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Friday, August 10, 2007

BC offers hospitals cash incentive to fast track patients

A new hospital funding plan in British Columbia will pay the Vancouver regional health authority extra money for treating patients faster, reports The Globe and Mail.

This is a major departure from the traditional block funding methods used across most of Canada.

The $16.4 million BC plan is just a pilot project for the time being to determine if the strategy works.

Starting in October, the B.C. government will pay an extra $100 for every patient requiring hospitalization who is admitted to a bed within 10 hours. There will be an extra $60 for patients who are treated and discharged within two to four hours, depending on the urgency of their needs. Hospitals can use the extra money to expand services, staff and space. In effect, the cash incentive turns the current payment system on its head.
This system, sometimes called patient-focused funding, or PFF for short, is strongly supported by both Dr Brian Day, the new president of the Canadian Medical Association, and Michael Kirby, the former Liberal Senator whose 2002 report on the healthcare system sparked national debate.

"The only way to get people to change their behaviour is by offering them an incentive to change," Mr Kirby told the Globe. "You have to do it with carrots, not sticks."

I wrote about Dr Day's support for the idea in February of this year. But not everybody thinks PFF is going to help:
"You have to make sure the incentives you have in place don't get in the way of what you need done," said Raisa Deber, PhD, a University of Toronto health policy expert. "It would be disastrous to move entirely to a service-based funding schedule. That would incentivize overuse instead of appropriate use."
Dr Day explained in a response to my article why he thinks the idea is a good idea:
It's no coincidence that the report of Senator Michael Kirby, a PhD in mathematics who applied simple logic and basic internal marketing principles, came out solidly in support of patient-based funding (PFF). In late October of 2006, the updated OECD report also came out solidly in support of it. Of course there must be safeguards in place, and it's not a panacea. Smaller rural hospitals can actually outperform large institutions, although the opposite has been claimed. We're very lucky to have the British experiment to learn from.
One potential caveat, however, may be a paucity of accurate performance measures in Canadian hospitals' reporting, according to a new study published this week by the Atlantic Institute for Market Studies.
[University of Melbourne research fellow Julia Witt] argues it may not always be true that a hospital where patients spend less time is a good hospital.

"Shorter lengths of stay could be the result of insufficient funds or space to keep patients for a more optimal length," she writes.

"If there is pressure on freeing up beds, patients may be released earlier in order to make beds available."

Sometimes, she writes, such "clinical efficiency measurements" assess if a hospital is saving money, but tell little about the quality of patient care.

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Ex CMA prez Schumacher joins the private healthcare fray

Windsor family physician Alberta Schumacher (right), former president of both the OMA and CMA, has added his voice to the apparently growing list of Canadian doctors advocating private healthcare delivery, reports the Windsor Star.

Dr Schumacher features prominently in a new National Citizens Coalition (NCC) online campaign called "Face the Facts: Help Cure Canadian Healthcare." He appears in a series of videos on subjects including wait times, human resources, public vs private, and funding issues.

The NCC is staging a series of public consultations, hosted by Dr Schumacher, across the country starting in September.

“The undertaking of this grassroots campaign will remove the political lens that is too often used when studying our national healthcare system,” said NCC president Peter Coleman in a statement released on Wednesday.

Will the NCC really de-politicize the healthcare debate? A better question might be whether that's even possible at this point, or whether groups like the anti-big government NCC are genuinely trying to accomplish that in the first place.


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Thursday, August 9, 2007

Premiers run into some trouble during morning jog

Gary Doer of Manitoba, Shawn Graham of New Brunswick and Rodney MacDonald of Nova Scotia got up early Thursday morning to go for a run in the rain before Council of the Federation meetings in Moncton, NB.

But it wasn't long before protesters, including Canadian Federation of Nurses Union president Linda Silas, stopped them in their tracks to lecture them on healthcare, the environment, labour mobility and trade, reports the CP. (The three runners apparently "sprinted ahead of protesters" before halting.)

CP reports that Premier Doer offered to "support their cause and wear the same hat," referring to the nurses' Medicare caps.

Given that it was raining in Moncton that morning, was his offer genuine - or was he just looking for a way to avoid getting all wet? This morning's report offers no clues, but Ms Silas, who is in Moncton to urge the provincial leaders to protect Canada's universal healthcare system, was left high and dry by the impromptu roadside pow wow: "I don't think they understand the urgency," she said.


