Defining Clinical Public Health.

PURPOSE: To solve complex health issues, an innovative and multidisciplinary framework is necessary. The Clinical Public Health (CPH) Division was established at the University of Toronto (UofT), Canada to foster inte-gration of primary care, preventive medicine and public health in education, practice and research. To better understand how the construct of CPH might be applied, we surveyed clinicians, researchers and public health professionals affiliated with the CPH Division to assess their understanding of the CPH concept and its utility in fostering broad collaboration. METHODS: A two-wave anonymous survey of the active faculty of the CPH Division, UofT was conducted across Canada. Wave 1 participants (n = 187; 2016) were asked to define CPH, while Wave 2 participants (n = 192; 2017) were provided a synthesis of Wave 1 results and asked to rank each definition. Both waves were asked about the need for a common definition, and to comment on CPH. RESULTS: Response rates for the first and second waves were 25% and 22%, respectively. Of the six definitions of CPH from Wave 1, "the intersection of clinical practice and public health," was most highly ranked by Wave 2 participants. Positive perceptions of CPH included multidisciplinary collaboration, new fields and insights, forward thinking and innovation. Negative perceptions included CPH being a confusing term, too narrow in scope or too clinical. CONCLUSION: The concept of Clinical Public Health can foster multidisciplinary collaboration to address com-plex health issues because it provides a useful framework for bringing together key disciplines and diverse professional specialties.

Corrigendum: Wastewater-based surveillance identifies start to the pediatric respiratory syncytial virus season in two cities in Ontario, Canada.

[This corrects the article DOI: 10.3389/fpubh.2023.1261165.].

Wastewater-based surveillance of SARS-CoV-2: Short-term projection (forecasting), smoothing and outlier identification using Bayesian smoothing.

BACKGROUND: Day-to-day variation in the measurement of SARS-CoV-2 in wastewater can challenge public health interpretation. We assessed a Bayesian smoothing and forecasting method previously used for surveillance and short-term projection of COVID-19 cases, hospitalizations, and deaths. METHODS: SARS-CoV-2 viral measurement from the sewershed in Ottawa, Canada, sampled at the municipal wastewater treatment plant from July 1, 2020, to February 15, 2022, was used to assess and internally validate measurement averaging and prediction. External validation was performed using viral measurement data from influent wastewater samples from 15 wastewater treatment plants and municipalities across Ontario. RESULTS: Plots of SARS-CoV-2 viral measurement over time using Bayesian smoothing visually represented distinct COVID-19 "waves" described by case and hospitalization data in both initial (Ottawa) and external validation in 15 Ontario communities. The time-varying growth rate of viral measurement in wastewater samples approximated the growth rate observed for cases and hospitalization. One-week predicted viral measurement approximated the observed viral measurement throughout the assessment period from December 23, 2020, to August 8, 2022. An uncalibrated model showed underprediction during rapid increases in viral measurement (positive growth) and overprediction during rapid decreases. After recalibration, the model showed a close approximation between observed and predicted estimates. CONCLUSION: Bayesian smoothing of wastewater surveillance data of SARS-CoV-2 allows for accurate estimates of COVID-19 growth rates and one- and two-week forecasting of SARS-CoV-2 in wastewater for 16 municipalities in Ontario, Canada. Further assessment is warranted in other communities representing different sewersheds and environmental conditions.

Wastewater-based surveillance identifies start to the pediatric respiratory syncytial virus season in two cities in Ontario, Canada.

