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Background: Despite broad scientific consensus about the importance of the early years in the lifelong health and wellbeing of children, there is debate about whether and how healthcare professionals can optimise early child development through monitoring or screening. The evidence in support of a systematic population-level intervention is disputed, which is reflected in the diversity of approaches to developmental screening internationally. Methods: Using a case-study design, and interpretive qualitative methods, we explored how Canadian experts in child health (n=39): a) rationalise why they do, or would, pursue population-level developmental screening; b) articulate the policy goals of such an intervention, and; c) justify the practice with reference to evidence. Findings: Respondents identified three distinct framings, or policy agendas, for what developmental screening can and should seek to achieve, specifically: 1) as medical intervention, facilitating the early identification of health risk or disorder; 2) as social intervention, providing an opportunity for communication and connection with parents for all children; and 3) as political intervention, staking a claim for early child health on the broader political agenda. Discussion and conclusions: Each agenda is justified by distinct types of evidence, posing a challenge to simplistic models of evidence-based policymaking, and demonstrating that evidence is not just an input, but a contested part of a dynamic and political policymaking process.

Drawing on institutional theory, this article articulates qualitative insights from a program of research on Canadian health technology-based ventures to examine the rules that characterize economic policy, capital investment, and regulatory approval as well as the way these institutions enable and constrain the development of ventures at an early stage. Our findings clarify how economic policy integrates these ventures into the entrepreneurial domain, how capital investment configures them for economic value extraction, and how regulatory approval fully releases their market value. These findings help to revisit current policy modernization initiatives by calling attention to the convergence among the three institutions. Rather than operating solely as a source of constraints, these institutions provide a highly integrated market-oriented space for health technology-based entrepreneurial activities to unfold. [ABSTRACT FROM AUTHOR]

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence. [ABSTRACT FROM AUTHOR]

Objective To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics. Research Design and Methods Observational, population-based cohort study of youth with type 1 diabetes (<19 yr) who received pump funding from 2006 to 2013 (n = 3700). We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. We tested the relationship between center-level pump uptake and center characteristics (center type, physician model, and availability of 24-h support) using an adjusted negative binomial model; we studied center- and patient-level factors (socioeconomic status and baseline glycemic control) associated with discontinuation using a Cox proportional hazards model with generalized estimating equations. Results Pump users were more likely to be in the highest income quintile than non-pump users (29.6 vs. 19.1%, p < 0.0001). In 2012, mean percent pump use was 38.0% with variability across centers. There was no association between uptake and center characteristics. Discontinuation was low (0.42/100 person-yr) and was associated with being followed at a small community center [hazard ratio ( HR): 2.24 (1.05-4.76)] and being more deprived [ HR: 2.36 (1.14-1.48)]. Older age was associated with a lower rate of discontinuation [ HR: 0.31 (0.14-0.66)]. Conclusions Rates of pump use have increased since 2006 and discontinuation is rare. Large variation in uptake across centers was not explained by the factors we examined but may reflect variation in patient populations or practice patterns, and should be further explored. [ABSTRACT FROM AUTHOR]

The Aamjiwnaang First Nations community is located in Canada's 'Chemical Valley' situated in southwest Ontario near Sarnia. Mercury pollution in the region has been known since the 1940s but little is known about levels in the environment and area residents. The current study, using ecological and human exposure assessment methods, was conducted at the community's request to help fill these gaps. First, Canada's National Pollutant Release Inventory and the U.S. Toxics Release Inventory were queried to investigate mercury releases from area facilities. In 2010, 700 pounds of mercury were emitted into the air, 25 pounds were released into water bodies, and 93 thousand pounds were disposed of on-site via underground injections or into landfills, and together these show continued releases into the region. Second, mercury levels were measured in stream sediment and nearby soil from sites at Aamjiwnaang ( n = 4) and off Reserve ( n = 19) in Canada and the U.S. during three seasons that spanned 2010-2011. Total mercury in sediment across all sites and sampling seasons ranged from 5.0 to 398.7 µg/kg, and in soils ranged from 1.2 to 696.2 µg/kg. Sediment and soil mercury levels at Aamjiwnaang were higher than the reference community, and Aamjiwnaang's Talfourd Creek site had the highest mercury levels. Third, a biomonitoring study was performed with 43 mother-child pairs. Hair (mean ± SD of all participants: 0.18 ± 0.16 µg/g) and blood (1.6 ± 2.0 µg/L) mercury levels did not differ between participants studied on- and off-Reserve, likely because of limited seafood intake (<1 serving/week). Urine mercury levels (0.5 ± 0.8 µg/L) were significantly higher (1.5-2.5 times) in mother-child pairs living on-Reserve versus those living off-Reserve. In general, the study links evidence of mercury sources, environmental fate, and human exposures, and in doing so it shows that mercury levels in ecological and human samples are similar to values found in other areas, though there are some trends and evidence of contamination at Aamjiwnaang that warrant attention. [ABSTRACT FROM AUTHOR]

