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Infertility is a common diagnosis: in its original, heteronormative definition, it is known to impact about 1 in 6 couples worldwide. Governments across Canada and beyond have been increasingly providing support for those undergoing fertility treatment, and BC is the most recent province to announce funding, beginning in 2025. As the amount of proposed funding is not sufficient to cover treatment for all who seek it, we look to examples from other provinces and countries to guide us in forming criteria that balance fair access with likelihood of successful treatment. A majority of Canadian provinces currently provide publicly funded fertility care, albeit with highly variable models. Quebec previously introduced a model with generous coverage, including up to three cycles of in vitro fertilization (IVF), along with medications, associated procedures, and embryo transfers for each live birth. Due to high costs, this funding was removed and reintroduced in 2021 with a more restrictive model, as well as age cutoffs for IVF and embryo transfers. In Ontario, the current funding model was introduced in 2015 and covers intrauterine insemination cycles and one cycle of IVF in patients younger than 43 years of age. Other provinces have offered a fertility treatment tax credit. While the BC announcement stated that one cycle of IVF with medications will be covered, the details on how this finite resource will be distributed are still unclear. We hope BC will consider the lessons learned from other provinces and countries and implement a program that is fair and accessible to those who need it. [ABSTRACT FROM AUTHOR]

With limited phosphorus (P) supplies, increasing P demand, and issues with P runoff and pollution, developing an ability to reuse the large amounts of residual P stored in agricultural soils is increasingly important. In this study, we investigated the potential for residual soil P to maintain crop yields while reducing P applications and losses in Canada. Using a P cycling model coupled with a soil P dynamics model, we analyzed soil P dynamics over 110 years across Canada's provinces. We found that using soil residual P may reduce mineral P demand as large as 132 Gg P year−1 (29%) in Canada, with the highest potential for reducing P applications in the Atlantic provinces, Quebec, Ontario, and British Columbia. Using residual soil P would result in a 21% increase in Canada's cropland P use efficiency. We expected that the Atlantic provinces and Quebec would have the greatest runoff P loss reduction with use of residual soil P, with the average P loss rate decreasing from 4.24 and 1.69 kg ha−1 to 3.45 and 1.38 kg ha−1, respectively. Ontario, Manitoba, and British Columbia would experience relatively lower reductions in P loss through use of residual soil P, with the average runoff P loss rate decreasing from 0.44, 0.36, and 4.33 kg ha−1 to 0.19, 0.26, and 4.14 kg ha−1, respectively. Our study highlights the importance of considering residual soil P as a valuable resource and its potential for reducing P pollution. [ABSTRACT FROM AUTHOR]

Lyme disease cases reported in seven Canadian provinces from 2009 to 2019 through the Lyme Disease Enhanced Surveillance System are described herein by demographic, geography, time and season. The proportion of males was greater than females. Bimodal peaks in incidence were observed in children and older adults (≥60 years of age) for all clinical signs except cardiac manifestations, which were more evenly distributed across age groups. Proportions of disease stages varied between provinces: Atlantic provinces reported mainly early Lyme disease, while Ontario reported equal proportions of early and late-stage Lyme disease. Early Lyme disease cases were mainly reported between May through November, whereas late Lyme disease were reported in December through April. Increased awareness over time may have contributed to a decrease in the proportion of cases reporting late disseminated Lyme disease. These analyses help better describe clinical features of reported Lyme disease cases in Canada. [ABSTRACT FROM AUTHOR]

