How Do Canadians Rate the Health Care System?

Christine Pierroz, Director, Communications, Health Council of Canada

Today the Health Council of Canada presents you with a revealing bulletin, How Do Canadians Rate the Health Care System?, based on survey results from the 2010 Commonwealth Fund International Health Policy Survey. http://bit.ly/bvq5pl

Canadians feel strongly about their health care system, but they recognize the need for improvement. The bulletin shows that of all the countries surveyed, Canadians have the greatest difficulty when it comes to access to care in the evenings, weekends, and on holidays – anywhere other than the emergency room. Other areas where Canada did not fare well, compared to international counterparts, were around timely access to medical appointments and coordination of care. In contrast, Canadians are very satisfied with the quality of medical care that they receive and are confident that they could have access to the most effective treatment should they become seriously ill.

This bulletin follows yesterday’s release in New York of the Commonwealth Fund’s own analysis of this 11-country survey. The focus there was on the US, a survey participant whose performance yielded statements such as “US adults most likely to forego care due to cost, have trouble paying medical bills; US stands our for highest out-of-pocket costs and most complex health insurance.”

In Canada, we stand to learn from survey results in some of the highest performing countries around questions of interest to us – countries such as the Netherlands, the United Kingdom, and Switzerland. Perhaps you have had some experiences with these systems you would like to share. We look forward to your insights.

Drug Safety and Effectiveness in Canada - David U Responds

David U, President and CEO, Institute for Safe Medication Practices Canada

On behalf of the Institute for Safe Medication Practices Canada (ISMP Canada), I would like to thank and congratulate the Health Council of Canada for preparing and disseminating their findings on the important topic of drug safety in Canada. It is encouraging to learn that a number of new initiatives are being put in place to enhance post-marketing surveillance and monitoring such as the “progressive licensing” approach, working with industry to encourage Phase 4 studies on marketed drugs, supporting Canadian research centres to focus on selected drugs for studying their real world effectiveness and safety, as well as creating the Drug Safety and Effectiveness Network. The discussion paper facilitates learning from information available nationally as well as internationally and will help enhance Canada’s ability to ensure the drugs being marketed and used in Canada are safe and will not trigger undesirable and potentially harmful side effects.

I would also like to take this opportunity to emphasize that we must ensure drugs are being used appropriately to prevent harm. Medication incidents (medication errors) leading to harm and death can be prevented. For example, there have been a number of fatal incidents involving the fentanyl transdermal system (fentanyl patches) and important information about this has been published by Health Canada. One such publication is the July 2008 issue of the Canadian Adverse Reaction Newsletter which highlights 52 cases with fatal outcome involving fentanyl patches; examples include incidents (errors) which involve healthcare professionals and consumers. ISMP Canada has also received incident reports related to fentanyl patches, and has issued several alerts and safety bulletins to healthcare practitioners as well as sharing learnings with manufacturer(s) for the purpose of enhancing labelling and packaging.

As part of Canadian Medication Incident Reporting and Prevention System (CMIRPS), the incident reports received by ISMP Canada contribute to knowledge in medication safety. For example, contributing to some harmful medication incidents is the confusion that has occurred from look-alike/sound-alike drug names and from look-alike labelling and packaging of pharmaceutical products. In October 2008, Health Canada initiated the development of a conceptual framework for the assessment of health product names for look-alike/sound-alike name attributes. An Expert Advisory Panel was created to support this development process, with representation from Health Canada, the Food and Drug Administration in the United States, ISMP Canada along with experts in the area of psycholinguistics and human factors. The proposed conceptual framework will inform the basis for the revision of the current Health Canada Guidance for Industry - Drug Name Review: Look-alike Sound-alike (LA/SA) Health Product Names. The guidance document will strive to bring greater scientific validity, transparency, objectivity and predictability to the evaluation of health product names for look-alike/sound-alike attributes. It is proposed that the framework and guidance will apply to the following product types for human use: prescription and non-prescription drugs, biologics, and natural health products. Over the past year, efforts have been focused on putting a number of health product names through each step of the proposed name review process to establish "proof of concept". It is anticipated that data gathering and analysis will be complete by 2011 followed by stakeholder consultation. Development of a similar framework is planned for labelling and packaging of pharmaceutical drugs for human use.