Recent expansion of the molecular diagnostics industry has revealed weaknesses in Canada's regulatory system for laboratory-developed tests, which are not subject to statutory regulations on medical devices. Absent regulation as medical devices, the only controls on test performance are laboratory regulation and accreditation, which are heterogeneous and sometimes flawed and do not necessarily include assessment of test validity, safety and efficacy. Diagnostics developed as "test kits" and sold to laboratories, hospitals and clinics are considered to be in vitro diagnostics devices under Medical Devices Regulation in accordance with the federal I Food and Drugs Act i . [Extracted from the article]

Background: The Network of Ontario Pediatric Diabetes Programs was established in 2001 to provide access to specialized pediatric diabetes care. Universal funding for pediatric insulin pump therapy has been available in Ontario since 2006. The objective of this study was to describe the distribution of patients, resources and insulin pump use across centres within the network, now called the Ontario Paediatric Diabetes Network. Methods: We conducted a cross-sectional survey in 2012 of the 35 pediatric diabetes centres in Ontario to measure centre characteristics, patient volume and available clinical and social resources. We used health administrative data from the provincial Assistive Devices Program to describe patients aged 18 years or less using insulin pumps by centre as a measure of technology uptake. Results: All 35 centres participated, reporting a total of 6676 children with type 1 diabetes and 368 with type 2 diabetes. Most (> 80%) children with type 1 diabetes were followed at tertiary (n = 5) or large community (n = 14) centres. Nursing patient load was similar between centre types, but there was a large range across centres within any type. Overall, percent insulin pump use was 38.1% and varied widely across centres (5.3%-66.7%). Funded 24-hour support for pump users was available at 5 (36%) small community centres, 3 (19%) large community centres and 2 (40%) tertiary centres. Interpretation: Our study showed differences in access to specialized and after-hours care for children with diabetes in Ontario. Pump use varied widely across centres. Further research is needed to assess the impact of these observed differences on quality of care and outcomes. [ABSTRACT FROM AUTHOR]

The article presents the study on the expectations of citizens on the academic entrepreneurship (AE), an academic nature of commercial science, and the analysis of the conflict of interest (COI), practical benefits, and general beliefs. A cross-sectional survey was designed to assess the approval of AE varying on the type of concerns. Results were outlined and conclude the support of citizens on AE considering their expectation on the benefits of academic-industry collaboration.

Objectives Newborn bloodspot screening ( NBS) panels have expanded to include conditions for which treatment effects are less certain, creating debate about population-based screening criteria. We investigated Canadian public expectations and values regarding the types of conditions that should be included in NBS and whether parents should provide consent. Methods Eight focus groups ( FG; n = 60) included education, deliberative discussion and pre-/post-questionnaires. Data were analysed quantitatively and qualitatively. Results Quantitatively, the majority supported NBS for serious disorders for which treatment is not available (95-98, 82%). A majority endorsed screening without explicit consent (77-88%) for treatable disorders, but 62% supported unpressured choice for screening for untreatable disorders. Qualitatively, participants valued treatment-related benefits for infants and informational benefits for families. Concern for anxiety, stigma and unwanted knowledge depended upon disease context and strength of countervailing benefits. Conclusions Anticipated benefits of expanded infant screening were prioritized over harms, with information provision perceived as a mechanism for mitigating harms and enabling choice. However, we urge caution around the potential for public enthusiasm to foster unlimited uptake of infant screening technologies. [ABSTRACT FROM AUTHOR]

