Cutting through the health system information fog: Royal College environmental scan
2017 Edition
Introduction
This environmental scan is an evergreen document and provides a snapshot in time of various aspects of Canada’s healthcare system.
In keeping with previous editions, this reference document provides a national overview of key indicators and trends in the following five domains:
• Political environment, • Economic environment, • Socio-demographic environment, • Healthcare system environment: Performance and Human Resources for Health • Technological environment
The health policy related events and data captured in this report is drawn from the most recent information that is publicly available at the time of release. As this edition has been drafted in early 2017, the scan largely utilizes sources that were released in 2016.
We encourage Fellows and all other readers to contact us at [email protected] if they have any comments, questions, or to suggest new content areas for future iterations of this environmental scan.
Political environment
On November 4, 2015, the Liberal Party formed a majority federal government. It replaced a Conservative government led by incumbent Prime Minister Stephen Harper, which held office for nearly a decade. Prime Minister Justin Trudeau’s mandate letter to the Minister of Health, Jane Philpott, explicitly called on the minister to deliver on a number of priorities, which included the areas of home care, mental health, prescription medicines, substance abuse, Indigenous health, public health and the legalization/regulation of marijuana.1
To date, the government has developed two federal budgets. The table below outlines some of the key health care related announcements made in these two budgets.
Table 1 – The Canadian federal budget, 2016, 2017: Health care highlights Source: Department of Finance, 2016, Budget 2016; Department of Finance, 2016, Budget 2017 2016 Federal Budget 2017 Federal Budget
• New funding of $95 million dollars on an • $100 million over five years to support ongoing basis to the research granting the Canadian Drugs and Substances councils, which includes an additional Strategy, aimed at addressing the $30 million to the Canadian Institutes of country’s opioid crisis. Health Research • $828.2 million over five years to support • $39 million over three years to investments aimed at improving health Canadian Foundation for Healthcare outcomes in First Nations and Inuit Improvement to support the communities. organization’s efforts around healthcare • $140.3 million over five years to Health innovation. Canada, the Patented Medicine Prices • $50 million over two years to Canada Review Board and the Canadian Agency Health Infoway, to support digital health for Drugs and Technologies in Health, activities in e-prescribing and tele- aimed at improving drug prices, homecare. prescribing practices and access • $5 million over 5 years to the Heart and prescription medications. Stroke foundation to support research in • $53.0 million over five years to the women’s health Canadian Institute for Health • $4 million dollars over 4 years to the Information” to strengthen health data Canadian Men’s Health Foundation on and reporting on health system men’s health initiatives. performance. • $47.5 million per year ongoing funding • $300 million over five years to Canada to the Canadian Partnership Against Health Infoway, to expand e- Cancer. prescribing, virtual care initiatives and • $25 million over five years to the the adoption of electronic medical Public Health Agency of Canada records.
targeted at improving immunization coverage. • $500 million in 2017–18 to develop a pan-Canadian framework on child care and early learning.
From a national health accord to bilateral health agreements – the new landscape of Federal/Provincial/Territorial cooperation in health care.
• The 2004 accord formalized a ten year agreement by First Ministers on a series of The Federal government has integrated commitments to improve Canada’s health care substantive changes to the CHT through system. The accord established a funding bilateral agreements with the provinces scheme that the federal government agreed to and territories, which raises various transfer to provincial/territorial governments questions around the fiscal burden being mostly through the Canada Health Transfer. placed on provinces/territories in the • In December 2011, the federal Conservative coming decade. government announced that there would no longer be a 6% annual increase (termed as the annual escalator) in the Canada Health Transfer (CHT), the federal funding scheme for health care. It was stated that following the 2016-2017 fiscal year, annual increases in the CHT would be tied to nominal Gross Domestic Product (GDP).2 • In December 2016, the federal, provincial and territorial ministers of health and gathered to discuss this change to the CHT, requesting that the current Liberal government revert to an annual escalator of 5.2%. The federal government countered with an annual escalator of 3.5% and additional targeted funding of $11 billion towards home care and mental health. The ten provinces and three territories rejected the federal government’s offer.3 • Subsequently however, the provinces and territories have come to terms individually with The Federal government has committed the federal government through bi-lateral to jointly develop, in conjunction with agreements. These agreements include an annual the provinces and territories, CHT escalator which will be tied to nominal GDP performance and reporting measures. (with a minimum 3% guaranteed), targeted funds Long-term, this initiative may be the in home care and mental health (see Figure 1 defining feature of leadership displayed below) 4,5,6,7,8,9,10,11,12, and a commitment to by the Federal government in health develop performance indicators and annual care. reporting practices.
Figure 1 - Funding agreements on home care and mental health care services with the Federal Government
Provincial Developments
Apart from discussions on the CHT transfer, there have also been a number of salient developments at the political level as it relates to health policy, over the past year. Some of the provincial highlights include the following:
Alberta
• The government and the Alberta Medical Association have agreed to implement various financial and non-financial amendments to their physician services agreement, set to expire in 2018. The deal notably introduces a cap on billings (which, if exceeded, is subject to financial penalties for physicians), the development of a blended capitation model option, a new peer-review/audit process and the formation of a Physician Resource Planning Committee assigned to develop a needs-based physician resource plan.13
British Columbia
• The government has announced that it will be reducing monthly health premiums that residents pay by half, in 2018. The government anticipates the cut will cost the government $810 million in the 2018-2019 fiscal year.14 • In September 2016, the Cambie Surgery Centre, a private clinic based in Vancouver, led a constitutional challenge of the province’s Medicare Protection Act. The plaintiffs are challenging the province’s ban on the purchase of private insurance for medically necessary services and its prohibitions on physicians practicing simultaneously in the public and private system.15 The case, which is being heard in the British Columbia Supreme Court, has been adjourned until September 2017.16 • The province’s Budget 2017 has outlined various mental health and substance abuse initiatives, totaling $140 million over three years. The funding announcement includes hiring additional 120 mental health practitioners and providing 28 new substance-use treatment beds across the province.17
Manitoba
• The provincial government is considering a report prepared by Health Intelligence Inc., a consulting firm which was commissioned by the previous NDP government to investigate the province’s health care services. The report outlines 10 recommendations on reorganizing service delivery, including the consolidation of acute care services in hospitals, the re-branding of select hospitals as convalescent and rehabilitation centers, use of technologies like Telehealth, and adopting new team-based models of care.18 • The government has also contracted a separate consulting group, KPMG, to assess its health spending.19 Although not released publicly, KPMG’s interim report reportedly recommends significant cuts related to staffing (e.g. staffing levels, overtime). 20 • In the coming year, the Manitoba government has set savings targets for its five regional health authorities, which includes a mandate to the Winnipeg Regional Health Authority to find $83 million in savings in the coming year.21
New Brunswick
• The provincial government intends to develop a health strategy framed around key determinants of health such as poverty and gender equality.22 The government will showcase the framework for action, titled the Family Plan, at various stakeholder summits planned in 2017.23 • The government’s Council on Aging has produced a report on addressing the province’s aging population following consultations with multiple stakeholders. Focused on ensuring that seniors stay at home and living independently, the report proposes various initiatives such as developing a dementia strategy, enhanced training and recruitment of caregivers, forming age-friendly communities and establishing New Brunswick as an exemplar in aging
research and innovation.24 19.5% of the population in New Brunswick was aged 65 and above in 2016 - the highest proportion of seniors among Canada’s provinces and territories.25
Newfoundland and Labrador
• In its efforts to streamline management structures, the government cut 93 positions from the province’s regional health authorities and Centre of Health Information, a crown corporation responsible for the province’s electronic health records.26 • A committee comprised of all political parties produced a report on addressing mental health and addictions. The report, chaired by Health Minister John Haggie, offers 54 recommendations including increased spending on mental health addictions from 5.7% of the health care budget, to 9% by April 2022.27 • The Minister of Health and Community Services announced Bill 70, which contains legislation addressing various issues around patient safety. The legislation includes mandatory reporting on quality indicators such as handwashing and infection rates, requirement for regional health authorities to form a quality assurance committee, and enhanced rights for patients to access their health information.28
Nova Scotia
• Doctors Nova Scotia has ratified two four-year contracts, the Physicians Master Agreement and a clinical-academic funding plan, with the provincial government. The contract freezes fee increases for two years, followed by a one per cent and 1.5 per cent increase in fees in subsequent years. It also offers additional investments in select areas including the hiring of new specialists and new fees for physicians providing patient care by telephone. In a news release, Dr. Michelle Dow, president of Doctors Nova Scotia, states that ““While physicians accepted the contract and welcomed modest critical investments, they were disappointed that this contract brought little innovation or opportunities to advance patient care”. 29 • The government announced that it is investing an additional $1.9 million to reduce wait lists for hip and knee replacements. The new funding brought the province’s overall investment in orthopaedic surgeries to $8.1 million in 2016.30 Nova Scotians have some of longest wait times for hip and knee replacements among Canadian provinces (see p.30).
Ontario
• The Ontario Medical Association (OMA) and the Relations between the medical provincial government have not come to terms on community and governments are a physician services agreement for the past three years. In December 2016, the OMA rejected a often strained. Present-day three year contract proposed by the government. relations pose a threat to The proposal offered to increase the physician physicians’ critical role in the services compensation by 2.5% annually. health care system and However, the proposal also called for cuts by 10 potentially damage the percent on various fees for diagnostic tests and profession’s image and trust with procedures, reduced fees to physician who bill over $1 million annually, and adjustments to select patients and the public. contracts with specialists.31 Subsequently, the OMA established a new negotiating committee due to the resignation of its executive committee in February 2017.32,33 On July 17, 2017, the OMA announced that its members have tentatively agreed on a binding arbitration process with the government to facilitate a return to negotiations.34 • Bill 41 was introduced, which makes changes to primary care delivery by giving new responsibilities to the province’s 14 local health integration networks (LHINs) at home, community, primary and hospital levels of care.35 OMA has expressed concerns, asserting that the Bill will erroneously add layers of bureaucracy (through the initiative’s creation of 80 ‘sub-LHINs’). Further the OMA argues that act imposes reporting requirement on doctors that will take away time from providing direct patient care.36 Prince Edward Island
• The government announced that it will provide abortion services in the province, for the first time in nearly 35 years.37 • The province passed a new health information act that will come into effect in 2017, requiring health providers to inform patients if their privacy has been breached. 38 • The government has released a 10 year mental health and addictions strategy. The plan outlines five strategic priorities: 1) a focus on children, young people and their families, 2) mental health promotion and illness prevention, 3) a tiered system of access based on need 4) a mental health workforce strategy, 5) fostering a process of recovery and well- being.39
Quebec
• Regulation was passed on January 26, 2017, abolishing user fees for medically required procedures that are covered by Disputes around extra- the province’s public insurance scheme. The move has billing in the provinces of drawn a mixed response from the medical community; British Columbia, Quebec groups such as the Quebec Doctors for Medicare have and Saskatchewan highlight expressed concerns in the past regarding the use of user the tensions that persist fees in the province, arguing that it contradicts provisions in regarding the role of the the Canada Health Act.40 In contrast, Quebec's federation of private sector in health medical specialists, the FMSQ, has criticized the government care. for the lack of consultation with the medical community. The organization has also noted that the government has not provided adequate compensation measures for doctors in freestanding clinics that will lose revenue as a result of the new rules.41 • Government announced it will invest $100 million towards creating additional spaces for mental health services, rehabilitations and convalescence, and full-time care facilities for seniors. The move is aimed at enhancing the transition of patients out of acute care settings.42 • The government has also committed $76.1 million over 10 years on a preventative health strategy which includes reducing the number of smokers in the province by half, and an 18% increase in the number of seniors in home care.43 Saskatchewan
• The province plans to amalgamate its current 12 existing regional health authorities into one provincial health authority, by fall 2017.44 The move follows the recommendations of an advisory panel commissioned by the provincial government, which also called on the government to pursue the consolidation of various clinical services such as tertiary acute services, laboratory and diagnostic imaging and emergency medical services.45 • Announced budgetary cuts to health spending amounting up to $63.9 million in 2016- 2017, which includes a hiring freeze in regional health authorities, reduced use of unscheduled temporary and casual staff and adjustments to various programs and grants.46,47 • The Federal Government has expressed concerns regarding the province’s sanctioning of private-pay MRI services, arguing that it is in contravention of the Canada Health Act. Since 2015, private clinics have been allowed to charge residents for an MRI in the province, with the proviso that clinics provide a scan to another patient that is on the public waitlist at no charge. In its response to the federal government, the province has asserted that it has saved approximately $1 million in spending and removed over 1,100 patients from its public wait-list as a result of the private-pay option.48 Other Healthcare Issues
A number of issues have been foremost on the agendas of the federal, provincial and territorial governments. Following are a few examples.
