Public Health Short Snappers: Women and equity, Public Health primer, HPV vaccine for men, Healthy Eating, Tough on Crime

A few gems that have been piling up in the in-box.

The previous posting on primary care models was in part led by ICES and St. Michaels.  St. Mikes also was one of the first to comment on the Drummond report implications for Ontario.   Kudos to this active unit in trying to address health issues in Toronto and more broadly. 

The group is also involved in the Project for an Ontario Women’s Health Evidence-Based Report (POWER) which recently published an accounting of gender inequity and inequalities amongst women.  The POWER study  is part of a larger document on social determinants of health in populations at risk.

The Associations of Faculties of Medicine of Canada have developed a short primer in public health for medical students.   Not a bad “short text” as an introduction to public health, and an on-line asset.  http://phprimer.afmc.ca/index

HPV vaccine for males will be an interesting debate. It also unmasks one of the challenges of the Canadian approval mechanism.   HPV vaccine was introduced as protection from cervical cancer (predominately serotypes 16 and 18).  additional benefit is protection from genital warts(serotypes 6 and 11).   Now the approved vaccine has been demonstrated to be efficacious and safe for males, and increasingly will be “recommended”.   While there is rationale in preventing infection with serotypes 16 and 18, the male vaccination recommendation is based solely in efficacy for genital wart protection and safety of the already approved vaccine.   A sneaky back door way to expanding the indications of the vaccine.   CMAJ news item on HPV vaccine

Two stories on what not to eat, both from the Health professions cohort study and some reference to the Nurses Health Study.  Both studies from the good food folks at Harvard who are asking many of the right questions   Harvard School of Public Health eating guidelines.   Sugary drinks linked with a 20% increase in male heart disease  Harvard study on sugary drinks ,   and the evils of red meat with a 13-20% increase in mortality red meat increases mortality risk.  Happy Nutrition month in Canada and thanks to all the great public health nutritionists that are pointing us in the right direction. 

Finally, this site has commented several times on the ineffectiveness of the tough on crime legislation.  DrPhealth War on Drugs  It is with regret that we must announce that it passed in the House on the evening of March 12 Crime bill passes.  Quebec has been the province with any fortitude to stand up and recognize the implications for provincial costs, both financial and social.    Quebec speaks against c-10  

Primary Health Care – Choosing the Best model for Canadians

The Alma Ata declaration of 1978 is a major landmark 3 – page document that deserves re-reading  Alma Ata declaration  . Alma Ata will be mostly known for the rallying call of “Health For All by the year 2000”. In addition to needing to redefine the target date there are a few other updates that might be suggested,  but the main components of the document are as relevant today 34 years later.   The foundation of subspecialites like “health promotion”, “determinants of health”, and “population health” are clearly visible in the text.  Alma Ata was predominately a call for reform of health care to ensure primary health care systems were the foundation of national health systems.  

While the document was often used to mobilize primary health care systems in underdeveloped countries (barefoot doctors), there was a subtheme for developed countries that health systems focused on secondary and tertiary care were not sustainable either.   How prophetic that vision has turned out to be.

Enlightened jurisdictions began primary health care reforms in the wake of Alma Ata.  One can argue on the relative success or failure of these efforts – but countries with more focus on primary health care tend to have more health equity and are expending less GDP than those that have invested in tertiary systems (see for example International comparisons on Determinants of Health ).  

Canada’s slow creep to reforming primary health care was in part driven by the medical profession’s realization that the proportion of medical graduates entering family practice was continuously eroding and had slipped to only 1/3^rd.  The other long standing driver is the history of and contributions of community health centres and CLSC structures.

 

There came a series of investments in the late 90’s of the typical Canadian pilot projects, atypically followed by further investments to disseminate and implement the knowledge gained.   Perhaps not the smoothest of transitions, and since provinces could choose their reform model, the diversity was notable.  Many provinces went the route of “building” primary health care with some shining examples but minimal success in changing the whole system.  Alberta more broadly stimulated joint ventures between physicians and health regions with mixed success.  Ontario stimulated physician to reform through “incentivizing” and supporting expansion of an already robust community health centre infrastucture.  

