Author Archives: supermarioelia

Mumps boosters: A quality improvement challenge

By now most of the public is aware of multiple mumps outbreaks taking place across Canada. Manitoba, Toronto, and even the Vancouver Canucks hockey team have been affected by outbreaks. Some public health officials have urged the public through the media to ask their doctor about their status, or to get a mumps booster, or some muddled message combining both.

This issue, potentially affecting millions of Canadians, deserves more clarity and organization in how we approach this problem.

Let me share my experience in my practice this week, which may shed some light on some possible solutions and pitfalls to address.

To begin, I ran a search of my EMR for patients born after 1970 AND 4 years of age and over AND with fewer than 2 mumps vaccines given. Of a roster of 2,200 patients, this yielded a list of 400 patients (I will refer to this list of those needing vaccination as the “cohort”). A couple of them were children who will be coming in soon for their MMRV (measles/mumps/rubella/varicella) vaccine. I ran another search for those in the cohort who have ever had a mumps blood test done. I had to go through these charts manually to see whether they were immune to mumps, because prior to OLIS, mumps bloodwork results coming from the lab was sent via fax, and entered manually as “reactive” or “immune”, so I could not rely on a keyword search to be accurate. A few dozen patients were found to be immune, mainly students and those working in health care, and they were eliminated from the cohort. Still close to 350 patients left to sort through.

But we had a major speed bump. Of the remaining cohort, there was no reliable way to distinguish which of these patients had complete childhood immunization records in their charts and truly required a mumps booster, and those that simply had incomplete records, without going through each individual chart. When I transitioned to my EMR in 2012 and took over from a retiring physician, I went through every sliver of paper in their paper chart and ensured that all vaccines were documented in the EMR. (6 months of 6-hour nighttime horror sessions with me and the EMR was certainly gruelling.) But many of these patients were not part of our practice as children, and their records were not always reliably part of their medical record.

Sifting through every electronic chart took a couple of hours, and I found around 60 charts that had no childhood immunization data. The London Middlesex Health Unit was kind enough to let us send faxes with the patient labels attached of the patients whose records we needed. (Usually they require individual patients’ names left on an answering machine). Some of our patients were not raised in the area, and the health unit did not have records on them.

Next speed bump. The health unit doesn’t have immunization data on anyone over the age of 35. And my electronic records have virtually no childhood immunization data from those over 35.

So here’s what I’ve done in my practice. We now have a list of around 200 patients between 24-35 who definitively require a mumps vaccination, and we have scheduled four walk-in vaccination clinics next week. My staff has called all of the patients to notify them of their status and the clinic availability. We have ordered around 100 doses of MMR from the health unit, and will likely require more in the coming weeks. In case the patients don’t attend the clinics, there are reminders in the patients’ charts for the next time they are seen for an unrelated reason.

But the 35yo+ group of around 150 patients? I haven’t decided yet. My options are to, a) call each of them and see if they can track down their immunization records (likely will be futile), b) have them get mumps titres done, or c) just go ahead and vaccinate them, or a combination of a), b), and c).

Most physicians are likely reading this, thinking that either the data quality in their EMRs is not reliable enough for this type of work, or that they are simply not interested in an undertaking of this magnitude for no monetary compensation.

This is where we need leadership from public health, especially provincially and locally. The message of “talk to your doctor about the mumps vaccine” is simply not adequate. We need guidance on many issues, including what to do about the 35yo+ cohort. Will there be enough vaccine supply if every practice is administering 200+ doses? Will health units across the province support physicians’ requests for immunization records?

And finally, this situation has underscored the desperate need for a provincial electronic immunization solution. I understand that Panorama is set to be released soon, but I think the province needs to give physicians an idea of its timeframe, and any available details on what Panorama will be able to achieve, and what gaps will remain.

I would propose that the proposed section 10 (2) of Bill 87, that states

“Every physician, nurse or prescribed person who administers an immunizing agent to a child in relation to a designated disease shall provide the prescribed information to the medical officer of health for the public health unit in which the immunizing agent was administered.”

be removed from the legislation until Panorama is fully functional. As someone who has spent an entire week cultivating electronic vaccination records and communicating with my local health unit, it is simply not practical or reasonable to expect physicians to fax isolated records after each administered vaccination. An open exchange of information is important, but this needs to wait until the proper electronic infrastructure is in place.