Background: Comprehensiveness of primary care has been declining, and much of the blame has been placed on early-career family physicians and their practice choices. To better understand early-career family physicians' practice choices in Canada, we sought to identify the factors that most influence their decisions about how to practice. Methods: We conducted a qualitative study using framework analysis. Family physicians in their first 10 years of practice were recruited from three Canadian provinces: British Columbia, Ontario, and Nova Scotia. Interview data were coded inductively and then charted onto a matrix in which each participant's data were summarized by code. Results: Of the 63 participants that were interviewed, 24 worked solely in community-based practice, 7 worked solely in focused practice, and 32 worked in both settings. We identified four practice characteristics that were influenced (scope of practice, practice type and model, location of practice, and practice schedule and work volume) and three categories of influential factors (training, professional, and personal). Conclusions: This study demonstrates the complex set of factors that influence practice choices by early-career physicians, some of which may be modifiable by policymakers (e.g., policies and regulations) while others are less so (e.g., family responsibilities). Participants described individual influences from family considerations to payment models to meeting community needs. These findings have implications for both educators and policymakers who seek to support and expand comprehensive care. [ABSTRACT FROM AUTHOR]

Unlike other high-income countries, Canada has no national policy for drugs treating rare diseases (orphan drugs). Nevertheless, in 2022, the Canadian government committed to creating a national strategy to make access to these drugs more consistent. Our aim was to study whether recommendations made by the Canadian Agency for Drugs and Technology in Health (CADTH) translated into coverage decisions for orphan drugs in Ontario, the largest Canadian province. This study is the first to look at this question for orphan drugs, which are at the center of policy attention. We included 155 orphan drug-indication pairs approved and marketed in Canada between October 2002 and April 2022. Cohen's kappa was used to test the agreement across health technology assessment (HTA) recommendations and coverage decisions in Ontario. Logistic regression was used to test which factors, relevant to decision-makers, might be associated with funding in Ontario. We found only fair agreement between CADTH's recommendations and coverage decisions in Ontario. Although a positive and statistically significant association between favorable HTA recommendations and coverage was found, more than half of the drugs with a negative HTA recommendation were available in Ontario, predominately through specialized funds. Successful pan-Canadian pricing negotiations were a strong predictor of coverage in Ontario. Despite efforts to harmonize access to drugs across Canada, considerable room for improvement remains. Introducing a national strategy for orphan drugs could help increase transparency, consistency, promote collaborations, and make access to orphan drugs a national priority. • Recommendations by the Canadian Agency for Drugs and Technology in Health do not always translate to provincial coverage decisions for new drugs. • We explored whether Canadian Agency for Drugs and Technology in Health's recommendations are aligned with coverage decisions for orphan drugs in Ontario. • Negative health technology assessment recommendations did not necessarily translate to no pan-Canadian pricing negotiations. • More than half the drugs with negative health technology assessment recommendations were available in Ontario through specialized funds. • A national strategy for orphan drugs could prioritize access to these treatments at a national level and harmonize access, at least to some extent, across Canada. [ABSTRACT FROM AUTHOR]

This article is an analysis of what is still a relatively new educational method in law schools, namely the use of simulated clients (SCs) for learning and assessment in legal education. We outline the method and its origins, give a brief history of it in law schools to the present, and then focus on two modalities of the method, namely the face-to-face client interview and the online client interview. We discuss two instances of SC use, namely the adaptation of the method in professional education across four provinces in Canada; and the use made of the method by one law school in the province of Ontario, Canada. We discuss the social and educational contexts of the two modalities and relate it to other literatures emerging from the experiences of pandemic learning in higher eduction (HE). Finally, we draw some conclusions in the light of wider considerations of simulation, digital simulation, and the future of experiential education. [ABSTRACT FROM AUTHOR]