Background: Almost four decades after the ground-breaking Declaration of Alma-Ata identified primary health care (PHC) as "essential health care," there is growing consensus across the industrialized world that improvements in "first contact" care are crucial not only to enhance population health but to sustain increasingly stretched health care systems. According to the World Health Organization (WHO, 2008), PHC that includes, but goes beyond a "narrow offer of specialized curative care" to embrace health promotion and the determinants of health, promises "better health, less disease, greater equity, and vast improvements in the performance of health systems.". Nevertheless, in many jurisdictions, including Ontario, Canada's richest and most populous province, progress toward primary health care (PHC) has been uneven. Since the 1980s, Ontario has implemented successive waves of primary care reform, producing a plethora of reform models, each with widely varying organizational characteristics, focus and "spread." For example, Community Health Centres (CHCs), first advocated in the 1970s, feature salaried physicians, interdisciplinary teams, community boards, and a focus on health promotion and population health; however, they are limited by policy fiat to serving underserviced and marginalized populations such as the poor, recent immigrants, and persons with special needs. This compares to the considerably more numerous Family Health Groups (FHGs) which require no more than three physician owners (not necessarily co-located), paid via "enhanced" feefor- service or mixed fee-for-service/capitation, with financial incentives for specified disease prevention and management procedures (e.g., cancer screening or diabetes management). Given multiple waves of reform, and widely varying reform models, how can observers judge the extent to which change has occurred within a jurisdiction like Ontario, or compare the pace and direction of change across jurisdictions?. Conceptual Approach: In this paper, funded through a CIHR grant looking at integrating care for older people with complex health needs (iCOACH), we draw on the comparative policy literature to develop a conceptual approach which recognizes the multidimensional nature of primary health care and PHC reform models, and which weights these models to account for their relative impact and "spread" within and across jurisdictions. This literature clarifies that reform is not a unitary construct, but rather, a multidimensional project spanning widely varying normative goals (e.g., curing individual illness, creating more equitable societies); target populations (e.g., individual patients, broad populations); operational elements (e.g., funding mechanisms, interdisciplinary teams); and service "baskets" (e.g., illness care, health promotion). It also clarifies that change may occur (or not) at different paces, and to different degrees along each of these different dimensions, noting that changes which alter historical "bargains" between public governments and the organized medical profession (especially those diminishing professional control over the content and conditions of medical work) will be hardest to achieve. We then apply this framework to the case of Ontario, assessing the extent to which PHC reform models represent substantive change along each of these four dimensions from historically dominant fee-for-service, solo doctor practice, providing individual services to individual patients, to more elaborated and expansive models of PHC including a focus on population health. Findings: Using provincial data from 2012, we observe that about a quarter (25.8%) of Ontario's patient population continued to be served by primary care physicians working in traditional fee-for-service solo practice. In comparison, more than half (53.0%) were rostered in forms of group practice including Family Health Groups (FHGs), Family Health Networks (FHNs) and Family Health Organizations (FHOs); however these are essentially business arrangements between small numbers of family doctors paid through fee-for-service with additional payments to provide specific services such as cancer screening and diabetes management to their rostered patients. Family Health Teams (FHTs), mostly physician-owned and operated small businesses accessing additional funding for interdisciplinary providers (e.g., nurses, dieticians, physical therapists, social workers), covered an additional 15.7% of patients (noting that in 2014 the province terminated any further expansion of FHTs). Considerably less widespread were Community Health Centres (CHCs) and Aboriginal Health Access Centres (AHACs); while representing the most radical shift toward PHC (including community governance, interdisciplinary teams of salaried providers, and a focus on underserviced populations, health promotion and population health) CHCs and AHACs together covered less than 2% of Ontario residents. Conclusions: Although Ontario, like other jurisdictions nationally and internationally has engaged in successive waves of reform stretching over decades, to date, this reform has produced little movement toward more expansive models of PHC of the type envisaged by the WHO and others. Where change has occurred, it has not fundamentally altered the hard-fought historical "bargain" underlying Canadian Medicare which saw public governments fund medical care, but left the organization and delivery of such care mostly under professional control. In Ontario, the vast majority of primary care practices continue to be small businesses owned and operated by physicians, funded mostly through fee-for-service, with few interdisciplinary teams, and only a limited focus on disease prevention and population health. We conclude that although portrayed by policy-makers and the profession as "transformative change," substantive change toward PHC has, as theory predicts, been mostly at the margins. [ABSTRACT FROM AUTHOR]

Genetic research in autism depends on the willingness of individuals with autism to participate; thus, there is a duty to assess participants' needs in the research process. We report on families' motives and expectations related to their participation in autism genetic research. Respondents valued having a genetic result, as it alleviates guilt, promotes awareness, and may be used to tailor interventions and for family planning. The act of participating was distinctly significant, as it provided personal control, a connection to autism experts, networking with families, and hope for the future. The results of this study highlight complex factors involved in families' decisions to participate in autism genetic research and provide points to consider for this population of research participants. [ABSTRACT FROM AUTHOR]

