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BACKGROUND: Many aging adults undergo progressive loss of autonomy, develop increasingly complex medical needs and experience multiple care transitions. We sought to determine the degree of variation in rates of transfer from home care services and long-term care in several Canadian jurisdictions. METHODS: In this retrospective cohort study, we examined transitions from home care services and long-term care to different possible end states: change in health stability (getting better or worse), transfer to hospital, transfer to another care setting or death. We used standardized interRAI assessments from long-term care and home care linked to hospital records (data from the Discharge Abstract Database and National Ambulatory Care Reporting System) from 2010 to 2016. Multistate modelling was used to adjust for patients with complex health status and transitions in care. RESULTS: We report data for 254 664 patients in home care programs and 162 045 residents in long-term care. Compared with patients in Ontario, patients requiring home care services in Alberta and British Columbia had increased odds of being admitted to hospital regardless of the underlying severity of illness (the adjusted odds ratios [OR] ranged from 2.08 to 3.77 in Alberta and from 1.28 to 1.46 in BC). Residents in long-term care in Alberta and BC had less than half the odds of being transferred to hospital, independent of all other factors, when compared with long-term care residents in Ontario (the adjusted OR ranged from 0.38 to 0.39 in Alberta and from 0.33 to 0.44 in BC). INTERPRETATION: Significant variations in transfer rates were observed between provinces, even after controlling for individual patient characteristics. These results suggest that transfers to hospital are largely driven by health care policies, health care professional practice patterns and available infrastructure rather than individual patient needs.

BACKGROUND Medical end-of-life practices are hotly debated in Canada, and data from other countries are used to support arguments. The objective of this pilot study was twofold: to adapt and validate a questionnaire designed to measure the prevalence of these practices in Canada and the underlying decision-making process, and to assess the feasibility of a nationally representative study. METHODS In phase 1, questionnaires from previous studies were adapted to the Canadian context through consultations with a multidisciplinary committee and based on a scoping review. The modified questionnaire was validated through cognitive interviews with 14 physicians from medical specialties associated with a higher probability of being involved with dying patients recruited by means of snowball sampling. In phase 2, we selected a stratified random sample of 300 Canadian physicians in active practice from a national medical directory and used the modified tailored method design for mail and Web surveys. There were 4 criteria for success: modified questions are clearly understood; response patterns for sensitive questions are similar to those for other questions; respondents are comparable to the overall sampling frame; and mean questionnaire completion time is less than 20 minutes. RESULTS Phase 1: main modifications to the questionnaire were related to documentation of all other medical practices (including practices intended to prolong life) and a question on the proportionality of drugs used. The final questionnaire contained 45 questions in a booklet style. Phase 2: of the 280 physicians with valid addresses, 87 (31.1%) returned the questionnaire; 11 of the 87 declined to participate, for a response rate of 27.1% (n = 76). Most respondents (64 [84%]) completed the mail questionnaire. All the criteria for success were met. INTERPRETATION It is feasible to study medical end-of-life practices, even for practices that are currently illegal, including the intentional use of lethal drugs. Results from this pilot study support conducting a large national study, but additional strategies would be necessary to improve the response rate.

Background: Prolonged immobility during a critical illness may predispose patients to the development of joint contracture. We sought to document the incidence of, the risk factors for and the reversibility of joint contractures among patients who stayed in a tertiary intensive care unit (ICU) for 2 weeks or longer. Methods: We conducted a chart review to collect data on the presence of and risk factors for joint contractures in the shoulders, elbows, hips, knees and ankles among patients admitted to the ICU between January 2003 and March 2005. Results: At the time of transfer out of the ICU, at least 1 joint contracture was recorded in 61 (39%) of 155 patients; 52 (34%) of the patients had joint contractures of an extent documented to impair function. Time spent in the ICU was a significant risk factor for contracture: a stay of 8 weeks or longer was associated with a significantly greater risk of any joint contracture than a stay of 2 to 3 weeks (adjusted odds ratio [OR] 7.09, 95% confidence interval (CI) 1.29–38.9; p = 0.02). Among the variables tested, only the use of steroids conferred a protective effect against joint contractures (adjusted OR 0.35, 95% CI 0.14–0.83; p = 0.02). At the time of discharge to home, which occurred a median of 6.6 weeks after transfer out of intensive care, 50 (34%) of the 147 patients not lost to follow-up still had 1 or more joint contractures, and 34 (23%) of the patients had at least 1 functionally significant joint contracture. Interpretation: Following a prolonged stay in the ICU, a functionally significant contracture of a major joint occurred in more than one-third of patients, and most of these contractures persisted until the time of discharge to home.

