A two-day workshop reviewing Canadian provincial and national HIV care cascade indicators, reporting, challenges, and recommendations.

BACKGROUND: The HIV care cascade is an indicators-framework used to assess achievement of HIV clinical targets including HIV diagnosis, HIV care initiation and retention, initiation of antiretroviral therapy, and attainment of viral suppression for people living with HIV. METHODS: The HIV Care Cascade Research Development Team at the CIHR Canadian HIV Trials Network Clinical Care and Management Core hosted a two-day virtual workshop to present HIV care cascade data collected nationally from local and provincial clinical settings and national cohort studies. The article summarizes the workshop presentations including the indicators used and available findings and presents the discussed challenges and recommendations. RESULTS: Identified challenges included (1) inconsistent HIV care cascade indicator definitions, (2) variability between the use of nested UNAIDS's targets and HIV care cascade indicators, (3) variable analytic approaches based on differing data sources, (4) reporting difficulties in some regions due to a lack of integration across data platforms, (5) lack of robust data on the first stage of the care cascade at the sub-national level, and (6) inability to integrate key socio-demographic data to estimate population-specific care cascade shortfalls. CONCLUSION: There were four recommendations: standardization of HIV care cascade indicators and analyses, additional funding for HIV care cascade data collection, database maintenance and analyses at all levels, qualitative interviews and case studies characterizing the stories behind the care cascade findings, and employing targeted positive-action programs to increase engagement of key populations in each HIV care cascade stage.

HISTORIQUE: La cascade des soins du VIH est un cadre d'indicateurs utilisé pour évaluer l'atteinte des cibles cliniques du VIH, y compris le diagnostic, le début et le maintien des soins, le début du traitement antirétroviral et l'obtention de la suppression virale chez les personnes qui vivent avec le VIH. MÉTHODOLOGIE: L'équipe de développement de la recherche sur la cascade des soins du VIH située au noyau de perfectionnement de la gestion clinique du Réseau canadien pour les essais VIH des IRSC a organisé un atelier virtuel de deux jours pour présenter les données sur la cascade des soins du VIH amassées dans les milieux cliniques locaux et provinciaux et les études de cohorte de tout le pays. L'article résume les présentations d'ateliers, y compris les indicateurs utilisés et les observations disponibles, et présente les défis et recommandations abordés. RÉSULTATS: Les défis mis en évidence incluaient 1) les définitions hétérogènes des indicateurs de la cascade des soins sur le VIH, 2) la variabilité entre l'utilisation des cibles d'ONUSIDA imbriquées et les indicateurs de cascade des soins du VIH, 3) des approches analytiques variables d'après diverses sources de données, 4) la déclaration des difficultés dans certaines régions à cause de l'absence d'intégration entre les plateformes de données, 5) l'absence de données vigoureuses sur la première étape de la cascade des soins infranationaux et 6) l'incapacité d'intégrer les principales données sociodémographiques pour évaluer les écueils de la cascade des soins populationnels. CONCLUSION: Quatre recommandations ont été formulées : la standardisation des indicateurs et des analyses de la cascade des soins du VIH, le financement supplémentaire de la collecte de la cascade des soins du VIH, l'entretien des bases de données et les analyses à tous les échelons, les entrevues qualitatives et les études de cas qui caractérisent les histoires qui se cachent derrière les observations tirées de la cascade des soins et le recours à des programmes d'action positive ciblés pour accroître la participation de populations clés à chaque étape de la cascade des soins du VIH.

Canadian physicians' knowledge and counseling practices related to antibiotic use and antimicrobial resistance: Two-cycle national survey.