So before these mumps outbreaks get any worse, we need urgent guidance from public health with specific guidelines and processes on how to best approach this issue.

Province ready to discuss arbitration…now what?

Well…that escalated quickly.

In mere hours today, we went from having no negotiations planning in place all the way to the composition of the OMA Negotiations Committe being announced and Premier Kathleen Wynne announcing that the government is “committed to the principle of interest arbitration”.

Ladies and gentlemen, the game is afoot.

A few things to address right off the bat. Some have questioned what exactly interest arbitration encompasses, and whether this would meet the “binding arbitration” requirement that was agreed to at the General Members’ Meeting. Interest arbitration is a form of binding arbitration, and is exactly the type of 3rd party dispute resolution mechanism that physicians have been clamouring for. Here is a primer on interest arbitration for OMA members.

Others have questioned the timing of the announcement and why the ministry is suddenly  interested in discussing an agreement. It is likely as simple as the election drawing near. Recall that the rationale of many rejecting the tPSA was that the ministry would be more likely to improve their offer as an election draws closer. Well here’s your opening. We need to keep in mind that Wynne’s language toward arbitration was more definitive than anything we’ve heard from the provincial Conservatives.

I have also heard it argued that the OMA should not enter into any negotiations without binding arbitration mechanism in place. The simple response to this is that you need to negotiate the terms of arbitration before you can negotiate a contract. Two different negotiations: one for the framework, one for the contract. The only way to negotiate the framework is by actually….negotiating.

I think it will be important for the OMA to set a timeline for the negotiation of a binding interest arbitration agreement. The OMA cannot allow the ministry to draw the process out for months as a distraction. Tight timeline and come to an agreement on a framework, or the OMA returns to internal deliberations on job action.

My preference for binding interest arbitration? Conventional interest arbitration, where the arbitrator can make any award that they deem appropriate. I think both parties have far too much to lose if they go for a final offer selection mechanism (where the arbitrator would select one party’s proposal in its entirety). The ministry cannot afford the fiscal disaster that would come with a loss in final offer selection, and the OMA will be challenged to effectively deliberate internally to allow for many concessions in a divided membership. Conventional interest arbitration allows for the ministry to maintain fiscal balance, and allows for the OMA to maintain the faith of its members.

One small request to both parties: while the negotiating process plays itself out, I think both parties need to commit to avoiding any emotional reactions to any strikes launched from either of their disliked newspapers. Physicians committing to not reacting to any material in the Toronto Star, and the government not reacting to any material in the Toronto Sun. Let the newspapers say what they will, and let’s get down to actually finally sorting out this mess.

Low back pain in the South West LHIN

It should come as no surprise to any health professional or patient in Southwestern Ontario that when it comes to low back pain, our region is a chaotic mess. Patients struggling to access adequate care, languishing on wait lists, with physicians powerless to provide them any help. The situation is a combination of many factors, including the aging demographics of the region, a disorganized primary care and specialist system, and underfunding of physiotherapy and spine surgery operating time. Where it has left us is with surgical wait lists approaching 3 years, with patients falling into severe disability while they await appropriate care.

The South West LHIN has begun work on initiating the Inter-professional Spine Assessment and Education Clinics (ISAEC) program in the region as a means to begin to address the local crisis. The program has been implemented with success at the University Health Network in the GTA, improving surgical wait times and improving patient satisfaction. The model includes an initial assessment by an Advanced Practice Clinician (physiotherapist or chiropractor) in the program assessing and educating the patient, and returning a consultation note with recommendations. Some patients are given self-management education, while some patients will be referred on to a Practice Lead (physiotherapist or chiropractor) at LHSC who would make recommendations for more complex patients (imaging, injections, or surgical consultation). It is being proposed as a pilot project in the South West LHIN, starting with a small group of physicians in 2017-18, and expanding to the entire region for 2018-19.

I agree with the principles in theory, but given the current complexity of the problem in the South West LHIN, there are a number of added issues that must be considered.