Learning from medication incidents occurs from reports received by both consumers and healthcare professionals as it provides useful information in detecting problems in the medication use system. In the spring of 2010, ISMP Canada launched a consumer medication incident reporting and learning web site: SafeMedicationUse.ca. Consumer reporting in Canada has resulted in important contributions to medication safety —10 newsletters and alerts have been published to provide incident learning and prevention strategies for all Canadians.

Another key project towards drug safety is the collaborative Canadian Pharmaceutical Bar Coding Project which aims to implement standardized bar codes on all aspects of pharmaceutical labelling. Headed jointly by the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI), the initiative is guided by a national Implementation Committee and being developed with assistance from a 34-member Technical Task Force (TTF), representing six identified healthcare sectors. Adoption of the GS1 global standard for automated identification (e.g., bar coding) of pharmaceutical products in Canada has been endorsed. The multiphase project has developed draft technical requirements for Canadian pharmaceuticals in the following areas: bar code components and symbologies, product database elements, medications to be included in the categories to be bar coded, and packaging levels and bar code placement.
The report prepared by the Health Council of Canada will no doubt help to further raise the profile of drug safety. It provides the opportunity for the collective challenge in Canada for all of us to move collaboratively towards the common goal of drug safety.

--
David U is the President and CEO at the Institute for Safe Medication Practices Canada (www.ismp-canada.org)

Drug Safety and Effectiveness in Canada - Hugh McLeod Responds

Hugh B. MacLeod , CEO, Canadian Patient Coalition

From the patient’s perspective, medication can be a tricky proposition. On one hand, we put our faith in pharmaceuticals in order to cure disease and improve our quality of life. On the other, we know the disastrous effect they can have if prescribed or taken incorrectly.

In a recent discussion paper commissioned by the Health Council of Canada, designed in part to inform Canadians and stakeholders about drug safety and effectiveness issues in Canada and abroad, it is suggested that Health Canada adopt a protocol for developing drug safety messages and disseminating them to the various stakeholders following harmful incidents.

As it happens, the Canadian Patient Safety Institute (CPSI) is involved in the creation of a series of initiatives to equip healthcare providers with the information and supports necessary to minimize, and hopefully eliminate, the occurrence and severity of harmful medication incidents in Canadian healthcare organizations. This work could not have been accomplished without the support and dedication of Health Canada, the Canadian Institute for Healthcare Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and stakeholders from throughout the healthcare sector.

For example, earlier this year, CPSI launched a project resulting in national consensus with respect to the use of GS1 global bar coding standards for labeling medication packaging in Canada. This system is far and away the safest way to track pharmaceutical products from manufacture to administration.

Another initiative is the Canadian Medication Incident Reporting and Prevention System (CMIRPS). The aim of the CMIRPS Program is to strengthen Canada’s capacity to reduce and prevent harmful medication incidents and to manage and share information about voluntarily reported medication incidents. For instance, in the aftermath of a death in hospital due to the inadvertent injection of the drug epinephrine, which is intended for topical use, ISMP Canada issued a nationwide alert giving healthcare providers the information they need to ensure the error is never repeated.

While this type of information sharing on a national scale is commendable, we need to start thinking about patient safety on a global scale – after all, why make our own mistakes causing undue harm to patients when we can learn from those who have already gone down that path?

In the words of Dr. Dale E. Turner, “the error of the past is the wisdom and success of the future.”

We encourage you to become a patient safety champion in your organization by kick-starting the discussion around medication safety and how you can leverage the wealth of information that exists to minimize, and hopefully eliminate, the occurrence and severity of harmful medication events.