Marijuana
• In June 2016, the federal taskforce on cannabis Public health will be of foremost legalization and regulation was struck to review the concern as Canada continues to potential impact of legalizing cannabis in Canada. The move towards the legalization of taskforce produced a final report recommending a Marijuana for recreational regulatory framework that includes: purposes. o provisions on manufacturing practices, o restrictions on advertising and marketing , o controls on the density and location of cannabis retail stores, o a separate medical cannabis regime, such as the current framework that falls under the purview of the Access to Cannabis for Medical Purposes Regulations (ACMPR), o promotion and support for pre-clinical and clinical research on the use of cannabis and cannabinoids, o development and dissemination of information and tools for the medical professions and patients.49
• On April 13, 2017, the federal government tabled (Bill C-45) legislation to legalize recreational use of cannabis in addition to increasing punitive measures regarding drug impaired driving(Bill C-46). The federal government anticipates full implementation of both Bill C-45 & C-46 no later than July 2018.50 • The federal government has previously stated that expected tax revenues of these legislative changes will be re-invested into mental health, addiction treatment and public health prevention programs.51 • Regulatory and professional medical associations such as the Canadian Medical Association (CMA), the Canadian Psychiatric Association (CPA) and the Canadian Paediatric Society (CPS) have stated that they would support federal legislation that leads with a strong public health approach, including an emphasis on: o preventing drug abuse and dependency, o ensuring assessment, counselling and treatment services are available for those who wish to stop using, and, o increasing safety for vulnerable groups such as young people, pregnant women and those with psychological and psychiatric illnesses.52,53,54 • Canada’s Lower-Risk Cannabis Use Guidelines which were released on June 23, 2017 aim to help protect public health and public safety.55 • Medical cannabis has become a far more common treatment among veterans with the number of reimbursed patients going from one veteran in 2007, to 3000 in 2016. Estimates suggest that the cost of medical cannabis treatment will reach $75 million in 2017. As such, starting April 1, 2017, Veterans Affairs Canada will be imposing limits on the amount of cannabis per person that will be reimbursed to a maximum of 3 mg/day down from the current maximum of 10 mg/day.56
Opioid Crisis
• Canadians are the second largest consumers per capita of prescription opioids in the world.57 • Between 1991 and 2007, annual prescriptions for opioids increased from 458 to 591 per 1000 individuals while opioid-related deaths doubled from 1991 to 2004.58 • In spring 2016, British Columbia declared a public health emergency in response to the increase in drug overdoses being witnessed in the province. In 2016, there were 914 deaths recorded in the province due to overdose deaths. The opioid fentanyl, was detected in 60% of these fatalities.59 • Opioid poisonings result in more than 13 hospitalizations a day in Canada. From 2010- 2011 to 2014-2015, the rate of emergency room visits due to opioid poisoning increased by 54% in Alberta (17.8 to 27.3 visits per 100,000 population) and 22% in Ontario (14.2 to 17.4 visits per 100,000 population).60 • Seniors aged 65 and above consistently record the highest hospitalization rates, reaching 20 per 100,000 population in 2014–2015.61
A National Issue Multiple specialists prescribe opioids to manage acute and chronic pain, making the issue opioid related harms of relevance to the scope of practice of many Royal College Fellows.
In November 2016, Federal Health Minister Jane Philpott and Ontario Health Minister Eric Hoskins hosted the Opioid Conference and Summit. Forty-two organizations representing government and health care organizations, including the Royal College, signed a joint statement of action committed to improving prevention, treatment, and harm reduction measures to mitigate problematic opioid use.62
Moving forward, the Royal College is looking to:
• Develop a Royal College statement of principles on safe opioid prescribing. • Create a central online catalogue to host educational and practice-related reference resources, accessible to all Fellows and residents. • Engage with and disseminate knowledge to Fellows.
Medical Assistance in Dying (MAiD)
• Prompted by a Supreme Court decision, the federal government passed bill C-14 in June 2016, which permits mentally competent adults to request MAiD. The legislation is restricted to those who have a serious and incurable illness, disease or disability, and where death is "reasonably foreseeable".63 • Since the legislation was passed, a survey of provincial and territorial health ministries found that there were at least 744 medically assisted deaths in 2016.64 As illustrated in Table 2 below, these deaths have been largely concentrated in the provinces of Alberta, British Columbia, Ontario and Quebec. Quebec, which legalized MAiD in December 2015, recorded the highest number of medically assisted deaths during this time period.
Table 2 - Number of medically assisted deaths, by province, by select time frame. Source: CTV News, 2016, At least 744 assisted Province Medical assisted deaths between June 17 and December 16, 2016 Alta. 63 B.C. 154 Man. 18 N.B. N/A N.L. 4 N.S.+ 16 Ont. 180 P.E.I 0 Que.* 300* Sask. 8 *Includes data from December of 2015 + Number of medically assisted deaths between June 17 and Oct. 31, 2016
• On December 13, 2016, the federal government announced that it is tasking the Council of Canadian Academies, an independent think tank, to conduct studies on MAID requests made by mature minors, advance directives and individuals who are solely suffering from a mental illness.65
The Royal College’s role in MAID:
The Royal College is committed to ensuring that Fellows and Residents are equipped to discuss the ethical principles associated with MAID. The Royal College has developed two bioethics cases: the first addresses the ethical issues relevant to a typical patient who meets the MAID eligibility criteria; and the second addresses the conscientious objection of a physician to participate in MAID. A MAiD web page was created on the Royal College website and includes links to available resources: http://www.royalcollege.ca/rcsite/bioethics/medical-assistance-in-dying-e Economic environment
Canadian economy: Overview
In June of 2016, according to the Bank of Canada’s governor, Stephen Poloz, the biggest issue facing Canada’s economy is The economic impact of the the uncertainty in resource prices particularly in the oil sector. new Trump administration This has resulted in a low Canadian dollar. Inflation is expected in the United States to be about two per cent for 2016/17.66 presents some uncertainty In November of 2016, the OECD’s economic forecast for Canada for Canada’s economic predicted a growth rate of 2.3 per cent into 2018. The OECD outlook. echoed the Bank of Canada’s inflation rate of two per cent. Contraction in the resources sector is expected to slow and the economy is expected to strengthen in non-energy sectors mainly due to stronger exports and a low Canadian dollar compared to the U.S. dollar.67
The Business Development Bank of Canada (2017) predicts Canadian economic indicators to improve in 2017 due to more stable oil prices and a continued low Canadian dollar which is attractive to a surging U.S. economy. This being said, the economic impact of the new Trump administration presents some uncertainty for Canada’s economic outlook.68 Table 3 shows the key economic indicators from Global Affairs Canada.
Table 3 - Canada: Economic Indicators Source: Global Affairs Canada, 2017, Annual Economic Indicators 69 Indicator 2012 2013 2014 2015 2016 Canada’s population in millions 34.8 35.2 35.5 35.8 36.3 GDP (Gross Domestic Product in $B) 1,823 1,898 1,983 1,986 2,027 GDP per capita (measure of productivity) 52,454 53,975 55,972 55,405 55,857 Health, education, social and government 20.9% 20.5% 20.2% 20.2% 20.3% services sector contribution to real GDP Rate of inflation of Consumer Price Index 1.5% 0.9% 2.0% 1.1% 1.4% Unemployment rate 7.3% 7.1% 6.9% 6.9% 7.0% Gross expenditures on R & D in $B 32.7 32.0 31.8 31.6 n/a Average prime rate of interest 3.00% 3.00% 3.00% 2.78% 2.70% Average exchange rate of 1 Cdn$ in US$ 1.00 0.97 0.91 0.78 0.75 Ratio of exports/imports as % of GDP 30.2/32.2 30.2/31.8 31.6/32.6 31.6/34.0 31.0/33.4
Health expenditure
• Total spending on healthcare in Canada is estimated to be $228.1 billion in 2016. 70 • As depicted in Figure 2 below, health expenditures have trended upwards for the last two decades. However, the growth in expenditures has slowed down in recent years. In constant dollars, total health spending on health care increased by 20.8% from 2005 to 2010. Whereas from 2011 to 2015, total health spending increased at a lower rate of 5.7%. This moderated rate of growth in health spending is indicative of Canada’s modest economic growth and focus on balanced budgets by governments. Figure 2 – Total Health Expenditure, Canada, 1996-2016 Source: CIHI, 2016, National Health Expenditure Trends
250,000.0
200,000.0 Current Constant (1997)
150,000.0
100,000.0 $Billions 50,000.0
0.0
• In international comparisons, statistics from 2014 (Figure 3) show that Canada’s health expenditure as a proportion of GDP was above peer OECD countries such as the United Kingdom, Sweden, New Zealand and Australia. However, the divergence is much more significant in the United States, which recorded the highest ratio to GDP at 16.6%.
Figure 3 – Total Health Expenditure as a % of GDP, Select Countries, 2014 Source: CIHI, 2016, National Health Expenditure Trends
Australia 9.0%
UK 9.9%
Sweden 11.2%
New Zealand 9.4%
Canada 10.0%
Germany 11.0%
France 11.1%
Netherland 10.9%
US 16.6%
0.0% 5.0% 10.0% 15.0% 20.0%
Public-Private expenditure
The public-private sector share of total health expenditure has remained stable, maintaining approximately a ‘70-30’ split proportionately since 199771. In 2016, it is forecasted that the public sector will spend $159.1 billion on health care. The private sector, which primarily consists of health expenditures by households and private insurance companies, will account for $68.9 billion of spending. 72 Use of funds
• Hospitals, drugs and physicians are the three largest components of health care spending, amounting up to $131.3 billion, 60.8% of total health expenditures in 2014.73 Hospitals and physicians were primarily funded by the public sector while drugs and other health professionals received the majority of financing from the private sector. 74
Figure 4 – Proportion of total health expenditure, by use of funds, 2014 Source: CIHI, 2016, National Health Expenditure Trends
Other Health Spending* 13.07% Hospitals 29.54% Public Health 5.60%
Drugs 16.02%
Other institutions 10.60% Other Professionals (Dental, vision etc.) 9.90% Physicians 15.26%
Drug spending75,76
In 2014, the cost of drugs reached $34.6 billion, 16.02% of total health expenditures. The public sector accounted for 36.2% of total spending on drugs, whereas private sector spending accounted for 63.8% of total spending on drugs.
Drug spending is predominantly made up of prescribed drug spending. In 2014, the public sector financed $12.5 billion (42.6%) of prescribed drug spending.
Compared to the tempered growth in health spending overall, public drug program spending increased 9.2% from 2014 to 2015. The spending increase has been largely associated with the introduction of new drugs used to treat hepatitis C A Pharmacare plan for Canada A study commissioned by the Canadian Federation of Nurses Unions compared Canada with select OECD countries that provide universal public drug insurance, and found that Canadians misspend approximately $7.3 billion a year due to Canadians paying among the world’s highest prices for prescription drugs. 77
In October 2016, the Citizens’ Reference Panel on Pharmacare – 35 randomly selected Canadians from across the country – met in Ottawa for five days to hear from a range of experts and consider diverse options on the issue of pharmacare. The reference panel was funded by UBC's Centre for Health Services and Policy Research, the Canadian Institutes of Health Research, and other partners. The panel’s efforts culminated in a report which called on the Federal government to establish a national pharmacare strategy which ensures universal drug coverage for all Canadians.78
Indeed, Canada is the exception rather than the norm, when it comes to providing universal health insurance without prescription drug coverage. 79 There is no targeted funding around pharmacare in the bilateral funding agreements that have been struck between the federal, provincial and territorial governments (see Political Environment section), despite prior claims implying otherwise.80 Therefore, pharmacare remains an orphan element of healthcare.
Physician spending Physicians are the • As highlighted in Figure 5, physician services accounted for third largest category 15.26% of health expenditures in 2014. Spending has of spending in health increased on an annual basis – high rates of growth were care. Over the last particularly apparent from 2005-2008, keeping pace with the decade, spending has growth of physician supply. Since 2009, the rate of growth has grown on an annual slowed down, with annual growth rates in physician spending basis. However, the ranging between 3-4%.81 rate of growth in Figure 5 – Annual growth rates in physician services spending, physician spending 2005-2014. Source: CIHI, 2016, National Health Expenditure Trends has slowed down in recent years, which is indicative of the 12.0 9.77% ongoing attempts by 10.0 7.87% 8.06% 7.13% 7.93% governments to 8.0 7.43% 6.29% control costs in 6.0 4.67% 3.45% 4.10% 4.0 health spending. 2.0 Percentage Growth Percentage 0.0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
Provincial Overview
Figures 6 and 7 show that public and private health expenditure per capita vary across the provinces and territories. • Public sector spending in 2014 shows that territorial governments reported the largest per capita spending in the country. Among provinces, Newfoundland and Labrador and Manitoba spend more per person than any other province, at $5,272.92 and $5,053.40 respectively. Whereas public sector spending was lowest in Ontario and Quebec, at $4,047.89 and $3,944.08 per capita respectively.
