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Abstract Background Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of most children and youth. Learning health systems are an approach to enhancing services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures provide a key data source for learning health systems. They have also been shown to improve outcomes for patients when integrated into routine clinical care. However, implementing these measures into health systems is a challenging process. This paper describes a protocol for a formative evaluation of the implementation of patient-reported measures in a newly operational child and adolescent mental health centre in Calgary, Canada. The purpose is to optimize the collection and use of patient-reported outcome measures. Our specific objectives are to assess the implementation progress, identify barriers and facilitators to implementation, and explore patient, caregivers and clinician experiences of using these measures in routine clinical care. Methods This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. Participants include patients and caregivers who have used the centre’s services, as well as leadership, clinical and support staff at the centre. Focus groups and semi-structured interviews will be conducted to assess barriers and facilitators to the implementation and sustainability of the use of patient-reported outcome measures, as well as individuals’ experiences with using these measures within clinical care. The data generated by the patient-reported measures over the first five months of the centre’s operation will be analyzed to understand implementation progress, as well as validity of the chosen measures for the centres’ population. Discussion The findings of this evaluation will help to identify and address the factors that are affecting the successful implementation of patient-reported measures at the centre. They will inform the co-design of strategies to improve implementation with key stakeholders, which include patients, clinical staff, and leadership at the centre. To our knowledge, this is the first study of the implementation of patient-reported outcome measures in child and adolescent mental health services and our findings can be used to enhance future implementation efforts in similar settings.

IntroductionCare Coordination (CC) is a significant intervention to enhance family’s capacity in caring for children with neurodevelopmental disability and medical complexity (NDD-MC). CC assists with integration of medical and behavioral care and services, partnerships with medical and community-based supports, and access to medical, behavioral, and educational supports and services. Although there is some consensus on the principles that characterize optimal CC for children with NDD-MC, challenges remain in measuring and quantifying the impacts of CC related to these principles. Two key challenges include: (1) identification of measures that capture CC impacts from the medical system, care provider, and family perspectives; and (2) recognition of the important community context outside of a hospital or clinical setting.MethodsThis study used a multilevel model variant of the triangulation mixed methods design to assess the impact of a CC project implemented in Alberta, Canada, on family quality of life, resource use, and care integration at the broader environmental and household levels. At the broader environmental level, we used linked administrative data. At the household level we used quantitative pre-post survey datasets, and aggregate findings from qualitative interviews to measure group-level impacts and an embedded multiple-case design to draw comparisons, capture the nuances of children with NDD-MC and their families, and expand on factors driving the high variability in outcome measures. Three theoretical propositions formed the basis of the analytical strategy for our case study evidence to explore factors affecting the high variability in outcome measures.DiscussionThis study expanded on the factors used to measure the outcomes of CC and adds to our understanding of how CC as an intervention impacts resource use, quality of life, and care integration of children with NDD-MC and their families. Given the heterogeneous nature of this population, evaluation studies that account for the variable and multi-level impacts of CC interventions are critical to inform practice, implementation, and policy of CC for children with NDD-MC.

Plain English summary Patient-reported outcome measures are standardized questionnaires that ask patients about their health and well-being and are useful for tracking patient progress and outcomes of care. Patient-reported experience measures ask patients about their experiences while receiving care and are useful for quality improvement and experience research. Clinicians can use them to help identify patients’ needs, monitor a person’s health status, and to give extra information that helps with planning treatment. These measures also provide data that health services can use to understand whether their programs are helpful from the patients’ perspective. We know that using these measures is beneficial, but there are many challenges to overcome before they are used consistently in a health system. In pediatrics there are special considerations, like whether a caregiver or child should be answering the questions, or whether a parent should be able to see their child’s answers. In this study, we interviewed people in the pediatric health system who are successfully using patient-reported outcome and experience measures about the challenges they face and the strategies they find helpful for using these measures. This information will be helpful for people who are planning to start using these measures in pediatric health care.

