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Canada's universal healthcare program, medicare, continues to evolve. An area of care that has gained increasing attention over the past several years is the general concept and specific components of patient centricity in healthcare delivery. This paper compares key measures of patient-centred care practices recorded in the 2013 and 2016 Health Care in Canada (HCIC) surveys, with the most recent preferences of the public and health professionals obtained in the 2018 HCIC survey, including priorities for improved future care. Timely access and caring care were the public's top-supported components of patient-centred care in the 2013 and 2016 HCIC surveys. In the 2018 HCIC survey, the Canadian public's overwhelming choice as the top-priority component of patient-centred care continued to be care readily and timely accessed, provided in a caring and respectful environment and based on need versus the ability to pay. In contrast, the public's lesser-supported option in all surveys was measurement and stakeholder feedback of actual care and outcomes. Among professionals in 2018, timely access and caring care were also rated as the top characteristics of patient-centred care, followed by care supported by research and expert opinion. Also similar to the public, Canadian healthcare professionals in 2018 rated measurement and feedback of delivered care and outcomes at the bottom of their support list. When the public and professionals were asked in the 2018 survey to prioritize their implementation choices for enhanced patient-centred care going forward, both stakeholder groups chose timely access as their first priority. Measurements and feedback of care and outcomes were rated at the lower end of choices in both groups in 2018. In summary, among key stakeholders, healthcare that is not readily and timely accessed remains the perceived greatest impediment to achievement of patient-centred care in contemporary Canadian medicare. The continued reality of undue delay in accessing healthcare in Canada is disturbing. A companion risk going forward is that all other components of patient-centred care will retreat to a level of irrelevance. Measurement and feedback of care, particularly its timeliness of access and outcomes, are necessary to monitor progress, stimulate innovation and ensure the success of Canadian medicare. Things can be better., (Copyright © 2019 Longwoods Publishing.)

Pharmacare, a recently proposed addition to Canada's universal medicare program, has become a prominent topic in the public discourse, but funding and leadership have not been established. Repeated Health Care in Canada (HCIC) surveys of the adult public and a broad spectrum of health professionals reveal very strong support for a national system that is easy to access and covers all prescribed pharmaceuticals. Although the practical details of universal pharmacare remain to be established, there is strong support among the public and professionals as well as increasing federal government interest in moving forward and ultimately implementing pharmacare. At the same time, HCIC surveys indicate that a high percentage of patients do not take their medications as directed, both for acute and chronic illnesses. The data suggest that pharmacare's success will be severely challenged by this. Of the four major challenges preventing usual care from being the best care - suboptimal access, non-diagnosis, non-prescription and non-adherence - risk from some form of non-adherence is often ranked first by care professionals. The most commonly reported reasons for non-adherence in clinical settings are patients' forgetfulness and how they feel in the moment on any given day. Costs of therapy, lack of understanding or poor knowledge transfer between prescribers and patients regarding therapeutic risks and benefits are rarely cited causes for poor adherence. These findings from the 2018 HCIC survey are not new. They are very consistent with measurements in the 2016 and other previous HCIC surveys. They do, however, raise practical challenges for the creation and ongoing management of universal pharmacare. Specifically, a patient-centred care component designed to improve non-adherence to prescribed therapies is needed. Ideally, it should include a measurement and feedback component on adherence that shares data with and between patients, health professionals and payers. Things can be better., (Copyright © 2019 Longwoods Publishing.)

Repeated Health Care in Canada (HCIC) surveys over the past two decades have consistently reported that the adult public and clinical and administrative health professionals consider medicare to be successful in terms of quality of care, despite a growing concern that timely access to care remains challenging. These key stakeholders have also recently signalled that major change strategies are likely necessary for continuing success. In the 2018 survey, both the public and professionals ranked highest the creation of a national comprehensive pharmacare plan, entirely funded by the federal government, or with federal funding for those not currently covered by existing pharmaceutical plans. The majority of the public and health professionals in 2018 were also remarkably concordant regarding preferred leadership for designing, instituting and managing a national pharmacare program. The public's priority, supported by 50% of the adult population, was shared leadership involving governments, medical academia and the pharmaceutical/biotech industries, followed by government leadership at 33%. Among professionals, preference for shared leadership averaged 60% and governmental leadership averaged 33%. Based on these data, restriction of pharmacare's leadership exclusively to any single stakeholder raises concern of a critical lack of support for success. A coalition of governments, research hospitals/health authorities and the pharmaceutical/biotech industry - the highest-ranked candidates as potential leaders - would likely provide the best chance to garner the majority of public support and enhance the chances of success in the short and long terms. In summary, the addition of universal pharmacare to medicare's existing healthcare portfolios is an attractive strategy to advance Canadian healthcare and outcomes. The federal government has taken the initial step. Recruitment of additional leaders sharing aspiration, inspiration and experience to optimize pharmacare's development and measure its outcomes is needed. Things can be better., (Copyright © 2019 Longwoods Publishing.)