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Smitherman ties the knot, but Dalton's a no-show

George Smitherman, Ontario's divisive deputy premier and health minister, took a break from campaigning long enough to marry his partner Christopher Peloso last Sunday.

Premier Dalton McGuinty was invited but didn't make it to the ceremony in Elliott Lake, Ontario; he had a "personal scheduling conflict," his office told CTV News.

"I've got nothing but the best of wishes for George and I'm hoping that this marriage will help him come out of his shell," Premier McGuinty quipped to reporters prior to the wedding.

"[H]e wasn't able to," Minister Smitherman said to the Toronto Star. "He worked hard on his schedule [but Elliot Lake] is a hard place to duck into – to drop in for the ceremony and head somewhere else."

Mr Smitherman, 43, is Ontario's first openly gay MPP. Mr Peloso, 33, a Lindt Canada manager, and he had been dating for 18 months. Mr Smitherman proposed at Christmastime by giving his partner a tuxedo with a wedding invitation in the pocket.

Part of the ceremony was conducted by Ojibway spiritual advisor Ron Indian-Mandamin, who, according to the Star, "referred to the ancient concept of gay or 'two-spirited people' who in generations past often served as tribes' mystics or medicine men."

Mr Smitherman, backing down from a claim he made in the Ottawa Citizen earlier this year, showed up in a blue suit instead of a thong. (See sidebar, right, to read what he told me in April about getting ready for the wedding.)

The NRM Award for the Best Smitherman Headline Ever goes to UK-based gay news service Pink News: Political bruiser shows softer side on gay wedding day


Photo: George Smitherman, in blue, and husband Christopher Peloso, in white; Toronto Star

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Weed spray ok'd for cancer pain

Health Canada has approved the cannabis-derived pain-reliever Sativex for neuropathic pain in advanced cancer patients. The drug, sprayed under the tongue, is intended as a therapeutic adjunct, for patients who haven't had decent relief with opioids.
Pot-based drugs are seldom used (legally) for medicinal purposes outside of clinical trials, and Canada is leading the pack in terms of access to it. Sativex is already available in the UK and Spain, although access in those countries is tighter than here.

Depending on your viewpoint, you'll be relieved or disappointed by the manufacturer's insistence that Sativex doesn't offer the psychotropic effects pot-heads typically seek, reports the Wall Street Journal Health Blog. I'm not sure how that works, considering Sativex contains THC, the main psychotropic compound in marijuana. At any rate, at $125 per vial, Dr Allan Gordon of Toronto’s Wasser Pain Management Centre at Mount Sinai notes that it wouldn't the most cost-efficient way to get high.

Canadian pain docs are pleased to have another drug option in their arsenal. "There's an unmet need there and finally we're seeing some attention being paid to the problem," Dr Gordon told the Globe and Mail.

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Dr Charles Smith inquiry gets underway

Embattled pediatric forensic pathologist Dr Charles Smith (right), who allegedly put a number of innocent people in jail after he gave inaccurate testimony as an expert witness in 20 cases in Ontario from 1991 to 2001, is the subject of a provincial inquiry ordered by premier Dalton McGuinty.

Eleven individuals or groups -- including Dr Smith himself -- have registered with inquiry commissioner Justice Stephen Goudge to testify at the hearings.

According to a Canadian Press report, the inquiry has a broader scope than just looking at Dr Smith:

The inquiry will examine the state of pediatric forensic pathology in Ontario and its practice and use in investigations and criminal proceedings between 1981 and 2001.

While the inquiry will examine the cases individually, Goudge has said he will not "correct errors in specific cases," provide financial compensation to any victims, or offer any conclusions or recommendations regarding discipline or criminal liability.

Instead, he will use the individual cases to determine what systemic issues they raise and will then make recommendations to restore public confidence in the pediatric forensic pathology profession.

The inquiry will submit recommendations to Ontario's attorney general by April 25, 2008.


You can read about the Dr Smith case in this NRM article from last year. The CBC profiled Dr Smith in April, as did the Star. A lawsuit was launched in Ontario against him in May, reported the Toronto Star.


Photo: CBC

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Wednesday, August 8, 2007

AMA turning blind eye to 'medicalization of torture': Harper's

Or should we say "enhanced interrogation," to use the new US administration parlance.