Figure 6 – Public sector health expenditure per capita, by province, 2014 Source: CIHI, 2016, National Health Expenditure Trends
Canada $4,277.71 Nun. $13,532.93 N.W.T $12,067.18 Y.T. $7,535.16 B.C. $4,175.39 Alta. $4,972.48 Sask. $5,039.81 Man. $5,053.40 Ont. $4,047.89 Que. $3,944.08 N.B. $4,351.22 N.S. $4,526.53 P.E.I $4,509.92 N.L. $5,272.92 $0.00 $4,000.00 $8,000.00 $12,000.00 $16,000.00 $ per capita • Private sector spending per capita in 2014 was recorded to be the highest in Yukon and Nova Scotia, at $2,144.16 and $1,930.62 respectively. Whereas Saskatchewan and Nunavut reported the lowest private spending, at $1,459.04 and $890.91 per capita respectively.
Figure 7 – Private sector health expenditure per capita, by province, 2014 Source: CIHI, 2016, National Health Expenditure Trends
Canada $1,794.79 Nun. $890.91 N.W.T $1,685.49 Y.T. $2,144.16 B.C. $1,759.07 Alta. $1,808.61 Sask. $1,459.04 Man. $1,625.37 Ont. $1,913.91 Que. $1,675.56 N.B. $1,880.59 N.S. $1,930.62 P.E.I $1,637.36 N.L. $1,619.66 0.00 500.00 1,000.00 1,500.00 2,000.00 2,500.00 $ per capita Socio-demographic environment
The Canadian Population
• In 2016, Canada's population was estimated to be over 36 million. The population has increased by 11.41% over the last ten years. • There is nearly an equal split of males and females in Canada’s population. • 8 in 10 Canadians reside in urban settings (i.e. communities over 1,000 population). • In 2016, approximately 16% of the population was aged 65 and above. For the first time, Canada’s elderly population surpassed the population of children and it is projected to accelerate at a pace that will continue to widen this gap in the future. • 4 out of 5 Canadians live in four provinces: Ontario, Quebec, British Columbia and Alberta. Figure 8 – Population Estimates, Canada, 2006-2016 Source: Statistics Canada, 2016, Table 051-0001
37,000,000 36.3 million 36,000,000
35,000,000
34,000,000
Population Population 33,000,000
32,000,000 32.6 million
31,000,000
30,000,000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Gender (2016)82 Age (2016)83 Rural-Urban (2011)84
Male Female <14 15-64 64+ Rural Urban
49.59% 50.41% 16.07% 67.42% 16.51% 18.9% 81.1% (<1000 pop.) (1000+ pop.) Population by province/territory (2016).85 N.L. 530,376 P.E.I 149,278 N.S. 952,333 N.B. 757,997 Que. 8,349,793 Ont. 14,063,256 Man. 1,323,958 Sask. 1,155,393 Alta. 4,268,929 B.C. 4,773,345 Y.T. 37,624 N.W.T 44,204 Nvt. 37,146 Health Conditions
• As illustrated in Figure 9, major chronic diseases such as cancers, diabetes, heart and respiratory diseases are among the leading causes of death. • 3 in 5 Canadians aged 20 years or older have a chronic disease.86
Figure 9 – Canada, Leading causes of death by proportion, 2012 Source: Statistics Canada, 2015, Leading Causes of Death
Cancers 30.2% All other Kidney disease 25.1% 1.3% Chronic lower Suicide respiratory diseases 1.6% 4.5% Influenza and pneumonia 2.3% Diabetes Alzheimer's disease Heart disease 2.8% 2.6% 19.7% Unitentional Stroke Injuries 5.3% 4.6%
• Looking at the top three causes of death by age group (Figure 10), accidents and suicide are particularly pervasive among youth and young adults aged between 15-34. Whereas cancer and heart disease are the leading causes of death among those aged 45 and above.87
Figure 10 - Top three leading causes of death, number of cases, by age group, 2012 Source: Statistics Canada, 2015, Leading Causes of Death, OMA Economics, Research and Analytics, 2017.
Top 3 causes of death Age Group 1 2 3 1-14 Accidents (161) Cancer (93) Congenital Abnormalities (68) 15-24 Accidents (852) Suicide (518) Cancer (141) 25-34 Accidents (848) Suicide (548) Cancer (387) 35-44 Cancer (1,220) Accidents (857) Suicide (662) 45-54 Cancer (5,231) Heart Disease Accidents (1,197) (2,003) 55-64 Cancer (12,889) Heart Disease Accidents (1,103) (4,5867) 60-64 Cancer (7,519) Heart Disease Chronic Lower Resp. (509) (2,620) 65-74 Cancer (18,910) Heart Disease Chronic Lower Resp. (2,133) (7,277) 75-84 Cancer (21,500) Heart disease Stroke (4,052) (13,070) 85+ Heart disease (21,065) Cancer (13,975) Stroke (6,319)
Cancer
• Cancer is the leading cause of death in Canada. • Approximately 2 in 5 Canadians will develop cancer and 1 in 4 will die of cancer. • Estimates project 202,400 Canadians will be diagnosed with cancer and 78,800 Canadians will die due to cancer in 2016. • Lung cancer is the leading cause of cancer-related death. Lung cancer, along with colorectal, prostate and breast cancer, accounts for half of new cancer cases. • Prostate cancer is the most commonly diagnosed cancer in Canadian males and breast cancer is most commonly diagnosed in females.88
89 Age Figure 11 – Age standardized incidence rates for all cancers by select age group, Canada, 2016 • 89% of all new cases of cancer are Source: Canadian Cancer Society, 2016, Canadian Cancer diagnosed among Canadians aged 50 and Statistics above. Approximately half of these new cases are estimated to occur among 50% 44% people aged 70 and above. 40%
90 28% Gender 30%
• The probability of developing cancer is 20% 17% higher for males than females, with males having a 45% lifetime probability of 10% developing cancer, in contrast to a 42% 0% lifetime probability in females. 50-59 years 60-69 years 70 years and • Although challenges remain significant, above there has been progress in the battle against cancer. As illustrated in Figure 12 below, mortality rates in cancer have declined in the last two decades, with notable decreases in lung, colorectal and prostate cancers for men and decreases in deaths from breast and colorectal cancers for women. • Incidence rates in males have declined this time period as well. However, there has been moderate growth in incidence rates amongst females, partly attributed to increases in incidence rates of specific cancers, such as melanoma, thyroid, uterine and liver cancer.
Figure 12 – Age standardized incidence (ASIR) and mortality rates (ASMR) for all cancers, by gender, Canada, 1988-2016 Source: Canadian Cancer Society, 2016, Canadian Cancer Statistics
650.0
550.0
Cases per 100,000 450.0 Males, ASIR Females, ASIR Males, ASMR 350.0 Females, ASMR
250.0
150.0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Income
• Mortality data from the 1991-2006 Canadian censuses highlight the disparity in life expectancy among low-income households in comparison to the highest-income households. In the lowest income households, males were 1.61 times more likely to die from all cancers, and females were 1.43 times more likely to die from all cancers.
Table 4 – ASMR for all cancers, by household income, by gender, per 100,000 Source: Statistics Canada. Tjepkema, Wilkins and Long, 2013 Lowest Income quintile Per, 100,000 Males 510.4 Females 316.6 Highest Income quintile Per, 100,000 Males 348.6 Females 244
Indigenous Peoples
• Survey data from 1991 to 2001 show that Indigenous peoples record lower mortality rates for cancer.
Table 5 –ASMR for all cancers, by Indigenous ancestry income, by gender, per 100,000 Source: Statistics Canada, 2009, Tjepkema, Wilkins, Senécal, Guimond and Penney Males Per, 100,000 First Nations 187.6 Métis 175.9 Non-Indigenous 162.5 Females Per, 100,000 First Nations 134 Métis 180.1 Non-Indigenous 134
Cardiovascular Disease
• Cardiovascular diseases are the second leading cause of death amongst Canadians. • Statistics Canada reports that in 2012, cardiovascular diseases accounted for over 48,000 deaths. Nearly 14,000 deaths occurred due to stroke during the same time period. 91 • The Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index, a measurement for optimal heart health, analyzed responses from 464,883 Canadians that participated in the Canadian Community Health Survey from 2003-2011. Maclagan et al. found that according to their CANHEART health index (which is based on health behaviors and factors that influence heart health), less than 10% of adults and 20% of youth met the criteria for ideal cardiovascular health. The researchers cited increasing trends of overweight/obesity, hypertension and diabetes as key factors that have influenced these scores.92 • Over 740,000 Canadian adults aged 20 and above suffered from the effects of a stroke in 2012-13.93 • The impact of heart disease and stroke on the Canadian economy has been profound. In 2010, the Conference Board of Canada reported that heart disease and stroke costs over $20 billion every year in physician services, hospital costs, lost wages and decreased productivity.94
Age
• Seniors aged 65 and above were the highest proportion of Canadians that reported they have a cardiovascular disease in 2014 (Figure 13).
Figure 13 – Prevalence rate of cardiovascular diseases (self-reported) by age group, 2014 Source: Canadian Community Health Survey, 2014
20.00% 18.30% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 7.10% 6.00% 4.00% 1.50% 2.00% 0.70% 0.00% 20-34 35-49 50-64 65+ Age group
• The Public Health Agency of Canada reports that from 2012-2013, the death rate among people aged 20 and above was: o 3 times higher among those who have been diagnosed with heart disease. 95 o 4 times higher among those who have had a heart attack.
Gender
• In 2014, 7.2% of males and 5.2% of females respectively reported living with a cardiovascular disease. 96 • The Public Health Agency of Canada reports that in 2012-2013, males were twice more likely to suffer a heart attack than females.97 Further, males were first diagnosed with heart disease approximately 10 years younger than females (55-64 years of age for the former and 65-74 years of age for the latter).98
Diabetes
• Provincial and territorial administrative health databases report that in 2011, 2.74 million Canadians lived with diabetes. Numbers have more than doubled since 2000.99 • It has been projected that the number of Canadians with the disease will continue to grow - the Canadian Diabetes Association estimates that there are 3.34 million Canadians with diabetes.100 • A significant number of diabetics tend to have compounding chronic diseases to contend with. Over a third of Canadian adults with diabetes reported having two or more other serious chronic conditions. Diabetics are also over three times more likely to be hospitalized with cardiovascular disease than individuals without diabetes. In 2008, 30% of all individuals who died suffered from diabetes along with other conditions.101 Age and Gender
• In 2011, there were 1.4 million males and 1.3 million females living with diabetes. During this time period, there were 109,590 males and 92,830 females that were diagnosed with the disease for the first time.102 • Table 6 shows that the proportion of prevalence and incidence is the highest among the elderly males and females aged 65 and above.
Table 6 – Diabetes prevalence and incidence*, by gender and age, 2011 Source: Public Health Agency of Canada, Last retrieved January 25, 2017, The Canadian Chronic Disease
Population Diabetes Diabetes (p) Prevalence Incidence
Cases (c) Percentage Cases (c) Percentage (p/c) (p/c) 1 to 24 5149900 21770 0.42% 2260 0.04%
25 to 44 4856610 116780 2.40% 14980 0.31% 45 to 64 5074610 618120 12.18% 55400 1.09%
Males 65 to 79 1837710 512950 27.91% 29130 1.59% 80 and above 599500 176070 29.37% 7820 1.30%
1 to 24 4918070 20620 0.42% 2370 0.05% 25 to 44 4882810 120800 2.47% 13290 0.27% 45 to 64 5101090 483630 9.48% 41470 0.81% 65 to 79 2002370 432330 21.59% 25310 1.26% Females 80 and above 972340 234240 24.09% 10390 1.07%
* Individuals diagnosed with diabetes for the first time during the time period.
Income
• Canadian adults in the lowest income quintile are more likely to report living with diabetes. In 2013, 10% of Canadians in the lowest income quintile reported living with diabetes, double the proportion of those in the highest income quintile (Figure 14).