Abstract Background Patient-reported outcome measures (PROMs) are standardized and validated self-administered questionnaires that assess whether healthcare interventions and practices improve patients’ health and quality of life. PROMs are commonly implemented in children and youth mental health services, as they increasingly emphasize patient-centered care. The objective of this study was to identify and describe the PROMs that are currently in use with children and youth living with mental health conditions (MHCs). Methods Three databases (MEDLINE, EMBASE, and PsycINFO) were systematically searched that used PROMs with children and youth

Abstract Introduction Patient engagement in youth mental health research has the potential to inform research on the interventions, services and policies that will benefit youth. At present, there is little evidence to guide mental health researchers on youth engagement. This systematic review aims to describe the impacts of youth engagement on mental health research and to summarize youth engagement in mental health research. Methods We searched the following databases: MEDLINE, EMBASE and PsycINFO, using a combination of subject headings, keywords and synonyms for the concepts ‘patient engagement’, ‘youth’ and ‘mental health’. Articles that described engaging youth in mental health research were included. Two reviewers performed the study selection. Study characteristics, research activities performed by youth, impacts of youth engagement, challenges, and facilitators to engagement and recommendations for youth engagement described by authors were extracted. Quality appraisal involved determining the level of engagement of youth and the stage(s) of research where youth were involved. Results The database search returned 2836 citations, 151 full‐text articles were screened and 16 articles, representing 14 studies, were selected for inclusion. Youth were involved at nearly all stages of the research cycle, in either advisory or co‐production roles. Youth engagement impacts included enhancing relevant research findings, data collection and analysis and dissemination to academic and stakeholder audiences. Both youth and academic researchers reported personal development across many domains. One negative impact reported was the increase in funding and resources needed for engagement. We produced a list of 35 recommendations under the headings of training, youth researcher composition, strategy, expectations, relationships, meeting approaches and engagement conditions. Conclusions This study provides an understanding of the impacts and recommendations of youth engagement in mental health research. The findings from this study may encourage researchers to engage youth in their mental health research and support youth engagement in funding applications. Patient and Public Contribution We consulted three youths with experience being engaged in mental health research about the review findings and the discussion. One youth designed a visual representation of the results and provided feedback on the manuscript. All youth's input informed the way the findings were presented and the focus of the discussion.

Abstract Background There is increasing evidence for early, active rehabilitation to enhance motor function following early brain injury. This is clear for interventions targeting the upper extremity, whereas passive treatment approaches for the lower extremity persist. The purpose of this trial is to evaluate the effectiveness of early, intensive rehabilitation targeting the lower extremity and delivered in a parent-therapist partnership model for children with perinatal stroke. Methods We describe a protocol for a waitlist-control, single-blind, mixed methods effectiveness randomized controlled trial, with an embedded qualitative study using interpretative description. Participants are children with perinatal stroke aged eight months to three years with signs of hemiparesis. Participants will be randomly allocated to an immediate ELEVATE (Engaging the Lower Extremity Via Active Therapy Early) intervention group, or a waitlist-control group, who will receive usual care for six months. The ELEVATE intervention involves one hour of training four days per week for 12 weeks, with a pediatric therapist and a parent or guardian each delivering two sessions per week. The intervention targets the affected lower extremity by progressively challenging the child while standing and walking. The primary outcome measure is the Gross Motor Function Measure-66. Secondary outcomes include the Pediatric Quality of Life Inventory™, Young Children's Participation and Environment Measure, and an instrumented measure of spasticity. A cost-effectiveness analysis and qualitative component will explore benefit to costs ratios and parents’ perspectives of early, intensive rehabilitation, and their role as a partner in the rehabilitation, respectively. Discussion This study has the potential to change current rehabilitation for young children with perinatal stroke if the ELEVATE intervention is effective. The parent interviews will provide further insight into benefits and challenges of a partnership model of rehabilitation. The mixed methods design will enable optimization for transfer of this collaborative approach into physical therapy practice. Trial registration ClinicalTrials.gov NCT03672864 . Registered 17 September 2018.

BackgroundConcussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.Materials and methodsA retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients

Abstract Background Persons with developmental disabilities (PWDD) face a number of individual, environmental and societal barriers when seeking employment. Integrated knowledge translation (IKT) involves ongoing and dynamic interactions between researchers and stakeholders for the purpose of engaging in mutually beneficial research to address these types of multi-faceted barriers. There is a knowledge gap in the IKT literature on effective stakeholder engagement strategies outside of the dissemination stage to inform policy. In this paper, we report on a number of engagement strategies employed over a 2-year period to engage a wide range of stakeholders in different stages of an IKT project that aimed to investigate the ‘wicked’ problem of employment for PWDD. Method Our engagement plan included multiple linked strategies and was designed to ensure the meaningful engagement of, and knowledge co-production with, stakeholders. We held two participatory consensus-building stakeholder policy dialogue events to co-produce knowledge utilising the nominal group technique and the modified Delphi technique. A total of 31 and 49 stakeholders engaged in the first and second events, respectively, from six key stakeholder groups. Focused engagement strategies were employed to build on the stakeholder dialogues for knowledge mobilisation and included a focus group attended only by PWDD, a stakeholder workshop attended only by policy/decision-makers, a webinar attended by human resources professionals and employers, and a current affairs panel attended by the general public. Results Our findings suggest that the level of engagement for each stakeholder group varies depending on the goal and need of the project. Our stakeholder dialogue findings highlight the inherent challenges in co-framing and knowledge co-production through the meaningful engagement of multiple stakeholders who hold different ideas and interests. Focused outreach is needed to foster relationships and trust for meaningful engagement. Conclusions In addition to providing guidance on how to implement adaptable meaningful engagement strategies, these findings contribute to discussions on how IKT projects are planned and funded. More studies to explore effective mechanisms for engaging a wide range of stakeholders in IKT research are needed. More evidence of successful engagement strategies employed by researchers to achieve meaningful knowledge co-production is also key to advancing the discipline.

Abstract Background Fetal Alcohol Spectrum Disorder (FASD) is characterized by physical and neurological abnormalities resulting from prenatal alcohol exposure. Though diagnosis may help improve patient outcomes, the diagnostic process can be costly. Subsequently, screening children suspected of FASD prior to diagnostic testing has been suggested, to avoid administering testing to children who are unlikely to receive a diagnosis. The present study set out to assess the cost-effectiveness of currently recommended FASD screening tools. Methods The screenings tools evaluated were chosen from Children’s Healthcare Canada’s National Screening Toolkit for Children and Youth Identified and Potentially Affected by FASD and include meconium testing of fatty acid ethyl esters (meconium testing) and the neurobehavioral screening tool (NST). An economic model was constructed to assess cost-effectiveness. One-way and probabilistic sensitivity analyses were conducted to assess the robustness of findings. Costs reflect 2017 Canadian dollars and the perspective is the public healthcare system. Results Both screening tools evaluated resulted in reduced costs and fewer diagnosed years of life than a no screening strategy in which all children suspected of FASD receive diagnostic testing. The model predicts that screening newborns with meconium testing results in a reduced cost of $89,186 per 100 individuals screened and 38 fewer diagnosed years of life by age 18, corresponding to an incremental cost-effectiveness ratio (ICER) of $2359. Screening children with the NST resulted in a reduced cost of $183,895 per 100 individuals screened and 77 fewer diagnosed years of life by age 18, corresponding to an ICER of $2390. Conclusion Findings suggest that screening is associated with less use of healthcare recourses but also fewer years of life with an FASD diagnosis over a no screening strategy. Since diagnosis can be key to children receiving timely and appropriate health and educational services, cost-savings must be weighed against the fewer years of life with a diagnosis associated with screening.

Abstract Background Early detection of neurodevelopmental disorders (NDDs) enables access to early interventions for children. We assess the Ages and Stages Questionnaire (ASQ)’s ability to identify children with a NDD in population data. Method Children 4 to 5 years old in the National Longitudinal Survey of Children and Youth (NLSCY) from cycles 5 to 8 were included. The sensitivity, specificity, positive and negative predictive values were calculated for the ASQ at 24, 27, 30, 33, 36 and 42 months. Fixed effects regression analyses assessed longitudinal associations between domain scores and child age. Results Specificity for the ASQ was high with 1SD or 2SD cutoffs, indicating good accuracy in detecting children who will not develop a NDD, however the sensitivity varied over time points and cut-offs. Sensitivity for the 1 SD cutoff at 24 months was above the recommended value of 70% for screening. Differences in ASQ domains scores between children with and without NDD increases with age. Conclusions The high specificity and negative predictive values of the ASQ support its use in identifying children who are not at the risk of developing a NDD. The capacity of the ASQ to identify children with a NDD in the general population is limited except for the ASQ-24 months with 1SD and can be used to identify children at risk of NDD.