Abstract: For years, scholars have debated the “commercial ethos” in higher education, and the rise of the entrepreneurial university. But what of the “entrepreneurial hospital”? Largely unnoticed by scholars, this unique organisational form differs from the entrepreneurial university in some significant ways, not least in its capacity to use its innovations, and to count patients—and even patient populations—amongst its human capital. Accordingly, this article provides an initial conceptualisation of the entrepreneurial hospital, along with an exploration of its larger implications. Using twenty-six semi-structured interviews with key-informants (2008–2009), who work in two networked organisations within a single academic health science system in a Canadian province, our analysis identifies distinctive characteristics of an entrepreneurial hospital. Informed by grounded theory, especially situational analysis, we derive from our data an illustration of potentially incommensurate understandings of the entrepreneurial hospital''s resources. On one hand, our study participants view patients and patient populations as a resource for research, linking its value to the contribution it can make to improved, more cost-effective care. On the other hand, some also see commercial potential in this resource. In both cases, exploitation is accompanied by perceived obligations to make proper use of patient populations, and to “give back” to the public-at-large, including through the entrepreneurial search for new ways of mobilising the resources of publicly-funded health care. Thus, a key task of the entrepreneurial hospital is to invent and mediate new uses for its care infrastructure and the unique resource constituted by patient populations. By drawing together care and research in new ways, the entrepreneurial hospital promises increased capacity for biomedical innovation. Yet, as it invents and mediates new uses for patient populations and health care infrastructure, the entrepreneurial hospital stands to significantly redefine both systems of care and the bonds of social solidarity. [Copyright &y& Elsevier]

OBJECTIVES: Newborn screening (NBS) programs may store bloodspot samples and use them for secondary purposes. Recent public controversies and lawsuits over storage and secondary uses underscore the need to engage the public on these issues. We explored Canadian values regarding storage and use of NBS samples for various purposes and the forms of parental choice for anonymous research with NBS samples. METHODS: We conducted a mixed-methods, public engagement study comprising 8 focus groups (n = 60), an educational component, deliberative discussion, and pre- and post-questionnaires assessing knowledge and values toward storage and parental choice. RESULTS: Canadian citizens supported the storage of NBS samples for quality control, confirmatory diagnosis, and future anonymous research (>90%). There was broad support for use of NBS samples for anonymous research; however, opinions were split about the extent of parental decision-making. Support for a "routinized" approach rested on trust in authorities, lack of concern for harms, and an assertion that the population's interest took priority over the interests of individuals. Discomfort stemmed from distrust in authorities, concern for harms, and prioritizing individual interests, which supported more substantive parental choice. Consensus emerged regarding the need for greater transparency about the storage and secondary use of samples. CONCLUSIONS: Our study provides novel insights into the values that underpin citizens' acceptance and discomfort with routine storage of NBS samples for research, and supports the need to develop well- designed methods of public education and civic discourse on the risks and benefits of the retention and secondary use of NBS samples. [ABSTRACT FROM AUTHOR]

Abstract: Governments have invested heavily in the clinical and economic promise of health innovation and express increasing concern with the efficacy and efficiency of the health innovation system. In considering strategies for ‘better’ health innovation, policy makers and researchers have taken a particular interest in the work of universities and related public research organizations: How do these organizations identify and transfer promising innovations to market, and do these efforts make best use of public sector investments? We conducted an ethnographic study of technology transfer offices (TTOs) in Ontario and British Columbia, Canada, to consider the place of health and health system imperatives in judgments of value in early-stage health innovation. Our analysis suggests that the valuation process is poorly specified as a set of task-specific judgments. Instead, we argue that technology transfer professionals are active participants in the construction of the innovation and assign value by ‘imagining’ the end product in its ‘context of use’. Oriented as they are to the commercialization of health technology, TTOs understand users primarily as market players. The immediate users of TTOs'' efforts are commercial partners (i.e., licensees, investors) who are capable of translating current discoveries into future commodities. The ultimate end users – patients, clinicians, health systems – are the future consumers of the products to be sold. Attention to these proximate and more distal users in the valuation process is a complex and constitutive feature of the work of health technology transfer. At the same time, judgements about individual technologies are made in relation to a broader imperative through which TTOs seek to imagine and construct sustainable innovation systems. Judgments of value are rendered sensible in relation to the logic of valuation for systems of innovation that, in turn, configure users of health innovation in systemic ways. [Copyright &y& Elsevier]

