blood test (FOBT) do not have an identifiable lesion found at colonoscopy to account for their positive FOBT screen. OBJECTIVE: To evaluate the evidence and provide recommendations regarding the use of routine esophagogastroduodenoscopy (EGD) to detect upper gastrointestinal (UGI) cancers in patients participating in a population-based CRC screening program who are FOBT positive and colonoscopy negative. METHODS: A systematic review was used to develop the evidentiary base and to inform the evidence-based recommendations provided. RESULTS: Nine studies identified a group of patients who were FOBT positive and colonoscopy negative. Three studies found no cases of UGI cancer. Four studies reported cases of UGI cancer; three found UGI cancer in 1% or less of the population studied, and one study found one case of UGI cancer that represented 7% of their small subgroup of FOBT-positive/colonoscopy-negative patients. Two studies did not provide outcome information that could be specifically related to the FOBT-positive/colonoscopy-negative subgroup. CONCLUSION: The current body of evidence is insufficient to recommend for or against routine EGD as a means of detecting gastric or esophageal cancers for patients who are FOBT positive/colonoscopy negative, in a population-based CRC screening program. The decision to perform EGD should be individualized and based on clinical judgement.

Fecal occult blood testing: people in Ontario are unaware of it and not ready for it.

OBJECTIVE: To determine factors that influence awareness of, and readiness to undergo, fecal occult blood testing (FOBT) for colorectal cancer (CRC) screening. DESIGN: Validated survey designed to ascertain respondents' stages of decision making regarding CRC screening using FOBT. SETTING: Ontario. PARTICIPANTS: A total of 1013 people 50 years old and older drawn from all regions of the province using a random-digit dialing telephone protocol. MAIN OUTCOME MEASURES: Awareness of FOBT and readiness to undergo it for screening for CRC. RESULTS: Response rate was 69%. Results indicated that 54% of women and 45% of men had "heard of" FOBT, and 26% of women and 17% of men had heard of it but were still "not considering" FOBT screening. Only 17% of all respondents had "decided to have" FOBT screening. Demographic factors associated with having heard of FOBT were female sex, completion of college or higher education, and being married or living as married. Demographic factors associated with active consideration of FOBT among those who reported awareness of it were male sex and being married or living as married. CONCLUSION: Many people seemed uninformed about FOBT and not ready to undertake this type of screening. Results of this survey could help guide strategies and develop programs to make eligible people aware of CRC screening using FOBT and to motivate them to undergo testing.

Role of the geriatrician, primary care practitioner, nurses, and collaboration with oncologists during cancer treatment delivery for older adults: A narrative review of the literature.

Cancer is a disease that mostly affects older adults. With the aging of the population there will be a considerable increase in the number of older adults with cancer. Optimal care of the older adult with cancer requires the involvement of many types of health care providers, including oncologists, nurses, primary care practitioners, and geriatricians. In this narrative review, the literature for evidence relating to the roles of and collaboration between geriatricians, primary care practitioners, nurses, and the oncology team during cancer treatment delivery to older adults was examined. Relevant abstracts were reviewed by all team members. The full texts were reviewed to identify common themes related to roles and collaboration. The results showed that primary care practitioners felt underutilized and that the communication and collaboration between oncologists and primary care practitioners is challenging due to lack of clarity about roles and lack of timely communication/sharing of all relevant information. Furthermore, some of oncology staff, but not all, saw a need for greater collaboration between oncologists and geriatricians. The lack of availability of geriatricians limited the collaboration. Geriatric oncology nurses perceived themselves as having an important role in geriatric assessment and management, but there was no data on their collaboration with these medical specialists. There is a clear need for improvement of collaboration to improve patient outcomes. In conclusion, further research is needed to examine the impact of geriatric oncology team collaboration on the quality of cancer care, in particular, the role of nurses in supporting quality of care during treatment.

Population-based longitudinal study of follow-up care for breast cancer survivors.