The overarching purpose of serial Health Care in Canada (HCIC) surveys of the adult Canadian public and a broad spectrum of healthcare professionals over the past two decades has been the development of an evidence-based map to inform strategic and clinical decisions to improve care and outcomes for Canadians. Recent surveys reveal a growing concern that medicare may require complete rebuilding or major strategic repairs. On the other hand, a majority of stakeholders perceive continuing underlying quality in our clinical care and look forward to both system- and patient-centred initiatives to improve future care. Currently, the most strongly supported strategic improvement target among the public and professional caregivers is enhanced availability of less expensive prescription medications. With regard to practical implementation of this strategy, the public's (39%) and healthcare professionals' (39-54%) preference was institution of a nation-wide pharmacare plan, funded by a federal tax. There was also pan-stakeholder concordance around the two least favoured potential strategies: increasing taxes and shifting money from other funded services. In terms of improving clinical care, the public and all professional groups were also concordant in most strongly supporting increases in home and community care services, disease prevention/wellness education and use of non-physician care providers and electronic health records. There was also remarkable concordance regarding who is most responsible for implementing these preferred innovations: research hospitals/health authorities, government funding agencies and pharmaceutical/biotech industries. In summary, contemporary Canadian public and health professionals agree on key strategic and practical priorities to improve future care and outcomes. Moreover, they concur on who should lead their implementation. This public/professional concordance supporting evidence-driven choices and leadership for improving care is not common. It is, however, an opportunity, providing a call to arms for other stakeholders, particularly governments and industry, to recognize the opportunity and their leadership expectations and to act upon them. Things can be better., (© 2018 Longwoods Publishing.)

Canadians' health and its care continue to evolve. Chronic diseases affect more than 50% of our aging population, but the majority of public and professional stakeholders retain a sense of care quality. An emergent issue, however, is generating an increasingly wide debate. It is the concept of patient-centred care, including its definition of key components, and efficacy. To advance the evidence base, the 2013-2014 and 2016 Health Care in Canada (HCIC) surveys measured pan-stakeholder levels of support and implementation priorities for frequently proposed components of patient centricity in healthcare. The public's highest rated component was timely access to care, followed by perceived respect and caring in its delivery, with decisions made in partnership among patients and professional providers, and within a basic belief that care should be based on patients' needs versus their ability to pay. Health professionals' levels of support for key components largely overlapped the public's levels of support for key components, with an additional accent on care influenced by an evidence base and expert opinion. In terms of priority to actually implement enhanced patient-centred care options, timely access was universally dominant among all stakeholders. Caring, respectful care, also retained high implementation priority among both the public and professionals, as did care decisions made in partnership, and, among professionals, care driven by research and expert opinion. Low priorities, for both the public and professionals, were the actual measurements of patient-centred care delivery and its impact on outcomes. In summary, there is remarkable concordance among all stakeholders in terms of favoured interventions to enhance patient-centred care, namely, timely access, caring, partnering and communicative delivery of evidence-based care. Unfortunately, the lack of contemporary imperative around the value of measuring and reporting actual use and outcomes of favoured interventions means uncertainty of their efficacy will persist for the foreseeable future. Things can be better.