We need to be very careful not to create multiple competing referral streams that all inevitably compete for the same surgical resources. CBI Westmount has already initiated a referral program in conjunction with a couple of the spine surgeons, where physicians can refer their patients to be seen within a short period of time. An ISAEC program working alongside the CBI program would end up at a bottleneck of the same scarce surgical and injection resources.

Here’s what I would propose:

  • A LHIN-led analysis of the current referral burden to all spine surgeons in the South West LHIN. This may include a complete re-design of the existing referral forms, which are currently inadequate for conveying relevant information from the referring physician to the surgeon. The referral form could include an area for the referring physician to designate why they believe the patient is a surgical case, with an educational component to the form that would dictate what constitutes a surgical referral and appropriate management/evaluation of back pain. Once an appropriate referral form is agreed upon, it may be necessary to ask referring physicians to re-refer patients using the appropriate form to be able to properly work through the existing glut of patients. This would also allow for the LHIN and surgeons to determine the exact magnitude of the surgical backlog and what surgical resources will be required to reduce surgical wait times expeditiously.
  • An analysis of the capacity in the South West LHIN for back injection services and existing wait times for epidural and facet injections. A majority of potential surgical cases are being sent for diagnostic injection by the surgeon, which ends up causing a frustrating delay for the patient because of the inadequate local resources. The LHIN needs to work with local interventional radiologists to ensure stable capacity.
  • Offer educational sessions for local family physicians on the CORE Back Tool, similar to the sessions presented by Dr. Hamilton Hall. I personally found this program to be transformative in how I diagnose and treat mechanical back pain, decreasing the number of unnecessary referrals. Identify physicians who refer a disproportionally high number of patients to spine surgeons, and encourage those physicians to attend the educational sessions.
  • I would suggest that the ISAEC model be revised for the South West LHIN whereby referrals are made by physicians directly to the Practice Lead, and that all interested local physiotherapists and chiropractors are provided complimentary education in the ISAEC model.
  • Work towards having ONE spinal surgery stream in the South West LHIN that flows through the Practice Lead, rather than allowing multiple competing streams to develop.
  • Ensure that patients with acute back pain, who do not have private benefits, have adequate access to a brief course of physiotherapy with a focus on transition to self-management and home exercise programs.
  • Focus on increasing the ability of family physicians to competently diagnose, triage, and manage acute and chronic mechanical back pain, rather than pushing resources towards creating more chronic pain clinics.
  • Develop a free local Spinal Stenosis Boot Camp, similar to the program offered at Mount Sinai, to support the increasing prevalence of spinal stenosis among the elderly. Participate in this program should be mandatory (with appropriate exceptions) for those seeking either surgery or ongoing epidural injections for pain relief.
  • Opening up FHT-led chronic pain self management programs to non-FHT patients, and advertising these widely.
  • Ensure that our local libraries have an abundance of copies of “A Consultation with the Back Doctor” by Dr. Hamilton Hall. This book has been invaluable for my patients with chronic back pain to understand the nature of mechanical back pain, and gives many patients the confidence to self-manage their pain.

Just a few ideas for now, but we need to have open discussions about our current local challenges before we move forward with an ISAEC pilot program.

Bibliotherapy: What are your favourites?

I’ve done some work on my practice website compiling bibliotherapy titles for most mental health conditions, along with some online resources as well.

https://www.drmarioelia.com/mental-health

For those of you with any experience in this field, I hope you can provide some feedback in the comments here:

  1. Which of the titles listed have you found particularly helpful for your patients? Include as many as you want! Do you have any negative experiences with any?
  2. Do you have any favourite titles that I haven’t come across? (Don’t hesitate to include any in a category that I have yet to include).

Once I get a good amount of feedback, I plan to include some annotations in the list to clearly identify which titles have the highest recommendation from mental health professionals.

Thanks in advance for your help with this!

Part II: TB screening prior to long term care admission: time to choose wisely

I’m happy that my initial post sparked a discussion about the existing policy across Ontario that every new patient admitted to long-term care has a chest x-ray done within 90 days of admission.