OBJECTIVE: To establish a baseline for physicians' knowledge of and counseling practices on the use of antibiotics and antimicrobial resistance (AMR), and to determine potential changes in these measures after the implementation of a national AMR awareness campaign. DESIGN: Cross-sectional design. SETTING: Canada. PARTICIPANTS: A total of 1600 physicians. MAIN OUTCOME MEASURES: Physicians' knowledge of and counseling practices on antibiotic use and AMR at baseline and after implementation of the AMR awareness campaign. RESULTS: A total of 336 physicians responded to the first-cycle survey (before the campaign), and 351 physicians responded to the second-cycle survey (after the campaign). Overall, physicians' knowledge of appropriate antibiotic use and AMR was high and their counseling practices in relation to antibiotics were appropriate in both surveys. Counseling levels about topics related to infection prevention and control (eg, food handling, household hygiene) were slightly lower. Counseling levels were also lower for certain antibiotic-use practices (eg, proper disposal of antibiotics). In addition, physicians with less than 10 years of practice experience had significantly lower odds of counseling their patients on topics related to preventing antibiotic resistance and infection prevention than those with 15 or more years of practice experience (adjusted odds ratio = 0.27, 95% CI 0.10 to 0.74). Significantly more physicians from the second-cycle survey counseled patients on the appropriate disposal of antibiotics (P = .03), as well as on some of the infection prevention topics (eg, using antibacterial hand soap [P = .02] and cleaning supplies [P = .01]). Most respondents in both surveys reported feeling confident with respect to counseling their patients on the appropriate use of antibiotics and AMR. CONCLUSION: Physicians' knowledge of and levels of counseling on the use of antibiotics and AMR were high and fairly stable in both survey results. This shows that Canadian physicians are demonstrating behaviour patterns of AMR stewardship. Existing gaps in counseling practices might be a result of physicians believing that pharmacists or nurses are addressing these issues with patients. Future national surveys conducted among pharmacists and nurses would contribute to the evidence base for AMR stewardship activities.

Management of gonococcal infection among adults and youth: New key recommendations.

OBJECTIVE: To provide recommendations on the management of gonococcal infection among adults and youth. QUALITY OF EVIDENCE: Treatment recommendations in the Canadian guidelines on sexually transmitted infections are based on review of the literature, as well as the grades of recommendations and the levels of evidence quality determined by a minimum of 2 reviewers. The recommendations are peer-reviewed and require approval by the expert working group. MAIN MESSAGE: The new key recommendations for managing gonococcal infection among adults and youth include using culture as a diagnostic tool when practical, providing treatment with combination antibiotic therapy (ceftriaxone combined with azithromycin), and promptly reporting all cases with treatment failure to public health. CONCLUSION: Following these new key recommendations might reduce treatment failure, contribute to better surveillance of antibiotic-resistance trends in Neisseria gonorrhoeae, and contribute to the prevention of transmission of multidrug-resistant gonorrhea.

Invasive cervical cancer incidence and mortality among canadian women aged 15 to 29 and the impact of screening.

OBJECTIVE: The utility of screening young women for cervical cancer is questionable given the likelihood of pre-cancer regression and the potential harm of the intervention. Our objective was to determine the incidence and mortality rates of invasive cervical cancer (ICC) in women aged 15 to 29 years and to assess changes in rates since the uptake of screening. METHODS: The incidence of ICC cases from 1970 to 2007 was obtained from records in the Canadian Cancer Registry and from the National Cancer Incidence Reporting System. Mortality rates in women with ICC for the same time period were obtained from the Canadian Vital Statistics Death Database. Data were classified by age group and year at diagnosis or death, assessed at five-year intervals. The incidence was further analyzed according to histology. RESULTS: ICC among 15- to 19-year-olds is rare and has remained relatively constant from 1970-1974 to 2005-2007. From 1975-1979 to 2005-2007, the incidence in 20- to 24-year-olds declined from 3.2 to 1.2 per 100 000. From 1980-1984 to 2005-2007, the incidence in 25- to 29-year-olds declined from 11.1 to 6.3 per 100 000. Deaths among 15- to 19-year-olds and 20- to 24-year-olds are rare, but in 25- to 29-year-olds mortality declined from 0.9 to 0.5 per 100 000 between 1975-1979 and 2005-2007. Among 20- to 24-year-olds, rates of all cervical cancers and squamous cell carcinomas declined, while adenocarcinomas and unknown types were rare. In 25- to 29-year-olds there was a decline in all cervical cancers and squamous cell cancers and an apparent increase in adenocarcinoma. CONCLUSIONS: ICC in adolescents is rare and does not justify population-based screening. Screening appears to have affected the incidence of ICC in 20- to 24-year olds and incidence and mortality from ICC in 25- to 29-year-olds.