A commentary in the August issue of Harper's Magazine looks at a claim by the US's director of national intelligence Admiral Mike McConnell on NBC's Meet the Press that "enhanced interrogation techniques" used on prisoners are conducted "under medical supervision."

In the commentary - provocatively entitled "The Ongoing Medicalization of Torture" - Harper's senior editor Luke Mitchell reports that he tried to get the American Medical Association (AMA) to comment on the claim and asked if they'd investigate the doctors who are taking part in the "enhanced interrogation." After dismissing the claim as a psychologist/psychiatrist mix-up, common among non-physicians, the AMA finally told Mr Mitchell that it has no plans to investigate the allegation that its members are involved in torture.

This seems strange since, a year ago, the AMA released ethical guidelines that prohibit doctors from participating in interrogations:

"Physicians must not conduct, directly participate in, or monitor an interrogation with an intent to intervene, because this undermines the physician’s role as healer."
Meanwhile, a new investigation into the US government's insistence that "enhanced interrogation" does not constitute torture by Physicians for Human Rights and Human Rights First concludes the the government's got it all wrong. Dr Scott Allen, co-author of the report and co-director of the Center for Prisoner Health and Human Rights at Brown University said in a release August 2:
"These 'enhanced' interrogation techniques can cause severe and often irreversible harm to their victims. The report's full and independent review of the medical literature and case studies concludes that these methods are likely to cause significant physical and mental harm to detainees, and they should be immediately and explicitly prohibited by the Bush Administration and by Congress."
Added Human Rights First's Elisa Massimino:
"The Administration's argument that doctors will oversee the program to ensure that interrogators don't go too far gives new meaning to the term 'calculated cruelty'."

Photo: A prisoner at Abu Ghraib - torture or 'enhanced' interrogation? (
BBC)

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Medicare defenders roll out Trojan Horse

A five-metre tall, wooden Trojan Horse is travelling across Ontario, accompanied by representatives of the Ontario Health Coalition.

The pro-medicare lobby group composed of healthcare union members says the stunt is a reaction to the provincial Progressive Conservative party's idea of introducing public-private partnership (P3) hospitals to Ontario. Like the Greeks' equine "gift" in Homer's Iliad, P3 healthcare will wreak unexpected and total havoc on medicare, argues the Coalition.

The Coalition's website expounds on the statue's symbolism:

Like the fortified walls of ancient Troy, a powerful national consensus has so far protected public health care from attempts to privatize it. P3s are packaged to circumvent these poweful defenses by deception. A giant five metre Trojan horse representing the devious plans to privatize health care via the P3 model has been crossing Ontario, drawing attention to the Conservatives' privatization of health care by stealth and the McGuinty Liberals' weak position on the issue.
What does the public think of the giant, wooden statue parked on hospital lawns from Kenora to Kingston? The Sudbury Star reports:
Laurent Nault, who works at Sudbury Regional Hospital's Memorial site and is a chief steward with CUPE 1623, said public reaction to the Trojan horse and its message was good.

"We've got people honking their horns," he said. "People are fully aware of the Trojan horse story."
The campaign is intended to raise public awareness of threats to the public healthcare system in anticipation of the October 10 Ontario election. As they travel with the horse the Ontario Health Coalition is handing out pamphlets to local residents. "[H]opefully they will make their decision on the information," Nault told the Star. "We will give them the facts."

The Coalition might first want to check those facts. The Trojan horse never existed. Turns out Homer likely invented it to represent Troy's destruction by earthquake in 1250 BC. Poseidon was god of the seas as well as earthquakes, was often associated with horses, according to National Geographic in its exposé of the 2004 Brad Pitt film "Troy," which would explain where Homer got the idea.

The war and the huge, fake animal made for a better story, apparently.


Describing a healthcare policy as a Trojan Horse is nothing new:
  • US Democratic presidential hopeful John Edwards's healthcare platform includes a "laudable" Trojan Horse that could undermine private insurers' plans and introduce greater government-financed healthcare, wrote Timothy Noah of Slate last month.
  • On the other side of the political spectrum, in 2005 an American blogger called then-Arkansas governor and current Republican presidential hopeful Mike Huckabee's requirement to measure schoolchildren's BMI a Trojan Horse that could lead to wider, "intrusive" government involvement in healthcare.
  • In California, Arnold Schwarzenegger's universal coverage plan was recently accused of being a Trojan Horse that would increase the price of health insurance premiums for families.
  • Wal-Mart's announcement last year that it would participate in a "big employers" EHR plan is a "perfect" Trojan Horse that could improve American health delivery overall, wrote a University of California at Berkeley School of Information professor.
  • And, last but not least, Ralph Klein himself is a Trojan Horse, according to a 2005 book put together by the University of Alberta's Parkland Institute.