I was shown this study from 2013 in the Canadian Journal of Public Health that detailed a TB outbreak in an Ontario long-term care home from 2010-2011, which is believed to be the only published report of a TB outbreak in a long-term care home in Canada. I would encourage anyone with an interest in this topic to read the study as it is quite interesting.

The index case for the outbreak was a 40-year old health care worker who presented with symptoms in April 2010. She had previously had a negative TST in 2007. Three residents developed active TB, diagnosed in July 2010, October 2010 and January 2011, respectively.

There were a number of issues identified that may have contributed to the outbreak. Baseline TST results were only available for 40% of staff members, while 96.5% of residents had a documented TST. The TST in residents is of limited use, however, as prevalence of latent TB infection (LTBI) in residents >65 years old in long-term care facilities in Canada may approach 20-30%. The residents with active TB also presented with subtle changes of weight loss and chronic cough which likely delayed a prompt diagnosis.

The recommendations made following this outbreak included (among other recommendations): mandatory baseline and annual TST for staff and volunteers, and to suspect TB in any resident with fever, cough > 3 weeks, unexplained weight loss, hemoptysis, lack of appetite, or night sweats.

Both recommendations are completely reasonable, and would potentially serve to reduce the risk of a future outbreak.

But here’s the recommendation that is completely out of thin air: “Baseline posterior-anterior and lateral chest X-ray for new residents”. 

There was no suggestion from the case report that the 3 active TB residents may have had active TB at the time of admission that would have been picked up on chest x-ray. One of the residents most likely had LTBI that activated at some unknown time. Given that 20-30% of the residents have LTBI, we cannot predict which of those patients will go on to develop active TB, nor can we reasonably or safely treat all of the LTBI patients with INH (recall from the case report that one of the active TB patients died of INH hepatitis).

As I mentioned in the first post, insisting on a chest x-ray of asymptomatic patients at the time of admission is completely arbitrary. If the patient is asymptomatic, they are just as likely to have asymptomatic active TB 6 months into their admission as they do at the time of admission. But we don’t insist on another chest x-ray at 3 months, 6 months, or 12 months. Wouldn’t their LTBI be just as likely activate at those time points?

I would argue that one of the most harmful aspects of the current screening program is that it creates a false sense of reassurance for physicians who may assume that their residents are low risk for TB because of their normal chest x-ray.

We need a change in the legislation and policy. Change the screening criteria to the following: at least one lifetime chest x-ray, and a completed set of screening questions to rule out any symptoms of TB at the time of admission. Part of the education around this change in protocol would raise awareness to physicians and staff about the high prevalence of LTBI, and the importance of being vigilant to look for subtle signs of active TB in residents. This heightened awareness would serve to reduce the risk of further outbreaks more than any chest x-ray screening program could ever achieve.

TB screening prior to long term care admission: time to choose wisely

I recently had a patient who was accepted for admission into long-term care, and I completed the usual paperwork detailing their active problem list, past history, medications, vaccinations, and last chest x-ray (for TB screening purposes).

A few days later, I received a call from the long-term care home. The patient’s chest x-ray was not done recently enough. I checked the file. It was done 110 days ago. They wouldn’t accept my patient for admission unless they had a chest x-ray from the past 90 days (if under 65, they require a TB skin test if they have never had a previous positive test). “It’s in the provincial legislation” was the rationale. No room for any negotiation, it had to be done.

Every family doctor in Ontario has been in this exact same situation, likely multiple times a year, held hostage to order a test that intuitively seems of very little use. But I wanted to do a deeper dive on this issue to see where the genesis of this policy is, and to see whether changes should be made (spoiler alert: changes should definitely be made).