We describe an evaluation model to guide public coverage of new predictive genetic tests in Ontario, Canada. The model confronts common "gray zones" in evaluation and coverage policy for challenging new technologies. Analysis addresses three domains of the evaluation picture. The first specifies evaluative criteria (purpose, effectiveness, additional effects, unit cost, demand, cost-effectiveness). The second induces or deduces acceptable cutoffs for each criterion. The third domain addresses the need to make decisions under uncertainty and to respond to "gray" evaluations with conditional-coverage decisions. The evaluation criteria should be applied within sound decision-making processes. [ABSTRACT FROM AUTHOR]

The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive. • Regulatory agencies to manage technology adoption have grown internationally. • HTA agencies and Group Procurement Organizations now exist in the same regime. • We identify four "modes of coordination" in the regime, including no coordination. • Only one mode aligns with the assumption of shared problem solving, guided by HTA. • Mutual learning is needed given differences in regulatory practice & epistemology. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Retaining residual newborn screening (NBS] bloodspots for medical research remains contentious. To inform this debate, we sought to understand public preferences for, and reasons for preferring, alternative policy options. METHODS: We assessed preferences among 4 policy options for research use of residual bloodspots through a bilingual national Internet survey of a representative sample of Canadians. Fifty percent of respondents were randomly assigned to select reasons supporting these preferences. Understanding of and attitudes toward screening and research concepts, and demographics were assessed. RESULTS: Of 1102 respondents (94% participation rate; 47% completion rate], the overall preference among policy options was ask permission (67%]; this option was also the most acceptable choice (80%]. Assume permission was acceptable to 46%, no permission required was acceptable to 29%, and no research allowed was acceptable to 26%. The acceptability of the ask permission option was reduced among participants assigned to the reasoning exercise (84% vs 76%; P = .004]. Compared with assume/no permission required, ordered logistic regression showed a significant reduction in preference for the ask permission option with greater understanding of concepts (odds ratio, 0.87; P < .001], greater confidence in science (odds ratio, 0.16; P < .001], and a perceived responsibility to contribute to research (odds ratio, 0.39; P < .001]. CONCLUSIONS: Surveyed Canadians prefer that explicit permission is sought for storage and research use of NBS bloodspots. This preference was diminished when reasons supporting and opposing routine storage, and other policy options, were presented. Findings warrant consideration as NBS communities strategize to respond to shifting legislative contexts. [ABSTRACT FROM AUTHOR]

The article offers information on the expansion of newborn screening in pursuit of the reproductive benefits in the U.S., Denmark, and Canada. Reproductive benefit has been considered secondary to identifying treatable condition in newborn screening within the consent or mandatory systems to receive information. Moreover, the author argues that pursuing health benefit through newborn screening program is not appropriate and may be best achieved through traditional antenatal screening programs.

As Canadian policy-makers recognize the urgency for concerted actions to reduce plastics (e.g., Canada's involvement in the international plastics treaty negotiations, zero plastic waste strategy, and single-use plastics regulations), the healthcare sector must also consider a more sustainable plastics system. In this context, the potential for novel bioplastics to mitigate healthcare's substantial plastic waste problem must be carefully interrogated. Our analysis examines the complexities of bioplastics, highlighting the technical challenges of identifying legitimate sustainable alternatives, and the practical barriers for implementing bioplastics as substitutes for consumable plastics in healthcare. We focus on the Canadian healthcare sector and regulatory landscape with the insights gained being applicable to other sectors and countries. Given the limitations identified, the focus on reducing consumption should remain the priority., Competing Interests: Declaration of conflicting interestsThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Health technology assessment (HTA) traditionally informs decision making for single health technologies, which could lead to ill-informed decisions, suboptimal care, and system inefficiencies. We explored opportunities for conceptualizing the decision space in HTA as a disease management question versus an intervention management question., Methods: Semistructured interviews were conducted between April 2022 and October 2022 with purposefully selected individuals from national and provincial HTA agencies and related organizations in Canada. We conducted manual line by line coding of data informed by our interview guide and sensitizing concepts from the literature. One author coded the data, and findings were independently verified by a second author who coded a subset of transcripts., Results: Twenty-four invitations were distributed, and eighteen individuals agreed to participate. A disease management approach to HTA was differentiated from traditional approaches as being disease-based, multi-interventional, and dynamic. There was general support for an explicit care pathway approach to HTA by informing discussions around patient choice and suboptimal care, creating a space where decision makers can collaborate on shared objectives, and in setting up a platform for open dialogue about managing high-cost and high-severity diseases. There are opportunities for a care pathway approach to be implemented that build on the strengths of the existing HTA system in Canada., Conclusions: A disease management approach may enhance the impact of HTA by supporting dynamic decision making that could better inform a proactive, resilient, and sustainable healthcare system in Canada.