Introduction: Detection of community respiratory syncytial virus (RSV) infections informs the timing of immunoprophylaxis programs and hospital preparedness for surging pediatric volumes. In many jurisdictions, this relies upon RSV clinical test positivity and hospitalization (RSVH) trends, which are lagging indicators. Wastewater-based surveillance (WBS) may be a novel strategy to accurately identify the start of the RSV season and guide immunoprophylaxis administration and hospital preparedness. Methods: We compared citywide wastewater samples and pediatric RSVH in Ottawa and Hamilton between August 1, 2022, and March 5, 2023. 24-h composite wastewater samples were collected daily and 5 days a week at the wastewater treatment facilities in Ottawa and Hamilton, Ontario, Canada, respectively. RSV WBS samples were analyzed in real-time for RSV by RT-qPCR. Results: RSV WBS measurements in both Ottawa and Hamilton showed a lead time of 12 days when comparing the WBS data set to pediatric RSVH data set (Spearman's ρ = 0.90). WBS identify early RSV community transmission and declared the start of the RSV season 36 and 12 days in advance of the provincial RSV season start (October 31) for the city of Ottawa and Hamilton, respectively. The differing RSV start dates in the two cities is likely associated with geographical and regional variation in the incidence of RSV between the cities. Discussion: Quantifying RSV in municipal wastewater forecasted a 12-day lead time of the pediatric RSVH surge and an earlier season start date compared to the provincial start date. These findings suggest an important role for RSV WBS to inform regional health system preparedness, reduce RSV burden, and understand variations in community-related illness as novel RSV vaccines and monoclonal antibodies become available.

Determining mortality rates attributable to Clostridium difficile infection.

To determine accuracy of measures of deaths attributable to Clostridium difficile infection, we compared 3 measures for 2007-2008 in Ontario, Canada: death certificate; death within 30 days of infection; and panel review. Data on death within 30 days were more feasible than panel review and more accurate than death certificate data.

Incidence of invasive breast cancer in the presence of competing mortality: the Canadian National Breast Screening Study.

Mortality due to causes other than breast cancer is a potential competing risk which may alter the incidence probability of breast cancer and as such should be taken into account in predictive modelling. We used data from the Canadian National Breast Screening Study (CNBSS), which consist of two randomized controlled trials designed to evaluate the efficacy of mammography among women aged 40-59. The participants in the CNBSS were followed up for incidence of breast cancer and mortality due to breast cancer and other causes; this allowed us to construct a breast cancer risk prediction model while taking into account mortality for the same study population. In this study, we use 1980-1989 as the study period. We exclude the prevalent cancers from the CNBSS to estimate the probability of developing breast cancer, given the fact that women were cancer-free at the beginning of the follow-up. By the end of 1989, from 89,434 women, 944 (1.1 %) were diagnosed with invasive breast cancer, 922 (1.0 %) died from causes other than breast cancer, and 87,568 (97.9 %) were alive and not diagnosed with invasive breast cancer. We constructed a risk prediction model for invasive breast cancer based on 39 risk factors collected at the time of enrolment or the initial physical examination of the breasts. Age at entry (HR 1.07, 95 % CI 1.05-1.10), lumps ever found in left or right breast (HR 1.92, 95 % CI 1.19-3.10), abnormality in the left breast (HR 1.26, 95 % CI 1.07-1.48), history of other breast disease, family history of breast cancer score (HR 1.01, 95 % CI 1.00-1.01), years menstruating (HR 1.02, 95 % CI 1.01-1.03) and nulliparity (HR 1.70, 95 % CI 1.23-2.36) are the model's predictors. We investigated the effects of time-dependent factors. The model is well calibrated with a moderate discriminatory power (c-index 0.61, 95 % CI 0.59-0.63); we use it to predict the 9-year risk of developing breast cancer for women of different age groups. As an example, we estimated the probability of invasive cancer at 5 years after enrolment to be 0.00448, 0.00556, 0.00691, 0.00863, and 0.01034, respectively, for women aged 40, 45, 50, 55, and 59, all of whom had never noted lumps in their breasts, had 32 years of menstruating, 1-2 live births, no other types of breast disease and no abnormality found in their left breasts. The results of this study can be used by clinicians to identify women at high risk of breast cancer for screening intervention and to recommend a personalized intervention plan. The model can be also utilized by a woman as a breast cancer risk prediction tool.

Predictors of competing mortality to invasive breast cancer incidence in the Canadian National Breast Screening study.

