Background:The province of British Columbia is facing a family physician shortage despite consistent increases in the number of physicians per capita and ongoing reforms to address the shortage. We identify physicians’ priorities for structural reform, describe the alignment of those priorities with BC’s suite of reforms and compare responses between established physicians and those new to practice; we also assessed rates of burnout.Methods:All family physicians credentialed within Vancouver Coastal Health in 2018 were invited to participate in a cross-sectional survey. Respondents were asked about their practice model and characteristics, demographics, level of burnout and reform priorities. We used χ2 tests and multivariable logistic regression to investigate associations between personal and practice characteristics, burnout and reform priorities.Results:Of the 1017 family physicians invited to participate, 525 (51.6%) responded. Of these, 399 (76.0%) indicated a need for fundamental change to how primary care is delivered; 244 (46.4%) would prefer to be a clinic employee rather than a small business owner. Other reform priorities included options to practise in a team (stated as very important by 69.6% of respondents), direct funding for team roles (66.7%), direct clinic funding (59.8%), part-time work options (64.7%), and ability to take planned vacations and parental leave (81.1%). The importance of individual reform priorities varied based on the participants’ model of practice, location and years in practice. Of respondents, 108 (21.1%) had experienced a high level of burnout.Interpretation:Almost half of family physicians would prefer to be employees rather than small business owners and over 20% reported a high level of burnout. Practice models offering direct employment model have very limited availability and are not included in the current suite of reforms in BC, potentially pulling physicians away from community-based family medicine and into other models or specialties.

Background:Penicillin is the most frequently reported drug allergen; however, most of these allergies are not true allergies and do not justify the prescription of alternative, less effective and more expensive antibiotic drugs. We aimed to show that patients at low risk of amoxicillin allergy can safely and efficiently undergo oral provocation challenge (OPC) by their primary care physician.Methods:In this descriptive analysis, we conducted a retrospective chart review of all primary care patients who had undergone OPC from November 2017 to October 2019 in the Amoxicillin Allergy Clinic at the North Perth Family Health Team, Listowel, Ontario. Eligibility for OPC among patients 18 months and older was determined through review of a self-reported patient intake form asking about symptoms, onset, duration, history and family history of allergic reactions, as well as the patient’s electronic medical record. Patients were considered to be at low risk of true penicillin allergy if there was no history of anaphylaxis or severe cutaneous reactions. Those with low-risk allergic reactions returned for testing with an OPC to amoxicillin. We collected data on clinical characteristics, antibiotic exposure, parental drug allergy, response to OPC and wait time from referral. We used t tests to describe and compare these variables. Our primary outcome was reaction to OPC by severity as categorized by the World Allergy Organization grading system. Our secondary outcome was the time from referral to completed testing.Results:In total, we included 99 patients (mean age 28.3, standard deviation [SD] 21.2 yr); 72 (73%) were female. Of those tested, 97% (n = 96) completed the OPC with no reaction, 3% (n = 3) had mild immediate reactions, and no serious immediate reactions developed. Mean wait time to testing was 59.0 (SD 69.8) days, with a median (interquartile range) of 39.5 (13.5–70.0) days.Interpretation:Oral provocation challenge presents a safe and accessible opportunity for primary care providers to address erroneous allergy labels to penicillin and related drugs within the primary care office setting. There could be positive public health implications if OPC to penicillin drugs is implemented in primary care.

Background:Severe obesity is associated with adverse health outcomes and increased risk of death. This study evaluates the real-world cost–utility of therapy for severe obesity, from the publicly funded health care system and societal perspectives.Methods:We conducted a cost–utility analysis using primary data from a prospective observational cohort of adults living with severe obesity (BMI ≥ 35 kg/m2 and a major medical comorbidity or BMI ≥ 40 kg/m2) who were enrolled in a regional obesity program over 2 years. We extrapolated 10-year and lifetime Markov models, validated and supplemented with literature sources, to compare medical, surgical and standard care therapies. We performed deterministic and probabilistic sensitivity analyses.Results:The cohort included 500 adults living with severe obesity, 150 of whom received laparoscopic surgical therapy. From a publicly funded health system perspective, at 2 years, surgical therapy had an incremental cost–effectiveness ratio (ICER) of $54 456 per quality-adjusted life-year (QALY) compared with standard care therapy. Over a lifetime, it had an ICER of $14 056 per QALY. From the societal perspective, at 2 years, surgical therapy had an ICER of $340 per QALY; over a lifetime, it was the dominant option. The results were robust to sensitivity analysis.Interpretation:From a public health care perspective, surgery for severe obesity is cost effective, and when approached from a societal perspective, it becomes cost saving. Real-world data support using surgical therapy for severe obesity, and our results contribute to the health economic and clinical literature with regard to a robust analysis from a societal perspective.