A new dimension has been added to Canadian Medicare ߝ exemption from prosecution for physicians, nurse practitioners and assistants providing medical assistance in dying for competent and informed adult patients with a grievous and irremediable medical condition causing intolerable physical or psychological suffering, irreversible decline in capabilities and reasonably foreseeable natural death. To define stakeholders' perceptions on all contemporary end-of-life care options, we analyzed data from the 2016 Health Care in Canada Survey comprising representative samples of the adult public (n = 1,500), physicians (n = 102), nurses (n = 102), pharmacists (n = 100), administrators (n = 100) and allied health professionals (n = 100). Among the public, enhanced pain management, hospice/palliative care and home/family care were all supported at, or above, the 80th percentile; medically assisted death was supported by 70%. Among all professionals, hospice/palliative care, pain management and home care garnered >90% support; support for medically assisted death ranged from 58% (physicians) to 79% (allied professionals). In terms of priority to implement available options, medically assisted death was rated first by 46% of the public, overall, and by 69% of the sub-group who strongly supported it, followed by enhanced pain management (45%) and home care (42%). Among professionals, top implementation priorities (range: 57ߝ61%) were: enhanced pain management, hospice/palliative care and home care support. Priority for medically assisted death ranged between 25% and 41%, although among professionals who strongly supported it, it was their top priority (52%). When asked to balance patients' right to access assisted death, versus some professionals' reluctance to provide it, 42% of the public and the majority of professionals thought providers should be allowed to opt out if they referred patients to another willing provider. And many professionals perceive some risk of either legal or regulatory reprisal if they assist in patients' deaths. In summary, there is substantial contemporary support for all components of end-of-life care among all stakeholders. However, non-lethal care modalities remain generally preferred, perhaps, at least in part, because medical professionals have a pervasive concern of going in harm's way by participating in assisted death, or by refusing. Things can be better.

Canada's health and its care are evolving. Evidence from serial Health Care in Canada surveys of the public and health professionals over the last two decades reveal a persistent sense of care quality, despite an aging population, decreasing levels of good and excellent health, increasing prevalence of chronic illnesses; and sub-optimal access to timely and patient-centred care. Stakeholders are, however, somewhat pessimistic and many sense complete rebuilding, or major changes, may be necessary. To improve access, the primary health concern of all Canadians - increasing medical and nursing school enrolment, and requiring professionals to work in teams - have attracted increasingly high support from both the public and professionals. However, physicians' support lags behind that of nursing, pharmacy and administrative colleagues; and, currently, only a minority of patients and professionals are actively involved in team care programs. Another example in which high levels of support may not necessarily translate into priority implementation of promising interventions is the realm of patient-centred care. The public and all professionals report a very high level of general support for care provided in a caring and respectful manner. However, while the public rank it second in implementation priority, following timely access, the majority of professionals rank it only fourth. By contrast, there is remarkable pan-stakeholder concordance around interventions to improve the overall health system, with the majority of public and professional stakeholders rating the creation of national supply systems as their top priority to expedite the clinical and cost efficiency of new treatments. There is a similar pan-stakeholder concordance around priority of responsibility to drive innovations, the top three being: federal/provincial governments; research hospitals/regional health authorities; and the pharmaceutical industry. In summary, Canadians are at a healthcare crossroads. Population health is decreasing, chronic diseases are increasing and desire for timely access to patient-centred, team-delivered and technology-supported care remain top concerns. Despite some disconnects between theoretical support for, and priority to implement, promising innovations, there is universal support to optimize resources to make things better. And there is concordance around the leadership best suited to lead innovation. Things can be better.

The Canadian public is aging. Population levels of excellent, or very good, health are decreasing, and the prevalence of chronic diseases is increasing. Timely access to caring and respectful care from health professionals, with supporting information transfer, are key qualities in patients' sense of centricity and hope for best outcomes. Data from the 2013-2014 Health Care in Canada (HCIC) survey reveal, however, that 38% of such patients do not always, or often, access this support. The lack of timely access may be one underlying driver for non-professional caregivers to contribute to the care, as well as the personal and financial management, of family members or friends with chronic disease. Previous HCIC surveys, in 2005, 2006 and 2007, reported non-professional caregivers' prevalence in the adult public at 21, 23 and 26%, respectively, compared with 19% in the 2013-2014 survey. In all the surveys, a notable feature of non-professional care providers has been their universality of contribution, across age, sex, geography and time. Caregivers pay, however, a price. They have a lower level of self-related health, a higher incidence of chronic illness and net-negative impacts on relationships, career and finances, including use of personal savings (53%) and necessity of quitting their job (12%). Conversely, they infrequently claim available tax (12%) or compassionate care (11%) benefits. Interestingly, non-professional caregivers work in team-care settings with health professionals more frequently (29%) than patients in the general population with chronic illnesses (18%). Nonetheless, their current levels of always, or often, receiving assisting support (46%) and information (53%) from health professionals are lower than the respective results reported by the general public (65% and 68%). In conclusion, non-professional patient care in Canada is a common, longstanding and not-for-profit enterprise. It is more likely driven by altruistic caring or sense of duty that balance, or overwhelm, its associated personal, medical and financial burdens. In the short term, practical opportunities for enhancement include broader recognition of caregivers' contributions, their improved access to professional support and communication and wider use of available governmental financial support. All are likely to enhance both patient-centred care and lessen the practical burdens of caregivers. Things can be better.