Reduced cervical cancer incidence and mortality in Canada: national data from 1932 to 2006.

BACKGROUND: High levels of participation in cervical screening are reported in Canada from the 1970's as a result of early uptake of the Pap smear and universal Medicare. Despite recommendations to the contrary, the programs have featured early age of initiation of screening and frequent screening intervals. Other countries have achieved successful outcomes without such features. We analyzed national data to better understand mortality and incidence trends, and their relationships to screening. METHODS: The Canadian Cancer Registry, National Cancer Incidence Reporting System, and the Canadian Vital Statistics Database were used to measure mortality and incidence rates. Cases and deaths from invasive cervical cancer were classified by 5 year age groups at diagnosis and death (15 to 19 years through to 80 to 84 years), year of diagnosis (1972 to 2006), and year of death (1932 to 2006). Probabilities of developing and dying from cervical cancer were calculated for age-specific mortality and incidence. The proportion of women reporting a timely Pap test was estimated for 1978 to 2006. RESULTS: Cervical cancer mortality has declined steadily from a peak of 13.5 to 2.2 per 100,000 (83%,) between 1952 and 2006, and 71% between 1972 and 2006. Incidence of invasive cervical cancer has declined by 58% since 1972. These declines have occurred more among older age groups than younger. Invasive cervical cancer incidence and mortality is less in each successive birth cohort of women. Participation rates in screening are high especially in women under age 50. CONCLUSIONS: Despite increasing risk factors for cervical cancer, both incidence and mortality have declined over time, across age groups, and across birth cohorts. Earlier increasing mortality (1932 - 1950) was likely related to improved classification of cancers and the early subsequent reduction (1950 - 1970) to improved treatment. Recent improvements in incidence and mortality are likely due to high rates of screening. For women under age 30 years there are low rates of disease but lesser improvement related to screening.

Childhood and adolescent cancer survival: a period analysis of data from the Canadian Cancer Registry.

This study provides up-to-date estimates of childhood and adolescent (ages 0-19) cancer survival in Canada using data from the Canadian Cancer Registry (CCR). Cases were classified according to the third edition of the International Classification of Childhood Cancer classification scheme. Follow-up for vital status was determined through record linkage to the Canadian Mortality Data Base, and from information reported by provincial/territorial cancer registries. Observed survival proportions (OSPs) were based on period analysis (1999-2003). The 1-, 3- and 5-year OSPs for all cancers combined were 92%, 85% and 82%, respectively. Among diagnostic groups, five-year survival estimates were highest for retinoblastoma (99%), carcinomas and other malignant epithelial neoplasms and malignant melanomas (91%) and for renal tumours (91%); they were poorest for hepatic tumours (68%) and for malignant bone tumours (68%). Survival for childhood and adolescent cancer in Canada has improved substantially since last reported.

Impact of age and diagnosis on waiting times between important healthcare events among children 0 to 19 years cared for in pediatric units: the Canadian Childhood Cancer Surveillance and Control Program.