Teen violence in dating and peer relationships has huge costs to society in numerous areas including health care, social services, the workforce and the justice system. Physical, psychological, and sexual abuse have long-lasting ramifications for the perpetrators as well as the victims, and for the families involved on both sides of that equation. An effective violence prevention program that is part of a school’s curriculum is beneficial not only for teaching teenagers what is appropriate behaviour in a relationship, but also for helping them break the cycle of violence which may have begun at home with their own maltreatment as children. The Fourth R program is an efficacious violence prevention program that was developed in Ontario and has been implemented in schools throughout Canada and the U.S. Covering relationship dynamics common to dating violence as well as substance abuse, peer violence and unsafe sex, the program can be adapted to different cultures and to same-sex relationships. The program, which gets its name from the traditional 3Rs — reading, ’riting and ’rithmetic — offers schools the opportunity to provide effective programming for teens to reduce the likelihood of them using relationship for violence as they move into adulthood. The federal government has estimated that the societal costs of relationship violence amount to more than $7 billion. These costs can continue to be incurred through the legal and health-care systems as the ripple effects of violence play out over the years, even after a relationship has ended. Other types of violence are also costly to society and not just in terms of dollars, but in young lives diverted into criminal activity. Up to 15 per cent of youth who become involved with the justice system grow into serious adult offenders who develop lengthy criminal careers. Yet, research shows that if prevention programs such as the Fourth R can deter just one 14-year-old high-risk juvenile from a life of crime, up to $5 million can be saved in costs to society. Research involving 1,700 Grade 9 students in 20 schools showed that those who did not take the Fourth R programming had a rate of relationship violence 2.5 times greater than those who did, and that the program had the greatest impact on boys, who are the most frequent perpetrators. There was also a significant reduction in violence towards peers, especially for youth who were at risk to be violent because they had experienced previous child abuse. Students likewise became more aware of violence and its impacts on others, and they gained a greater command of coping strategies. The program’s start-up costs vary depending on the school’s geographical location. This paper shows that the program’s costs per student are small compared to the savings to society in terms of violence avoidance. In a large Ontario school board, costs were down to $5 per student. In the Northwest Territories, smaller class sizes and bigger geographic distances make implementing the program more expensive, but still only $15-33 per student. The authors calculated savings based on costs avoided related to dating and peer violence at $2,101 per student. Violence prevention is an ethical imperative and it must start with teenagers. In an era of fiscal restraint and demand for more financial accountability, the Fourth R has proven to be a pro-active success in terms of saving both public money and young lives from the deleterious effects of violence.

Early Childhood Caries (ECC) is a serious disease that is about much more than cavities on baby teeth. In Canada, it is a growing public health problem with adverse long-term effects on children's physical, emotional and intellectual well-being. The failure to invest in preventive care has resulted in reactive, rather than proactive, measures against this disease. These measures are expensive and a needless drain on costs in the public health-care system. Children with severe ECC end up in hospital; in fact, in Canada, this disease is the most common reason children undergo day surgery. From 2010 to 2012, one in 100 children under age five required day surgery for ECC, with approximately 19,000 of these surgeries performed each year on children under age six. Canadian hospital costs for ECC day surgery in children aged one to five ranged from $1,271 to $1,963 per child, totalling $21.2 million between 2010 and 2012. Children from low-income families, along with aboriginal, immigrant and refugee children are disproportionately affected by dental disease, with between 50 per cent and 90 per cent of suffering from some form of ECC. This compares to an average of 57 per cent of children affected in the general population. A recent Alberta study indicates that when municipalities cease fluoridating their water supplies, children suffer increased levels of tooth decay. This has reignited the discussion around whether municipalities should add fluoride to the drinking water, or reinstate it in places where the water used to be fluoridated. While fluoridation can be an effective prevention strategy, this study also shows that fluoride alone is not enough. To reduce the costs and developmental consequences associated with severe ECC and improve well-being, oral health policies focused on disease prevention and health promotion are still necessary. This briefing paper provides background on the etiology, risk factors and prevalence of ECC in Canada to provide scope for the magnitude of this preventable disease in children. To address the avoidable socioeconomic costs, three areas require policy development. First is the need for increased public education and access to ECC prevention services for at-risk populations. Parents need to know they should reduce their children’s intake of sweet drinks, and avoid filling bottles with sugar water, juice or soft drinks, especially at night. They should also clean an infant’s gums with a soft toothbrush or cloth and water starting at birth. When the baby’s first tooth erupts, parents should commence daily brushing with toothpaste and book a first dental visit. Second is the need to empower health-care professionals to integrate ECC prevention in their early visits with parents of young children. Such visits are more common in family medicine, and these primary care providers can play a critical role in educating parents and promoting children’s oral health. Curriculum and continuing education for these health professions should be enhanced to emphasize ECC’s long-term health effects. Third, government should invest in preventive oral health services for children rather than relying on emergency dental care. Children should have access to early preventive dental services to instill in them habits for lifetime oral health. Provinces without universal public funding for children’s preventive dental health should remove the access barriers that children without dental insurance face.