BACKGROUND: Evaluating the cost-effectiveness of breast cancer screening requires estimates of the absolute risk of breast cancer, which is modified by various risk factors. Breast cancer incidence, and thus mortality, is altered by the occurrence of competing events. More accurate estimates of competing risks should improve the estimation of absolute risk of breast cancer and benefit from breast cancer screening, leading to more effective preventive, diagnostic, and treatment policies. We have previously described the effect of breast cancer risk factors on breast cancer incidence in the presence of competing risks. In this study, we investigate the association of the same risk factors with mortality as a competing event with breast cancer incidence. METHODS: We use data from the Canadian National Breast Screening Study, consisting of two randomized controlled trials, which included data on 39 risk factors for breast cancer. The participants were followed up for the incidence of breast cancer and mortality due to breast cancer and other causes. We stratified all-cause mortality into death from other types of cancer and death from non-cancer causes. We conducted separate analyses for cause-specific mortalities. RESULTS: We found that "age at entry" is a significant factor for all-cause mortality, and cancer-specific and non-cancer mortality. "Menstruation length" and "number of live births" are significant factors for all-cause mortality, and cancer-specific mortality. "Ever noted lumps in right/left breasts" is a factor associated with all-cause mortality, and non-cancer mortality. CONCLUSIONS: For proper estimation of absolute risk of the main event of interest common risk factors associated with competing events should be identified and considered.

Measuring data reliability for preventive services in electronic medical records.

BACKGROUND: Improvements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable new sources of health data. However, data quality in EMRs may not be optimal and should be assessed. Data reliability (are the same data elements being measured over time?) is a prerequisite for data validity (are the data accurate?). Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR. METHODS: Our data sources were randomly selected eligible patients' medical records and data obtained from provincial administrative datasets. Eighteen community-based family physicians in Toronto, Ontario that implemented EMRs starting in 2006 participated in this study. We measured the proportion of patients eligible for a service (Pap smear, screening mammogram or influenza vaccination) that received the service. We compared the change in rates of selected preventive services calculated from the medical record audits with the change in administrative datasets. RESULTS: In the first year of EMR use (2006) services decreased by 8.7% more (95% CI -11.0%- - 6.4%, p < 0.0001) when measured through medical record audits as compared with administrative datasets. Services increased by 2.4% more (95% CI 0%-4.9%, p = 0.05) in the medical record audits during the second year of EMR use (2007). CONCLUSION: There were differences between the change measured through medical record audits and administrative datasets. Problems could include difficulties with organizing new data entry processes as well as continued use of both paper and EMRs. Data extracted from EMRs had limited reliability during the initial phase of EMR implementation. Unreliable data interferes with the ability to measure and improve health care quality.

Clinical public health: harnessing the best of both worlds in sickness and in health. / Santé publique clinique : exploiter le meilleur des deux mondes pour la santé comme pour le traitement des maladies.

INTRODUCTION: Effective, sustained collaboration between clinical and public health professionals can lead to improved individual and population health. The concept of clinical public health promotes collaboration between clinical medicine and public health to address complex, real-world health challenges. In this commentary, we describe the concept of clinical public health, the types of complex problems that require collaboration between individual and population health, and the barriers towards and applications of clinical public health that have become evident during the COVID-19 pandemic. RATIONALE: The focus of clinical medicine on the health of individuals and the aims of public health to promote and protect the health of populations are complementary. Interdisciplinary collaborations at both levels of health interventions are needed to address complex health problems. However, there is a need to address the disciplinary, cultural and financial barriers to achieving greater and sustained collaboration. Recent successes, particularly during the COVID-19 pandemic, provide a model for such collaboration between clinicians and public health practitioners. CONCLUSION: A public health approach that fosters ongoing collaboration between clinical and public health professionals in the face of complex health threats will have greater impact than the sum of the parts.

INTRODUCTION: Une collaboration efficace et soutenue entre cliniciens et professionnels en santé publique peut améliorer la santé des individus et la santé de la population. Le concept de santé publique clinique favorise cette collaboration entre médecine clinique et santé publique et permet de relever des défis complexes en matière de santé. Dans ce commentaire, nous décrivons le concept de santé publique clinique, les types de problèmes complexes qui nécessitent une collaboration entre les professionnels responsables de la santé des individus et ceux responsables de la santé de la population, de même que les obstacles à la santé publique clinique et les applications de la santé publique clinique qui ont émergé pendant la pandémie de COVID-19. ARGUMENTAIRE: Il existe une complémentarité entre la médecine clinique, qui est axée sur la santé des individus, et la santé publique, qui est axée sur la promotion et la protection de la santé des populations. Une collaboration entre ces deux disciplines est nécessaire pour résoudre les problèmes de santé complexes. Pour ce faire, toutefois, il convient de s'attaquer aux obstacles relatifs aux disciplines, ainsi qu'aux obstacles culturels et financiers qui empêchent une collaboration accrue et durable en la matière. Les succès récents, particulièrement durant la pandémie de COVID-19, constituent un modèle de collaboration de ce type entre cliniciens et praticiens en santé publique. CONCLUSION: Une approche en matière de santé publique qui favorise une collaboration permanente entre cliniciens et professionnels en santé publique pour lutter contre des menaces sanitaires complexes aura plus d'impact que la somme de ses parties.