Figure 14 – Proportion living with diabetes by income quintile, 2013 Source: CIHI, 2015, Trends in income-related
Q5 (highest income quintile) 4.9
Q4 6.2
Q3 6.7
Q2 8.9
Q1 (lowest income quintile) 10
0 2 4 6 8 10 12 Age-standardized rate (%) Indigenous Peoples
• Combined data from the 2011 to 2014 Canadian Community Health Survey suggest that off-reserve First Nations and Métis have a higher prevalence of diabetes in comparison to the non-Indigenous population (Figure 15).
Figure 15 –Prevalence of self-reported diabetes, by Indigenous identity, 2011-2014 Source: Statistics Canada, Last retrieved February 26, 2017, Canadian Community Health Survey
Indigenous Identity Age Standardized rate First Nations (off-reserve) 8.2 Métis 6.0 Inuit 3.2* Non-Indigenous 4.9
*Interpret with caution due to potential of statistical error
• The prevalence rate is particularly high among First Nations adults who live on- reserve. Data collected from 2008-2010 reported that the age-standardized prevalence of diabetes was 20.7% for Indigenous adults aged 25 and above.107
Mental Illness
• A national survey conducted in 2014 As of January 29, 2017, 40,081 Syrian found that 6.3% of Canadians aged 12 refugees have arrived in Canada since and above rated their mental health as November 4, 2015.103 fair or poor.108 • A simulation model commissioned by Studies suggest that the health status of refugees can be unique in comparison to the Mental Health Commission of Canadian born individuals and Canada estimates that in 2011, one in 5 immigrants.104,105 Canadians – 6.7 million people in total – lived with a mental illness.109 A Senate report tasked with reviewing the • Mood and anxiety disorders are the integration of Syrian refugees, cited most common mental disorders. The mental health as a major area of concern. abovementioned model estimates that 4 Witnesses that were part of the Senate’s investigation “identified a shortage of million Canadians lived with a mood psychiatrists and mental health resources, and/or anxiety disorder in 2011, and language barriers and cultural norms as projects that this will increase to being factors that delay or impede access approximately 4.9 million by the year to mental health resources”.106 2041.110
Age and Gender
• The prevalence rates of mental illness for males and females are comparable – 20.9% for the former and 18.7% for the latter. Furthermore, both genders track similarly in terms of age. 111 In 2011, prevalence rates were estimated to be high among youth and young adults, dropping in subsequent years and rising again among those aged 70 and above (Figure 16). Figure 16 – Estimated annual prevalence rates of mental illness, by age and sex, 2011 Source: Mental Health Commission of Canada, 2013, Making the case for 45% 42.1% 40% 36.7% 35% 25.9% 28.1% 33.8% 30% 25% 25.9%
25% 28.7% 20.6% 28.3% 29.1% 26.3% 17.6% 20% 17.5% 15.6% Females 19.5% 15% 17.8% 15.1% Males 10% 12.8% 10.6% Estimated Prevalence Rate Prevalence Estimated 5% 0% 9-12 13-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+ years years years years years years years years years years Age
Income
• Low income adults are more likely to rate their mental health as fair or poor in comparison to the highest income-Canadian adults. • Survey data suggests that this disparity is widening over time. As illustrated in Figure 17 below, in 2003, the percentage of Canadians rating their mental health as fair or poor was four times higher among adults in the lowest income quintile in comparison to those in the highest-income quintile. Whereas in 2013, the lowest-income Canadian adults were reporting fair or poor mental health at rates that were five times higher than those in the highest-income bracket. 112
Figure 17 – Prevalence rate of population aged 18 and older who rated their own mental health status as poor or fair, by income quintile, 2003, 2014 Source: CIHI, 2015, Trends in income-related
16 Highest Income Quintile 14.5 14 Lowest Income Quintile 12 9.7 10 8 6 4 2.5 2.8 2 0 Age standardized rate (%) rate Age standardized 2003 Year 2013
Indigenous Peoples
• Combined data from the 2007 to 2010 Canadian Community Health Survey suggest that a higher proportion of off-reserve First Nations and Métis rate their own mental health as fair or poor, in comparison to the non-Indigenous population.113 Table 7 –Perceived mental health, by Indigenous identity, 2007-2010 Source: Gionet & Roshanafshar, 2013, Select health indicators of Indigenous Identity Perceived mental health, Perceived mental health, fair Very good or excellent or poor First Nations (off-reserve) 66 8 Métis 67 8 Inuit 65 5* Non-Indigenous 75 5
*Interpret with caution due to potential of statistical error
Injuries
• In 2010, over 15,000 Canadians deaths occurred due to injury. Over 230,000 Canadians were hospitalized due to serious injury in the same year.114 • From 2004 to 2010, the injury death rate increased by 2.8% from 42.06 per 100,000 population to 43.25 per 100,000 population.115 • The direct and indirect costs (i.e. costs from reduced productivity due to hospitalization, disability and premature death) of injuries was estimated to amount to $26.8 billion in 2010. 116 • As illustrated in Figure 22 below, falls are the leading cause of unintentional injury deaths and suicide/self-harm incidents are the leading cause of intentional injury deaths, accounting for 4071 (25.7%) and 3948 (24.9%) deaths respectively.
Table 8 – Number of injury deaths, by cause, 2010 Source: Parachute Canada, 2015, The Cost of Injury
Description Number of Deaths
Falls 4071 Other Unintentional Injuries 1792 Transport Incidents 2620 Fire/Burns 234 Undetermined intent 749 Unintentional Poisoning 1568 Violence 515 Suicide/Self-harm 3948 Struck by sports equipment 5 Drowning 369
Age and Gender (Falls)
• As depicted in Table 9 below, among both genders, there is a higher likelihood that Canadians aged 65 and above die, get hospitalized and make emergency room visits as a result of a fall. • These high rates within Canada’s elderly population are particularly significant among males and females aged 85 and above. For instance, the rate of deaths per 100,000 among males aged 85 and above was 21 times the rate of males aged 65-74 and nearly 5 times the rate of males aged 75-84. The rate of deaths per 100,000 among females aged 85 and above was 31 times the rate of females aged 65-74 and over 5 times the rate of females aged 75-84. Table 9 - Rates of deaths, hospitalizations, and emergency room visits due to falls by age and sex, 2010 Source: Parachute Canada, 2015, The Cost of Injury
Age group Deaths Hospitalizations Emergency Room Visits (per 100,000) (per 100,000) (per 100,000) (per 100,000)
Male 0-4 0.21 151.48 5,845.36 Male 5-9 0.11 147.17 3,840.53 Male 10-14 0.10 137.50 4,581.92 Male 15-19 0.87 125.29 3,082.91 Male 20-24 1.44 121.16 2,472.93 Male 25-64 3.18 180.63 1,930.32 Male 65-74 18.56 552.27 2,786.29 Male 75-84 83.54 1,475.65 5,339.16 Male 85+ 396.29 4,277.54 11,889.13 Female 0-4 0.11 118.77 4,844.83 Female 5-9 0.00 120.27 3,478.76 Female 10-14 0.00 72.91 3,738.57 Female 15-19 0.09 54.03 2,412.11 Female 20-24 0.44 59.71 1,993.51 Female 25-64 0.83 167.01 2,205.58 Female 65-74 10.33 783.07 4,036.33 Female 75-84 60.01 2,377.57 7,524.40 Female 85+ 327.94 6,323.72 15,185.41
Age and Gender (Suicide)
• The suicide rate for males (17.4 per 100,000) was three times higher than the suicide rate for females (5.7 per 100,000) in 2013.117 The higher rate of suicide among males is consistent with long-term trends in Canada over the last six decades. 118 • Suicide rates are highest among those aged 40 to 59. 119
Figure 18 – Suicide rate by select age group, 2013 Source: Statistics Canada, CANSIM, Table 102-0551.
18.4 18.3 17.4 20 15.5 15 11.5 10 5
population 0 Rate per 100,000 40 to 44 45 to 49 50 to 54 55 to 59 All Ages Age group
Indigenous Peoples
• Survey data collected from 2008-2010 found that among First Nations adults who live on-reserve, one-in-five aged 18 and above (18.6%) reported they sustained an injury in the previous year.120 • In 2012, 20% of First Nations living off reserve, 21% of Métis and 16% of Inuit aged 19 years and older reported they sustained an injury in the previous year.121 • In 2016, tragic events in Northern Manitoba’s Pimicikamak Cree Nation and Northern Ontario’s Attawapiskat First Nation exposed the ongoing suicide risk in Indigenous communities. • Survey data collected from 2008-2010 found that among First Nations adults who live on-reserve, 22% reported having had thoughts of suicide at some point in their life. 122 As illustrated in Figure 19 below, suicidal thoughts have been reported to be high in off-reserve First Nations, Métis and Inuit adults as well.123
Figure 19: Prevalence of lifetime suicidal thoughts among Indigenous adults aged 18 and over, by Indigenous identity, 2012 Source: Statistics Canada, 2016, Lifetime and past-year suicidal Indigenous Identity Percent First Nations (off-reserve) 21.1 Métis 17.5 Inuit 22.3 Non-Indigenous 11.5
Risk Factors
Obesity
• Obesity is a major risk factor for numerous diseases, Social determinants of health including cardiovascular The health status of population groups are strongly diseases, diabetes, influenced by limited access to social, cultural and economic resources. Among Canada’s Indigenous musculoskeletal disorders and populations, the issue is further compounded by the certain cancers. Childhood historical remnants of racism and colonialism. For obesity has also been instance: associated with increased • Half of First Nations children live in poverty. breathing difficulties, risk of • 48% of children and youth in foster care are fractures, hypertension, Indigenous (from 4.3% of the population). cardiovascular concerns and • There are more than 40,000 Indigenous children and youth in foster care — more than three times psychological effects. 125 the number of children in residential schools at the • The rate of obesity has height of the Indian residential schools system. trended upwards over the last • Secondary school graduation rates are 35% for decade. In 2014, 20.2% of First Nation students on-reserve, compared to 85% Canadians aged 18 and older graduation rates for other Canadians. • self-reported their Body Mass There are more than 1,200 cases of missing and murdered Indigenous women and girls. Index (BMI) that classified • Indigenous individuals account for almost one- them as obese. quarter of all adults and youth incarcerated in Canada. Age and Gender • As of 2015, 132 First Nations communities were under boil water advisories.124 • 2014 data shows that males recorded a slightly higher rate Addressing these types of issues will be critical in of obesity than females, ensuring health and wellness equity at the individual, 21.8% and 18.7% community and jurisdictional levels. respectively. Both genders track similarly in terms of age. Self-reported rates of obesity rose between the ages of 18 and 54 and dropped at the age of 65 and above.