WHY IS THIS AN IMPORTANT ISSUE? An estimated 1 in 86 children are diagnosed with Autism Spectrum Disorder (ASD)1 making it the most commonly diagnosed childhood neurological condition in Canada.2 Transportation challenges for those with ASD are a growing issue in Canada. People living with ASD3 and others who live with neurodevelopmental disability (NDD)4 rely almost exclusively on public transit and caregivers for transportation. The current transportation options are insufcient in meeting the needs of this population. WHAT DOES THE RESEARCH TELL US? Transportation is essential to promoting quality of life The transit system plays an essential role in improving quality of life for individuals with ASD and for their caregivers. However, problems with cognition, perception and communication are barriers to independence in transportation. Availability of transportation is critical to enable high levels of physical activity among those with intellectual disabilities.5 Safe and reliable transportation improves one’s ability to participate in programs that support quality of life and impacts employment, volunteering, religious participation, exercise, self-advocacy and health care for people with intellectual and developmental disabilities.6 Caregivers for those with ASD emphasize that transportation is critical to enable meaningful opportunity and community engagement in employment, education, healthcare and social pursuits.

WHY IS THIS AN IMPORTANT ISSUE? An estimated 1 in 86 children are diagnosed with Autism Spectrum Disorder (ASD)1 making it the most commonly diagnosed childhood neurological condition in Canada.2 Adults living with ASD3 have the poorest employment outcomes of those with disabilities. Most earn less than the national minimum hourly wage, endure extended periods of joblessness and frequently shuffle between positions, further diminishing their prospects. These poor employment outcomes result in lower quality of life and often lead to steep economic costs. WHAT DOES THE RESEARCH TELL US? Employment success increases quality of life Employment enhances quality of life, cognitive functioning and overall well-being of persons with ASD by increasing economic self-sufficiency, financial security, independent living, community participation and self-esteem.4, 5, 6 Unfortunately, employment outcomes for those living with ASD are poor; only 25 per cent of adults with ASD are employed, most of this group is considered high-functioning and only six per cent are competitively employed.7, 8 Success in employment is attributable to a combination of individual characteristics, external supports and policy enabling employment opportunities.

WHY IS THIS AN IMPORTANT ISSUE? An estimated 1 in 86 children are diagnosed with Autism Spectrum Disorder (ASD)1 making it the most commonly diagnosed childhood neurological condition in Canada.2 The true costs of lifelong support for people living with ASD3 are often underestimated and fail to acknowledge the value of caregiver time over the lifespan. Significant gaps in publically provided support systems leave the cost burden to be picked up by families. Relying on continued family supports where community services are fragmented or unavailable is not a sustainable approach. WHAT DOES THE RESEARCH TELL US? A continuum of supports are needed Most people living with ASD need supports that range from occasional assistance with higher level tasks, like organizing appointments or banking, to those who need continuous help with daily living.4 Areas where supportive care may be needed can be categorized broadly to include: self care, home living, service co-ordination, personal organization, health and safety management, adult day opportunities/employment, transportation, advocacy and social skills. These supports are most successful when they address the individual’s uniqueness in terms of communication, social, sensory, behavioural needs and physical and/or mental health conditions. Currently there are a lack of available supports, limiting opportunities for socialization, employment and residential living resulting in reduced independence for adults with ASD.

WHY IS THIS AN IMPORTANT ISSUE? Autism Spectrum Disorder (ASD)1 is the most common neurological condition diagnosed in children in Canada. Estimates of prevalence are reported as national numbers but may not reflect local numbers and consequently local needs. Local and provincial ASD prevalence estimates can be used by policy makers to inform local service delivery, resource allocation and future planning. WHAT DOES THE RESEARCH TELL US? ASD prevalence is on the rise Estimates of ASD prevalence in Canada have risen dramatically over the past several decades.2 The reason for the dramatic rise is uncertain and may be a result of a combination of a true rise in incidence, changing diagnostic criteria and increased awareness.3 It has been speculated that Alberta may have higher numbers of persons with ASD due to family in-migration to utilize higher levels of funding for ASD supports compared to other provinces.4 Prior to this study, there were no prevalence estimates for Alberta to assess this theory. A better understanding of Alberta ASD prevalence is critical as these estimates assist policy-makers, clinicians and educators in planning for school supports, adult day programs, employment programs, housing options and other programs essential to enhancing quality of life for individuals living with ASD and their families.