Background:There is a lack of Métis-guided participatory research on factors that contribute to individual, family and community well-being, such as developing social support and engaging in cultural, social and historical processes for healing and health. The purpose of this study was to explore links among health, spirituality and well-being within the Métis Nation of Alberta (MNA) – Region 3.Methods:In the largest of 12 MNA – Region 3 communities, together with a working group of 9 community members, informal and elected leaders, and an Elder, we codeveloped a qualitative structured survey exploring health, spirituality and well-being. Following face-to-face distribution of the paper survey to community members (February to March 2019), we engaged with 7 working group members in coding and theme development. Results were shared with the community.Results:Thirty-one community members requested surveys, with 29 participants aged 28–80 years (mean 54.77 yr, standard deviation 15.31 yr) completing the surveys (94% completion rate). Six participants were in the working group that codeveloped the survey. An overarching theme of connection and 4 corresponding subthemes were identified; central to well-being was maintaining connection and balance in mental, emotional, spiritual and physical aspects of health. Connection to Métis ancestry required understanding identity; connection to community involved feeling at home; connection to land included belonging; and connection to tradition encompassed blending of cultures.Interpretation:Connection among ancestry, land, community and tradition contributed to well-being in our sample. Under the direction of each MNA region, exploration of health, spirituality and well-being with the use of our survey could be considered in community-specific Métis-guided ways across the remaining 5 MNA regions; the survey may also be of use to other provincial bodies in the Métis Nation.

Background:In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences.Methods:We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%–19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories.Results:Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%–25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%–43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients.Interpretation:Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.

Background:The COVID-19 pandemic has resulted in unique pressures on the emergency services system. This study describes changes in the presentation, presenting severity and disposition of patients accessing emergency services in Calgary, Alberta, during the first wave of the pandemic.Methods:In this descriptive study, we constructed a population cohort of all patients who accessed emergency services by calling emergency medical services (EMS) (ambulance service that provides prehospital treatment and transport to medical facilities) or presenting directly to an emergency department (4 adult and 1 pediatric) or 2 urgent care centres in Calgary during the exposure period (December 2019 to June 2020) compared to 2 historical control periods (December to June, 2017–2018 and 2018–2019) combined. Outcomes included frequency of presentation, system flow indicators, patient severity, disposition and mortality. We used a locally estimated scatterplot smoothing function to visualize trends. We described differences at the maximum and minimum point of the exposure period compared to the control period.Results:A total of 1 127 014 patient encounters were included. Compared to the control period, there was a 61% increase in the number of patients accessing EMS and a 35% decrease in the number of those presenting to an adult emergency department or urgent care centre in the COVID-19 period. The proportion of EMS calls for the highest-priority patients remained stable, whereas the proportion of patients presenting to an emergency department or urgent care centre with the highest-priority triage classification increased transiently by 0.9 percentage points (increase of 89%). A smaller proportion of patients were transported by EMS (decrease of 21%), and a greater proportion of emergency department patients were admitted to hospital (increase of 25%). After the first case was reported, the mortality rate among EMS patients increased by 265% (3.4 v. 12.4 per 1000 patient encounters).Interpretation:The first wave of the COVID-19 pandemic was associated with substantial changes in the frequency and disposition of patients accessing emergency services. Further research examining the mechanism of these observations is important for mitigating the impact of future pandemics.

Background:A gluten-free diet (GFD) is required for the management of some conditions, whereas some Canadians may follow a GFD for discretionary reasons. We sought to estimate the prevalence of Canadians who adhere to a GFD, identify factors associated with adherence to a GFD, and describe and compare the location of food preparation and consumption for those who follow a GFD, those who report no dietary avoidances and those reporting other dietary avoidances.Methods:We used cross-sectional data from the 2015 Canadian Community Health Survey — Nutrition (n = 20 487). Demographic variables included sex, age group, ethnicity, highest level of household education and income adequacy. The relations between respondent characteristics and report of a GFD were estimated using logistic regression. Respondents were further categorized as avoiding dietary gluten, other dietary avoidances and no dietary avoidances.Results:An estimated 1.9% of Canadians follow a GFD. Women had 2 times higher odds (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.32 to 3.27) of reporting a GFD than men. After adjustment for income adequacy, household education, sex, age group and ethnicity, residents of Ontario and Quebec had about half the odds (OR 0.52, 95% CI 0.31 to 0.87, and OR 0.55, 95% CI 0.32 to 0.94, respectively) of reporting a GFD compared with residents of Atlantic Canada. Canadians who followed a GFD consumed significantly fewer calories from foods prepared at restaurants than both Canadians who reported no dietary avoidances and those who reported dietary avoidances other than gluten. Canadians following a GFD reported that 2.0% (95% CI 1.1% to 2.9%) of their daily kilocalories were from foods prepared at restaurants, compared with 6.7% (95% CI 5.4% to 7.9%) for Canadians reporting 1 or more dietary avoidances other than gluten, and 6.4% (95% CI 6.0% to 6.9%) for those reporting no avoidances.Interpretation:The estimated 1.9% prevalence of dietary gluten avoidance likely includes individuals with celiac disease, wheat allergies and nonceliac gluten sensitivity, as well as individuals excluding gluten in the management of irritable bowel syndrome or for reasons related to dietary trends. Canadians eating GFDs consume fewer daily calories from restaurant-prepared foods than other Canadians, which may have social implications.

