Consensus Statement Regarding the Application of Biogen to Health Canada for Approval of Aducanumab

Alzheimer’s disease is a major cause of morbidity and mortality. Currently, there are no disease-modifying pharmacotherapies for this condition. Aducanumab, an amyloid beta-directed monoclonal antibody that targets aggregated forms of amyloid-beta in the brains of people with Alzheimer’s disease, has raised hopes that such a therapy has been discovered, but its approval by the US Food and Drug Administration has engendered a good deal of controversy. A similar application for approval has been submitted to Health Canada. In response to this, a group of Canadian clinical dementia experts representing a number of organizations, including the Canadian Geriatrics Society, was convened by the Canadian Consortium on Neurodegeneration in Aging (CCNA) to discuss the evidence currently available on this agent and seek consensus on what advice they would offer Health Canada on the application. There was wide-spread agreement that it would be premature for aducanumab to receive approval for the treatment of Alzheimer’s disease. It was also noted that the Canadian health-care system is poorly prepared at this time to deal with a disease-modifying therapeutic with targeting, administration, and monitoring characteristics like aducanumab. In this paper, the consensus reached is presented along with its underlying rationale.

Improving physician diversity and inclusion benefits physicians and patients

A diverse physician workforce in the Canadian health care system would result in more cultural competence, greater patient satisfaction, and improved population health. However, increasing representation and diversity does not automatically resolve issues of inequity, inequality, and discrimination. In this article, we discuss three broad areas of health care — the clinical environment, academic advancement, and leadership — that require intentional, systemic change if we are to make a lasting impact in terms of increasing the diversity and inclusion of underrepresented groups in medicine, and consequently, improve health outcomes. Inclusive and equitable practices to target pay inequity, unconscious bias, opposition to career advancement, and sexual harassment are integral to diverse physician recruitment and retention. Equity strategies and checks to remediate systemic biases in academic advancement through grant funding, academic criteria of merit for promotion, and the acknowledgment of differences of experience can be employed to improve equity in academic medicine. The long-standing culture, policies, and traditions of institutions within the medical establishment must be combated with a collaborative effort to foster equity through the engagement of academics and physicians from underrepresented minority groups, and the implementation of implicit bias training and meaningful accountability for creating a safe, equitable work environment for diverse physicians. Any proposed solution to improve equity and diversity should not be taken as a fixed principle to follow uncritically, but rather as a starting point for understanding and implementing the unique changes required in various local contexts.

Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic

The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.

The Safe Resumption of Elective Plastic Surgery in Accredited Ambulatory Surgery Facilities During the COVID-19 Pandemic

Background On March 11, 2020 the World Health Organization declared COVID-19 a worldwide pandemic resulting in an unprecedented shift in the Canadian health care system, where protection of an already overloaded health care system became a priority; all elective surgeries and non-essential activities were ceased. With the impact being less than predicted, on May 26, 2020, elective surgeries and non-essential activities were permitted to resume. Objectives To examine outcomes following elective aesthetic surgery and the impact on the Canadian health care system with the resumption of these services during the COVID-19 worldwide pandemic. Methods Data was collected in a prospective manner on consecutive patients undergoing elective plastic surgery procedures in six accredited ambulatory surgery facilities. Data included patient demographics, procedural characteristics, COVID-19 PCR test status, airway management and postoperative outcomes. Results 368 patients underwent elective surgical procedures requiring a general anesthetic. All 368 patients that underwent surgery were negative on pre visit screening. A COVID-19 PCR test was completed by 352 patients (95.7%) and all were negative. In the postoperative period, seven patients (1.9%) had complications, three patients (0.8%) required a hospital visit, and one patient (0.3%) required hospital admission. No patients or health care providers developed COVID-19 symptoms or had a positive test for COVID-19 within 30 days of surgery. Conclusions With appropriate screening and safety precautions, elective aesthetic plastic surgery can be performed in a manner that is safe for patients and health care providers and with a very low risk for accelerating virus transmission within the community.

Changes in the incidence of seasonal influenza in response to COVID-19 social distancing measures: an observational study based on Canada’s national influenza surveillance system

Objectives: Seasonal influenza is an acute respiratory infection that presents a significant annual burden to Canadians and the Canadian health care system. Social distancing measures that were implemented to control the novel coronavirus outbreak were also investigated for their ability to lessen the incidence of seasonal influenza.Methods: We conducted an ecological study using data from Canada’s national influenza surveillance system to investigate whether social distancing measures to control COVID-19 reduced the incidence of seasonal influenza. Data taken from three separate time frames facilitated analysis of the 2019-20 influenza season prior to, during, and following the implementation of COVID-19 related measures and enabled comparisons to the same time periods during three preceding flu seasons. The incidence of specific influenza strains was of primary focus. Further analysis was performed to determine the number of new laboratory-confirmed influenza or influenza like illness outbreaks.Results: Our results indicate a premature end to the 2019-20 influenza season, with a significantly fewer number of cases and outbreaks being recorded following the enactment of many COVID-19 social distancing polices. The incidence of influenza strains A (H3N2), A (unsubtyped), and B were all significantly lower at the tail-end of the 2019-20 influenza season, compared with preceding seasons.Conclusion: Specific social distancing measures and behaviours may serve as effective tools to limit the spread of influenza transmission moving forward, as they become more familiar.

Health-care Workforce Training to Effectively Support Family Caregivers of Seniors in Care

Introduction Family caregivers (FCGs) play an integral, yet often invisible, role in the Canadian health-care system. As the population ages, their presence will become even more essential as they help balance demands on the system and enable community dwelling seniors to remain so for as long as possible. To preserve their own well-being and capacity to provide ongoing care, FCGs require support to the meet the challenges of their daily caregiving responsibilities. Supporting FCGs results in better care provision to community-dwelling seniors receiving health-care services, as well as enhancing the quality of life for FCGs. Although FCGs rely upon health-care professionals (HCPs) to provide them with support and services, there is a paucity of research pertaining to the type of health workforce training (HWFT) that HCPs should receive to address FCG needs. Programs that train HCPs to engage with, empower, and support FCGs are required. Objective To describe and discuss key findings of a caregiver symposium focused on determining components of HWFT that might better enable HCPs to support FCGs. Methods A one-day symposium was held on February 22, 2018 in Edmonton, Alberta, to gather the perspectives of FCGs, HCPs, and stakeholders. Attendees participated in a series of working groups to discuss barriers, facilitators, and recommendations related to HWFT. Proceedings and working group discussions were transcribed, and a qualitative thematic analysis was conducted to identify key themes. Results Participants identified the following topic areas as being essential to training HCPs in the provision of support for FCGs: understanding the FCG role, communicating with FCGs, partnering with FCGs, fostering FCG resilience, navigating healthcare systems and accessing resources, and enhancing the culture and context of care. Conclusions FCGs require more support than is currently being provided by HCPs. Training programs need to specifically address topics identified by participants. These findings will be used to develop HWFT for HCPs.

Best practices in refugee mental health

Canada has a long history of accepting immigrants and refugees. These populations may have unique health care needs that the Canadian health care system must adequately address. Currently, there are numerous barriers to the treatment of refugee mental health concerns. These include cultural, language, financial, and systemic barriers. Best practices for treatment in this population include psychotherapies such as cognitive behavioural therapy and narrative exposure therapy, medications, and health promotion and psychosocial interventions. Physicians have previously advocated for improving health care for Canada’s refugee population and medical schools are working to incorporate multicultural education into their curricula.