First, the legislation. Any health unit or long-term care home that makes reference to the legislation cites the same two pieces of legislation, the Long Term Care Homes Act from 2007 and the Retirement Homes Act from 2010. Here are the excerpts that make reference to tuberculosis:

The Long Term Care Homes Act 2007
(10) The licensee shall ensure that the following immunization and screening measures are in place:
1. Each resident admitted to the home must be screened for tuberculosis within 14 days of admission unless the resident has already been screened at some time in the 90 days prior to admission and the documented results of this screening are available to the licensee.
4. Staff is screened for tuberculosis and other infectious diseases in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices. O. Reg. 79/10, s. 229 (10)
Retirement Homes Act 2010
(8) The licensee of a retirement home shall ensure that,
(b) each resident is screened for tuberculosis within 14 days of commencing residency in the home, unless the resident has been screened not more than 90 days before commencing residency and the documented results of the screening are available to the licensee;
(c) each member of the staff has been screened for tuberculosis and all other infectious diseases that are appropriate in accordance with evidence-based practices or, if there are no such practices, in accordance with prevailing practices; and
(d) the screening for each of the infectious diseases described in clause (c) has been done using procedures that accord with evidence-based practices or, if there are no such practices, with prevailing practices. O. Reg. 166/11, s. 27 (8).

A couple of things to note. The legislation makes no specific mention of chest radiography, and does not explicitly state what form of “screening” is compulsory. Is screening for risk factors sufficient, or is it necessary to order a test of some sort?

What do the guidelines say? The Canadian Tuberculosis Standards were last updated in 2013 with the 7th edition, and chapter 15 is the relevant section for this topic (Prevention and Control of Tuberculosis Transmission in Health Care and Other Settings). Table 6 outlines the recommendations for TB screening in long-term care:

tb1

“Baseline posterior-anterior and lateral chest radiography on admission for people >65 years old from identified populations.” Which populations? “People known to belong to an at-risk population group listed in the section ′′Identification of patients with active respiratory TB within hospitals′′. Here’s that list:

tb2.png

So nearly all patients admitted to long-term care would meet at least one of these criteria, bring born prior to 1966. The rationale for the 1966 criteria is that the TB incidence rate in Canada prior to 1966 was similar to that in a high TB incidence country. The guidelines therefore state that these patients should have a baseline chest x-ray, but do not specify when this has to be done. There is absolutely no mention in the guidelines to any 90-day cutoff. According to the guidelines, for the TB skin test for those under 65 years old, a negative skin test in the past 12 months is sufficient.

What does clinical common sense dictate? One would think that a clinician should be able to look at the guidelines, look at the patient’s risk factors, and determine whether it is reasonable to repeat a chest x-ray given recent possible exposures. If a 90 year old patient had a chest x-ray during a hospitalization 4 months ago, and hasn’t left their home since, requiring them a repeat x-ray to rule out TB is lunacy. There is no reasonable explanation for why this can’t be left to clinical discretion. Keep in mind that a significant portion of admitted patients to long-term care homes have been hospitalized in the last year, likely receiving at least one chest x-ray, and have been waiting months for admission.

The selective insistence on overly prescriptive TB screening in long-term care homes has always struck me as odd. Yes, patients admitted to long-term care are higher risk for TB than their age-matched cohort. But we don’t insist on chest x-rays for high-risk individuals who are hospitalized for a non-respiratory cause. We don’t insist on chest x-rays for incarcerated individuals unless they will be in jail for over 1 year. We don’t insist on chest x-rays for all individuals spending time in a homeless shelter or drop-in centre. So why are we so militant with screening in long-term care, especially when most long-term care homes would be designated as low-risk according to the guidelines?

tb3

The answer is clearly a desire for the ministry to avoid any medico-legal risks, but we need to base our decisions on more than just a fear of litigation. There has not been a single case of LTC-associated TB in London-Middlesex in at least the past two years (health unit is tracking down earlier data for me). Having spoken to local infectious disease experts, that is not necessarily a product of good screening, as they aren’t seeing any significant number of elderly patients with active TB detected through the screening process.

The logic of the “90-day chest x-ray” is also significantly flawed. I will grant that patients born in Canada prior to 1966 are higher risk for TB, and deserve a chest x-ray at some point prior to admission. But if they have been continually asymptomatic, why does this particular time point of admission deserve any further scrutiny? They have been asymptomatic for 50 years or more, and had a chest x-ray done at some point to rule out TB. Do we honestly think we are going to pick up TB that has magically decided to re-activate at the exact point the patient is admitted to long-term care? And what about if another patient has a normal chest x-ray at admission, but develops a non-productive, afebrile (likely viral) cough two months after admission? Is it not more likely that this symptomatic patient has TB than the patient who was asymptomatic at admission with a previous normal chest x-ray? The bottom line is that the hypothetical viral cough patient doesn’t need a chest x-ray, nor does the asymptomatic patient require a chest x-ray at admission if a previous chest x-ray was clear (with no other subsequent high-risk exposures since 1966). They’re both exceedingly low risk for TB.