BACKGROUND: The objectives were to describe and compare waiting times to diagnosis and treatment of children and adolescents who accessed pediatric oncology centers in Canada for healthcare, and to assess the effects and relative contributions of age, sex, and diagnosis to waiting times. METHODS: Waiting times were assessed for 2,365 children (0 to 14 y) and 375 adolescents (15 to 19 y) diagnosed with cancer between 1995 and 2000 inclusive and followed by the Treatment and Outcome Surveillance system of the Canadian Children's Cancer Surveillance and Control Program. Differences were assessed using the chi2 test, Fisher exact test, and Wilcoxon test statistic. RESULTS: Median waiting times between first assessment by treating oncologist or surgeon and definitive diagnostic procedure, and the subsequent interval to first therapeutic event, were 2 days each. Significant variation existed in both periods when stratified by age and diagnosis but not sex. The most significant differences between age groups were eliminated when stratified by diagnosis. INTERPRETATION: This analysis suggests that once they enter the healthcare system, children and adolescents treated in pediatric centers in Canada experience short waiting times to key diagnostic and treatment events. Differences in wait times between the 2 age groups are not clinically significant and can be attributed to the differences in the types of cancer experienced by adolescents compared with children.

Quality of life among long-term adolescent and adult survivors of childhood cancer.

PURPOSE: We assessed effects of childhood or adolescent cancer on quality of life among adolescent and adult cancer survivors, a group who are thought to be at particular risk for adverse late effects. PATIENTS AND METHODS: We studied 1,334 survivors and 1,477 age- and sex-matched, general population controls from across Canada using a mailed questionnaire which included the Short Form-36 (SF-36) and measures of self-esteem, optimism, and life satisfaction. General linear models and logistic regression were used. Survivor-control differences corresponding to an effect size (ES) > or = 0.5 were considered clinically important. RESULTS: Participants were age 15 years to 37 years. Most survivors (83.8%) were diagnosed > or = 10 years earlier. Fewer survivors (62.1%) than controls (71.1%) reported very good or excellent general health (adjusted odds ratio, 0.6; 95% CI, 0.5 to 0.7). However, quality of life differences between survivors and controls were small, and for the most part probably not clinically important. Three clinical characteristics-having had CNS or bone cancer, more than one treatment series, and > or = two organs with a dysfunction at treatment end-were independently associated with poorer quality of life in the physical dimensions. Only survivors with > or = two organs with dysfunction (8.7%) reported poorer quality of life in both physical and psychosocial domains, with several clinically important ES. The largest ES for the SF-36 physical summary scores were found in the 8% of survivors with two or three of these characteristics simultaneously, compared with those survivors who had none (-0.79 and -1.13, respectively). CONCLUSION: Overall, a sizeable majority of adolescent and adult long-term survivors of childhood cancer in Canada appear to have adapted well.

Use of health care services by survivors of childhood and adolescent cancer in Canada.

BACKGROUND: The number of survivors of childhood cancer in Canada is growing. The large majority of survivors experience at least 1 adverse late effect of their cancer therapy, which often becomes more severe and clinically apparent with time. The extent of survivors' use of health services in Canada is unknown, although coordinated, continuous, long-term follow-up care has been recommended by numerous investigators. METHODS: Information on reported consultations with healthcare practitioners in the past year was obtained from 2152 survivors of child and adolescent cancer (mean age at diagnosis, 7.3; range, 0-19) and 2432 age- and sex-matched population-based controls through a mailed questionnaire. RESULTS: Similar proportions of survivors (71%) and controls (73%) reported consulting a general practitioner in the past year. Survivors were more likely than controls to consult with any specialist (68% vs. 46%), including an oncologist (29% vs. 0.3%). Survivors' consultations with oncologists increased with concurrent physical health problems (adjusted odds ratio [OR(adj)], 1.7, 95% confidence interval [CI], 1.4-2.1), history of high risk therapy (OR(adj), 2.4, 95% CI, 1.9-2.9), and multiple treatment series (OR(adj), 2.2, 95% CI, 1.7- 3.0), but decreased with time since diagnosis (OR(adj), 0.3, 95% CI, 0.2-0.4). CONCLUSION: Although most survivors reported consulting with at least 1 healthcare practitioner in the past year, the large majority did not report consulting an oncologist and thus may not be receiving optimal follow-up care. Moreover, consultations decreased with time since diagnosis, exactly when risk of late effects increases. This limited preventive care could have major implications on survivors' long-term health.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD.