Eleven Health Care in Canada (HCIC) surveys, spanning 1998-2014, offer a comprehensive overview of the changing perceptions of physician, nurse, pharmacist, administrator and public stakeholders of the nation's health status, its burden of illness and its quality and cost of care. Overall, there persists a universal sense of quality in our health system--despite evidence that national health status is declining, chronic illnesses are increasing, patients' timely access to care and ability to afford care are diminishing and all these indicators are predicted to worsen over time. Among the public and health professionals, key priorities for improving future patient care are increasing professional schools' output and team-based care, along with enhanced use of national supply systems to reduce costs of care. Among HCIC survey partners, the overarching goal has been, and remains, the utilization of knowledge gained from the surveys to facilitate evidence-driven health policy and improved patient care and outcomes. Practical foci are the development of knowledge translation (KT) activities and assessment of their impact. This paper outlines current initiatives to track reach of member and non-member audiences for HCIC information; to ascertain how they perceive and value the various KT messages, vehicles and metrics; and to potentially identify a hierarchy of efficacy for impact factors. The primary objective is to inform future HCIC survey design and reporting, especially identification of KT vehicles and venues that are most effective in terms of reach and impact in facilitating understanding of, and subsequent action around, the knowledge generated.

Patient health management (PHM) was launched as a promising paradigm to close care gaps, the inequities between usual and best care, for whole patient populations. PHM's core premise was that interventions of multidisciplinary, community-oriented partnerships that used repeated measurement and feedback of provider practices, clinical and economic outcomes and general communication of relevant health knowledge to all stakeholders would continuously make things better. This article reviews the evolution of PHM from its genesis in a series of casual hospital-based networks to its maturation in a province-wide, community-focused, clustered-lattice social network that facilitated the improved clinical and cost-efficient care and outcomes of whole patient populations. The factors underlying PHM's clinical and cost efficacy, specifically its patient-centric social networking structures and integral measurement and knowledge translation processes, offer continuing promise to optimally manage the care of our increasingly aged patient populations, with their high burden of chronic diseases and disproportionately large care gaps. In an era when patients are demanding and leading change, and governments are struggling fiscally, PHM's clinical efficacy and cost-efficiency are especially resonant. Things can be better.

In an effort to assess and advance the community-based model of chronic care, we reviewed a contemporary spectrum of Canadian chronic disease management and prevention (CDMP) programs with a participatory audience of administrators, academics, professional and non-professional providers and patients. While many questions remain unanswered, several common characteristics of CDMP success were apparent. These included community-based partnerships with aligned goals; inter-professional and non-professional care, including patient self-management; measured and shared information on practices and outcomes; and visible leadership. Principal improvement opportunities identified were the enhanced engagement of all stakeholders; further efficacy evidence for team care; facile information systems, with clear rationales for data selection, access, communication and security; and increased education of, and resource support for, patients and caregivers. Two immediate actions were suggested. One was a broad and continuing communication plan highlighting CDMP issues and opportunities. The other was a standardized survey of team structures, interventions, measurements and communications in ongoing CDMP programs, with a causal analysis of their relation to outcomes. In the longer term, the key needs requiring action were more inter-professional education of health human resources and more practical information systems available to all stakeholders. Things can be better.