Figure 20 – Percentage of those that were obese (self-reported) Source: Canadian Community Health Survey, 2014
30 26.4 25.3 25 23.3 20.3 23.7 20 17.4 20.4 19.3 19.7 15 11.1
Percentage 13.8 10 Males Females
5 4.5 0 18 to 19 35 to 44 55 to 64 Age Group
• Survey data collected in 2013 showed that the prevalence of obesity among females in low income households was 1.5 times higher than that among females in higher- income households. This significant disparity in obesity based on income, was not observed in males.126
Indigenous Peoples
• Obesity rates are significantly higher among Indigenous peoples in comparison to the general population. In 2012, nearly one in three (31%) First Nations people off- reserve reported being obese. 127 • Survey data collected from 2008-2010 found that among First Nations adults who live on-reserve, 40% aged 18 and above reported they were obese.128
Smoking
• Smoking rates have consistently declined over time. In 1999, 25.2% of Canadians were smokers. In 2013, 14.6% of Canadians, approximately 4.2 million were smokers.129 Notwithstanding, smoking remains a major risk factor to multiple diseases and conditions including heart disease, oral, lung and cervical cancer, emphysema and bronchitis, to list a few.130
Income
• Survey data from 2013 found that 29.1% of adults aged 18 and above in low income households reported they were smokers. Whereas 15.2% of adults aged 18 and above in the highest income quintile indicated they smoked.131 Age
• Smoking rates were highest among young adults aged between 20-34.132
Figure 21 – Smoking prevalence, by age group, Canada, 2013 Source: Reid, Hammond & Burkhalter, 2015, Tobacco use in Canada
20 17.9 18.5 18 16.7 16.3 16 14 12 10.7 10.8 10 8
Prevalence (%) Prevalence 6 4 2 0 15-19 20-24 25-34 35-44 45-54 55+ Age group
Indigenous Peoples
Table 10: Smoking prevalence among adults aged 18 and over, by Indigenous identity, 2007-2010 Source: Gionet and Roshananfshar, 2013, Select health indicators of Indigenous Identity Percent First Nations (off-reserve) 40 Métis 36 Inuit 48 Non-Indigenous 21
• Combined data from 2007-2010 showed that Indigenous peoples had a higher smoking prevalence than non-Indigenous people.133
• Survey of First Nations adults on reserve from 2008-2010 found that over half (57%) smoked daily or occasionally.134
Health Indicators – How we compare
• As Table 11 shows, life expectancy for Canadians is comparable with peer countries. Canada performed strongly compared to its peers in regards to self-reported health status and mortality due to stroke. However, Canada lagged behind in indicators such as infant mortality and mortality due to cancer–areas that might merit further consideration. 135 Table 11 - International comparisons on select health status indicators, 2013 or most recent year Source: Canadian Institute for Health Information, OECD Interactive Tool: International Comparisons
Select Indicator Canada Australia Germany Sweden New United Zealand Kingdom Life Expectancy: 79.3 80.1 78.6 80.2 79.5 79.2 Males (Years) Life Expectancy: 83.6 84.3 83.2 83.8 83.2 82.9 Females (Years) Infant Mortality 4.8 3.6 3.3 2.7 5.2 3.8 (Age standardized rate per 100,000) Perceived health status: 88.7 85.4 64.9 81.1 89.6 73.7 Age +15 (% report health to be ‘good’ or better) Cancer Mortality: Males 253.9 257.2 270.9 227.8 259.5 275.9 (Age standardized rate per 100,000) Cancer Mortality: 181.4 160.2 169.6 171.8 191.3 193 Females (Age standardized rate per 100,000) Heart Disease Mortality 95.2 98.2 115.2 104.7 137.9 97.6 (Age standardized rate per 100,000) Stroke Mortality 37.8 51.4 52.1 54.6 66.7 52.6 (Age standardized rate per 100,000) Suicide: Males 15.9 15.6 17.2 17.5 17.7 12.2 (Age standardized rate per 100,000) Suicide: Females 5.3 4.8 5.3 7.3 5.2 3 (Age standardized rate per 100,000) Health System Environment
Health System Performance
Wait Times
In December 2005, first ministers of health agreed to establish evidence based benchmarks in the ‘priority areas’ of radiation therapy, cardiac surgery, hip fracture repair, hip and knee replacement and cataract surgery.136 National estimates show that approximately 3 out of 4 patients receive priority procedures within established benchmarks.
• There has been mixed progress since 2011. As shown in Figure 22 below: o Most patients receive radiation treatment for cancer care within the benchmark of four weeks. o Wait times for hip fracture repair has improved by 5 percentage points since 2012. o Progress has stagnated in wait times for hip and knee replacements. o The percentage meeting the established benchmark for cataract surgeries has trended downwards, declining by 10 percentage points since 2012. 137
Figure 22 - Proportion of patient’s accessing care within wait time benchmarks, by priority area, 2011-2015 Source: CIHI, 2016, Wait times for priority
100% 97% Radiation 97% Therapy 95% Hip Replacement
90% Cataract Surgery
86% 85% Hip fracture 84% repair 80% 81% Knee 81% Replacement 79% 75% 76% 73% 73% 70% 2012 2013 2014 2015 2016
Note: Quebec’s hip fracture repair data not included due to the methodological differences.
• There are certain instances where the disparity between provinces is significant. Approximately nine in 10 from Newfoundland and Labrador residents receive cataract surgery within 16 weeks, in contrast to approximately 3 in 10 in Manitoba. For knee replacements, the proportion of citizens receiving surgery within the established benchmark is significantly higher in Ontario (81%) than Nova Scotia (38%). Table 12 - Proportion of patient’s accessing care within wait time benchmarks, by priority area, by province, 2012, 2016 Source: CIHI, 2012, 2017, Wait times for priority
Hip replacement Knee Province replacement repair Hip fracture Cataract surgery Radiation ≤ 48 hours ≤ 16 weeks therapy Alta 82% ≤ 2677% weeks ≤ 4891% hours 58% ≤ 499% weeks % point change -2 -2 +11 -11 +2 since 2012 B.C. 61% 47% 86% 66% 91% % point change -19 -27 +5 -19 -4 since 2012 Man. 66% 58% 91% 34% 100% % point change +10 +12 +5 -27 - since 2012 N.B. 60% 57% 89% 78% 98% % point change -12 -4 +9 -7 +4 since 2012 N.L. 77% 70% 90% 90% 100% % point change -6 -11 +9 +8 +2 since 2012 N.S. 56% 38% 85% 65% 94% % point change +9 +5 +9 +7 +5 since 2012 Ont. 85% 81% 85% 70% 99% % point change -4 -3 +3 -16 +1 since 2012 P.E.I 70% 77% 76% 92% 95% % point change +18 +42 +3 +25 -4 since 2012 Que. 85% 80% ** 86% 98% % point change +6 +4 -2 - since 2012 Sask. 80% 73% 79% 79% 97% % point change +11 +18 - +22 -1 since 2012
+/- 10% +/- 11 to 19% +/- 20% and above
**Data not included due to methodological differences
• Looking at performance over time, since 2012, Variances in wait times Saskatchewan has observed an improvement of 11-22 percentage points in the proportion of patients having hip provincially highlight the replacements, knee replacements, and cataract surgeries. disparities in access that Whereas British Columbia has trended in the opposite persist for Canadians. direction, declining by 19-27 percentage points in the proportion of patients meeting the benchmark of the three procedures. • Many provinces are also reporting wait times for select cancer surgeries, CT scans and MRIs. • Among provinces reporting, Nova Scotia recorded the longest wait times for CT scans and MRIs, with 9 out of 10 patients receiving services within 74 days and 202 days respectively. • Provincial performance varied in wait times for breast, colorectal, prostate, lung and bladder cancer. The 90th percentile wait is lowest o in Saskatchewan for bladder cancer (29 days) and lung cancer (27 days) surgeries, o in Newfoundland and Labrador for colorectal cancer surgery (32 days), o in British Columbia and New Brunswick for prostate cancer surgery (70 days).
Table 13 – Wait times by select procedure, by province, 2015 Source: CIHI, 2017, Wait times for priority
CT Scan MRI Scan Bladder Colorectal Lung Prostate Benchmark 90th 90th Cancer Cancer Cancer Cancer Percentile Percentile Surgery Surgery Surgery Surgery (in Days) (in Days) 90th 90th 90th 90th Percentile Percentile Percentile Percentile (in Days) (in Days) (in Days) (in Days) Alta. 56 172 70 70 62 109 B.C. N/A N/A 50 56 41 70 Man. 28 189 N/A N/A 34 N/A N.B. N/A N/A 47 37 54 70 N.L. N/A N/A 53 32 53 72 N.S. 74 202 97 55 84 89 Ont. 37 91 58 39 32 78 P.E.I 61 167 65 38 N/A N/A Que. N/A N/A 63 50 63 85 Sask. 50 149 29 38 27 138
International Comparisons
• In an international survey of 11 countries, 93% of Canadians indicated that they had a regular doctor or place of care. However, they reported longer wait times than peer countries in a number of areas. Canadians were the lowest proportion of respondents to indicate that they were able to get a same or next-day appointment at their regular place of care (Figure 23). 34% of Canadians stated that they found it very or somewhat difficult to get medical care in the evenings, weekends or holidays unless they went to an emergency department. Further, Canada recorded the longest waits for primary and specialist care (Figure 24) against these select countries. Figure 23 – Percent of respondents indicating they could get Figure 24 – Percent of respondents indicating they waited a same- or next-day appointment to see a doctor or a nurse, 4 weeks or longer to see a specialist, by country. by country. Source: CIHI, 2017, How Canada Compares
Source: CIHI, 2017, How Canada Compares
New Zealand 77% Netherlands 22% Australia 76% United States 23% United Kingdom 67% Germany 24% Switzerland 57% Australia 25% France 57% France 35% Germany 56% United Kingdom 36% United States 53% Sweden 37% Sweden 51% New Zealand 42% Norway 49% Norway 44% Canada 43% Canada 52% 0% 50% 100% 0% 20% 40% 60% Quality of Care:
Table 14 - Quality of care, by indictor Source: CIHI, 2017, Health Indicators
` Quality Indicator Data Year Measure Indicator Result Repeat Hospital Stays for Mental Illness 2013–2014 Percentage 11.2% Obstetric Trauma (With Instrument) 2014–2015 Percentage 18.3% In-Hospital Sepsis 2014–2015 Per 1,000 4.1 Potentially Inappropriate Medication Prescribed to Seniors 2014–2015 Percentage 49.7% Worsened Pressure Ulcer in Long-Term Care 2014–2015 Percentage 2.9% All Patients Readmitted to Hospital 2014–2015 Percentage 13.6% Hospital Deaths Following Major Surgery: 2014-2015 Percentage 1.6% Ambulatory Care Sensitive Conditions* 2014-2015 Per 100,000 331
* Age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to hospital, per 100,000 population younger than age 75.
How Canada measures up internationally
• As displayed in Table 15, Canada ranks relatively well on certain indicators such as survival rates for breast, colorectal and cervical cancer. However, in the areas of patient safety and adverse events, Canada reported high rates of obstetric trauma and a number of cases where unwanted foreign bodies were left in during procedures.
Table 15 - Quality of care, by indictor, by select OECD country Source: OECD, 2016, Health Data
Quality Indicator Measure Canada Germany Italy United United Kingdom States Avoidable Admissions, Admissions 95.3*** 216.3*** 43.5*** 64.3*** 198.2** Diabetes per 100,000 Admissions 14.9*** 22.6*** 9.8*** 60.5*** 103.1** Avoidable Admissions, Asthma per 100,000 Breast cancer: Percentage 87.7+ 84.4+ 85.8++ 78.9+ 88.3+ Five-year survival rate. Cervical cancer: Percentage 66.0+ 65.3+ 70.6++ 55.7+ 62.1+ Five-year survival rate. Colorectal cancer: Percentage 63.5+ 63.5+ 63.7++ 51.3+ 34.5+ Five-year survival rate. Rate per 100 17.1*** 8.1* 1.4*** 7.2*** 10.3*** Obstetric Trauma: patients With Instrument Foreign Body left in during Rate per 8.6*** N/A 1.7*** 7.1*** 7.8*** procedure 100,000
* 2011 Data ** 2012 Data *** 2013 Data + 2003-2008 Data ++ 2002-2007 Data Human Resources for Health (HRH)
Appropriate supply, mix, and distribution of physicians and other health professionals are essential to ensure timely access to quality health care services. A number of global and Canadian initiatives are afoot to look at human resources for health (HRH) planning. For example:
• In early 2016, the World Health Organization launched their report entitled “Global strategy on human resources for health: Workforce 2030”. 138 • Canadian HRH initiatives include the Committee on Health Workforce (CHW)139 and its sub- committee, the Pan-Canadian Physician Resources Planning Advisory Committee (PRPAC). A physician supply-based model has been developed by PRPAC with efforts currently underway to build a needs-based modeling tool.
This section provides a high-level snapshot of the physician workforce supply in Canada using several authoritative data sources including the Canadian Resident Matching Service (CaRMS), the Canadian Post-M.D. Education Registry (CAPER), the College of Family Physicians of Canada (CFPC), the Royal College of Physicians and Surgeons of Canada (RCPSC), and the Canadian Institute for Health Information (CIHI).
Post-Graduate Trainees
• In 2016, 3,310 residency positions were available during the R-1 match (incl. first and second iteration).140 • Overall, 46% of these positions were allocated to Family Medicine with the remainder distributed between Medical (40%), Surgical (12%), and Laboratory specialties (2%).141 • Nearly all available positions were filled (98%), leaving only 51 vacant positions at the end of the matching process (80% of vacancies in Family Medicine).