• All-cancer radiotherapy utilization ratios (RTUR) varied across Canada by 9%, and up to 28% by cancer type. • RTURs were below Ontario benchmarks for many provinces and cancer subsites. • RTURs can be a reasonable surrogate for linked (patient-specific) utilization. Access to radiotherapy (RT) is a key component of a cancer control strategy. However, radiotherapy utilization (RTU) rates fall short of desired benchmarks in certain Canadian provinces. We aimed to describe provincial variations in RTU across Canada. We calculated radiotherapy utilization ratios (RTUR) for each Canadian province from 2016 (RT case counts divided by incidence counts), by cancer type (all cancers, lung, breast, rectal, prostate) and treatment intent (curative, palliative) where data were available. Data were extracted from each provincial RT data repository, cancer registry and/or RT department. We compared RTURs descriptively across provinces and to Ontario benchmarks, and calculated an estimated national RTUR. In provinces with capacity for data linkage, RTURs were compared to a linked (patient-specific) method of calculating utilization, by linking each incident case to whether RT was received within 1 year of diagnosis (RTU-1 yr). Excluding three provinces that included re-treatments, all-cancer RTURs ranged from 0.31 in Manitoba to 0.40 in Nova Scotia. The national all-cancer RTUR was 0.35, which was comparable to Ontario benchmarks (0.34). Larger variations were seen by cancer type, with an absolute difference in RTURs of 28% for lung cancers, 27% for breast cancers, 21% for rectal cancers, and 18% for prostate cancers. RTURs for nearly all provinces were below established Ontario benchmarks for each cancer type, except prostate cancer. RTURs over-estimated RTU-1 yr by at most 5%, except for prostate cancers where they over-estimated RTU-1 yr by up to 15%. RTU varies by province in Canada, and most notably by cancer subsite. More granular data at the regional level and by healthcare facility is required to further tailor strategies aimed at improving RT access. RTURs also serve as a reasonable surrogate for linked RTU, and both methods can contribute meaningfully to measure RTU depending on the context and data availability. [ABSTRACT FROM AUTHOR]

In Canada, greenhouse gas (GHG) emissions continue to remain high despite the federal government's commitment to reduce GHG emissions. Environmental policy across Canadian provinces has largely lacked consistency with some provinces implementing targeted policy such as carbon taxes while others have strongly resisted the federal government's attempts to encourage such policy. This study examines the impact of environmental policy on GHG gas emissions across Canadian provinces with policy uniquely measured by public and business sector spending on environmental protection as well as notable province-specific policies. An extended STIRPAT model is specified with the inclusion of proxies for environmental policy using panel data from Canada's ten provinces from 1995 to 2019. The cointegration and the error correction modelling approaches are employed to estimate the non-stationary panel data. A pooled mean group estimation is applied to provide short run and long run coefficients. The findings indicate that although per capita GDP is the main driver of GHG emissions in Canada, environmental policy has a significant mitigating effect, as shown by the negative association between emissions and private and public sector spending on environmental protection in the long run. Furthermore, provinces with targeted policies, such as Ontario's coal phase-out and British Columbia's carbon tax, experienced significant emissions reductions. The theoretical implication is the successful addition of policy variables to the STIRPAT model, providing the model a new application for future research. [Display omitted] • Assess the impact of environmental protection policies on per capita greenhouse gas emissions in Canada. • Utilize public and private expenditures on environmental protection, along with provincial policies. • Extend the STIRPAT model to incorporate environmental protection policies in an empirical model. • Demonstrate a significant negative relationship between environmental protection policies and GHG emissions. • Offer insights with implications for global environmental sustainability efforts. [ABSTRACT FROM AUTHOR]