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Hugh B. MacLeod is CEO of the Canadian Patient Safety Institute (CPSI) 

To learn more about CMIRPS and bar coding visit www.patientsafetyinstitute.ca and to learn more about our medication reconciliation intervention visit www.saferhealthcarenow.ca.

Drug Safety and Effectiveness in Canada - Susan Eng Responds

Susan Eng, Vice-President, Advocacy, CARP

Are our drugs safe? Most Canadians assume so, given the clinical trials and multiple layers of government regulation – and perhaps more persuasively, complaints from pharmaceutical companies that such regulation unduly impedes market entry of their drugs. But it may not be so, according to the just released Health Council of Canada report, “Keeping an Eye on Prescription Drug, Keeping Canadians Safe.”

Once drugs get on the Canadian market, according to the report, there is no systematic scrutiny of the real world experience with the drugs. Clinical trials are limited in size and scope and do not usually include people with multiple medical conditions. The report concludes that as a result, more and more people are being exposed to unsafe drugs and cites the example of the high profile withdrawal of Vioxx and Baycol for safety reasons.

Consumer safety now depends on voluntary reporting of adverse drug reactions but this captures only 1% – 10% of such reactions. What is needed is a system to protect the public through early detection of safety concerns – called pharmacovigilance – a systematic monitoring of drug safety once the product is released onto the market.

Pharmacovigilance is still new and evolving worldwide, and the report canvasses and compares some international examples. None are comprehensive but Canada is barely on the grid.

A big part of the problem is that Health Canada – which has the primary responsibility for consumer safety – has limited authority to order the kind of steps necessary to monitor or uncover safety problems or to take action to prevent further use of drugs with safety problems. The report argues it has also failed to fully and effectively utilize the authority it does have. Presumably, the technical review and modernization process now being undertaken by Health Canada will help address these gaps.

The report argues for the establishment and funding of independent research and monitoring of the safety and effectiveness of drugs after they have been put onto the market plus a progressive licensing system to give Health Canada continuing authority to require compliance with drug safety measures including post–market [Phase IV] clinical trials. [1]

Hopeful signs include the recent creation and funding of the Drug Safety and Effectiveness Network which will research post market drug safety – but with no apparent responsibility for monitoring – and the proposed progressive licensing system which died on the order papers at the last prorogation.

CARP is a national, non-profit, non-partisan organization with 300,000-plus members across the country which advocates for changes that improve the quality of life for all Canadians as we age. Consumer safety is clearly a priority and our members would be appalled to think that the safety of the drugs they are taking [especially the newer ones] is not monitored on a systematic basis much less guaranteed and that there is no apparent process or responsibility to provide that guarantee.

Canadians are right to expect from the drug companies themselves a high level of integrity and good quality testing for safety and effectiveness before a drug comes onto the market. However, the limitations of the pre-market testing and the lack of systematic monitoring of post-market drug safety is a cause for concern.

The report’s recommendations are directed at redressing this concern and action should be taken on them as soon as possible.

--Susan Eng is Vice President of Advocacy for CARP, the national, non-partisan, non-profit organization committed to advocating for social change that will bring financial security, equitable access to health care and freedom from discrimination for all Canadians as we age.

Drug Safety and Effectiveness in Canada - Dr. Proton Rahman Responds

Dr. Proton Rahman, MD, FRCPC 

I wish to thank Health Canada for providing me with the opportunity to comment on this discussion paper. The paper which highlights why effective regulatory systems are needed is well informed providing a clear summary of the pharmacovigilance systems in place in a number of countries. This information is concisely summarized within table 3; although the inclusion of further information regarding the systems currently in place in Canada would add value to both the body of the text and the summary table. Analysis of this information will provide regulatory bodies with a springboard from which to develop a strategic vision for the implementation of effective pharmacovigilance systems throughout Canada.