Allocation of residency quota is changing. For example, the Quebec government has created a “Special Quota”, which applies to certain types of applicants (e.g. Canadian citizens who trained abroad) and limits specialties (e.g., Psychiatry, Family Medicine). Source: McGill University, 2017, Contingent particulier
Figure 25 - Physicians matched into a Canadian residency program. Source: CaRMS, 2016, Summary of match results • As shown in Figure 25, almost all Canadian medical graduates CMG 2833 135 (CMGs) were placed into a residency program (95%) as compared to only IMG 408 1407 22% of international medical graduates (IMGs).142 Matched • In the 2015-16 academic USMG year, 80% of IMGs in first-year Unmatched residency training were Canadian 0 1000 2000 3000 4000 citizens/permanent residents (CCPRs); an increase from 64% in Physicians 2005-06.143 • CCPRs who completed their MD degree abroad are eligible to participate in the match whereas visa trainees are not and therefore access residency by way of contractual agreements between the source country & the faculty of medicine • CCPRs who study abroad commonly complete their medical degree in different geographic regions as compared to Visa trainees.144
Figure 26 – Top five countries where International Medical Graduates received their MD degree (CCPRs vs. Visa Trainees). Source: CAPER, 2015-2016, Table C-2
CCPRs Visa Trainees
•Ireland •Saudi Arabia •Australia •India •Iran •United Kingdom •United States •Oman •Egypt •Ireland
• In the 2015-2016 academic years, 16,200 total trainees (regardless of rank) were enrolled in specialty and subspecialty residency programs across Canada.145 • Approximately 55% of all trainees were registered in medical residencies; comprised of large programs such as Family Medicine (n=3476), Internal Medicine (n=1651), Psychiatry (n=997), and Anesthesiology (n=820) with the remainder in other medical (n=5470), surgical (n=3340), and laboratory disciplines (n=446). • Slightly more females than males were present in residency programs (53.4% vs. 46.6%), excluding visa trainees; representing a consistent trend since the demographic shift in 2005/2006.146 • Differences in the gender distribution exist by broad specialty with 46.7% female surgical trainees versus 61.2% female family medicine trainees.147
Figure 27 - Gender distribution by broad specialty, 2015-16 academic year. Source: CAPER, 2015-16, Table I-3
Family Medicine 39% 61%
Medical Specialties 48% 52%
Male
Female Laboratory Specialties 48% 52%
Surgical Specialties 53% 47%
0% 50% 100% New Certificants
Since 2011, the Royal College has been conducting a survey of its new certificant population to study physician employment status after certification148. • 36% response rate (5,143 individuals/14,244 new certificants) over 6 years. • As shown in Figure 28, physician employment challenges are still present with 14-18% of specialists and subspecialists indicating overall that they could not find a job placement. • Several disciplines have a higher rate of unemployment compared to the overall average (Table 16). For example, over 65% of Radiation Oncologists specified that they were unable to find a job placement post-certification in 2015-2016.
Figure 28 - Summary of employment status for newly certified specialists and subspecialists. Source: Royal College, 2013-16, Employment Survey
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
44% Additional Training Already Planned 46% 42% 45% 34% Found Employment 36% 38% 38% 11% No Job Placement, Pursuing Training 8% 8% No job 2013 10% placement 7% (TOTAL) 2014 No Job Placement, Not Pursuing Training 6% 6% 2015 4% 2016
Table 16- Most impacted disciplines reporting unemployment (discipline-specific response rate > 25%), 2015-2016. Source: Royal College, 2015-16, Employment Survey Unable to find a job placement Discipline 2015 (%) 2016 (%) Neonatal-Perinatal Medicine 3/9 (33.3%) 2/7 (28.6%) Nephrology 5/15 (33.3%) 3/8 (37.5%) Neurosurgery 7/13 (53.9%) 3/5 (60.0%) Orthopedic Surgery 17/35 (48.6%) 13/34 (38.2%) Pediatric Emergency Medicine 4/10 (40.0%) 2/6 (33.3%) Plastic Surgery 3/12 (25.0%) 7/14 (50.0%) Radiation Oncology 8/12 (66.7%) 7/11 (63.6%) Vascular Surgery 4/5 (80.0%) 2/5 (40.0%) In 2014, the Cohort Study was launched to further monitor individuals facing employment challenges in the initial survey including those who 1) had not yet found employment but were successful in securing additional training; 2) had not yet found employment and were not pursuing further training; 3) had not yet applied for employment.
• 51% response rate for 2013 -2015 (230 respondents /453 physicians experiencing employment challenges). • Over 60% of respondents indicated that they had found a job placement within 1-1.5 years after their Royal College certification in 2015 (Figure 29). • Of those that indicated that they had not yet found a job placement, a large proportion of this group was continuing training (47% in 2013; 39% in 2014; 48% in 2015). The remaining individuals were either unemployed, waiting to hear back from job applications, or had indicated another reason for not finding employment.
Figure 29 - Summary of employment status within the Cohort population. Source: Royal College, 2013-2015, Cohort Study
0% 20% 40% 60% 80% 100%
Yes 2013 2014 2015
No
Licensed Physician Workforce
• Between Nov. 1, 2014 and Nov. 1, 2015, 4,275 physicians exited post-M.D training at a rank level consistent with completion of training.149 • In 2015, the total licensed physician workforce in Canada was 82,198 with Head counts and physician-population a near 50/50 split between family ratios are often utilized in studying human physicians (41,551) and specialists resources for health. These metrics are (40,647)150, shown in Table 17. limited as they do not take into account • As seen in Table 17, Nova Scotia had workload, time allocation, scope of the highest proportion of physicians practice, practice organization, patient per 100,000 compared to PEI which needs and mobility among other factors. had fewer FPs & SPs per 100,000 in Canada, excluding the territories. • Yukon had six times more family physicians per 100,000 than specialists. Table 17 – Number of Family Physicians and Specialists, by jurisdiction (2015). Source: CIHI, 2015, Supply, Distribution, and Migration
Family Physicians Specialists Total Physicians British Columbia 5,852 5,065 10,917 Alberta 5,213 4,806 10,019 Saskatchewan 1,245 996 2,241 Manitoba 1,386 1,273 2,659 Ontario 15,077 15,417 30,494 Quebec 9,703 10,352 20,055 New Brunswick 914 760 1,674 Nova Scotia 1,241 1,224 2,465 Prince Edward Island 147 119 266 Newfoundland and Labrador 666 616 1,282 Yukon 68 11 79 CanadaNorthwest Territories 41,55130 40,6477 82,19837 Nunavut 9 1 10
Figure 30 - Number of Family Physicians and Specialists per 100,000 population, by jurisdiction (2015). Source: CIHI, 2015, Supply, Distribution, and Migration 200 Family Physicians 180 Specialists
160 183 140 120 131 129 126 125 124 100 123 121 117 117 115 114 113 111 109 109 108 106 80 98 101 100 87 60 81 68 40 Physiciansper 100,000 20 30 3 24 16 0 BC AB SK MB ON QC NB NS PE NL YT NT NU CAN Jurisdiction
• Canada had 2.6 practicing physicians per 1,000 population in 2014; in contrast, Norway had a higher number of doctors (4.4 per 1,000).151
Figure 31 - Comparison of select OECD countries on total number of doctors per 1,000 inhabitants, 2015 or latest available. Source: OECD, last accessed on April 12, 2017, Doctors (indicator) The total number of doctors per 1,000 Total Doctors per population is utilized as a broad marker for 1,000 population comparing physician supply. However, Poland 2.3 caution should be utilized when analyzing United States 2.6 Canada 2.6 the ratios of various countries given the United Kingdom 2.8 variability in their health systems. For Australia 3.5 example, the public health care system in Denmark 3.6 Canada versus the private health care Germany 4.1 system in the United States. Sweden 4.1 Norway 4.4 Physicians in Canada: Remuneration
• Fee-for-service (FFS) payment programs represented the majority (71%) of total clinical payments in 2014-2015152 • Mixed funding programs were also evident in 2014-2015 as most Canadian physicians received some form of FFS payment (95%) and a large proportion (70%) received some form of APP payment. • Alternative payment programs (APPs) are becoming more common in the Canadian health care system (10% of payments in 1999-2000 vs. 29% in 2014-2015). • As illustrated in Figure 32, Nova Scotia had the highest proportion of physicians paid through APP; in contrast, British Columbia had the highest proportion of physicians paid through FFS.
Figure 12 – Distribution of total clinical payments by jurisdiction, 2014-2015. Source: CIHI, 2014-15, Understanding the Physician Workforce
100% 90%
80% 64% 63% 53% 62% 78% 66% 71% 81% 60% 71% 70% 60% 50% 40% 30% 20% 47% 40% 38% 37% 34% 36% 22% 29% 10% 19% 29% 0% N.L. P.E.I. N.S. N.B. Que. Ont. Man. B.C. Y.T. All Jurisdiction
APP clinical payments FFS clinical payments
Physicians in Canada: Geographic Distribution
• According to the most recent Statistics Canada data (2011), 19% of Canadians were living in rural areas, that is areas with fewer than 1000 inhabitants and a population density below 400 people per square kilometer.153 • Of the 82,198 physicians in Canada in 2015, only 8% practiced in rural locations. • Family Physicians comprised the largest share of physicians in rural areas (Figure 33).
Figure 33 – Distribution of physicians in urban vs rural locations, by broad specialty category. Source: Supply, Distribution and Migration of Physicians in Canada, 2015 (CIHI) 100%
80%
60% 98% 86% Rural 40% Urban 20%
0% Family Physicians Specialists
• Excluding the Territories, BC, ON and QC experienced the closest alignment in the country between the distribution of physicians and populations in rural areas in 2015, whereas PEI, NB and NS experienced the greatest difference in that year (Figures 34 and 35).
Figure 34 – Distribution of physicians in urban versus rural locations by jurisdiction. Source: CIHI, 2015, Supply, Distribution and Migration 100% 80% 95% 93% 93% 92% 90%
60% 89% 87% 86% 86% 83% 80% 78%
40% 70%
Physicians 20% 0% BC AB SK MB ON QC NB NS PE NL YT NT NU CAN Urban Rural Jurisdiction Figure 35 – Distribution of the population in urban versus rural locations by jurisdiction. Source: Statistics Canada, 2011, Population, urban and rural 100%
80%
60% 86% 86% 83% 81% 81%
40% 72% 67% 61% 59% 57% 54% Population 20% 53% 47% 0% BC AB SK MB ON QC NB NS PE NL YT NT&NU CAN Jurisdiction Urban Rural
Physicians in Canada: Age
Figure 36 - Age distribution for the total licensed physician • In 2014, 14% of all licensed physicians workforce (Family Medicine and Specialists), 2014 were aged 65+ and 13% are aged < 35 (Figure 36). • Figure 37 shows specialties with higher < 35, percentages of younger physicians (e.g. 65+, 13% 47% of Emergency Medicine physicians 14% are <45 years old compared to 28% of 35-44, 55-64, 23% Cardiac Surgeons) or older physicians 24% (e.g., 48% of Psychiatrist are >54 years old compared to 30% of Radiation 45-54, 25% Oncologists). • For more information about other Royal College specialties, go to http://www.royalcollege.ca/rcsite/health-policy/medical-workforce-knowledgebase-e Figure 37 - Age distribution, by select specialty, 2014 35% 30% Emergency 25% Medicine 30% 20% 30% Radiation 27% 27% 27%
26% Oncology 15% 25% 23% 23% 23% 22% Psychiatry 21% 21% 10% 21% Physicians 15% Percentage of 3% Cardiac
5% 13% 9% 8% 0% 7% Surgery <35 35-44 45-54 55-64 65+ Age group Physicians in Canada: Sex
• Almost three quarters of specialists were male in 2005; dropping to 65% in 2015. • Most surgical specialties are still male-dominated with the exception of Obstetrics & Gynecology, as is seen in Figure 38.
Figure 38 – Distribution of males and females in the licensed physician workforce by specialty – select disciplines. Source: CIHI, 2015, Supply, Distribution, and Migration
Orthopedic Surgery 89% 11%
Ophthalmology 77% 23%
General Surgery 74% 26%
Diagnostic Radiology 69% 31%
Male Anesthesiology 68% 32%
Internal Medicine 67% 33% Female Psychiatry 57% 43%
Anatomical Pathology 57% 43%
Pediatrics 44% 56%
Obstetrics and Gynecology 44% 56%
0% 50% 100%
Physicians in Canada: Work Hours
• Overall, male and female physicians report working fewer hours in 2014 compared to 1998 (excluding on-call service). Male physicians have seen a 9.7% reduction, going from 55.5 hours per week in 1998 to 50.1 in 2014. Female physicians have seen a 4.0% reduction, going from 48.2 hours per week in 1998 to 46.3 in 2014. • While time spent on direct patient care has decreased, male and female physicians have both seen an increase in time spent on other professional tasks, such as indirect patient care, continuing professional development and administrative activities. Female physicians have seen a 6.4% increase in weekly time spent on other professional activities and males have seen a 1.6% increase.