Is referral to a spine surgeon a double-edged sword?: patient concerns before consultation.

OBJECTIVE: To assess the concerns of adult patients with spine-related complaints during the period between referral to and consultation with a spine surgeon. DESIGN: Prospective survey. SETTING: Toronto, Ont. PARTICIPANTS: A total of 338 consecutive, nonemergent patients before consultation with a single spine surgeon over a 5-month period. MAIN OUTCOME MEASURES: Patient concerns, effect of referral to a spine surgeon, and effect of waiting to see a spine surgeon. RESULTS: The issues patients reported to be most concerning were ongoing pain (45.6% rated this as most concerning), loss of function (23.4%), need for surgery (12.1%), and permanence of the condition (9.6%). Regression analysis demonstrated that older age was an independent predictor of increased level of concern regarding pain (P=.01) and disability (P=.04). Forty-seven percent of all patients listed the need for surgery among their top 3 concerns. Mere referral to a spine surgeon (P=.03) was an independent predictor of increased concern regarding the need for surgery. Sex, diagnosis, surgical candidacy, and actual wait time were not predictive of increased concerns. Patients reported family physicians to be their most influential information source regarding spinal conditions. CONCLUSION: Timely provision of more specific information regarding the benign and non-surgical nature of most degenerative spinal conditions might substantially reduce patients' exaggerated concerns regarding the probability of surgery for a considerable number of patients referred to spine surgeons.

Implementation of electronic medical records: effect on the provision of preventive services in a pay-for-performance environment.

OBJECTIVE: To study the effect of electronic medical record (EMR) implementation on preventive services covered by Ontario's pay-for-performance program. DESIGN: Prospective double-cohort study. PARTICIPANTS: Twenty-seven community-based family physicians. SETTING: Toronto, Ont. INTERVENTION: Eighteen physicians implemented EMRs, while 9 physicians continued to use paper records. MAIN OUTCOME MEASURE: Provision of 4 preventive services affected by pay-for-performance incentives (Papanicolaou tests, screening mammograms, fecal occult blood testing, and influenza vaccinations) in the first 2 years of EMR implementation. RESULTS: After adjustment, combined preventive services for the EMR group increased by 0.7%, a smaller increase than that seen in the non-EMR group (P = .55, 95% confidence interval -2.8 to 3.9). CONCLUSION: When compared with paper records, EMR implementation had no significant effect on the provision of the 4 preventive services studied.

Implementation of electronic medical records: theory-informed qualitative study.

OBJECTIVE: To apply the diffusion-of-innovations theory to the examination of factors that are perceived by family physicians as influencing the implementation of electronic medical records (EMRs). DESIGN: Qualitative study with 2 focus groups 18 months after EMR implementation; participants also took part in a concurrent quantitative study examining EMR implementation and preventive services. SETTING: Toronto, Ont. PARTICIPANTS: Twelve community-based family physicians. METHODS: We employed a semistructured interview guide. The interviews were audiotaped and transcribed verbatim; 2 researchers independently categorized and coded the transcripts and then met to compare and contrast their findings, category mapping, and interpretations. Findings were then mapped to an existing theoretical framework. MAIN FINDINGS: Multiple barriers to EMR implementation were described. These included lack of relative advantage for many processes, high complexity of the system, low compatibility with physician needs and past experiences, difficulty with adaptation of the EMR to the organization and adaptation of the organization to the EMR, and lack of organizational slack. Positive factors were the presence of a champion and relative advantages for some processes. CONCLUSION: Early EMR implementation experience is consistent with theoretical concepts associated with implementation of innovations. A problematic implementation process helps to explain, at least in part, the lack of improvement in preventive services in our quantitative results.