The paper helpfully presents two planned developments for enhancing pharmacovigilance in Canada; the development of the Drug Safety Effectiveness Network (DSEN) and the introduction of Progressive Licensing. While the development of both of these initiatives should be applauded it should be noted that the DSEN is still in very early stages of development and a thorough review of the network’s effectiveness should be undertaken following an appropriate period of operation. The development of the DSEN should not lead to the exclusion of other post marketing research. As highlighted in the paper there is some concern regarding the impartiality of industry funded research, however this research should not be disregarded but instead the research environment be managed in such a way as to ensure impartiality in reporting.

The proposed introduction of Progressive Licensing, including conditional licensing (or release) would have a positive impact on “Keeping Canadians Safe” and potentially allow the earlier introduction of new drugs, however unless the introduction is backed with adequate legislation this impact will be severely reduced. The examples given of systems in place in other countries clearly highlight the need for supporting legislation to ensure the success of Progressive Licensing. Only through supporting legislation can it be ensured that pharmaceutical industries will abide by the terms of the license, such as the requirement for monitoring adverse events and the development and implementation of risk management plans. Progressive Licensing should not however be seen as the only answer, as there is benefit in other initiatives such as approvals through surrogate endpoints and mandatory post marketing surveillance of drugs known to have a higher risk of adverse events.

It should be noted that not all clinically relevant situations are assessed by randomized controlled trials. In such circumstances, information from disease registries can make an important contribution to the evidence base. In order for non-randomized prospective disease registries to adequately reflect clinically relevant outcomes it is important to register all relevant patients and capture accurate and comprehensive data through the collection of information on these patients in a defined area in a set time period. For this to occur it is vitally important for funding agencies to provide adequate and sustained resources for national disease registries. In the past, this has often not been a priority of funding agencies as such registries have been considered a “non hypothesis driven” initiative.

Regardless of how effective the pharmacovigilance and post-marketing surveillance systems are they are of limited use without the incorporation of effective methods of communication with prescribing Drs. The discussion paper highlights the need for developing more effective ways of communicating safety messages and this should be seen as one of the priorities of any resulting strategic plan.

The discussion paper also raises a number of issues regarding data collection, with many of the recommendations put forward reflecting the systems currently in place in Newfoundland and Labrador, where partner agencies have developed effective collaborative working arrangements to identify how disparate data sets may be shared and analyzed in a secure environment. Any initiatives to bring about collaboration and data sharing between provinces must give full consideration to the privacy and confidentiality issues that will arise, and as to how these relationships will be impacted by provincial privacy legislation.

On reading the paper it became clear that in order to prevent confusion in the future development of policy there is a need to ensure consistency in terminology when discussing pharmacovigilance and post marketing surveillance.

In order to ensure that any future strategies or policies reflect emerging technologies and future trends it is essential that consideration be given to the role of pharmacogenetics and personalized medicine in the enhancement of drug safety.

In summary this paper provides a good starting point for the development of a strategic vision for the introduction of nationally regulated pharmacovigilance, however if we are to truly “Keep Canadians Safe”, the vision must be developed in concert with all partners and address the broader issues of governance, privacy, data access and drug accessibility.

--
Proton Rahman MD, FRCPC a rheumatologist and genetic epidemiologist in the Faculty of Medicine at Memorial University. He is an associate professor of medicine and consultant rheumatologist to Eastern Health at the St. Clare’s site.

Roy West1 PhD, Don MacDonald2 PhD, Catherine Street1 B.Pharm(Hons), Khokan Sikdar2 MSc, MAS, PhD (candidate), Proton Rahman1 MD1Population Therapeutic Research Group, Memorial University, St. John’s NL
2Newfoundland and Labrador Center for Health Information, St. John’s, NL

What's Your Story?

This is part of the Health Council of Canada’s engagement with Canadians, health care stakeholders and governments who are working toward strengthening our health care system. Attendees at the 2010 National Healthcare Leadership Conference this year in Winnipeg, Manitoba were invited to submit entries to our Tell Us Your Success Story (now called What’s Your Story?) poll. We wanted to hear inspiring stories of best practices and innovation that have led to better outcomes for clients/patients and/or for the health system in general.