Personal Protective Equipment (PPE) that was intentionally designed and manufactured as reusable, including gowns, goggles, face shields, and elastomeric respirators, took on a heightened role during the pandemic. Healthcare workers who had access to these products and infrastructure for cleaning and sterilizing them had a greater sense of confidence to undertake their jobs due to an increased sense of personal safety. Using multiple data sources, including a literature review, roundtables, interviews, surveys, and Internet-based research, the project team investigated the impact of disposable PPE and role of reusable PPE during the pandemic in Canada. This research supports the claim that adopting and supporting reusable PPE systems throughout the health sector can, if used appropriately on an ongoing basis, provide continuous access to reusable PPE while also contributing many co-benefits, including lower costs, domestic jobs, and improved environmental performance such as reduced waste and greenhouse gas emissions.

Increasing numbers of health-care professionals are aware of the need to deliver low-carbon sustainable health systems. We aimed to explore how physicians can be motivated and supported to pursue this ambition by conducting an exploratory qualitative descriptive study that involved individual in-depth interviews with climate-engaged Canadian physicians participating in health-care sustainability advocacy and action. Interview transcripts were analysed to identify themes related to the actions that physicians can take to promote sustainable health care, and the motivators and enablers of physician engagement in sustainable health care. Participants (n=19) engaged in a spectrum of health-care sustainability initiatives ranging from reducing health-care waste to lobbying and political action. They were motivated to advance health-care sustainability by their concern about the health implications of climate change, frustration with health-care waste, and recognition of their locus of influence as physicians. Participants articulated that policy and system, organisational and team, and knowledge generation and translation supports are required to strengthen their capacity to advance health-care sustainability. These findings can provide inspiration for engagement opportunities in health-care sustainability, guide service delivery and educational innovations to promote health-care professionals' interest in becoming sustainability champions, and extend the capacity of health-care professionals to reduce the climate impact of health care., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Outpatient technologies are important for maintaining health and overall quality of life, yet the degree of access and coverage of these technologies remains variable within and across jurisdictions. In Canada, assistive technologies are not included in universal health coverage, and are not subject to the Canada Health Act's criteria and conditions that provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer. As such, the thirteen Canadian provincial and territorial governments make separate decisions on programs and coverage. Drawing on the WHO Universal Coverage Cube we compare who gets access, the types of technologies that can be accessed, and the level of coverage (total costs covered) in Canada. Overall, each Canadian jurisdiction had at least one publicly supported program. All relied on a 'health assessment' of an individual's need to determine eligibility. Income and eligibility for social assistance was used as eligibility criteria in 6 of the 13 jurisdictions. Mobility aids as well as audio, visual, and communication aids were included in all jurisdictions. While some programs offered full financial support for some technologies, forms of cost sharing were common. The results are discussed in the context of international experiences, demographic changes, and health system trends to highlight areas for policy learning., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2021. Published by Elsevier B.V.)

The phrase, "the federal spending power," identifies the federal government's ability to spend in areas beyond its constitutional authority to legislate-a power that has supported the development of a national system of universal healthcare coverage in Canada. Even before the COVID-19 pandemic, this power was critical to the expansion of Canada's narrow but deep basket of universally covered services. The challenges exposed by the pandemic mean that still more federal investment will be required. Yet for traditionalists, the material basis of this power is now constrained: the federal government may possess the constitutional authority to invest, but it lacks the fiscal capacity; some form of belt tightening-even austerity-will be necessary. As debates over public spending intensify, health leaders will need to address these questions. Depending on how they do so, health leaders will either support or detract from a healthy recovery.

"Toward a Sustainable Health System: A Call to Action" speaks of the challenge that the climate crisis poses for health systems. The scale of the accelerating crisis will require that health systems adapt in response and also become visible champions for change, mitigating the environmental harms of their operation and mobilizing their social networks and leadership potential to build community resilience and transformative capacity. The authors pay principal attention to the issues of environmental sustainability and also review the linked challenges of social and economic sustainability, given the imperatives of environmental and social justice and the need for a revitalized economic vision to support livable futures. The authors' aim is to accelerate ambition in Canada, where coordinated effort and national leadership have been lacking. They close with recommendations to achieve a net-zero health system in Canada by or before 2050., (Copyright © 2020 Longwoods Publishing.)