Characteristics of Anti-SARS-CoV-2 Antibodies in Recovered COVID-19 Subjects.

Coronavirus Disease 2019 (COVID-19) is a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While detection of SARS-CoV-2 by polymerase chain reaction with reverse transcription (RT-PCR) is currently used to diagnose acute COVID-19 infection, serological assays are needed to study the humoral immune response to SARS-CoV-2. Anti-SARS-CoV-2 immunoglobulin (Ig)G/A/M antibodies against spike (S) protein and its receptor-binding domain (RBD) were characterized in recovered subjects who were RT-PCR-positive (n = 153) and RT-PCR-negative (n = 55) using an enzyme-linked immunosorbent assay (ELISA). These antibodies were also further assessed for their ability to neutralize live SARS-CoV-2 virus. Anti-SARS-CoV-2 antibodies were detected in 90.9% of resolved subjects up to 180 days post-symptom onset. Anti-S protein and anti-RBD IgG titers correlated (r = 0.5157 and r = 0.6010, respectively) with viral neutralization. Of the RT-PCR-positive subjects, 22 (14.3%) did not have anti-SARS-CoV-2 antibodies; and of those, 17 had RT-PCR cycle threshold (Ct) values > 27. These high Ct values raise the possibility that these indeterminate results are from individuals who were not infected or had mild infection that failed to elicit an antibody response. This study highlights the importance of serological surveys to determine population-level immunity based on infection numbers as determined by RT-PCR.

Game-based versus traditional case-based learning: comparing effectiveness in stroke continuing medical education.

OBJECTIVE: To evaluate family physicians' enjoyment of and knowledge gained from game-based learning, compared with traditional case-based learning, in a continuing medical education (CME) event on stroke prevention and management. DESIGN: An equivalence trial to determine if game-based learning was as effective as case-based learning in terms of attained knowledge levels. Game questions and small group cases were developed. Participants were randomized to either a game-based or a case-based group and took part in the event. SETTING: Ontario provincial family medicine conference. PARTICIPANTS: Thirty-two family physicians and 3 senior family medicine residents attending the conference. INTERVENTION: Participation in either a game-based or a case-based CME learning group. MAIN OUTCOME MEASURES: Scores on 40-item immediate and 3-month posttests of knowledge and a satisfaction survey. RESULTS: Results from knowledge testing immediately after the event and 3 months later showed no significant difference in scoring between groups. Participants in the game-based group reported higher levels of satisfaction with the learning experience. CONCLUSION: Games provide a novel way of organizing CME events. They might provide more group interaction and discussion, as well as improve recruitment to CME events. They might also provide a forum for interdisciplinary CME. Using games in future CME events appears to be a promising approach to facilitate participant learning.

A population-based nested case-control study of the costs of hip and knee replacement surgery.

BACKGROUND: Studies of total joint arthroplasty (TJA) have not evaluated the costs and outcomes in the context of expected arthritis worsening. OBJECTIVES: Using a cost-consequence approach, to examine changes in direct health care costs and arthritis severity after TJA for hip/knee arthritis compared with contemporaneous changes in matched controls. RESEARCH DESIGN: Case control study nested in a population-based prospective cohort. SUBJECTS: In a population cohort with disabling hip/knee osteoarthritis followed from 1996 to 2003, primary TJA recipients were matched with cohort nonrecipients on age, sex, region of residence, comorbidity, and inflammatory arthritis diagnosis. MEASURES: Pre- and postoperative total and arthritis-attributable direct health care costs, arthritis severity, and general health status were compared for cases and matched controls. RESULTS: Of 2109 participants with no prebaseline TJA, 185 cases received a single elective TJA during the follow-up period; of these, 183 cases and controls were successfully matched. Mean age was 71 years, 77.6% were female, 35.5% had > or =2 comorbidities, and 81.5% had > or =2 joints affected. At baseline, controls had less pain and disability and lower total and arthritis-attributable health care costs than cases. After surgery, although overall health care utilization was unchanged, cases experienced significant decreases in arthritis-attributable costs (mean decrease $278 including prescription drugs) and pain and disability (P < 0.0001 for all). Over the same time period, controls experienced a significant increase in total health care costs (mean increase $1978 including prescription drugs, P = 0.04) and no change or worsening of their arthritis status. CONCLUSION: Compared with matched controls, arthroplasty is associated with significant reductions in pain, disability, and arthritis-attributable direct costs.