Here we are some 15 years into the primary health care reform process and the volume of information gained on what works and what doesn’t is deafening.  Or, perhaps we just can’t hear it. Or, perhaps it wasn’t well evaluated, or.......etc.      CIHI was supposed to lead the evaluation, and that toppled in the early 2000’s with hardly a peep , does anybody know what happened? The lack of formal evaluations is appalling to say the least given the hundreds of millions invested, it rivals regional health authority reforms in bureaucractic decision making without rigorous evaluations.  

At last, something concrete, although perhaps biased.   From the Institute for Clinical Evaluation Studies in Toronto www.ices.on.ca  comes a comparative analysis based on the multiple primary care models[i] that co-exist in Ontario.  The problem is the study was commissioned by the Association of Ontario Health Centres and some of the measures used are not as forthcoming in openly comparing the different models. The long list of limitations of the data speak to some of the assumptions and problems.  CHC enrollees represent only 1% of the provincial residents. The presented data strongly support CHCs as a preferred model of care.

However, at last something that uses the wealth of administrative data sets to do comparisons of persons using the various different models.    There is a reasonable  set of references that can be accessed with additional recent comparative statistics.   Watch for the peer reviewed materials, but there is finally some progress on trying to answer the question of how to improve the primary care system in Canada ICES comparison of primary care models.   

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[i] Purists can argue for days on the differences between primary health care and primary care.   The two are intertwined and reform in one cannot proceed without the other.   

Immunization Error Incidents – shhhhh – don’t tell anyone they happen.

In 2004 (Canadian Adverse Events Study ), the Baker/Norton report was published that spoke to the size of the problem of medical error – the culmination of multiple health care processes that sometimes resulted in minor annoyances but occasionally in tragic outcomes.  They estimated one in 13 adult patients suffered an adverse event.  About one-quarter were due to medication errors. 

8 years later, sophisticated drug dispensing systems are the norm, and reducing adverse drug events have been promoted as one of the six initial Safer Health Care now initiatives Safer Healthcare Now (Medication Reconciliation).   Stacked up against the manufacturing industry, healthcare performs very poorly.   While manufacturing processes aim for zero defects – error rates of 0.3%-1.0% are relatively typical.

Canada had 386000 births in 2010/11.  Assuming about 95% get immunized, and the average male child now receives 14 injections and female receives 17.  Add to this at least one-third of all Canadians receive influenza vaccine.    Canada now provides about 6.5 Million vaccine injections a year (give or take 10% for some assumptions).

Applying the best manufacturing defect rates suggest we should see no less than 20,000 vaccine error incidents annually.  This would be about the order of magnitude for the number of medication error incidents (occurring at a rate close to 4.5% of admissions) .  On this concern, have you ever seen a good  local report in Canada that openly discusses vaccine error incidents for a local jurisdiction as part of vaccine quality control programming. (please correct us if you can send one to drphealth@gmail.com)   Based on what is currently reported, one would incorrectly assume an error rate more likely in the 0.01% range – seems pretty unlikely given the vaccine system problems we know exist through poor documentation, complex schedules, provider interpretation of paper based business rules, vaccine packaging that can be similar, client memories that are sometimes less than perfect etc...  

The financial implication is while we have seen hundreds of millions invested in safer patient care for medical purposes in the last decade.  We are only just going to field trials of a newer vaccine database to help case manage individuals, and this was driven more by preventing outbreaks than reducing immunizing incidents or tracking vaccine adverse events.

Why can we (or any vaccine system globally) not have the following:

1.       National database immunization registry accessible and interoperative with all points of health care so that vaccines can be provided at any health interaction? 