With the way the legislation reads, I understand why Health Units and long-term care homes are interpreting it as they are, here, herehere, and everywhere. The long-term care homes are understandably fearful of inspections from the Ministry of Health that could find that they are not “compliant” with the legislation. The health units understandably want to be conservative in their recommendations, not leading any of their local long-term care homes to be “non-compliant”.

Without either 1) a change in legislation or 2) a public memo from the Ministry of Health clarifying the legislation and how it will be enforced, we’re not going to see any of the health units or the long term care (or retirement) homes make any changes in what is expected of physicians. Until we see a change from the ministry on this, we’re going to continue to be forced to order low-utility chest x-rays, wasting valuable health care dollars. One lifetime chest x-ray (with a physician review to rule out other subsequent high-risk features) should be sufficient for admission to long-term care in Ontario.

My Christmas wish-list for primary care in Ontario

It’s Christmas Eve, and I only have a few hours to articulate my demands (sorry, requests) to Santa for changes I want to see to our primary care system in Ontario. I won’t be going into a ton of detail on each point, because 1) family obligations are waiting, and 2) Santa needs time to put these into action before he arrives tonight.

Off we go…

  1. Increase the fee paid for consults in specialties across the board, and decrease the fees paid for follow-up visits by specialists (with the exception of time-based services, those will remain the same). OMA Economics can do the math to ensure this remains cost neutral. This will incentivize specialists to see new patients to help family doctors, reducing wait lists, while encouraging the discharging patients who can be easily and competently taken care of by their family doctor. Require that any consult billed is preceded by a new referral by another physician. Any diagnostic test performed by a physician requires a referral from another doc for that specific test (echocardiograms, holters, etc.). Any billed visit by a specialist for consult or follow-up must produce a note to be provided to the family doctor.
  2. Any walk-in clinic visit must produce a note to be provided to the family doctor. Yes, I realize a universal EMR would solve this problem with information going in both directions, but in the meantime, we need to improve communication.
  3. I’m still waiting for this wish to come true about transparency of office hours.
  4. Make second opinions by specialists for the same issue non-insurable by OHIP, and allow specialists to bill patients privately for those consultations. The logistics of this are challenging, but we first need consensus among physicians, the public, and the government, on the general premise of the idea, before moving forward with an implementation plan that will require significant electronic infrastructure (for checking consults by other physicians, etc).
  5. Make “physicals” non-insurable by OHIP, unless done for a pre-approved indication (cancer follow-up, weight loss, lymphadenopathy, etc). If a patient still requests a physical, they can be privately billed at OMA rates. Specify what tasks are exactly encompassed within a Periodic Health Examination, based on what methods of screening there is firm evidence for.
  6. Stop the practice of primary care physicians (paediatricians or family doctors) running large ambulatory clinics manned by nurse practitioners, where the physician bills OHIP and pays the NPs a wage or salary for their services. We don’t have the money in our system to pay doctors to be middle-men. A separate OHIP Schedule of Benefits strictly for delegated acts could be a possibility in under-serviced areas where non-MDs are necessary to maintain adequate patient care.
  7. Add shadow tracking codes for family physicians in FHOs or FHGs who correspond with patients via email or telephone (or any non-in-person visit). If they’re dealing with issues outside of a traditional visit, let’s give them credit for it.
  8. Fix the FHO out-of-basket service codes that are not a reflection of adequate access to primary care. An ER physician appropriately suturing a laceration for a patient who felt it was an emergency should not penalize their family physician.
  9. House calls performed by physicians outside of the group to whom the patient is rostered, should NOT be insurable through OHIP (exceptions being those with certification in palliative care). We should not be funding convenience visits for patients who saw an advertisement for “doctors who will come to your house!”

Alright Santa, there’s the list. Make it happen.