Autism spectrum disorder (ASD) is the most commonly diagnosed neurological disorder in children. Adults with ASD have some of the poorest employment outcomes in comparison to others with disabilities. While data in Canada is limited, roughly 25 per cent of Americans living with ASD are employed and no more than six per cent are competitively employed. Most earn less than the national minimum hourly wage, endure extended periods of joblessness and frequently shuffle between positions, further diminishing their prospects. Poor employment outcomes result in lower quality of life and often lead to steep economic costs. Governments are wise to pay attention to the poor employment outcomes as the high numbers of children now diagnosed with ASD will become adults in the future in need of employment opportunities. Improving employment outcomes for those living with ASD is an important policy objective. Work opportunities improve quality of life, economic independence, social integration, and ultimately benefit all. Adults with ASD can succeed with the right supports. Fortunately, there are many emerging policy and program options that demonstrate success. This paper conducts a review of studies and provides policy recommendations based on the literature, to help governments identify appropriate policy options. Some key factors are both those that are unique to the individual and the external supports available; namely school, work, and family. For example, factors that contribute to successful employment for people living with ASD may include IQ, social skills and self-determination, but for all, even for the less advantaged, external assistance from schools, employers and family can help. Inclusive special education programs in high school that offer work experiences are critical as are knowledgeable employers who can provide the right types of accommodation and leadership. In the work environment the use of vocational and rehabilitative supports, from job coaching to technology-mediated training are a few of the work related factors that enhance success. Information in this paper provides policy makers with a way to move forward and enhance the current employment situation for those living with ASD ultimately improving quality of life and economic independence.

With rising health care costs, often health research is viewed as a major cost driver, calling to question the role and value of provincial funding of health research. Most agree that the quality of healthcare provided is directly linked to our ability to conduct quality research; however currently there is little empirical evidence supporting the link between engagement in health research and healthcare performance. In Canada this has resulted in funding for health research that varies over time and between provinces. While medical knowledge is a public good, we hypothesize there are local benefits from health research, such as the attraction of a specialized human capital workforce, which fosters a culture of innovation in clinical practice. To address this question, we look at whether health outcomes are impacted by changes in provincial research funding in Alberta compared to other provinces. Provincial funding for medical research, which varies greatly over time and among provinces, is used as a proxy for medical treatment inputs. Trend rates of reduction in mortality from potentially avoidable causes (MPAC) (comprised of mortality from preventable causes (MPC) and mortality from treatable causes (MTC)), are used as a proxy health outcome measure sensitive to the contributions of technological progress in medical treatment. Our analysis suggests that investment in health research has payback in health outcomes, with greater improvements in the province where the research occurs. The trend declines seen in age standardized MPAC rates in different Canadian provinces may be impacted by shifts in provincial research funding investment, suggesting that knowledge is not transferred without cost between provinces. Up until the mid-1980s, Alberta had the most rapid rate of decline in MPAC compared to the other provinces. This is striking given the large and unique investment in medical research funding in Alberta in the early 1980s through AHFMR, the only provincial health research funding agency at the time. However in recent years, Alberta’s rate of decrease in MPAC has occurred at a rate slower than the other provinces (British Columbia, Ontario or Quebec) with provincial medical research funding. This is striking at a population level, where Alberta’s failure to achieve a reduction in age standardized rates of MTC comparable to British Columbia, Ontario or Quebec after 1985 represents 240 unnecessary deaths in 2011 and 48,250 Potential Life Years Lost worth around $4.8 billion. The findings from our study suggest that some of the divergence in the rates of reduction in MPAC between provinces may be due to beneficial changes in institutional structure and human capital, resulting in differences across provinces in the capacity to adopt new effective healthcare innovations. While health indicators such as MPAC are the result of complex interactions between the patient, treatment and the healthcare system, as well as socioeconomic and demographic factors, this analysis suggests that a different capacity for health research within the provinces impacts health outcomes. The findings from this analysis are limited by the lack of data related to research funding and the health research workforces within provinces. This analysis has important implications for health research policy and funding allocations, suggesting that decision makers should consider the long-term impact provincial funding for health research has on health outcomes. This study also highlights the lack of longitudinal public data available for provincial health research funding. This information is critical to inform future health research policy.