• In 2014, two-thirds of physicians said they provide on-call service, 67.0% of male physicians and 65.9% of female physicians. Those who provided on-call service said they worked an average of 107.17 on-call hours per month.154
Figure 39 – Physicians’ average weekly work hours by type of activity and sex, Canada, 1998 and 2014 (Excluding on-call hours). Source: CMA, CFPC, Royal College, 1998 & 2014, Physician Resource Questionnaire & NPS 70 Other professional activities 60 55.5 Direct Patient Care 50.1 50 48.2 17.5 46.3 40 17.8 16.5 17.6 30
Hours week per Hours 20 38.0 32.3 31.7 28.7 10
0 1998 2014 1998 2014
MEN WOMEN
• Generational differences are oft discussed, be it among physicians, other professions or society more broadly. • With respect to self-reported work hours, the change that has occurred among physicians has been generally uniform across age groups (see Figure 40). • As shown in Figure 40 all physician age groups report working fewer hours in 2014 compared to 1998. The largest reduction (8.8%) was among physicians aged 55-64. The smallest reduction (6.2%) was among physicians aged 65+.
Figure 40 - Physicians' average weekly work hours by age group, Canada, 1998 and 2014 (Excluding on-call hours). Source: CMA, CFPC, Royal College, 1998 & 2014, Physician Resource Questionnaire & NPS 60 54.2 54.9 54.7 55 52.3
50 51.0 50.0 49.9 43.6 45 48.0
Hours week per Hours 40 1998 40.9 2014 35
30 <35 35-44 45-54 55-64 65+ Age group Trends in Physician Workforce Supply
The Royal College Medical Workforce Knowledgebase155 provides key insights on the size and composition of Canada’s current and future physician workforce based on four indicators.
Total Licensed New Trainees •The number of • The number of Physicians residency positions physicians who offered in the first •The number of first became newly- •The number of iteration of the year (PGY1) post- certified by the active physicians in CaRMS R-1 match M.D. trainees CFPC and/or Royal Canada as reported (residents) College by CIHI
New R1 quota Certificants
Current highlights for primary specialties (2010-2014) include: • 13% and 12% overall increase in residency quota and new trainees, respectively • 26% increase in medical, surgical, and laboratory new certificants (Figure 41) • 13% increase in the licensed physician workforce
Figure 41 - Snapshot of physician workforce supply by broad specialty group, 2010-2014. Source: Royal College Medical Workforce Knowledgebase© Residency New New Licensed Trending Up quota Trainees Certificants Physicians Family Medicine 22% 25% 37% 15% No Trend Medical Specialties 11% 10% 28% 11% Surgical Specialties 8% 10% 22% 12% Laboratory Specialties 5% 3% 23% 10% Trending Down
• Family Medicine, Anatomical Pathology and Emergency Medicine experienced above average annual growth on all four indicators • Some disciplines were trending up (increased residency quota and new trainees) while others were trending down (decreased residency quota and new trainees)
Figure 42 – Primary specialty disciplines that were trending up (increased residency quota & new trainees) or trending down (decreased residency quota & new trainees), 2010-2014. Source: Royal College Medical Workforce Knowledgebase©.
Emergency Medicine General Surgery Anatomical Pathology Orthopedic Surgery TREND UP Family Medicine Radiation Oncology Plastic Surgery Psychiatry DOWN TREND Dermatology Otolaryngology - Head and Neck Surgery Internal Medicine Obstetrics & Gynecology Pediatrics Neurology Ophthalmology Diagnostic Radiology Scope of Practice
• Scope of practice is becoming an increasingly important consideration as the health workforce grows and diversifies. In a recent report, the Canadian Academy of Health Sciences states that “increased flexibility around scopes of practice and models of care is required to meet the changing population health needs and the diversity represented in communities across Canada”.156 • Physicians’ scope of practice can change in numerous ways. For example, a physician may start providing a new type of care that they didn’t in the past. A physician may practice largely as she/he did in the past, but stop providing a few specific types of medical care. Or a physician may significantly reduce his/her scope of practice, focusing in on a specific area of care and a more narrowly defined set of medical services. • Older physicians are more likely to reduce their scope of practice. About 6% of physicians aged <45 report reducing their scope of practice, compared to just over 12% of those aged 55-64 (see Figure 43).157 • Younger physicians are more likely to increase their scope of practice. About 11% of physicians aged <45 report increasing their scope of practice, compared to just over 5% of those aged 55-64 (see Figure 43).158 Figure 43 - Percent of physicians who reduced/increased their scope of practice in the last two years, by age group, Canada, 2013. Source: CMA, CFPC, & Royal College, 2013, National Physician Survey 25% 21.5% 20%
15% 12.3% 11.1% 11.3% 9.7% 10.2% 10% 8.7% 7.7% 6.2% 6.1% 5.2% 5% 2.0%
0% <35 35-44 45-54 55-64 65+ All Physicians Reduced Scope of Practice Increased Scope of Practice
• Healthcare providers have overlapping The CMPA on scope of practice… scopes of practice as they share and The new reality: Expanding scopes of collaborate in patient care. For practice example: o In 2012, Ontario became the Today's reality is that physicians are increasingly first province to allow nurse working with—and relying on—other health care practitioners (NPs) to admit and professionals when treating patients. Evolving discharge patients from models for health care delivery mean that other hospital. Other provinces are health professionals are playing an increasingly considering granting this significant and valuable role in the care of patients… Expanding the scope of care of each authority to NPs.159 member of the team improves access.
Source: Canadian Medical Protective Association, 2010. https://www.cmpa-acpm.ca/en/advice-publications/browse- articles/safety-of-care
o Canada’s new legislation on medical assistance in dying grants physicians and nurse practitioners similar authority to provide this new area of care.160 o In most Canadian jurisdictions, the pharmacists’ scope of practice includes a measure of authority to prescribe and/or manage medications.161
Technological environment
Technology is embedded in medical practice, and technological advancements constantly change physicians’ ability to diagnose and treat conditions.
Technology has been associated with driving up short term-costs, while concurrently facilitating savings in the medium and long-term. 162 For instance, it is estimated that since 2007, investments in telehealth, drug information systems, diagnostic imaging and physician and ambulatory clinic electronic medical records (EMRs) have produced cost savings and efficiencies in Canada worth approximately $16 billion.163
Electronic Health Records (EHR)
• As of March 31, 2016, 93.8% of Canadians have EHR data available to authorized physicians across six clinical domains: client demographics, provider demographics, diagnostic images, laboratory test results, clinical reports/immunizations and drug information systems.
• Figure 44 shows that the availability of drug information systems lags furthest behind. Canada Health Infoway (CHI) has identified this as an area of focus moving forward and plans to develop a pan-Canadian electronic prescribing system, known as PrescribeIT. The service will look to provide prescribers the ability to electronically transmit a prescription to a patient’s pharmacy of choice. CHI believes the service will “reduce the use of paper prescriptions, enhance patient safety and facilitate better health outcomes for Canadians.”164
Figure 44 - EHR Availability as of March 2016, by clinical domain Source: Canada Health Infoway, 2016, Annual Report 2015-2016
Canada continues to make strides in 100% 100% 100% 94% 100% 100% providing health professionals’ access to EHRs across the country - but what about patients? 80% 69% The Federal Government’s Advisory Panel on 60% Healthcare Innovation cites this gap in its 40% 2015 report on healthcare innovation, calling 20% on the Federal government to “support the 0% development of policy and legislative tools to
% available % available across Canada enable patient access to, and co-ownership of, their own personal health records”
Source: Advisory Panel on Healthcare Innovation (2015). Unleashing Innovation: Excellent Healthcare for Canada.
Electronic Medical Records (EMR)
• In the 2014 National Physician Survey165:
o 77.8% of specialist physicians reported using a combination of paper and electronic charts, or exclusively using electronic records.
o Specialist physicians identified technical glitches/reliability (52%) and compatibility with other systems (47.6%) as the top 2 barriers they experienced in accessing information. Medical oncologists were the highest proportion of specialists (70%) to record technical glitches as a challenge.
o 60.7% of specialist physicians who used EMRs stated they felt they provided better or much better quality of care since they adopted EMRs.
Telehealth
• A bi-annual survey of jurisdictional telehealth programs and networks found that166: o Most jurisdictions across Canada provide desktop or mobile video conferencing services for administrative, educational and clinical consultation purposes. o The total number of clinical telehealth sessions has more than doubled, from 187,385 sessions in the 2010 iteration of the survey, to 411,778 sessions in the 2014 survey. o Clinical services in mental health, neurology, oncology, pediatrics and rehabilitations were reported to be the most common services delivered with telehealth. o Telehealth is being utilized to provide educational services to healthcare professionals, with services in oncology, pediatrics and pharmacy being particularly prevalent across jurisdictions.
Other digital health solutions
E-booking: E-visits: Telehomecare:
Enabling patients to schedule and Enabling secure digital Enabling clinicians to remotely manage their appointments online. communication between health manage chronic health conditions. E-booking has been shown to be a providers and patients that can Telehomecare has been shown to popular digital health solution include emails, text messaging and improve patient and caregiver among Canadians; in a 2013 video conferencing. A patient quality of life and prevent survey, 90 percent of respondents survey in British Columbia found unnecessary hospital visits. stated that they would like the that among respondents who Approximately 5000 Canadians were ability to do e-bookings.167 accessed e-visits, over 90 percent enrolled in telehomecare programs indicated saving on travel time, in 2015-2016.169 expressed satisfaction with the security and privacy of their information, and felt that their health issue was addressed appropriately.168
E-Renewals: E-consultation: E-Referrals:
Enabling prescription renewals Enabling timely communication Enabling physicians to request a online. between providers through referral from another health computer applications about general provider electronically, avoiding the or patient-specific questions. In need for mail, fax or phone. 2013, the evaluation of an e- consultation system in Ontario found high levels of satisfaction among primary care providers and specialists, enhanced integration of referrals and consultations and the prevention of unnecessary specialist visits.170
Emerging technologies
Artificial Intelligence (AI):
It is estimated that: AI, software algorithms that perform tasks which • In 1950, it took 50 years to double the traditionally require human intelligence, is evolving rapidly world`s medical knowledge in many industries including health care. There is even a • By 1980, seven years dedicated journal, Artificial Intelligence in Medicine, which • By 2015, less than 3 years. publishes articles on the theory and practice of AI in • By 2020, 73 days.171 medicine, human biology and health care. AI is expected to increasingly support clinical decision-making moving AI will increasingly support clinical forward. For instance: decision-making in an increasingly complex medical data world. • Companies and researchers worldwide are leading promising clinical studies on sensors that analyze the chemical trail left by human body odor, to diagnose early signs of cancer and other diseases172. • A self-learning algorithm technique in devices and software that is often referred to as ‘deep learning’, has been shown to predict cardiovascular risk in patients173 and diagnose skin lesions as accurately as dermatologists174.
Robotics:
• Specialists are using a telepresence robot named Rosie to virtually offer real-time diagnosis and monitoring of patients in the Indigenous community of Pelican Narrows, Saskatchewan.175 • The next generation of surgical robotics will include Google, which has announced a partnership with pharmaceutical company Johnson & Johnson to develop robots that will assist surgeons with minimally invasive surgeries. Google is looking to enhance surgical robotic tools by leveraging technologies it is deploying in other areas of its business, such as their self-driving car project. By 2020 surgical robotic sales are forecasted to generate $6 billion, double the sales recorded in 2014, according to a report prepared by Allied Market Research.176
3-D Printing: The convergence of technologies 3-D printing is expanding rapidly and expected to such as artificial intelligence, revolutionize health care with its manufacturing techniques robotics and 3-D printing provide a used to create three-dimensional objects such as customized implants, prosthetics, medical models and medical devices. small sampling of the broader For instance: emergence of new technologies that may potentially drive significant • Nia technologies, a Canadian non-profit company, is changes to the delivery of health 3-D printing prosthetic sockets and ankle foot care in the future. What impact will orthoses to children and youth from less developed new technologies have on countries with lower-limb disabilities. Preliminary physicians’ scope of practice, results suggest that the technology is producing curriculum content, physician supply objects in 1.5 days, instead of 5 days through and practice standards? Will new conventional methods.177 • 3-D printers have produced over 60 million custom- technologies play a facilitative role, shaped hearing-aid shells and ear molds since or will they replace select work of 2000.178 physicians moving forward? The • Prospective applications of 3-D printing include the medical profession will need to construction of human tissues by 3-D printing cells (e.g. reflect on these questions, among to address shortages in organ donations) and printing others, as proven innovations drugs (e.g. printing nonstandard doses for children or the elderly); the latter achieved by downloading assimilate into clinical practice pharmaceutical recipes into a 3-D printer. 179 moving forward.