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Prevalence of diabetes and cardiovascular comorbidity in the Canadian Community Health Survey 2002-2003.

Diabetes mellitus is a major risk factor for heart disease (heart attack, angina, and heart failure), stroke, and hypertension, which shorten the average life expectancy. The main objective of this study was to describe the prevalence of heart disease, hypertension, and stroke among Canadians with diabetes compared to those without diabetes in the Canadian general population aged 12 years and over. It also estimated the strength of association between diabetes, heart disease, hypertension, and other factors such as age, gender, cigarette smoking, alcohol drinking, education status, body mass index (BMI), and other socioeconomic factors. Descriptive statistics were used initially to estimate the prevalence of related comorbidities by age and gender. Logistic regression was then employed to determine the potential strength of association between various effects. Data included 127,610 individuals who participated in the 2.1 cycles of the Canadian Community Health Survey (CCHS) in 2002-2003. The prevalence of self-reported hypertension, heart disease, and stroke among individuals with diabetes were 51.9, 21.7, and 4.8%, respectively. By comparison, prevalence among those without diabetes was 12.7, 4.2, and 0.9%. Adjusted Odds Ratios (OR) were 4.15, 5.04, and 6.75 for males', and 4.10, 5.29, and 4.56 for females' hypertension, heart disease, and stroke, respectively. Lower income (OR from 1.27-1.94) and lower education (OR from 1.23-1.86) were independently associated with a high prevalence of hypertension, heart disease, and stroke among diabetics. Alcohol consumption (OR from 1.06-1.38), high BMI (OR from 1.17-1.40), physical inactivity (OR from 1.21-2.45), ethnicity, and immigration status were also strongly associated with hypertension, heart disease, and stroke. The adjusted prevalence of hypertension, heart disease, and stroke in the CCHS-2003 health survey in Canada was significantly higher among those with diabetes compared to those without. Other factors such as age, gender, BMI, lifestyle, family incomes, physical activity levels, and socioeconomic status also affected the strength of association between diabetes and resulting comorbidities.

Health status in survivors of cancer in childhood and adolescence.

BACKGROUND: Assessing health status in survivors of childhood cancer is increasingly important due to improved survival rates. However, there are limited estimates available for this population based on large samples and compared to population controls. METHODS: In a retrospective cohort study, 2,152 long-term survivors and 2,432 controls, aged 5-37, who had survived cancer during childhood or adolescence were compared on the Health Utilities Index Mark III (HUI3). Descriptive and logistic regression analyses were used to assess the effect of age at diagnosis, type of cancer and therapy received on HUI3 domains. MAJOR FINDINGS: More survivors than controls showed deficits in dexterity, ambulation, hearing, speech and cognition but not in vision, emotion or pain. The largest numbers of survivors reporting excess impairment was found in the cognition attribute. Survivors of central nervous system tumors were most likely to show impairments across multiple domains. Lastly, impairments in cognition were found most commonly in survivors exposed to cranio-spinal radiation at young ages. CONCLUSIONS: Seventy-five percent of childhood cancer survivors and 80% of controls were found to have two or fewer impaired attributes. Those reporting impairments that were most likely to be of clinical relevance were among survivors diagnosed with central nervous system and bone tumours, and those exposed to cranial radiation as young children. Tools assessing health status should be included in prospective trials to more clearly assess the contribution of therapy to reduced long-term health status.

Educational and social late effects of childhood cancer and related clinical, personal, and familial characteristics.