With most of the country situated above the latitude of the 42nd parallel north, there is a significant portion of the Canadian population that is not getting enough of the sunshine vitamin during the winter. Vitamin D is naturally produced when skin is exposed to sunlight, however during the winter months in Canada the sun is too low in the sky for this to occur. A full quarter of the Canadian population is estimated to have vitamin D levels so low as to be considered insufficient or deficient by Health Canada guidelines. Increasing vitamin D intake should be considered a public health priority. Vitamin D deficiency is known to be linked to rickets in children and osteomalacia in adults (bone softening and malformation) as well as osteoporosis (loss of bone density, increasing susceptibility to fractures). However a growing body of evidence also suggests that vitamin D may have a role in the prevention of chronic diseases such as heart disease, high blood pressure, diabetes, cancer, cognitive decline, Parkinson’s disease, multiple sclerosis and arthritis. There is, of course, no way to change Canada’s proximity to the equator. But there are ways to help Canadians get more vitamin D through dietary intake. Improving the vitamin D status of the Canadian population through food fortification and dietary supplements represents an inexpensive intervention that can improve the health of the population, but debate remains over how much vitamin D the Canadian population needs and how to ensure the population adheres to whatever recommendations are made. Food fortification has already demonstrated its effectiveness in improving vitamin D levels (as it has for other public health priorities, such as with iodized salt). Decades ago, the prevalence of rickets in Canadian children led health professionals to lobby for, and win, legislation making vitamin D fortification mandatory for milk. Other foods, such as orange juice, milk of plant origin and margarine are sometimes also fortified with vitamin D. However many Canadians do not consume milk or the other fortified foods or do not take dietary supplements at the current recommended levels, increasing their risk of vitamin D insufficiency. It is clear there is a need to gain a better understanding of the benefits and the costs of strategies associated with vitamin D intake in the general population. There have been longstanding concerns about the risk of people consuming too much vitamin D (leading to hypercalcemia). More recently there has emerged great disagreement in the scientific and regulatory communities over what constitutes an excessive dosage of vitamin D, and even what constitutes the optimal blood-serum level for vitamin D. The inability to settle on firm guidelines is paralyzing any movement towards increasing vitamin D intake in the Canadian population. Fortification and public health strategies are needed to ensure current vitamin D targets are met. Health Canada’s proposal to allow greater levels of vitamins and minerals to be added to foods, to meet consumer demand (within maximum limits), has been on the table since 2005. A decade later, the Canadian winters have grown no shorter, and the solar zenith angle has not changed. It is becoming an increasingly urgent matter of public health to reach a consensus on updated guidelines for vitamin D intake levels and limits, to better inform Canadians.

Over the course of more than 30 years, a series of Canadian government commissions and health policy researchers have repeatedly identified the importance of “bending the cost curve” to sustain publicly funded health care, and the potential to do so through upstream investment in health promotion and disease prevention. So far, however, the level of public investment in prevention represents only a slight portion of total public health care expenditure, largely consisting of traditional public health initiatives such as vaccinations, disease screening and information campaigns. This study of the Pure North S’Energy Foundation’s preventative health care program — wherein health care usage by program participants was measured against age- and sex-matched control samples — finds that the sort of preventative health care services offered by Pure North can lead to genuine and significant near-term cost savings for Canada’s single-payer health care system. Participants in the first year of the program required 25 per cent fewer hospital visits and 17 per cent fewer emergency room visits compared to the control group. Among those who persisted in the program for a year or longer, the effects were even more significant: 45 per cent fewer hospital visits in the year after joining, and 28 per cent fewer visits to emergency departments, compared to the control group. This represents real cost savings for a public health service: From $388 per person who joined the program to $677 per person who persisted beyond the first year. As a proportion of annual health spending for these participants on hospitals, emergency departments and general practitioners, this represents a cost reduction ranging from 22 to 39 per cent. If the Alberta government were able to implement this kind of program provincewide (at an estimated cost of $500 per participant), and were to realize similar results in terms of reduced strain on acute care services, it is possible that the province could free-up the equivalent of 1,632 hospital beds every year. That is roughly the same as building two entirely new hospitals each on the scale of Calgary’s Foothills Medical Centre. This demonstrates that “bending the cost curve” for public health care spending is not merely something that is realizable in the long term, but rather in the immediate future, as quickly as within a year after this kind of program could be implemented province-wide. And yet, the near-term savings in acute care services represent only the first wave of benefits. The prevalence of chronic diseases and conditions, including diabetes, heart disease, cancer and mental illness, have been rising and are projected to keep doing so over the coming decade. The Pure North program aims to prevent and address these health conditions and chronic diseases through a combination of screening and testing, lifestyle modification, nutrition education, the identification of nutritional deficiencies, and dietary supplements. The long-term benefits of a Pure North-style program implemented province-wide in Alberta are likely to be that much greater as the prevalence of diabetes, heart disease, cancer and mental illness is tempered through the use of widespread preventative care. Then there are the broader “indirect benefits” of a generally healthier population: higher labour productivity, higher incomes and greater well-being. These returns to the Alberta government, and taxpayer, have the potential to be as large, if not larger, than the direct benefits of significantly reduced acute care costs.