2.       Scanning technologies for vaccine documentation and charting (and reconciliation)

3.       No less than annual reports on adverse reactions to vaccines

4.       No less than annual reports on vaccine error incidents

A reader brought to our attention a technology innovation using smart phones to record influenza immunization  or other mass vaccination scenarios Smart phone use for vaccine documentation.   Once again perhaps local innovations will conquer and  proliferate.  

Then we will find ourselves asking the question why can’t we move information with the client from one place to the next?  

Losing weight – Important progress to support recommendations

DrPHealth depends on you to support continuing.  The past month has seen a major decrease in the primary audience Canadian readership.  Please indicate your support by visiting frequently, sending the link to public health colleagues, post a comment, send an email to drphealth@gmail.com or follow on Twitter at @drphealth

There are two major questions facing the public health nutrition community.  How do we prevent overweight and obesity?  And what do we do to reduce weight in those who are overweight or obese? See amongst other links the posting: Obesity a big problem...  ,  health evidence - bottom paragraph on obesity reduction in schools ,  Public health hot topics - motivational counselling for obesity

There is not a concensus on what to recommend for persons who are fighting the battle of the bulge.  Yes fewer calories makes sense but is hard to sustain.   There are advocates of low fat, and those for high fat,  low and high carb and low and high protein.   Some suggestion that lower carb, low sugar and healthy fats may be percolating to the top, but far from consensus yet (see   Harvard School of Public Health eating guidelines   for state of the science).   There is a growing consensus that physical activity alone is not a great method for weight loss, but is part of a program of support to maintaining healthy weights.

A recent BMJ article begins to look more closely at the practical issue of what actually works.  Individuals were randomly assigned to a variety of for-profit, professional, and compared with a group given passes to a fitness facility. An eloquent but simple design.  All groups lost weight over the study time period.  Professional support by physicians and pharmacists did not result in sustained loss at one year.  Commercial programs, led by Weight Watchers, were the most successful in both short term total loss and sustainability of loss.  They were also much less expensive that the less effective professional support options.  

It is just one study, but puts the commercial for profit weight loss programming against each other and against the “professional model”.  It should be enough to turn heads and stimulate replication studies looking at finer detail comparing subtle differences between different types of programs and variables within programs.   BMJ article on comparing weight loss programs

Chronic disease survey in Canada: Diabetes and COPD Fast facts

PHAC’s relative silence is sometimes deafening, so when good work comes forward it is well worth celebrating.  Not only that, the good news was Tweeted out and put up on the PHAC front page.  No formal media release though, but it is progress.

The good news relates to short reports stemming from a 2011 survey on living with Chronic Diseases in Canada.   The two summary documents focus on Diabetes and COPD (Chronic Obstructive Pulmonary Disease).   Diabetes Fast Facts  COPD Fast Facts.   The Statistics Canada methodology can be found at Stats Can survey information  and references a third component on Asthma which does not appear to have been released as of this date.

Participants in the survey were found through the 2010 Canadian Community Health Survey as positive respondents to questions on the three chronic illnesses.  The most reassuring thematic coming forward from the survey are:

78% of COPDers and 82% of diabetics have a family doctor who coordinates their care – Bonus!!!

79% of COPDers and 50% of diabetics had seen at least one other health care provider in the previous year

Over 75% of diabetics reported positive responses on what would be considered good clinical care – Hgb A1c, cholesterol levels,  BP measurements

Conversely, only 22% of COPDers have seen a respiratory educator;  20% had visited the ER  and 8% were hospitalized within the previous year

Both groups demonstrate the challenge in adopting healthier behaviours despite significant underlying health conditions:  36% of COPDers still smoke.  77% of diabetics being overweight or obeses.  

There are many more gems to be found in these reasonably well written, 4 page fast facts.  

As a bonus, concurrently Health Evidence has released a summarization of the effectiveness of population interventions to prevent diabetes.  Population interventions for diabetes prevention.  Not surprising in a developing science that there is poor evidence of effective interventions at this time.   