PURPOSE: To describe the patterns of follow-up care provided to a population-based cohort of breast cancer survivors, and to assess factors associated with adherence to guidelines on follow-up care. PATIENTS AND METHODS: We conducted a retrospective longitudinal study of all women with surgically treated breast cancer who were without evidence of recurrence, advanced breast cancer, or new primary cancer and were diagnosed in Ontario, Canada, within a 2-year period (n = 11,219). They were followed for 5 years. The cohort was identified through the Ontario Cancer Registry, and individuals were linked across population-based administrative health databases. Frequency of and adherence to guideline recommendations for oncologist and primary care physician (PCP) visits; surveillance imaging for metastatic disease; and surveillance mammograms by year from diagnosis, age group, and income quintile were analyzed. Factors associated with adherence to guideline recommendations were analyzed. RESULTS: Most women saw both oncologists and PCPs in each follow-up year. Approximately two thirds had surveillance mammograms in each follow-up year. Overall, two thirds had either fewer or greater than recommended oncology visits, one quarter had fewer than recommended surveillance mammograms, and half had greater than recommended surveillance imaging for metastatic disease. CONCLUSION: This population-based study shows substantial variation in adherence to guideline recommendations, with both overuse and underuse of surveillance visits and tests. Most importantly, a substantial proportion are receiving more than recommended imaging for metastatic disease but fewer than recommended mammograms for detection of local recurrence or new primary cancer, for which effective intervention is possible.

Primary care physicians' views of routine follow-up care of cancer survivors.

PURPOSE: Routine follow-up of adult cancer survivors is an important clinical and health service issue. Because of a lack of evidence supporting advantages of long-term follow-up care in oncology clinics, there is increasing interest for the locus of this care to be provided by primary care physicians (PCPs). However, current Canadian PCP views on this issue have been largely unknown. METHODS: A mail survey of a random sample of PCPs across Canada, stratified by region and proximity to urban centers, was conducted. Views on routine follow-up of adult cancer survivors and modalities to facilitate PCPs in providing this care were determined. RESULTS: A total of 330 PCPs responded (adjusted response rate, 51.7%). After completion of active treatment, PCPs were willing to assume exclusive responsibility for routine follow-up care after 2.4 +/- 2.3 years had elapsed for prostate cancer, 2.6 +/- 2.6 years for colorectal cancer, 2.8 +/- 2.5 years for breast cancer, and 3.2 +/- 2.7 years for lymphoma. PCPs already providing this care were willing to provide exclusive care sooner. The most useful modalities PCPs felt would assist them in assuming exclusive responsibility for follow-up cancer care were (1) a patient-specific letter from the specialist, (2) printed guidelines, (3) expedited routes of rereferral, and (4) expedited access to investigations for suspected recurrence. CONCLUSION: With appropriate information and support in place, PCPs reported being willing to assume exclusive responsibility for the follow-up care of adult cancer survivors. Insights gained from this survey may ultimately help guide strategies in providing optimal care to these patients.

Breast self-examination: resistance to change.

OBJECTIVE: To investigate whether Canadian family practitioners routinely teach breast self-examination (BSE) after publication of the 2001 Canadian Preventive Health Task Force guideline advising them to exclude teaching BSE from periodic health examinations. DESIGN: Self-administered cross-sectional mailed survey. SETTING: Canada. PARTICIPANTS: A random sample of English-speaking general practitioners and physicians certified by the College of Family Physicians of Canada. MAIN OUTCOME MEASURES: Current and past BSE practices and opinions on the value of BSE. RESULTS: Response rate was 47.4%. Most respondents (88%) were aware of the new recommendations, yet only 16% had changed their usual practice of routinely teaching BSE. Most physicians agreed that before the recommendation they almost always taught BSE (74.3%). Only 9.5% agreed that physicians should follow the recommendation and not routinely teach BSE. A few also agreed that they now spend less time discussing BSE (25.7%) and that the recommendation has influenced them to stop teaching (12.4%) and encouraging (12.9%) women to practise BSE. Physicians who had changed their BSE practices were less likely to agree that BSE increases early detection of breast cancer and more likely to agree that BSE increases benign breast biopsies. They were also more likely to agree that screening mammography in women older than 50 decreases mortality from breast cancer. CONCLUSION: This survey, which assessed routine teaching of BSE, revealed poor adherence by Canadian family physicians to a well publicized evidence-based guideline update. Resistance to change could in part be attributed to a lack of knowledge of the supporting evidence, a lack of confidence in the evidence to date, and personal experiences with patients within their practices.