Background:Deaths related to opioid overdoses are increasing in North America, with the emergency department being identified as a potential contributor toward this epidemic. Our goal was to determine whether a departmental guideline for the prescribing of restricted medications resulted in a reduction in opioids prescribed in a Canadian setting, with a secondary objective of determining the impact on local overdose frequency.Methods:We conducted a retrospective analysis of the prescribing habits of emergency department physicians in 3 hospitals in the Saskatoon Health Region, Saskatchewan, before (Nov. 1, 2015, to Apr. 30, 2016) and after (Nov. 1, 2016, to Apr. 30, 2017) implementation of a guideline in September 2016 for the prescribing of restricted medications. We quantified opioids prescribed per hour worked and per patient seen. We performed Student paired 2-tailed t tests for both individual drug formulations and the combined total morphine equivalents.Results:Thirty-two emergency department physicians were included. We found a decrease of 31.1% in opioids prescribed, from 10.36 morphine milligram equivalents (MME) per patient seen to 7.14 MME per patient seen (absolute change −3.22 MME, 95% confidence interval −4.81 to −1.63 MME). Over the same period, we found no change in prehospital naloxone use and a modest increase in the amount of naloxone dispensed by emergency department pharmacies. There was no decrease in the number of overdoses after guideline implementation.Interpretation:Implementation of a guideline for the prescribing of restricted medications in a Canadian emergency department setting was associated with a decrease in the quantity of opioids prescribed but not in the number of overdoses. This finding suggests that the emergency department is unlikely the source of opioids used in acute overdose, although emergency department opioid prescriptions cannot be ruled out as a risk factor for opioid use disorder.

Background:Burnout and distress have a negative impact on nurses and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among nurses in a cardiovascular centre at 2 quaternary referral hospitals in Canada, and compare these outcomes to those for nurses at academic health science centres (AHSCs) in the United States.Methods:We conducted a survey of nurses practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work–life integration, meaning in work and distress; a score of 2 or higher on the WBI indicated high distress. We also evaluated nurses’ perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal–Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nurses at AHSCs in the US who completed the WBI to responses from our participants.Results:The response rate to the survey was 49.1% (242/493). Of the 242 respondents, 188 (77.7%) reported burnout in the previous month; 189 (78.1%) had a WBI score of 2 or higher, and 132 (54.5%) had a score of 4 or higher (indicative of severe distress). Ordinal multivariable analysis showed that lower WBI scores were associated with satisfaction with staffing levels (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.16–0.69) and the perception of fair treatment in the workplace (OR 0.41, 95% CI 0.23–0.74). Higher proportions of our respondents than nurses at AHSCs in the US reported burnout (77.7% v. 60.5%, p < 0.001) and had a WBI score of 2 or higher (78.1% v. 57.0%) or 4 or higher (54.5% v. 32.0%) (both p < 0.001).Interpretation:Although levels of burnout and distress were high among nurses, their perceptions of adequate staffing and fair treatment were associated with lower distress. Addressing inadequate staffing and unfair treatment may decrease burnout and other dimensions of distress among nurses, and improve their work experience and patient outcomes.

Genetic testing in families with hereditary cancer enables identification of people most likely to benefit from intensive screening and preventive measures; however, the uptake of testing in relatives (known as cascade carrier testing) for hereditary colorectal cancer syndromes has been shown to be low. Our objective was to report rates of familial testing for hereditary colorectal cancer syndromes in a publicly funded hereditary cancer clinic in Canada. A cross-sectional retrospective database review was used to determine testing uptake between 1997 and 2016 for families served by the provincial Hereditary Cancer Program for British Columbia and Yukon. Analyses were conducted for genes associated with syndromes with an increased risk for colorectal cancer, including Lynch syndrome (MLH1, MSH2, MSH6, PMS2 and EPCAM) and familial adenomatous polyposis (APC), and for additional moderate- to high-penetrance genes (STK11, TP53, SMAD4, MUTYH, PTEN and CHEK2). Descriptive statistics were used and all analyses were 2-tailed. The study cohort included 245 index patients, with carrier testing performed in 382 relatives. The mean age at family member testing was 41.2 years, and most (61.0%) of the family members who underwent testing were women. The median time between disclosure of index cases and their family member's results was 8.3 months. Among eligible first-degree relatives, 32.6% (268/821) underwent testing in BC. Of 67 cancer diagnoses in family members, most (62.7%) occurred before genetic testing. A substantial proportion of people at risk for hereditary colorectal cancer do not undergo genetic testing. This gap highlights the need to explore barriers to testing and to consider interventions to promote uptake; more aggressive efforts by hereditary cancer programs are needed to reach this highest risk population.