The following What’s Your Story? Submission came from Ms. Susan Bisaillon, Executive Director for Clinical Operations at the Trillium Health Centre in Mississauga, Ontario. It describes a project designed to tackle a specific problem related to the shifting care needs of elderly patients within the local health care system. The Health Council interviewed Ms. Bisaillon to find out more about how the centre was able to achieve such change, transforming its operation and discharge processes into an award-winning leading practice. Next month, the Health Council will produce a podcast of this story for Canadians visiting us at www.healthcouncilcanada.ca.

Q. Can you describe the specific challenge you and your colleagues at the Trillium Health Centre were facing?

A. In March, 2009, the number of Alternate Levels of Care (ALC)* cases in our facility peaked at 131, representing 18% of the hospital’s beds. These high ALC rates created Emergency Room gridlock, blocking patient access to acute care beds. Trillium was struggling to flow admitted patients out of the ER as the number of ALC cases increased. Emergency waits were very long and the Mississauga-Halton Local Health Integration Network (LHIN) challenged us—along with our Community Care Access Centre (CCAC) partner—to create innovative changes. The goal was to reduce ALC pressures to improve our emergency wait times.

* When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in the specific care setting, the patient must be designated Alternate Level of Care (ALC) at that time by the physician or her/his delegate. The ALC wait period starts at the time of designation and ends at the time of discharge/transfer to a discharge destination (or when the patient’s needs or condition changes and the designation of ALC no longer applies).

Q. How did you approach the problem?

A. In addressing the complex problem of ALC pressures, we realized it was important to move forward with the support of partners—in this case, with our LHIN and the Mississauga-Halton CCAC.

First, we were able to obtain consensus on a number of underlying issues contributing to long waits in ER, including the complexities around our ALC cases and opportunities for leveraging funding sources that already existed.

One of our strategies was to utilize a Lean consultant to identify the non-value-added or “waste” in our process. We aimed to clarify roles within the current system in order to develop more accountable and collaborative discharge processes. This included expediting the transition of acute care patients back into appropriate community settings.

We were able to do this by leveraging community capacity expansions that were funded by the Mississauga-Halton LHIN “Aging at Home” initiative from the Ontario Ministry of Health and Long-Term Care.

Q. Were these efforts successful?

A. In just over 12 months, we were able to achieve a 67% reduction in our ALC cases, bringing the proportion of ALC patients down to 7% of our inpatient beds. And we experienced positive satisfaction from our patients and staff as a result of this change.

Q. What were some of the changes in practices and protocols that you made in order to improve the discharge processes?

A. We were able to create a sense of urgency—what’s known as a “burning platform”—which encouraged everyone to fully engage in this important work. Individuals were seconded to focus attention on achieving traction and movement on the work needed. We learned that we needed to:

• create a one-team approach with the CCAC partners, which meant establishing a Joint Discharge Operation group where Trillium’s discharge planning staff and the Mississauga-Halton CCAC case managers worked together;
• segment the ALC patients into manageable streams such as “home first”, chronic, chronic palliative and rehabilitation;
• hold daily review sessions to ensure that any new information about the patient was communicated and acted upon immediately;
• establish key protocols contributing to “Home First,” an initiative in the Mississauga-Halton LHIN that aims to have patients who are admitted to hospitals return home immediately after discharge from acute care;
• revamp our Information Technology (IT) functions;
• tighten the approval process for placement on the ALC long-term care list; and
• introduce the role of Patient Navigator to assist with discharge planning.

Q. What kind of support did you give to the patients returning home after discharge from the hospital?

We ensured that these patients received full assessment and review by Trillium and the Mississauga-Halton CCAC. This enabled all necessary supports to be implemented in the right care environment to support safe post-discharge care. Successful implementation depended on getting physicians on board with a consistent message about having the patient go home first—before being placed in long-term care.

Furthermore, we introduced IT solutions with software (Medworxx) that measures utilization to determine more accurately when a patient needed to be deemed ALC or ready for discharge. We are now one of the six ALC beta testing sites for the province of Ontario, which is piloting new software for ALC with Cancer Care Ontario’s Wait Times Information System (WTIS).