Background: Mortality associated with colorectal cancer can be reduced by early detection. However, the participation of eligible people in colorectal cancer screening is thought to be inadequate. We examined the frequency of colorectal cancer screening in 4 Canadian provinces and the influence of patient contact with a family physician on the uptake of cancer screening. Methods: We performed analyses using data from the 2003 Canadian Community Health Survey. The study population included 12 776 people at average risk for colon cancer living in British Columbia, Saskatchewan, Ontario, and Newfoundland and Labrador who were aged 50 years or older and who were eligible for colorectal cancer screening. We assessed the proportion of respondents who reported having previous colorectal cancer screening tests and the degree of contact with a family physician. Results: The provincial response rates for the survey were 78.5%–87.0%. The proportion of respondents who reported any history of colorectal cancer screening was 23.5%. This value dropped to 17.6% when only up-to-date screening was considered (screening within the time frame recommended in guidelines). The proportion of people with up-to-date colorectal cancer screening varied significantly among provinces, but it was low in all provinces sampled. Contact with a family physician was associated with increased colorectal cancer screening. Compared with no physician contact, the odds of screening associated with 1–2 physician contacts in the 12 months before the survey was 1.97 (95% confidence interval [CI] 1.56–2.48], and the odds of screening associated with more than 4 contacts was 2.75 (95% CI 2.14–3.53). Interpretation: Self-reported colorectal cancer screening falls well below acceptable levels. People with increased contact with a family physician are more likely than those without contact to report a history of up-to-date colorectal cancer screening.

Despite the frequency of use of do-not-resuscitate orders, there is still uncertainty regarding their optimal use. We discuss a controversial issue concerning end-of-life care arising from two cases from the Office of the Chief Coroner for Ontario: What are the limits of medical therapy for patients

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

On Apr. 18, 2007, the world of medical publishing became larger with the debut of Open Medicine , a new online-only general medical journal. We welcome the arrival of a new venue that shares CMAJ 's objective of providing timely dissemination of research findings and clinical knowledge to as broad a

In Canada, an uncertain and fragmented approach to early detection and care of eye diseases results in preventable blindness. Loss of vision from all causes — especially diabetic retinopathy, glaucoma, macular degeneration and cataracts — may not kill, but it is responsible for profound loss of

Physicians caring for Canadian children are frequently denied easy access to important prescribing information. The reason? The pharmaceutical industry generally has not submitted evidence in its possession supporting safe pediatric doses and dosing intervals to Health Canada. As a result, the

Governments have promised to modernize Canada’s antiquated laws governing therapeutic drugs since 1995 — only to balk on the threshold of change, at best tinkering around its edges. As a consequence, Canadians are left inadequately protected by a federal Food and Drugs Act that’s a dusty relic

It’s no exaggeration to say that people have been proclaiming a crisis in Canadian health care for decades. Perhaps that rhetoric is wearing thin, because according to leaders today, our health care system is no longer in crisis; it is simply unsustainable. When and if health is raised as an

On Mar. 18, 2011, the Harper government announced its “Open Government” strategy.[1][1],[2][2] Although it appears to have been borrowed from President Barack Obama’s Open Government directive,[3][3] the piecemeal and toothless approach adopted in Canada falls short of the openness that has

Highly processed, nutritionally deprived and calorie-rich foods tend to be the profit drivers most heavily marketed by their manufacturers. Their promotion and consumption contradict government guidance on healthy food choices and the aims of health organizations fighting an epidemic of childhood

The benefits and risks of off-label use of recombinant factor VIIa in patients without hemophilia are contested. We performed a systematic review to assess the effectiveness and safety of such use.We searched electronic databases including MEDLINE, EMBASE and CENTRAL for randomized controlled trials comparing recombinant factor VIIa with placebo in any patient population except those with hemophilia up to January 2010. Eligible articles were assessed for inclusion, data were extracted, and study quality was evaluated. Outcomes included mortality, blood loss, requirements for red blood cell transfusion, number of patients transfused and thromboembolic events.We identified 26 trials: 14 on off-label prophylactic use of recombinant factor VIIa (n = 1137) and 12 on off-label therapeutic use (n = 2538). In the studies on prophylactic use, we found no significant difference in mortality or thromboembolic events between the treatment and placebo groups. We found modest benefits favouring recombinant factor VIIa in blood loss (weighted mean difference -276 mL, 95% confidence interval [CI] -411 to -141 mL), red blood cell transfusion (weighted mean difference -281 mL, 95% CI -433 to -129 mL) and number of patients transfused (relative risk 0.71, 95% CI 0.50 to 0.99). In the therapeutic trials, we found a nonsignificant decrease in mortality and a nonsignificant increase in thromboembolic events but no difference in control of bleeding or red blood cell transfusion.Clinically significant benefits of recombinant factor VIIa as a general hemostatic agent in patients without hemophilia remain unproven. Given its potential risks, such use cannot be recommended, and in most cases, it should be restricted to clinical trials.