First photo: Thunder Bay Chronicle Journal
Second photo: "Troy" movie still

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Canada (nearly) ready to export first cheap AIDS drugs to Africa

After three years of bureaucratic paralysis, the first pharmaceutical agreement has finally been made under Canada's Access to Medicines Regime (CAMR), a WTO-associated program intended to provide any inexpensive AIDS drugs to Africa by coordinating distribution of generic versions of patent-protected medications.

Rwanda requested July 17, via the WTO's 31f Agreement of its TRIPS intellectual property treaty, that Canada supply 18 million Apo-triAvir tablets, reported the Toronto Star. The drug's generic manufacturer Apotex needed permission from Boehringer Ingelheim (Canada) Ltd and GlaxoSmithKline Inc. Boehringer agreed July 25 and now, with GSK's approval announced today, the shipment will go ahead.

CAMR has faced serious criticisms for its failure to export any drugs since its formation in 2004. Federal health minister Tony Clement (left, with Stephen Harper) ordered a full review of the program at last year's International AIDS Conference in Toronto. The Star reports parliamentary hearings won't begin on the matter until mid-September at the earliest.

For a backgrounder on the issues, check out this NRM story from last year.

Photo: www.harperindex.ca

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Tuesday, August 7, 2007

Does Accutane prove vanity trumps good sense?

Tight FDA controls on isotretinoin (Accutane) prescribing have failed to reduce the number of pregnancies in women on the acne drug. Isotretinoin, a vitamin A derivative, carries a 35% risk of severe birth defects. The drug is indicated for severe cystic acne, but is commonly prescribed for mild cases.

A year ago, concerned by the high number of women becoming pregnant while taking isotretinoin, the FDA required patients, physicians and pharmacists to enrol in its iPledge program. This includes receiving and understanding detailed information about the drug and its side effects and, for premenopausal women, taking birth control and passing pregnancy tests before each refill. After a year, the number of pregnancies remained constant at about 120.

The FDA data doesn't know why the pregnancies occurred. Although all childbearing-age women were supposed to be using two forms of birth control, only 90% of the pregnant women were. Seventy-two percent say they were on the pill and using male condoms; an astonishing 18% cited "abstinence" as their birth control method. The remaining 10% aren't accounted for, although the FDA reported that two women, who were pregnant when they started on the drug, had prescribers falsify their pregnancy tests to get access to Accutane.

So are these pregnancies the result of bad luck, carelessness, stupidity or deceit? It's most likely a combination.

Another culprit is overprescibing of this strong med. Although it's only indicated for "severe recalcitrant nodular acne," which affects a tiny proportion of the population, it's commonly prescribed for normal acne. "[I]t's estimated that in the U.S., 90% of prescriptions are off label," Lynn Martinez, Utah State Health Department coordinator of the Pregnancy Riskline in Salt Lake City told WebMD.

The same article points out that isotretinoin is far worse than thalidomide, carrying a 35% chance of birth defects versus 20% with thalidomide. However, many dermatologists consider isotretinoin something of a wonder drug and oppose tighter restrictions or its removal from the market. "[iPledge] is one of the worst things that's happened to our specialty. We're taking a very good drug that is for many people the only real choice out of reasonable access," Boston dermatologist Dr Ranella Hirsch told the New York Times. In fact, an FDA advisory committee recommended on August 1 that prescribing restrictions be relaxed slightly.

In Canada, isotretinoin carries an additional warning about depression and suicidal ideation, but there is no equivalent safety program to the FDA's iPledge. Health Canada reports a total of three fetal disorders possibly caused by Accutane from January 1983 to December 2004, but the Motherisk program at Toronto's Hospital for Sick Children says they see up to 20 such cases per year.

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US docs should strike... for universal care?