We are fortunate to have the reflections and wisdom of experts from multiple disciplines in this issue's discussion of healthcare sustainability. In the lead paper of this issue of Healthcare Papers, we issued a call to action drawing on the capacity of the Canadian health sector to address climate change (Miller and Xie 2020). Our colleagues agree on the need to deliver sustainable care and raise important questions about how such an aim can be achieved. In this response, we consider and revisit three themes: feasibility of a sustainable healthcare system, theories of change that support our recommendations and capacities that enable change., (Copyright © 2020 Longwoods Publishing.)

Preimplantation genetic diagnosis (PGD) allows couples to test for a genetically affected embryo prior to implantation. Patient access to this ethically complex and expensive technology differs markedly across jurisdictions, with differences in private/public insurance coverage and variations in patient inclusion and diagnostic criteria. The objective of the study was to identify trade-offs regarding PGD coverage decisions amongst genetic counselors. To quantify stated preferences for PGD coverage, we conducted a discrete choice experiment with Canadian genetic counselors (GC) considering attributes regarding the scope of testing (PGD indication, risk of the condition and number of cycles covered) and patient inclusion criteria (fertility status and family history). Multinomial logit regression was used to estimate trade-offs amongst attributes using part-worth utilities and importance scores. The completed response rate was 41% with 126 GC completing the survey. Risk of the genetic condition was the most important attribute. Overall, GC were more responsive to the scope of testing criteria including the condition's risk (importance score of 42%) and PGD indication (31%) rather than family history (11%) and fertility status (8%). Based on this study's attributes and levels, condition characteristics are prioritized even above patient characteristics for PGD coverage., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Procurement's important role in healthcare decision making has encouraged criticism and calls for greater collaboration with health technology assessment (HTA), and necessitates detailed analysis of how procurement approaches the decision task., Methods: We reviewed tender documents that solicit medical technologies for patient care in Canada, focusing on request for proposal (RFP) tenders that assess quality and cost, supplemented by a census of all tender types. We extracted data to assess (i) use of group purchasing organizations (GPOs) as buyers, (ii) evaluation criteria and rubrics, and (iii) contract terms, as indicators of supplier type and market conditions., Results: GPOs were dominant buyers for RFPs (54/97) and all tender types (120/226), and RFPs were the most common tender (92/226), with few price-only tenders (11/226). Evaluation criteria for quality were technical, including clinical or material specifications, as well as vendor experience and qualifications; "total cost" was frequently referenced (83/97), but inconsistently used. The most common (47/97) evaluative rubric was summed scores, or summed scores after excluding those below a mandatory minimum (22/97), with majority weight (64.1 percent, 62.9 percent) assigned to quality criteria. Where specified, expected contract lengths with successful suppliers were high (mean, 3.93 years; average renewal, 2.14 years), and most buyers (37/42) expected to award to a single supplier., Conclusions: Procurement's evaluative approach is distinctive. While aiming to go beyond price in the acquisition of most medical technologies, it adopts a narrow approach to assessing quality and costs, but also attends to factors little considered by HTA, suggesting opportunities for mutual lesson learning.

Growing discussion on the use of whole-genome or exome sequencing (WG/ES) in newborn screening (NBS) has raised concerns regarding the generation of incidental information on millions of infants annually. It is unknown whether integrating WG/ES would alter public expectations regarding participation in universal NBS. We assessed public willingness to participate in NBS using WG/ES compared with current NBS. Our secondary objective was to assess the public's beliefs regarding a parental responsibility to participate in WG/ES-based NBS compared with current NBS. We examined self-reported attitudes regarding willingness to participate in NBS using a cross-sectional national survey of Canadian residents recruited through an internet panel, reflective of the Canadian population by age, gender and region. Our results showed that fewer respondents would be willing to participate in NBS using WG/ES compared with NBS using current technologies (80 vs 94%, P<0.001), or perceived a parental responsibility to participate in WG/ES-based NBS vs current NBS (30 vs 48%, P<0.001). Our findings suggest that integrating WG/ES into NBS might reduce participation, and challenge the moral authority that NBS programmes rely upon to ensure population benefits. These findings point to the need for caution in the untargeted use of WG/ES in public health contexts.