Le 26 juin, invoquant des preoccupations reliees a la vie privee, le Cabinet a annonce qu’un Canadien sur cinq ne serait plus oblige de remplir la version detaillee du questionnaire du recensement du Canada. Le gouvernement propose plutot qui un sondage aupres des menages, a

Le Canada se glorifie d’etre le premier pays a avoir un plan en cas de pandemie d’influenza – le resultat, en partie, de la penurie de vaccins lors de la fausse alerte a la grippe porcine en 1976. On nous garantit un approvisionnement adequat de source canadienne en vaccins contre la

Plus de 100 000 enfants et adolescents au Canada sont sous la protection des services a l’enfance et a la famille, et il n’est pas etonnant que bon nombre d’entre eux affichent, a leur arrivee, des troubles emotionnels, physiques ou comportementaux devant etre traites. Ce qui est stup

We must not underestimate an enemy like pandemic (H1N1) 2009, especially now. This influenza pandemic has already created havoc in communities worldwide, including some in Canada. The virus’s place of origin, the speed of its spread and the severity of the illness in otherwise healthy people could

Il ne faut pas sous-estimer un adversaire comme la pandemie de grippe A H1N1 2009, particulierement par les temps qui courent. En effet, cette pandemie a deja occasionne un certain chaos dans plusieurs collectivites a travers le monde, y compris au Canada. Avant les premieres eclosions, m

Depuis le 20 juillet, vous aurez sans doute remarque que nous avons renove de fond en comble le site jamc.ca. Cette refonte du site web denote un virage vers l’edition electronique, ce qui s’inscrit dans notre plan visant a faire du JAMC un journal medical general international de haut

Le train de mesures budgetaires annoncees par le gouvernement canadien et appuyees par l'opposition officielle tente de stimuler une economie malade en phase critique. Il vise en grande partie a proteger des emplois, grâce a des projets d'infrastructure «prets a construire», et a

In this era of evidence-based medicine, the scarcity of high-quality evidence for mental health care is striking. Mental health practitioners often cannot obtain useful information to guide their clinical decisions, a situation that the director of the US National Institutes of Mental Health

Making the decision to withdraw or withhold life-sustaining care is difficult at the best of times, but when families and caregivers disagree about the course of action, the conflict disrupts patient care and consumes enormous personal resources for all parties. The case of Samuel Golubchuk, an

Decider de retirer ou de retenir des soins de maintien de la vie, c'est difficile dans le meilleur des cas, mais lorsque les familles et les soignants ne s'entendent pas sur les mesures a prendre, le conflit perturbe le soin du patient et absorbe d'enormes ressources personnelles de toutes les

At a recent conference on continuing education involving many major US stakeholders and the CMAJ , participants agreed that our current system of continuing professional development is in dire need of a major overhaul. Currently, continuing medical education activities are, for the most part

Au cours d'une recente conference sur l'education continue a laquelle ont participe de nombreux intervenants americains de premier plan et le JAMC , les participants ont convenu que notre systeme actuel de perfectionnement professionnel continu aurait vivement besoin d'une refonte majeure

Many consumers believe that natural health products are effective therapies and are safer than prescription drugs. This is oddly illogical reasoning. Although both appear to carry a similar Health Canada stamp of approval, there remains a specious dichotomy in the criteria and evidence needed for

Recently, we caught up with Mister and Missus Average Canadian. Like classmates at our high school reunions (but Hey, not us of course!), they’ve changed a lot over the years, thanks in no small part to our federal government’s health policies. Back in the day, Mister Average Canadian was a

Personalized medicine is holding out the promise of administering medicines specifically tailored to a person’s specific genome or metabolism — drugs that cure without adverse effects.1 No doubt, “stretch goals” and strong convictions help in the long and laborious struggle to unlock the

Completion of medical training does not render doctors immune to problems related to sleep deprivation. Evidence suggests that prolonged work periods without sleep can increase the risk of complications for patients and may be detrimental to physicians’ health.[1][1],[2][2] For residents and

Canadian political leaders, regardless of ideology, have all learned to pledge allegiance to the principle of a universal public health care system. But in terms of tangible commitments, federal leaders only seem prepared to throw more money into transfer payments to provinces and territories rather

In 1911, when CMAJ began publishing, the seriousness of tuberculosis was such that CMAJ devoted six articles to the topic in its first volume. Among them was the journal’s first editorial on tuberculosis, which prophetically noted the then-novel recognition of the role of childhood latent

Alcohol use is the third greatest contributor to the global burden of disease,[1][1] estimated to cause 3.8% of all deaths. Among people aged 15 to 44 years, alcohol is estimated to result in 4.6% of all disability-adjusted life years lost and a disproportionate number of fatal injuries.[2][2]