Doctors should go on strike to demand a universal, single-payer healthcare system, urges prominent American psychiatrist and author Stephen J Bergman (right) in a Boston Globe op/ed:

Soon after HMO/managed care came to Massachusetts in the late '80s, I got a call from a patient I had admitted to the 28-day alcohol unit at the hospital. He said that he was being discharged after three days because that was all that the HMO would now pay for alcoholism. He said the HMO representative told him to go out and get drunk again and they would readmit him. [...]

Change will not originate from the top. In any hierarchical system, the only threat to the dominant group is the quality of connection among the subordinate group. This is true of race, gender, class, ethnicity, and sexual preference. In three great movements of my lifetime -- women's rights, civil rights, and the ending of the Vietnam War -- change came from my generation seeing an injustice and believing that by organizing together at the grass-roots level we could right an obvious wrong. And now?

I propose a doctors strike.

It seems strange that as Canadian physicians edge towards increased privatization, many American doctors are headed in the opposite direction. (I brought this up in our recent roundtable discussion about Michael Moore's SiCKO.)

(Thanks to Josh Umbehr, writing at KevinMD.)

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Monday, August 6, 2007

"The doctor will triage you now"

An Edmonton hospital's new "triage liaison physician," or TLP, cut wait times by 36 minutes, says a new study published in Academic Emergency Medicine. Lead author Dr Brian Holroyd, speaking to the Edmonton Journal, called the TLP idea the "most effective" change that the University Hospital ED has made to reduce wait times. The Journal explains how the TLP works:

The new doctor, who works 11 a.m. to 8 p.m. each day, takes all phone calls from ambulances and rural centres so other treating doctors aren't interrupted at patients' bedsides. The doctor also helps the triage nurses by visiting patients in the waiting room and on ambulance gurneys, and ordering early blood work and lab tests so that there is no delay when the patient gets a bed.

That extra physician hand decreased the total amount of time spent in emergency to four hours and 21 minutes from four hours and 57 minutes. The time is measured from when a patient walks in the doors until he or she is completely treated or else admitted.

Unfortunately, the hospital's innovative wait-time reduction strategy is being undermined by an overall physician shortage, the Journal reports.

Photo: Dr Holroyd talks to Capital Health dignitaries (www.capitalhealth.ca)

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Hospital laptops stolen, health authority keeps mum

Last week Edmonton's Capital Health Region admitted that four hospital laptops containing medical records of 20,000 patients' records were stolen. In May.

That's right, the laptops were stolen in May.

So why is this just coming to light now, not only for the media but for the patients whose information was stolen? The CBC reports:

[Capital Health Region] spokesman Steve Buick said the reason they took so long to inform the public is because they wanted to consult with the Privacy Commissioner.

'There's no particular urgency to this, no one's health is going to be compromised,' he said.

What leads them to believe that?

The laptops had cable lock devices to secure them to staff desks in a secure building, but the thieves managed to steal them in the evening, said the health authority. Only one of the four computers had patient information on it, information that is only available by getting past two passwords.

Was three months a reasonable amount of time for the Capital Health Region to delay notification?

Last Wednesday, the Privacy Commissioner of Canada, Jennifer Stoddart, released new privacy breach guidelines (PDF). A sentence in Step 3: Notification reads, "Notification of individuals affected by the breach should occur as soon as reasonably possible following assessment and evaluation of the breach."

Police and Alberta privacy commissioner investigations are ongoing.

The CBC article provides some context for a reasonable notification time: Last December, just a quick drive south on provincial highway 2, Calgary Health Region lost a laptop to theft, compromising over 1,000 patients' information -- all of them children in a mental health program. The Calgary administration notified families immediately.

The result? The health region got a slap on the wrist from the provincial privacy commissioner for failing to follow several security policies, but got away largely unscathed. An investigator even lauded their efforts: "For the most part, the Calgary Health Region does a good job protecting information, and has been taking steps to improve security."

In January, a doctor's laptop containing health info on nearly 3,000 Toronto Sick Kids' patients was stolen. The hospital in that case waited two months before telling the public, leading to a change in Ontario's privacy rules. In June, Lonny Rosen, NRM's Health Lawyer columnist, offered advice to docs on how to keep patient information safe on a laptop:

I'm afraid this decision sends a clear message that sensitive patient information should never be stored on a laptop (or even sent by email) unless it's de-identified or encrypted.

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