The Canadian Agency For Drugs And Technologies In Health (CADTH), an independent agency that publishes Horizon Scan Roundup, a series of reports that identify new and emerging technologies that may have an impact on Canadian healthcare. The 2016 iteration of the reports highlights various medical technologies including medical devices, laboratory tests, biomarkers, programs, and procedures that may have an impact in the future, including the following:
• FLEXISEQ, a topical gel for treating symptoms of osteoarthritis. • GPS locator devices for people with dementia, often at risk of wandering. • ReActiv8, a device that consists of a pulse generator and wires that is implanted for treating chronic low back pain. • STAR Tumor Ablation System, a device used for the palliative treatment of metastatic spinal tumors. • PATHFAST Presepsin, a laboratory analysis device developed for the rapid diagnosis of sepsis. • Mobi-C, a prosthetic device for adults with neck problems due to cervical disc degeneration. • AVATAR, computer software that looks to treat select hallucinations that are common in serious mental illnesses such as schizophrenia. • Get SET Early Model, a screening tool for pediatric autism spectrum. 180 Final thoughts
This document provides a snapshot of what influences and shapes our health and health care system. Parts of this environmental scan became out-of-date while you read it given the quick changing nature of the environment. It is hoped, however, that it does help demystify the maze of health, health care and health system information that surrounds us. We encourage readers to contact the Office of Health Policy at [email protected] with any comments, questions, or to suggest new content for future iterations of this environmental scan.
1 Office of the Prime Minister, 2016, Minister of Health Mandate 2 Department of Finance, 2011, Backgrounder on Major Transfer 3 Campion-Smith, 2016, Health talks fail despite 4 Canada News Wire, 2017, Canada Reaches Health Funding 5 Canada News Wire, 2017, Canada Reaches Health Funding 6 Government of Canada, 2016, Canada reaches agreement with 7 Government of Canada, 2017, Canada reaches health funding 8 Government of Canada, 2017, Canada reaches health funding 9 Government of Canada, 2017, Canada reaches health funding 10 Government of Canada, 2017, Canada reaches health funding 11 New Brunswick Canada, 2016, REVISED / Canada-New Brunswick health 12 Canada News Wire, 2017, Canada Reaches Health Funding 13 Alberta Medical Association, 2016, Overview: Amendments to the 14 Zussman, 2017, Health premiums cut in 15 Picard, 2016, Private vs. public: B.C. 16 Dhillon, 2017, Financial hurdles halt lawsuit 17 Government of British Columbia, 2017, $140 million to improve 18 Health Intelligence Inc. and Associates, 2017, Provincial Clinical Preventive Services 19 Manitoba Government, 2016, Province Awards Contract for 20 Annable, 2017, Privatization an option for 21 Annable, 2017, Privatization an option for 22 Government of New Brunswick, 2017, New Brunswick Family Plan 23 Government of New Brunswick, 2017, Premier Launches New Brunswick 24 Province of New Brunswick, 2017, We are all in 25 Statistics Canada, 2016, Population by sex and 26 McCabe, 2017, 'Difficult day': 93 health 27 All-Party Committee on Mental Health and Addictions, 2017, Towards Recovery: A Vision 28 Government of Newfoundland and Labrador, 2017, Increasing Patient Safety 29 Doctors Nova Scotia, 2016, Doctors accept new four 30 Province of Nova Scotia, 2016, More Nova Scotians to 31 Grant, 2016, Ontario Doctors won’t rule 32 Ontario Medical Association, 2017, Statement from the Board 33 Ontario Medical Association, 2017, OMA Response to Premier’s 34 Ontario Medical Association, 2017, Members ratify binding 35 Government of Ontario, 2016, Ontario Reintroduces Legislation to 36 Ontario Medical Association, 2017, Bill 41 is a 37 Fraser & Sinclair, 2016, Abortion services coming to 38 Yarr, 2016, New P.E.I. health act 39 Province of Prince Edward Island, 2016, Mental Health and Addiction 40 Pindera and Shingler, 2017, What can you be 41 Montpetit, 2017, Fed up with combative 42 CTV News, 2016, $100 million to reduce 43 Solyom, 2016, Quebec pledges $76.1 million 44 Government of Saskatchewan, 2017, Government Announces Move to 45 Government of Saskatchewan, 2016, Saskatchewan Advisory Panel on 46 Charlton, 2016, Provincial health cuts will 47 Charlton, 2016, Provincial health cuts will 48 Huffman and Dao, 2016, Federal health minister tells 49 Government of Canada, 2016, A Framework for the 50 Harris, 2017, Liberals table bills to 51 Cheadle, 2016, Legal marijuana tax revenue 52 Canadian Medical Association, 2017, Protecting health of Canadians 53 Canadian Psychiatric Association, 2017, Implications of Cannabis Legalization 54 Grant et. al., 2016, Cannabis and Canada’s children and youth 55 Centre for Addiction and Mental Health, 2017, Canada’s Lower-Risk Cannabis 56 Hager, 2016, Among veterans, opioid prescription 57 International Narcotics Control Board, 2013, Narcotics Drugs: Estimated World 58 Dhalla, et. al., 2009. Prescribing of opioid analgesics, 891-896 59 Russell, 2016, Year in review: 5 60 Canadian Institute for Health Information, 2016, Hospitalizations and Emergency Department 61 Canadian Institute for Health Information, 2016, Hospitalizations and Emergency Department 62 Government of Canada, 2016, Joint Statement of Action
63 Government of Canada, 2016, Medical assistance in dying 64 CTV News, 2016, At least 744 assisted 65 Government of Canada, 2016, Government of Canada Initiates Studies 66 Bank of Canada, 2016, The Canadian Economy: A 67 Organisation for Economic Co-operation and Development, 2016, Canada — Economic Forecast Summary. 68 Business Development Bank of Canada, 2017, 2017 economic outlook: Expect 69 Global Affairs Canada, 2017, Annual Economic Indicators 70 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 71 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 72 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 73 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 74 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 75 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 76 Canadian Institute for Health Information, 2016, Prescribed Drug Spending in 77 Mackenzie, 2016, Down the Drain: How 78 Citizens’ Reference Panel on Pharmacare in Canada, 2016, Necessary Medicines: Recommendations from 79 Morgan, et. al., 2015, Estimated cost of universal 80 Galloway and Grant, 2016, Philpott, provinces hit impasse 81 Canadian Institute for Health Information, 2016, National Health Expenditure Trends 82 Statistics Canada, 2016, Table 051-0001 Estimates of 83 Statistics Canada, 2016, Table 051-0001 Estimates of 84 Statistics Canada, 2011, Population, urban and rural,2011 85 Statistics Canada, 2016, Table 051-0005 Estimates of 86 Public Health Agency of Canada, 2014, Monitoring chronic diseases in 87 Statistics Canada, 2013, Table 102-0561 Leading causes 88 Canadian Cancer Society, 2016, Canadian Cancer Statistics 2016 89 Canadian Cancer Society, 2016, Canadian Cancer Statistics 2016 90 Canadian Cancer Society, 2016, Canadian Cancer Statistics 2016 91 Statistics Canada, 2013, Leading Causes of Death 92 Maclagan et al., The CANHEART health index, 185 93 Government of Canada, 2016, Stroke in Canada 94 Bond, Stonebridge, and Theriault, The Canadian Health Heart Strategy 95 Government of Canada, 2016, Heart Disease in Canada 96 Statistics Canada, 2015, Canadian Community Health Survey 97 Government of Canada, 2016, Heart Disease in Canada 98 Government of Canada, 2016, Heart Disease in Canada 99 Canadian Diabetes Association, 2015, 2015 Report on Diabetes 100 Canadian Diabetes Association, 2015, 2015 Report on Diabetes 101 Public Health Agency of Canada, 2011, Diabetes in Canada: Facts, 4 102 Public Health Agency of Canada, 2016, The Canadian Chronic Disease 103 Government of Canada, 2016, #WelcomeRefugees: Key figures 104 Gushulak et al., 2011, Migration and health in, E952-8 105 Pottie et al., 2011, Evidence-based clinical guidelines, E824-925 106 Senate Canada, 2016, Finding Refuge in Canada: 107 First Nations Information Governance Centre, 2012, First Nations Regional Health 108 Statistics Canada, 2016, Table 105-050 Health indicator 109 Mental Health Commission of Canada, 2012, Making the Case for 110 Mental Health Commission of Canada, 2012, Making the Case for 111 Mental Health Commission of Canada, 2012, Making the Case for 112 Canadian Institute for Health Information, 2015, Trends in income-related 113 Statistics Canada, 2013, Table 105-0513, Health indicator profile, by 114 Parachute Canada, 2015, The Cost of Injury 115 Parachute, Injury in Canada 116 Parachute, Injury in Canada 117 Statistics Canada, 2013, Table 102-0551 Deaths and 118 Navaneelan, 2015, Suicide rates: An overview 119 Statistics Canada, 2013, Table 102-0551 Deaths and 120 First Nations Information Governance Centre, 2012, First Nations Regional Health 121 Statistics Canada, 2012, Aboriginal Peoples Survey, 2012 122 First Nations Information Governance Centre, 2012, First Nations Regional Health 123 Statistics Canada, 2012, Aboriginal Peoples Survey, 2012 and Canadian Community Health Survey 124 Assembly of First Nations, 2015, 2015 Federal Election Priorities 125 World Health Organization, 2003, Obesity and Overweight 126 Canadian Institute for Health Information, 2015, Trends in income-related 127 Statistics Canada, 2016, Aboriginal Peoples Survey, 2012
128 First Nations Information Governance Centre, 2012, First Nations Regional Health 129 University of Waterloo, 2015, Tobacco Use in Canada 130 Health Canada, 2011, Smoking and Your Body 131 Canadian Institute for Health Information, 2015, Trends in income-related 132 University of Waterloo, 2015, Tobacco Use in Canada 133 Gionet and Roshananfshar, 2013, Select health indicators of 134 First Nations Information Governance Centre, 2012, First Nations Regional Health 135 Canadian Institute for Health Information, OECD Interactive Tool: International Comparisons 136 Canadian Institute for Health Information, 2016, Wait times for priority 137 Canadian Institute for Health Information, 2016, Wait times for priority 138 World Health Organization, 2016, Global strategy on human 139 Health Canada, 2016, Committee on Health Workforce 140 CaRMS, 2016, R1 Match - Table 3 & 5 141 CaRMS, 2016, R1 Match - Table 12 & 14 142 CaRMS, 2016, R1 Match - Table 1 Summary of Match Results 143 CAPER, 2015-16, Table F-1 Legal Status 144 CAPER, 2015-16, Table C-2 International Medical 145 CAPER, 2015-16, Table A-1 Field of 146 CAPER, 2015-16, Table A-3 Visa Trainees 147 CAPER, 2015-16, Table I-3 Visa Trainees 148 Royal College, 2013, What’s really behind Canada’s 149 CAPER, 2014-15, Table H-1 & H-2 150 Canadian Institute for Health Information, 2015, Supply, Distribution and Migration 151 Organisation for Economic Co-operation and Development, 2014, Doctors (indicator) 152 Canadian Institute for Health Information, 2014-15, Understanding the Physician Workforce 153 Statistics Canada, 2011, Population, urban and rural 154 Canadian Medical Association, et al., 2014, 2014 National Physician Survey 155 Royal College, 2016, Medical Workforce Knowledgebase 156 Nelson et al., 2014, Optimizing Scopes of Practice 157 Canadian Medical Association, et al., 2013, 2013 National Physician Survey 158 Canadian Medical Association, et al., 2013, 2013 National Physician Survey 159 Canadian Medical Protective Agency, 2014, Physicians and nurse practitioners 160 Government of Canada, 2017, Medical assistance in dying 161 Canadian Pharmacists’ Association, 2016, Pharmacists' Scope of Practice 162 Canadian Institute for Health Information, 2011, Health Care Cost Drivers 163 Canada Health Infoway, 2015-2016, A Conversation about Digital 164 Canada Health Infoway, 2016, New e-Prescribing Service to 165 Canadian Medical Association, et al., 2014, 2014 National Physician Survey 166 Canada’s Health Informatics Association, 2015, 2015 Canadian Telehealth Report 167 Canada Health Infoway, 2014, Exploring the value, benefits 168 Canada Health Infoway, 2016, Virtual Visits in British 169 Canadian Health Infoway, 2015-2016, A Conversation about Digital 170 Liddy et al., 2013, Building access to specialist 171 IBM, Hamilton looks to AI 172 Murphy, 2017, One Day, A Machine 173 Weng et al., 2017, Can machine-learning improve 174 Esteva et al., 2017, Dermatologist-level classification of 175 Allen, 2015, 5 Ways Robots are 176 Dhabale, 2016, Surgical Robotics Market by 177 Ali, 2016, Nia Technologies brings 3D 178 The Economist, 2016, Additive manufacturing: A printed smile 179 Dodziuk, 2016, Applications of 3D printing 180 Canadian Agency for Drugs and Technologies in Health, Horizon Scanning Publications
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