Purpose: To quantify and compare the preferences of researchers and laypeople in Canada regarding the outcomes of basic biomedical research., Method: In autumn 2010, the authors conducted a cross-sectional, national survey of basic biomedical researchers funded by Canada's national health research agency and a representative sample of Canadian citizens to assess preferences for research outcomes across five attributes using a discrete choice experiment. Attributes included advancing scientific knowledge (assessed by published papers); building research capacity (assessed by trainees); informing decisions in the health products industry (assessed by patents); targeting economic, health, or scientific priorities; and cost. The authors reduced a fractional factorial design (18 pairwise choices plus an opt-out option) to three blocks of six. They also computed part worth utilities, differences in predicted probabilities, and willingness-to-pay values using nested logit models., Results: Of 3,260 potential researchers, 1,749 (53.65% response rate) completed the questionnaire, along with 1,002 citizens. Researchers and citizens prioritized high-quality scientific outcomes (papers, trainees) over other attributes. Both groups disvalued research targeted at economic priorities relative to health priorities. Researchers granted a premium to proposals targeting scientific priorities., Conclusions: Citizens and researchers fundamentally prioritized the same outcomes for basic biomedical research. Notably, they prioritized traditional scientific outcomes and disvalued the pursuit of economic returns. These findings have implications for how academic medicine assigns incentives and value to basic health research and how biomedical researchers and the public may jointly contribute to setting the future research agenda.

Background: Despite the mandate to examine the medical, ethical, and economic implications of the development and use of health technology, health technology assessment (HTA) reports often emphasize the epidemiologic and economic aspects, and omit ethical considerations. This study examines both whether and how ethical issues are incorporated into HTA., Objectives: We aim to (i) review a set of Canadian HTA reports for ethics content, (ii) describe the strategies used to incorporate ethically relevant information into HTA, and (iii) determine the presence of implicit ethical issues in a sample of HTA reports., Methods: Descriptive and qualitative content analysis of 608 HTA reports produced by six Canadian HTA agencies from January 1997 to December 2006., Results: We found that (i) a minority (17 percent) of Canadian HTA reports addressed ethical issues, (ii) secondary research predominates while primary analysis is rare, (iii) implicit ethical issues are present in HTA reports that do not purport to address ethics., Conclusions: Canadian HTA reports rarely explicitly, and then only superficially, address ethics, though implicit ethical issues abound.

Objectives: We used a qualitative empirical study of Canadians' values toward their health system to develop more meaningful conceptualizations of trust and health systems that can inform the pursuit of more trustworthy health systems., Methods: We convened nine focus groups in three Canadian cities in 2002 and 2004 in conjunction with a national public opinion telephone survey of Canadians' attitudes and values toward their health system. Health system trust emerged as a significant theme in focus group discussions and was investigated using a modified grounded theory approach., Findings: Respondents construct cleavages and alliances to position themselves in relation to different features of the trusted health system. The health system and Canadian Medicare are identified sources of trust just as are individual health care providers. Core to the trust relationship is the experience of vulnerability which provides the impetus for placing trust (in providers, governments and health systems) or seeds distrust, mistrust and resilience in the same., Conclusions: We offer a more robust conceptualization of what it means to trust a health system. Policy maker efforts to intervene to restore lost trust could usefully be informed by these findings.

Background: Research ethicists have recently declared a new ethical imperative: that researchers should communicate the results of research to participants. For some analysts, the obligation is restricted to the communication of the general findings or conclusions of the study. However, other analysts extend the obligation to the disclosure of individual research results, especially where these results are perceived to have clinical relevance. Several scholars have advanced cogent critiques of the putative obligation to disclose individual research results. They question whether ethical goals are served by disclosure or violated by non-disclosure, and whether the communication of research results respects ethically salient differences between research practices and clinical care. Empirical data on these questions are limited. Available evidence suggests, on the one hand, growing support for disclosure, and on the other, the potential for significant harm., Methods: This paper explores the implications of the disclosure of individual research results for the relationship between research and clinical care through analysis of research-based cancer genetic testing in Ontario, Canada in the late 1990s. We analyze a set of 30 interviews with key informants involved with research-based cancer genetic testing before the publicly funded clinical service became available in 2000., Results: We advance three insights: First, the communication of individual research results makes research practices seem like clinical services for our respondents. Second, while valuing the way in which research enables a form of clinical access, our respondents experience these quasi-clinical services as inadequate. Finally, our respondents recognize the ways in which their experience with these quasi-clinical services is influenced by research imperatives, but understand and interpret the significance and appropriateness of these influences in different ways., Conclusion: Our findings suggest that the hybrid state created through the disclosure of research results about individuals that are perceived to be clinically relevant may produce neither sufficiently adequate clinical care nor sufficiently ethical research practices. These findings raise questions about the extent to which research can, and should, be made to serve clinical purposes, and suggest the need for further deliberation regarding any ethical obligation to communicate individual research results.