Agriculture produces food, fiber and biofuels for the world's growing population, however, agriculture can be a major contributor of nitrogen (N) losses including emissions of ammonia (NH 3), nitrous oxide (N 2 O) and nitrate (NO 3 −) leaching and runoff. A Canadian Agricultural Nitrogen Budget for Reactive N (CANBNr) model was developed to estimate the soil N balance in 3487 soil landscape of Canada polygons from 1981 to 2016. The CANBNr model integrates NH 3 emission from fertilizers, manure from housing, storage and field, as well as direct/indirect N 2 O emissions from fertilizers, manures, crop residues and soil organic matter. The NO 3 − leaching is estimated based on the residual soil N (RSN) at harvest and drainage derived with the DeNitrification-DeComposition (DNDC) model. From 1981 to 2016, the N input from fertilizer and N fixation increased at a greater rate than N removal in harvested crops in all provinces of Canada, resulting in an increase in the RSN and N losses. In 2016, the Prairie provinces had lower N losses (11.7 kg N ha−1) from N 2 O, NH 3 and NO 3 − compared with 43.2 kg N ha−1 in central Canada, and 76.5 kg N ha−1 in Atlantic Canada. However, the Prairie provinces had 84.3% of the total Canadian farmland (74.3% of the total Canadian N input), while central Canada had 12.9% of Canadian farmland (21.7% of the total Canadian N input). In the Prairie provinces, the total N 2 O loss from fertilizer N ranged 4.4–8.6 Gg N whereas NH 3 loss ranged from 17.1 to 44.6 Gg N and these values were influenced by both emission intensity and total land area. Total N 2 O losses from manure were highest in Alberta, Ontario and Quebec resulting in 4.8, 4.4, and 3.4 Gg N and NH 3 losses from manure were also highest in these 3 provinces at 61.1, 45.2 and 40.4 Gg N, respectively. Nitrate leaching was impacted by drainage volumes, soil type and N inputs. In the non-growing season, NO 3 − leaching losses (36-yr average) were 63.3 Gg in Ontario and 57.5 Gg N in Quebec compared with 20.8 Gg N for Ontario and 35.5 Gg N for Quebec in the growing season. In contrast, the Prairie provinces showed higher NO 3 − leaching in the growing season (23.1–37.4 Gg N) than in the non-growing season (10.4–13.7 Gg N). In summary, total fertilizer N increased the most over the 36 years in the Prairies which resulted in increased RSN and N leaching losses that will require further intervention. [Display omitted] • Canadian Agricultural Nitrogen Budget for Reactive N (CANBNr) model was developed. • The N budget were simulated at 3487 soil landscape of Canada polygons from 1981 to 2016. • RSN and N losses increased due to the greater increase in N input from fertilizer and N fixation than N removal by crop. • The Prairie provinces had lower N 2 O, NH 3 and NO 3 − leaching losses per hectare farmland than other provinces. [ABSTRACT FROM AUTHOR]

Context: Recently, updated Canadian surgical and medical abortion practice guidelines were released, mifepristone was approved by Health Canada for first trimester medical abortion (FTMA) as a regular prescription, and nurse practitioners (NPs) began to independently provide abortion care. These changes enabled a shift for abortion provision into primary care. Objective: (1) Describe the abortion care workforce, (2) Evaluate the reported clinical abortion practice compared to current clinical practice guidelines, and (3) Assess stigma and harassment experienced by providers. Study Design: Cross-sectional, self-administered, anonymized survey available in French and English. Setting: National survey of abortion providers in Canada. Population studied: Physicians and NPs providing abortion care in 2019 were contacted through national professional health care organizations. Outcome measures: Respondent demographics, characteristics of first and second trimester surgical and first, second and third trimester medical abortion (STTMA) practices, and stigma and resilience experienced by providers. Results: Between July and December 2020, 435 physicians and 30 NPs were recruited, representing every province and territory in Canada. The highest proportions were from the most populated provinces: Ontario (31.8%) and Quebec (23.6%). Most physicians were family physicians (n=246) or obstetrician-gynaecologists (n=185). Among 358 FTMA respondents, 61.3% reported having less than five years experience and 99.4 % used a mifepristone misoprostol regimen. Of 115 STTMA respondents, 58.5% used an off-label but guideline supported mifepristone misoprostol regimen. Respondents included 222 first and second trimester surgical abortion providers. Only 4.6% of 109 second trimester surgical abortion provider respondents used mifepristone for preoperative cervical ripening. Twelve percent of respondents experienced harassment or violence in 2019, most commonly as picketing or confrontations at their workplace. Conclusion: Introduction of mifepristone and changes in abortion guidelines, regulations and licensing changed the abortion workforce and care in Canada. Respondents reported overall provision of FTMA in line with current guideline. Guideline supported second trimester use of mifepristone has not been fully adopted yet. The results of this study will inform knowledge translation activities directed at health system, policy, and service leaders. [ABSTRACT FROM AUTHOR]

Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials. [ABSTRACT FROM AUTHOR]