Well done PHAC.  

Child Health – a Scorecard of Provincial Comparisons

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The Canadian Paediatric Society has been a great advocate for the health and wellbeing of children.   The resources that have been developed are excellent, professional and generally targeted at a lay population.   Their activities are to be commended and supported.   Check out the website and take a tour of what is readily accessible for professionals and public alike Canadian Paediatric Society

The joy of working outside the government structures is the ability to produce comparison analysis that provincial and federal governments fear.   A recent addition to their advocacy efforts is a report card on healthy public policy for children CPS report card.    How is your province/territory  stacking up on these 13 indicators that might be semi-randomly selected but should be on any good public health shopper’s wish list. 

The CPS is also raising out the caution flag on the failures in improvement over the past 2 years.  The Healthy Early Learning Partnership has also flagged deteriorating preparedness of children for school over the past iteration of their BC surveys help ubc .   While the recession has impacted all ages and parts of society, as the CPS eloquently state in their preamble “children and youth are our most powerful assets” and that they “offer the best possible return on public investment towards ensuring a strong economy and a healthy nation”.   There are many bank executives that would concur with these statements, however until children are granted a vote – politicians can too easily afford to ignore their plight.

The most notable finding in the report is the inequities that exist nationally in access to healthy child initiatives.     Developing a crude imputed variable based on the four points of the scale used to rate the 13 variables, gives a relative score and ranking from highest to lowest (maximum score of 39)

Ontario                                       28

New Brunswick                          25

British Columbia                         22

Nova Scotia                               21

Quebec and PEI                         19

Newfoundland and Labrador      17

Manitoba and Saskatchewan      14

Yukon                                        11

NWT and Alberta                       10

Nunavut                                        7

 The federal government received 7 out of 27 points which would have put them proportionately on par with NWT and Alberta. 

Another way to look at the data is who is made progress and who is falling back from the previous report care in 2009.  

Ontario and New Brunswick were the big gainers (+5): 

PEI (+3);  BC and Manitoba (+2); Saskatchewan and Newfoundland (+1)  

Quebec, Yukon, NWT, Nunavut and the federal government all netted zero.  

Alberta and Nova Scotia slipped a single point. 

Perhaps not the way that the CPS wanted the data used, but sometimes a story can be told in a just a few simple numbers.   

Determinants of Health – good resources showing how bad Canada is doing

There are innumerable resources on Determinants of Health.  One came up on a Twitter recently through Health Evidence.ca based on a 2010 report that is well worth reading SDOH The Canadian Facts 

The report by Juha Mikkonen and coauthored by a strong Canadian advocate for population health in Dennis Raphael looks at Canada’s positioning globally on a variety of indicators regarding Determinants.  There is a cutting and poignant introduction by another Canadian icon,  Monique Bégin,  whose sojourn as the federal Minister of Health produced the Canada Health Act among other noteworthy accomplishments.

The document does not reflect well on the Canadian track record and even less so on the US record.  Some key highlights comparing the two countries with the best of the rest of the 28 OECD countries

Gini coefficient –                                       Denmark 0.23    Canada 0.32      US  0.38

International education testing scores:        Luxembourg 1^st  Canada 4^th        US 10^th

Employment protection                             Turkey 1^st          Canada 26^th      US 28^th

Child Poverty                                           Denmark 3.5%   Canada  15%     US 22%

Public expenditures on children                 Iceland 1^st          US  20^th            Canada 27^th

Social assistance levels as % of median household income

                                                                 UK 1^st              Canada 22^nd      US 27^th

Percentage of GDP spent on health care     France 8.9%     Canada 7.0%      US  7.0%

Gender Gap in wages                                 Belgium 9%      US 19%              Canada 21%  

An interesting read, lots of good data and punctuated by the authors recommended policy solutions.   A definite addition to the national resources accumulating on Canada’s relative performance on addressing determinants of health.