College of Physicians and Surgeons of Ontario

Abstract Introduction British Columbia is one of only two provinces in Canada that mandate accreditation for HSAT facilities. After achieving provisional accreditation by passing a desktop audit, 151 facilities became eligible to obtain full accreditation. This study examines the types of nonconformance identified during the full on-site assessment process. Methods Between 2022 and 2024, 95 facilities (62.9%) underwent on-site visits, which involved formal interviews with management and staff, evidence review, patient set-up observation, evaluation of ten clinical cases (final report packages), assessments of physical space, safety measures, and scoring quality. The process followed a standardized protocol based on 329 standards published in 2021 (1). The assessment results identified areas of nonconformance that facilities needed to address to achieve full accreditation. Results By December 2024, 95 out of 151 facilities in British Columbia (62.9%) had completed the accreditation process, with a total of 916 nonconformance issues identified during on-site assessments. These nonconformance issues were categorized as follows: procedural and documentation areas: 219 (23.8%); human resources standards: 139 (15.2%); medical director’s duties: 114 (12.5%); ethical standards: 76 (8.3%); HSAT equipment evaluation and maintenance: 66 (7.2%); reporting standards: 54 (5.9%); scoring and Interpretation: 46 (5.0%); client complaints and; feedback requirements: 45 (4.9%); safety and privacy: 38 (4.2%); patient communication: 32 (3.5%); technical HSAT Issues: 26 (2.8%); test appropriateness, infection prevention, and information management: 61 (6.7%) combined. This analysis shows that procedural and documentation issues were the most common area of nonconformance, followed by human resources standards and the medical director’s duties. We found that 10 out of 95 HSAT facilities (10.5%) fully met the current HSAT accreditation standards without any outstanding requirements. Conclusion Independent HSAT facilities are still essential in delivering diagnostic sleep services in British Columbia. These facilities have continuously embraced the accreditation process to enhance patient care and safety. This study, which presents the initial experience with the HSAT accreditation process, aims to pave the way for future research into the positive impact of accreditation programs on public health outcomes. Support (if any) Reference: 1. College of Physicians and Surgeons of British Columbia. (2021). Home Sleep Apnea Testing. Accreditation Standards, Version 1.0. https://www.cpsbc.ca/files/pdf/DAP-AS-Home-Sleep-Apnea-Testing-V1.0.pdf

ABSTRACT This is a discussion of “Permeable boundaries: Therapeutic benefits,” by Geist and Nocek. In my opinion, the core of their paper is the mutuality of their love and trust for each other, and they use the term “permeable boundaries” as a metaphor for these feelings, rather than it being the kind of singular, relational state they are proposing. As a positive contribution, the experience-near description of their mutual love for each other expands the degree of intimacy in psychoanalytic writing about analytic love. However, there is a lack of sufficient information to understand their paper as a psychoanalytic treatise, and I have a number of disagreements with their conceptualization of “permeable boundaries,” as well as concerns about the quality of their mutual love which they portray as idyllic but which, in my opinion, lacks certain key elements of analytic love.

BackgroundClinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program.MethodsA review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations.ResultsWe identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program.ConclusionsComprehensive care requires the ability to address a person’s overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

There has been a resurgence of interest in psychiatric rehabilitation to cater to patients with chronic and complex mental illnesses. This study is aimed at examining patients' characteristics and the prevalence of psychiatric and non-psychiatric comorbidity in a local inpatient rehabilitation service, as well as to investigate the impact of the whole-system approach to rehabilitation on future utilization of mental health services and to analyze the cost-effectiveness and quality of this service. Patients managed over 3 years in a psychiatric rehabilitation inpatient unit were self-controlled; they were retrospectively (pre-rehabilitation) and prospectively (post-rehabilitation) examined for readmission rate, length of stay (LOS), and emergency room (ER) visits. Relevant information was retrieved from Discharge Abstract Database (DAD), Patient Registration System (STAR), and Emergency Department Information System (EDIS). The quality of care in the rehabilitation unit was examined using the Quality Indicator for Rehabilitative Care (QuIRC), and the cost analysis was conducted using data obtained from a single-payer government medical service insurance (MSI) billing system. Of the 185 patients admitted over the study period, 158 were discharged. There was a significant reduction in readmission rate (64% decrease), LOS (6,585 fewer days spent in hospital), and ER presentations (166 fewer visits) (P < 0.0001), respectively. There were substantial subsequent cost savings in the post-rehabilitation year. In the 3-year study, an inpatient psychiatric rehabilitation service in Nova Scotia, Canada, resulted in the successful discharge of most patients with severe and persistent mental illness to more socially inclusive environments. It also reduced their post-rehabilitation mental health service utilization, hence greatly enhancing the effectiveness and efficiency of these services.