BACKGROUND: The objectives of this study were to compare educational and social outcomes for young survivors of childhood cancer with a population control group of individuals who were never diagnosed with cancer and to identify risk and protective factors for these outcomes. METHODS: In this multicenter, Canadian, retrospective cohort study, 800 survivors age 17 years or younger were matched by age and gender with a group of 923 control participants. Using a mailed survey that was completed by parents, educational outcomes were assessed with questions about the child's enrollment in disability or special-education programs, repeating a grade, and academic or other school problems. Using friendships was the measure of social outcomes. RESULTS: Based on parental reports, significantly more survivors than controls repeated a grade (21% vs. 9%), attended learning-disability (19% vs. 7%) or special-education programs (20% vs. 8%), had educational or other school problems (46% vs. 23%), had no close friends (19% vs. 8%), and were less likely to use friends as confidants (58% vs. 67%). Survivors of central nervous system (CNS) tumors reportedly were more likely than controls to have educational problems and no close friends, followed by survivors of leukemia, and survivors of neuroblastoma. Among survivors, cranial radiation increased the likelihood of having educational difficulties and having no close friends compared with survivors who did not receive cranial radiation. Survivors who reportedly had high self-esteem and whose parents had postsecondary education had fewer educational and social problems. CONCLUSIONS: Children and adolescents who survived cancer, particularly those who had CNS tumors, leukemia, and neuroblastoma, required close monitoring for early educational and social difficulties, and such children should be offered educational rehabilitation and social skills training to maximize their academic and social success.

Waiting times for cancer care in Canadian children: impact of distance, clinical, and demographic factors.

BACKGROUND: The objective of this study was to evaluate the impact of distance from residence to pediatric oncology centers on waiting times to diagnostic assessment and treatment in Canadian children with cancer. PROCEDURE: Two thousand three hundred sixteen children (< 15 years of age) captured by the Canadian Childhood Cancer Surveillance and Control Program's (CCCSCP) Treatment and Outcome Surveillance (TOS) system were included in the analysis. The number of days between onset of symptoms and first anti-cancer therapy was compared for those living less than 25, 25-99, and more than 100 kilometers from their treating center. For each time period, the adjusted odds of falling into the longest time quartiles were estimated using logistic regression analysis. RESULTS: Thirty-four percent (n = 786) of children lived more than 100 kilometers from their treating center. There were no significant differences in age at diagnosis (P = 0.33), sex (P = 0.68), or ICCC diagnosis (P = 0.02) by distance from center, though there was a significant difference in region of residence (P < 0.01) and the first health care professional contacted (P < 0.01). Except for waiting time from first health care contact to first assessment by treating oncologist which increased with increasing distance (P < 0.01), there were no significant differences in waiting times by distance. When adjusted for important demographic and clinical characteristics, distance to center did not affect the odds of waiting longer for any event. CONCLUSIONS: Distance to treating center had no significant impact on waiting times for important diagnostic and treatment events, when adjusted for age at diagnosis, diagnosis, region, and first health care professional seen.

The late effects study: design and subject representativeness of a Canadian, multi-centre study of late effects of childhood cancer.

The Late Effects Study of the Canadian Childhood Cancer Surveillance and Control Program was designed to assess psychosocial and physical health outcomes among survivors of childhood cancer compared to general population controls. The objectives of this paper are to describe the design and methodology of the multi-centre, retrospective cohort study, present clinical characteristics of the survivor population, and evaluate the representativeness of study controls. Response rates were 63% for surivors (n = 2,152) and 49% for controls (n = 2,432). Survivors with germ cell turmours and carcinomas were slightly under-represented among participants as were those who received more intense or multiple series of therapy. Study controls were similar to Census individuals based on marital and work status but did have a slightly higher level of education and income. Otherwise, no large or systematic differences were found. Thus, these long-term survivors and population controls can be validly studied to evaluate whether and to what extent survivors experience an excess of psychosocial or physical health problems compared to similarly aged Canadians who have never had cancer.