Improving Cardiovascular Outcomes in Nova Scotia (ICONS) was a multidisciplinary-partnership, measurement-driven disease management project designed to improve the care and outcomes of patients with acute and chronic heart diseases in Nova Scotia. Previous analyses demonstrated beneficial clinical and macroeconomic end points at the population and system levels, including heightened awareness of the value of team care, increased use of proven therapies, decreased re-hospitalizations and a positive dollar return on investment for the economies of Nova Scotia and Canada. This article analyzes the additional cost-reduction benefits resulting from the reduced re-hospitalizations that occurred among patient populations with heart attacks and heart failure. Over the five-year course of ICONS, one-year readmissions and readmission rates fell continuously for both index disease states. Despite a general inflationary rise in real hospital costs, the per-event cost of readmissions expressed in constant 2002 dollars also decreased: from $10,377 in 1997 to $9,022 in 2002 for the heart attack patient population; and from $9,020 to $8,697 for patients with heart failure. Total real yearly costs for heart attack readmissions fell from $7.4 million in 1997 to $6.4 million in 2002, a 14% decrease; for heart failure, yearly costs decreased by 26%, from $9.2 million to $6.8 million. These microeconomic data supplement the previously reported improvements in patient care and the positive macroeconomic impact of ICONS. Overall, ICONS demonstrated that quality and cost of healthcare could be simultaneously and successfully managed over a sustained period of time for whole patient populations in a real-world setting. ICONS offers strong evidence of the value of the partnership-measurement model of disease management and prevention as a reproducible and desirable template for next-generation healthcare in Canada.

Canadian healthcare is changing. Over the course of the past decade, the Health Care in Canada Survey (HCIC) has annually measured the reactions of the public and professional stakeholders to many of these change forces. In HCIC 2008, for the first time, the public's perception of their health status and all stakeholders' views of the burden and effective management of chronic diseases were sought. Overall, Canadians perceive themselves as healthy, with 84% of adults reporting good-to-excellent health. However, good health decreased with age as the occurrence of chronic illness rose, from 12% in the age group 18-24 to 65% for the population =65 years. More than 70% of all stakeholders were strongly or somewhat supportive of the implementation of coordinated care, or disease management programs, to improve the care of patients with chronic illnesses. Concordant support was also expressed for key disease management components, including coordinated interventions to improve home, community and self-care; increased wellness promotion; and increased use of clinical measurements and feedback to all stakeholders. However, there were also important areas of non-concordance. For example, the public and doctors consistently expressed less support than other stakeholders for the value of team care, including the use of non-physician professionals to provide patient care; increased patient involvement in decision-making; and the use of electronic health records to facilitate communication. The actual participation in disease management programs averaged 34% for professionals and 25% for the public. We conclude that chronic diseases are common, age-related and burdensome in Canada. Disease management or coordinated intervention often delivered by teams is also relatively common, despite its less-than-universal acceptance by all stakeholders. Further insights are needed, particularly into the variable perceptions of the value and efficacy of team-delivered healthcare and its important components.

Disease management is increasingly considered a valid strategy in the chronic care of our aging patient populations with multiple diseases. The Improving Cardiovascular Outcomes in Nova Scotia (ICONS) project examined whether a community-oriented health management partnership would lead to enhanced care and improved outcomes across an entire healthcare system. ICONS was a prospective cohort study, with baseline and repeated measurements of care and outcomes fed back to all project partners, along with other interventions aimed at optimizing care; preceding interval cohorts served as controls to post-intervention cohorts. The setting was the province of Nova Scotia, whose population is approximately 950,000. All 34,060 consecutive adult patients hospitalized in Nova Scotia with acute myocardial infarction (AMI), unstable angina (UA) or congestive heart failure (CHF) October 1997-March 2002 were included. Interventions were a combination of serial audits and feedbacks of practices and outcomes, web-based publication of findings, newsletter-based education and reminders, physician small-group workshops, pharmacy monitoring and compliance programs, care maps, algorithms, discharge forms and patient information cards. Rates of use of evidence-based marker therapies were the primary outcome measure. Secondary measures included one-year, all-cause mortality and re-hospitalization. Evidence-based prescription practices, for all target diseases, continuously and markedly improved over time. At the population level, there were no changes in one-year mortality for any disease state, although use of proven therapies predicted survival at the individual level throughout the five-year period for all disease states. Rates of re-hospitalization decreased significantly for all disease states over the course of ICONS; but most traditional positive and negative predictors of this outcome, like advanced age and use of proven therapies, respectively, were not predictive. ICONS demonstrated that provider prescribing patterns and patient re-hospitalization rates were continuously improved in three disease states and across an entire health system, through a community partnership model of disease management that was sustained over a long time. Further studies are needed to better understand the drivers and modifiers of patient outcomes at the population level.