As society and health care have evolved, so too has CMAJ . Indeed, the journal is a reflection of the society in which it is firmly rooted. With its 100-year history and the many successes highlighted by CMA President Dr. Jeffrey Turnbull,[1][1] CMAJ is ready to move into its second century. CMAJ

Arguably the biggest threat to our public health care system is not our ability to pay for the increasing cost of care, but rather a loss of public confidence. In Canada, numerous government reports and royal commissions dating back to the early 1970s have called for increased public engagement as a

Everyone, from the Prime Minister and Privacy Commissioner of Canada to veterans and their families, are crying foul over the alarming breach of Gulf War veteran Captain Sean Bruyea’s privacy. [1][1] The complete disregard by a federal institution of privacy rights that involved sensitive personal

Although many of us regularly enjoy tea, coffee and other caffeinated beverages, most of us have enough common sense not to willingly allow children to consume 10 cans of cola in one sitting — the amount of caffeine in 500 mL of some energy drinks. [1][1] Owing to inadequate labelling requirements

Canada has invested $1.6 billion — and counting — in federal funds to develop integrated electronic health records that will, among other things, help provide seamless and timely care to a growing population with complex needs. So what have we received for that massive investment? Not nearly

Are we prepared for a disaster? We certainly should be, given that we’ve invested hundreds of billions of dollars internationally to help communities respond to emergencies. But our system of preparedness has a fundamental flaw: emergency response plans are developed without incorporating the

We thank both Anne Doig and Elwyn Griffith for noting that we did not accurately characterize Canada’s position on approval of the H1N1 vaccine1. Our readers should be made aware that in mid-September, the US Food and Drug Administration approved all H1N1 vaccines including the live attenuated

As of July 20, you may have noticed major improvements to cmaj.ca. Our redesign of the website signals a significant focus on electronic publishing. This is part of the next step in making CMAJ a top international general medical journal. We hope to serve the needs of our broad readership including

The editors respond: The preceding letters are representative of the approximately 275 letters that CMAJ received following the publication of a recent News article1 and Dispatch from the Medical Front.2 As with previous articles that CMAJ has published about health issues in war zones,3 neither article forayed into geopolitical debate about the root causes of the conflict. In keeping with this policy, the News article primarily quoted sources from international aid organizations, while the Dispatch was a first-hand, front-line account by a staff member of Medecins Sans Frontieres, which was providing humanitarian aid and medical treatment in Gaza. In retrospect, publishing 2 articles on this subject in 1 issue, albeit normal in news organizations, may have made it appear that CMAJ was taking an editorial position on the Arab–Israeli conflict. This is certainly not the case. We have now received, and will soon publish, several Dispatch articles with interesting perspectives on the health-related consequences of the Middle East conflict in Israel.

Dear Honourable Leona Aglukkaq, Belated congratulations on your appointment. We are heartened by the appointment of someone with your experience as a health minister in Nunavut. By now, you will have settled in, been brought up to speed by ministry officials and learned how Cabinet sets priorities

Madame la Ministre, Permettez-moi d’abord de vous feliciter de votre nomination. Comme vous avez ete ministre de la Sante du Nunavut, la designation d’une personne de votre competence est de bon augure. Vous aurez sans doute eu le temps de vous installer, de vous initier aux principaux

Au Canada l'an dernier, les programmes scolaires de vaccination contre le virus du papillome humain (VPH) ont suscite de vives preoccupations. Ce fut particulierement le cas en Ontario, ou l'acceptation du vaccin a atteint a peine 50 %, ecart important par rapport aux 80 % et plus atteints en

Loudly voiced concerns greeted Canada's school-based human papillomavirus (HPV) vaccine programs last year. This was particularly the case in Ontario, where vaccine uptake was only about 50%, a sharp contrast to over 80% uptake in Nova Scotia and Australia. In comparison, uptake of the hepatitis B

Le scandale Ben Johnson il y a pres de 20 ans aux Jeux olympiques a Seoul en Coree a attire l'attention sur la question du dopage. Avons-nous fait des progres depuis pour regler cet important probleme pour la sante publique et le sport? Un organisme autonome, rebaptise Centre canadien

Despite federal regulations forbidding direct-to-consumer advertising for drugs and medical devices, it has become commonplace in Canada. From the pages of People , Ladies' Home Journal , Redbook and other US-based publications, you can glean how to protect your young daughter from the ravages of

Meme si les reglements federaux interdisent la publicite directe au consommateur pour les medicaments et les instruments medicaux, elle est devenue courante au Canada. Dans les pages de People, Ladies' Home Journal, Redbook et autres publications americaines, on peut apprendre comment prote

Bien des medecins diraient sans doute que leurs etudes de medecine ont ete longues et ardues et que certains cours ont ete en fin de compte d'une pertinence douteuse pour leur pratique. Cela n'est peut-etre pas aussi vrai chez les medecins plus jeunes qui ont suivi leur formation depuis l'