BACKGROUND Diabetes—a high-burden chronic disease—requires lifetime active management involving the use of different tools and health care resources to improve patient health outcomes. Recent studies have demonstrated promising results regarding the impact of the use of virtual care technology on the treatment of chronic diseases, such as diabetes. However, it is unclear whether the use of technologies, such as secure messaging, improves the quality of care and reduces diabetes-related costs to the health care system. OBJECTIVE The purpose of our scoping review is to explore what is known about the use of secure messaging in the treatment of diabetes within the primary care setting and how its impact has been assessed from the patient and health system perspectives. Our review aims to understand to what extent secure messaging improves the quality of diabetes care. METHODS Our scoping review will follow the 6-step Arksey and O’Malley methodological framework, as well as the Joanna Briggs Institute methodology for scoping reviews and their recommended tools. The tools to guide the development and reporting of the review in a structured way will include the Population, Concept, and Context framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines and checklist. The search strategy was developed iteratively in collaboration with a professional information specialist. Furthermore, a peer review of electronic search strategies was also conducted by an independent, third-party, professional information specialist. A systematic literature search will be conducted against databases, including Ovid MEDLINE ALL, Embase, APA PsycINFO, Cochrane Library on Wiley, CINAHL on EBSCO, and PubMed. Grey literature sources will also be searched for relevant literature. Literature on the use of secure messaging in the treatment of diabetes (types 1 and 2) within a primary care setting will be included. Two reviewers will review the literature based on the inclusion criteria in the following two steps: (1) title and abstract review and (2) full-text review. Discrepancies will be discussed to reach consensus where possible; otherwise, a third reviewer will resolve the dispute. RESULTS The results and a final report are expected to be completed and submitted to a peer-reviewed journal in 6 months. CONCLUSIONS The review will examine existing literature to identify the impact of secure messaging in diabetes treatment within primary care settings. Research gaps will also be identified to determine if there is a need for further studies. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/42339

Abstract Background: The opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013-2018 in Alberta, Canada.Methods: All adult patients defined as chronic opioid users who received medical cannabis authorization in the province of Alberta from 2013-2018 were propensity score matched to non-authorized chronic opioid using controls. 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users.Results: Average age was 52 years and 54% were female. Patients on low dose opioids (&lt;50 OME) had a slightly increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME &gt;100), showed a significant decrease over 6 months (-435.5, 95% CI: -596.8 to -274.2) compared to controls. Conclusions: This short-term study found that medical cannabis authorization showed intermediate effects on opioid utilization, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME&gt;100); however, continued surveillance of patients utilizing both opioids and medical cannabis – is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.

To be effective, palliative care education interventions need to be informed, among others, by evidence and best practices related to curriculum development and design. Designing palliative care continuing professional development (CPD) courses for large-scale, national deployment requires decisions about various design elements, including competencies and learning objectives to be addressed, overall learning approaches, content, and courseware material. Designing for interprofessional education (IPE) adds additional design complexity. Several design elements present themselves in the form of polarities, resulting in educators having to make choices or compromises between the various options. This article describes the learning design decisions that underpin Pallium Canada's interprofessional Learning Essential Approaches to Palliative Care (LEAP) courses. Social constructivism provides a foundational starting point for LEAP course design, as it lends itself well to both CPD and IPE. We then explore design polarities that apply to the LEAP courseware development. These include, among others, which professions to target and how to best support interprofessional learning, class sizes, course length and content volume, courseware flexibility, regional adaptations, facilitator criteria, and learning methods. In some cases, compromises have had to be made between optimal perfect design and pragmatism.

Medical regulatory authorities are legally mandated to protect patients by monitoring the practice of medicine. While principally a matter of public safety, many pursue this mission by establishing quality improvement initiatives that prioritize professional development for all rather than identification of substandard performers. Engaging practitioners in directed learning opportunities, however, is rife with challenge given inherent social complexities. This study was run to explore whether relationship-centered coaching could improve physicians' perceptions of the value of engaging with College-mandated peer review. A quasi-experimental analysis was performed on physician ratings of the effectiveness of peer assessor interactions and assessment processes during 3 time periods: (1) an historical control (March 2016-December 2016; n = 296); (2) a period after assessors were trained to deliver feedback using relationship-centered coaching (December 2016-March 2017; n = 96); and (3) after physicians were given more capacity to choose patient records for peer review and engage in discussion about multisource feedback results (March 2017-December 2018; n = 448). Psychometric analyses supported the aggregation of survey items into assessor interaction and assessment process subscores. Training assessors to engage in relationship-centered coaching was related with higher assessor interaction scores (4.64 vs 4.47; P < .05; d = 0.37). Assessment process scores did not increase until after additional program enhancements were made in period 3 (4.33 vs 4.17, P < .05, d = 0.29). Despite peer interactions being inherently stressful for physicians when they occur in the context of regulatory authority visits, efforts to establish a quality improvement culture that prioritizes learning can improve physicians' perceptions of peer review.

Assessor training is essential for defensible assessments of physician performance, yet research on the effectiveness of training programs for promoting assessor consistency has produced mixed results. This study explored assessors' perceptions of the influence of training and assessment tools on their conduct of workplace-based assessments of physicians. In 2017, the authors used a constructivist grounded theory approach to interview 13 physician assessors about their perceptions of the effects of training and tool development on their conduct of assessments. Participants reported that training led them to realize that there is a potential for variability in assessors' judgments, prompting them to change their scoring and feedback behaviors to enhance consistency. However, many participants noted they had not substantially changed their numerical scoring. Nonetheless, most thought training would lead to increased standardization and consistency among assessors, highlighting a "standardization paradox" in which participants perceived a programmatic shift toward standardization but minimal changes in their own ratings. An "engagement effect" was also found in which participants involved in both tool development and training cited more substantial learnings than participants involved only in training. Findings suggest that training may help assessors recognize their own subjectivity when judging performance, which may prompt behaviors that support rigorous and consistent scoring but may not lead to perceptible changes in assessors' numeric ratings. Results also suggest that participating in tool development may help assessors align their judgments with the scoring criteria. Overall, results support the continued study of assessor training programs as a means of enhancing assessor consistency.