Health or disease management (DM) has emerged as a promising solution to improve the quality of healthcare and patient outcomes in a cost-efficient way. This solution is particularly relevant in the care of our increasing, and aging, patient populations with multiple chronic diseases. This article reviews the recent history and current status of DM in the province of Quebec and summarizes its evolving perspectives and future prospects. Most DM projects in Quebec have developed from a public-private partnership, and they have addressed several disease states. The results of completed programs confirmed the presence of care gaps--the differences between best and usual care in several disease states. They also identified process changes leading to improved practices and enhanced professional satisfaction among stakeholders. Priorities identified for further research include increased knowledge of the underlying causes of care gaps and greater concentration on the measurement of clinical, humanistic and fiscal outcomes and their causal links to DM structures and processes. Although still embryonic in Quebec and Canada, the available evidence suggests that DM partnerships are practical and functional vehicles to expedite knowledge creation and transfer in the care of whole populations of patients. Future projects offer the promise of updated knowledge and continuously improved care and outcomes.

Improving Cardiovascular Outcomes in Nova Scotia (ICONS) was a five-year, community partnership-based disease-management project that sought, as a primary goal, to improve the care and outcomes of patients with heart disease in Nova Scotia. This program, based on a broad stakeholder partnership, provided repeated measurement and feedback on practices and outcomes as well as widespread communication and education among all partners. From a clinical viewpoint, ICONS was successful. For example, use of proven therapies for the target diseases improved and re-hospitalization rates decreased. Stakeholders also perceived a sense of satisfaction because of their involvement in the partnership. However, the universe of health stakeholders is large, and not many have had an experience similar to ICONS. These other health stakeholders, such as decision-makers concerned with the cost of care and determining the value for cost, might, nonetheless, benefit from knowledge of the ICONS concepts and results, particularly economic analyses, as they determine future health policy. Using budgetary data on actual dollars spent and a robust input-output methodology, we assessed the economic impact of ICONS, including trickle-down effects on the Canadian and Nova Scotian economies. The analysis revealed that the $6.22 million invested in Nova Scotia by the private sector donor generated an initial net increase in total Canadian wealth of $5.32 million and a global net increase in total Canadian wealth of $10.23 million, including $2.27 million returned to the different governments through direct and indirect taxes. Thus, the local, provincial and federal governments are important beneficiaries of health project investments such as ICONS. The various government levels benefit from the direct influx of private funds into the publicly funded healthcare sector, from direct and indirect tax revenues and from an increase in knowledge-related employment. This, of course, is in addition to the clinical benefits associated with the partnership-measurement disease-management model. Because of their uniquely simultaneous roles as beneficiary and major resource provider, the public payer can play an early and active role in such partnerships to enhance its efficiencies and increase the likelihood of sustainability if the original concepts are proven of value.

The gap between best care and usual care is large for many important diseases. In particular, poor adherence remains a significant, inadequately addressed, cause of the care gap. About half of all patients with chronic diseases stop refilling prescriptions by one year. Several effective interventions are available and adaptations of clinical trials practices offer promise for further improvement. Poor adherence is a remedial problem in healthcare quality and its improvement and accountability offer shared opportunities for providers and patients. There is a large gap between best care, defined as the optimal use of proven efficacious therapies in whole populations at risk from any disease, and usual care, the actual level of efficacious care being provided (Montague et al. 1997). This gap in patient care has four main causes: diseases may not be diagnosed, efficacious therapies may not be prescribed, access to therapy may be restricted or patients may not adhere to prescriptions. Irrespective of causation, the ultimate result of care gaps is the same--less than optimal clinical outcomes and associated lost opportunities for improved quality of life and productivity. Systematic approaches to improving prescribing practices are increasing, and there is much debate around improving patients' access to care. Poor diagnosis is judged to be relatively uncommon, leaving decayed adherence as the major under-addressed cause of care gaps and a major opportunity for improvement. This paper reviews the scope and causation of sub-optimal adherence, evaluates improvement strategies and explores a best-practice benchmark.