Over the course of more than 30 years, a series of Canadian government commissions and health policy researchers have repeatedly identified the importance of “bending the cost curve” to sustain publicly funded health care, and the potential to do so through upstream investment in health promotion and disease prevention. So far, however, the level of public investment in prevention represents only a slight portion of total public health care expenditure, largely consisting of traditional public health initiatives such as vaccinations, disease screening and information campaigns. This study of the Pure North S’Energy Foundation’s preventative health care program — wherein health care usage by program participants was measured against age- and sex-matched control samples — finds that the sort of preventative health care services offered by Pure North can lead to genuine and significant near-term cost savings for Canada’s single-payer health care system. Participants in the first year of the program required 25 per cent fewer hospital visits and 17 per cent fewer emergency room visits compared to the control group. Among those who persisted in the program for a year or longer, the effects were even more significant: 45 per cent fewer hospital visits in the year after joining, and 28 per cent fewer visits to emergency departments, compared to the control group. This represents real cost savings for a public health service: From $388 per person who joined the program to $677 per person who persisted beyond the first year. As a proportion of annual health spending for these participants on hospitals, emergency departments and general practitioners, this represents a cost reduction ranging from 22 to 39 per cent. If the Alberta government were able to implement this kind of program provincewide (at an estimated cost of $500 per participant), and were to realize similar results in terms of reduced strain on acute care services, it is possible that the province could free-up the equivalent of 1,632 hospital beds every year. That is roughly the same as building two entirely new hospitals each on the scale of Calgary’s Foothills Medical Centre. This demonstrates that “bending the cost curve” for public health care spending is not merely something that is realizable in the long term, but rather in the immediate future, as quickly as within a year after this kind of program could be implemented province-wide. And yet, the near-term savings in acute care services represent only the first wave of benefits. The prevalence of chronic diseases and conditions, including diabetes, heart disease, cancer and mental illness, have been rising and are projected to keep doing so over the coming decade. The Pure North program aims to prevent and address these health conditions and chronic diseases through a combination of screening and testing, lifestyle modification, nutrition education, the identification of nutritional deficiencies, and dietary supplements. The long-term benefits of a Pure North-style program implemented province-wide in Alberta are likely to be that much greater as the prevalence of diabetes, heart disease, cancer and mental illness is tempered through the use of widespread preventative care. Then there are the broader “indirect benefits” of a generally healthier population: higher labour productivity, higher incomes and greater well-being. These returns to the Alberta government, and taxpayer, have the potential to be as large, if not larger, than the direct benefits of significantly reduced acute care costs.

Claims have been made that families with children living with autism spectrum disorders (ASD) have been migrating to Alberta because of higher funding available for ASD supports compared to other provinces. The legitimacy of these claims, along with many others about the adequacy or inadequacy of funding for supporting persons living with ASD, has not been evaluated because we simply don’t know how many people in Alberta are living with ASD. Typically in Canada, ASD prevalence is reported in national figures, based on international estimates. Canadian prevalence estimates for ASD are needed. With no national surveillance system in place, national estimates are difficult to determine. In addition, such broad measurements are problematic as they may not adequately inform the service delivery needs for specific jurisdictions. A new study shows that 1,711, or 1 in 94, school age children in the Calgary region have an ASD diagnosis. As this number matches what is often reported for the national prevalence of ASD, it suggests that Alberta’s relatively higher ASD funding is not inducing in-migration of families seeking better support. The data also show that the prevalence is higher in elementary-grade children, with a diagnosis in one of every 86 children. In the senior grades, there are significantly fewer students with ASD diagnoses, specifically within the Calgary Board of Education. There is no evident reason for diagnoses to seemingly dematerialize in the older grades. These students could be dropping out or choosing home-schooling in greater numbers. Possibly there has been an increase in prevalence. These prevalence estimates help to inform the demand for special-needs services within the local school system. In addition, there is growing concern that upon graduation there is a “support cliff” resulting from a less systematized, less generous support system available for adults with neurodevelopmental disability. Families that need support for ASD face enough challenges; it is critical for policy-makers to be aware of the extent of the situation in their own jurisdiction so as to develop the right kinds of supports for these families.