Q. In hindsight, what did you learn from this successful effort that might be of use to colleagues in other areas of the health care system?

A. Translating the “Home First” changes into practices with Trillium and our regional CCAC was challenging at first, but we were able to make it work. It continues to be a journey that we work on and sustain on a daily basis.

What we have seen is that it’s all about getting the patient to the right placement and continuing to give the support that is needed. It was a significant change for our organization and the Mississauga-Halton CCAC that affected how we worked together. The CCAC and Trillium had to change their focus. This was an interesting project for us to work on. We were very fortunate that everyone stepped up and got on board to do what we could to make the situation better.

Also, it was a change internally for our staff because we had to redefine the roles and responsibilities of everyone involved in discharge planning at the Centre. We redesigned the roles and responsibilities around discharge planning and placement, and there was a significant change in management process with respect to roles and accountabilities.

Q. What is your big “take away” message for others?

A. You can have the investment—that is, both the funding and the human resources— but if you do not have the desire and commitment to do what is best for the patients, the change will not happen.

Q. What are the next steps for Trillium?

A. Trillium will continue to refine its protocols and roles and procedures related to discharge practices for ALC patients, while working closely with the Mississauga-Halton CCAC to improve all aspects of this transition. We will also seize opportunities to enhance the partnership with the LHIN.

We continue to discuss the challenges associated with hard-to-serve/hard-to-please patients and have created protocols and documents to assist Trillium and CCAC staff in handling these cases. Tools were also developed for staff, patients and families to facilitate a safe and timely discharge to the most appropriate placement.

Background
The Trillium Health Centre is a large academic-affiliated hospital within the Mississauga-Halton Local Health Integration Network (LHIN) that serves an area of over one million residents. The hospital serves as a regional centre for advanced cardiac and neuroscience, including stroke and vascular care, and provides specialized services in dealing with sexual assault and domestic violence.

Conversation on Health Care in Canada

John G. Abbott, CEO, Health Council of Canada

Recently, many health care thought leaders have come forward to voice the need for an “adult conversation” on health care. With just over three years remaining in the 2004 10-Year Plan to Strengthen Health Care, these pre-emptive conversations are essential at all levels, but need to shift their focus to strengthening the current system.

Canadians have had many opportunities to review the health care system and determine what they want in such a system. These questions were answered in detail by the Kirby Report and the Romanow Commission. Health care experts need to be focused on building a stronger, comprehensive system, and the actions needed to move Canada forward.

Currently, Canada spends over $180 billion a year on health care costs (2009); an amount that will continue to rise unless we address the key issues. For example, the use of pharmaceutical drugs, especially by an aging population subject to multiple chronic diseases, is costing Canadians about $30 billion a year (2008). In the past 10 years, the number of prescriptions filled at community pharmacies has increased by almost 80%, and at the same time Canada’s relatively high generic drug prices are ensuring that filling this large number of prescriptions is expensive. The government has options to institute reforms and reduce costs, but we need a national pharmaceuticals strategy in order to do this. A national pharmaceutical strategy that governments have committed to since 2004.

As well, long-term care and home care are aspects that should be explored to improve the efficiency of the system. In 2009, $51 billion went to hospitals, and some of this was attributed to patients who would have been better served in long-term care facilities or under home care instead of occupying expensive hospital beds. Investing in long-term and home care has the potential to save the health care system a lot of money.

It is clearly important to have a dialogue on health care, but not to discuss and reiterate what we already know. The aforementioned reports have spoken: the majority of Canadians are committed to a publicly-funded health care service covered under Medicare. Now we need to discuss how we take this current system that Canadians value and move forward to make it better, stronger and more sustainable.

See The Globe and Mail’s “We need an ‘adult’ conversation on health and social transfers” by André Picard.

Key Words: Home and Community Care, Pharmaceuticals Management