Assessing Canadian medical students' familiarity with and interest in pursuing a career in community medicine.

OBJECTIVES: Following the SARS outbreak, large gaps in the public health workforce have been identified. This study sought to understand the perceptions and attitudes of Canadian medical students with regard to public health to determine how this impacted their choice towards a career in Community Medicine (CM). METHODS: Five focus groups of 11-12 medical students from all years were recruited at McMaster University, Université de Sherbrooke, University of Toronto, University of Manitoba and the University of British Columbia. A professional facilitator was hired to conduct the focus groups using a unique computer-based facilitation system. Questions in both the focus group and an accompanying survey sought to determine medical students' understanding and exposure to public health and how this impacted their attitude and choice towards a career in community medicine. The transcripts were independently reviewed and analyzed by each of the authors to identify themes. RESULTS: Four major themes related to choosing Community Medicine as a career were identified: 1) poor understanding of the role of Community Medicine specialists in public health practice, 2) perceived lack of clinical work and relevance of public health to clinical practice, 3) perceived lack of exclusivity of Community Medicine specialty, 4) incentives and disincentives to pursuing Community Medicine. CONCLUSION: Better education of students on the role of CM specialists through increasing exposure to role models and demystifying inaccurate perceptions of CM through integration of public health with clinical medicine may potentially increase medical student entry into Community Medicine.

Integrating clinical medicine and population health: where to from here?

Efforts to contain healthcare costs have led a renewed clinician interest in addressing population-level outcomes, with some proposing that the integration of population health into clinical practice represents a novel concept entitled "clinical population medicine" (CPM). This commentary offers an examination of the function and utility of CPM. In reviewing relevant literature, we note several inconsistencies in CPM's purported mandate, which ranges from simply incorporating the social determinants of health into clinical practice to broad involvement in community health planning. The latter of these seems to overlap, and potentially conflict, with the work of public health practitioners, and cited examples of activities used to define "CPM" seem to apply a label to established clinician activities around the determinants of health that would be captured more simply as research, evaluation, or advocacy undertaken by clinicians in other areas of practice. Our analysis suggests that CPM may have value in encouraging clinicians to incorporate community determinants and contextual considerations into their practices, but must take care to remain complementary and distinct from public health practice.

Using Simulation to Model and Validate Invasive Breast Cancer Progression in Women in the Study and Control Groups of the Canadian National Breast Screening Studies I and II.

BACKGROUND: Modeling breast cancer progression and the effect of various risk is helpful in deciding when a woman should start and end screening, and how often the screening should be undertaken. METHODS: We modeled the natural progression of breast cancer using a hidden Markov process, and incorporated the effects of covariates. Patients are women aged 50-59 (older) and 40-49 (younger) years from the Canadian National Breast Screening Studies. We included prevalent cancers, estimated the screening sensitivities and rates of over-diagnosis, and validated the models using simulation. RESULTS: We found that older women have a higher rate of transition from a healthy to preclinical state and other causes of death but a lower rate of transition from preclinical to clinical state. Reciprocally, younger women have a lower rate of transition from a healthy to preclinical state and other causes of death but a higher rate of transition from a preclinical to clinical state. Different risk factors were significant for the age groups. The mean sojourn times for older and younger women were 2.53 and 2.96 years, respectively. In the study group, the sensitivities of the initial physical examination and mammography for older and younger women were 0.87 and 0.81, respectively, and the sensitivity of the subsequent screens were 0.78 and 0.53, respectively. In the control groups, the sensitivities of the initial physical examination for older and younger women were 0.769 and 0.671, respectively, and the sensitivity of the subsequent physical examinations for the control group aged 50-59 years was 0.37. The upper-bounds for over-diagnosis in older and younger women were 25% and 27%, respectively. CONCLUSIONS: The present work offers a basis for the better modeling of cancer incidence for a population with the inclusion of prevalent cancers.