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So instead of obliterating FHOs….

Family physicians across Ontario were dealt an absolute gut-punch by the Ontario government this past week, as the government’s arbitration position for primary care was released. In short: way more work for FHO physicians, less money, and an unimaginable amount of logistical disruption. If adopted, it would undoubtedly result in every FHO physician reverting back to a fee-for-service (FFS) model. This would make Ontario one of the only jurisdictions in the world moving towards FFS in primary care, while every other region moves towards capitation models and the resulting efficiencies that can be found in those models.

Let me start by acknowledging that there is a glimmer (if you squint) of rationale to most of the points in the government proposal. The auditor general was clear that major changes to the FHO model are needed. Doug Ford’s special health care advisor, Reuben Devlin, has not been shy about sharing his opinions that FHOs have not demonstrated the improvements in access that the government expected given their investment. But rather than put forward progressive solutions to the acknowledged problems in the FHO model, and do so in a collaborative manner, the arbitration position is a complete mishmash of ideas, each with significant, inevitable consequences that will destroy primary care right across the province.

(For my previous posts about fixing FHOs, see here, here, and here.)

I’m going to go section by section, explain the likely rationale from the government’s perspective, explain the problematic consequences of each proposal, and where appropriate, I will outline a potential alternative solution. (Government’s position in bold, with my response below each position).

 

A) Recalibrate Base Capitation Rates for FHOs

Adjust the base capitation rate paid to FHO physicians for enrolled patients to reflect the changes in volume of services and changes in demographics since the 1999 base year.

The impact of recalibration to the foundation principles behind the calculation of an appropriate capitation rate would result in a change from $165.41 to $120.89 per enrolled patient based on the current basket of included services. This estimate is based on the 2015-16 OHIP utilization and population statistics.

Effective April 1, 2019, reduce the base capitation rate paid to FHO physicians by 33.3% of the resulting gap between the current capitation rate and the appropriate, recalibrated capitation rate (e.g. reduced by $14.84 per enrolled patient based on the current basket of included services).

 

When the government and OMA first created the FHO model, the capitation rate was calculated by taking all of the expected total billings for each demographic (age and gender), and averaged them out to give an appropriate capitation rate per patient. FHO physicians are paid the capitation rate per patient, plus 15% of the value of fee-for-service billing (called shadow billing).

What the government is claiming is that the value of the services that FHO physicians are providing is equal to $120 per patient (when they calculate the value of current fee-for-service billing), roughly $45 lower than the projected number of billings, and their likely contention is that this is due to a combination of worse access to visits and decreased patient demand.

But let’s think about this. Do we really think that, in an era where patients are requiring more and more care, and we know that overall utilization is rising, that demands on FHO physicians have suddenly dropped by 27%? Did walk-in visits rise by 27%? Did non-urgent visits to ER rise 27%? The answer to those questions is no, they did not.

We know exactly why the value of billings dropped for FHO physicians. Because part of the rationale in moving to a capitation model was to find efficiencies. Doing virtual care (which is not billable), emails with patients (which are not billable), patient portals (which are not billable), and phone calls with patients (which are not billable), are incentivized in a model where physicians do not rely on face-to-face encounters to make money. And patients generally love this type of access to physicians.

But look at how the government has manipulated this. They have created a model which created incentives to do patient care that was not billable, then used the lack of billed services to argue for FHO physicians being overpaid for less work.

Let me be clear to the government. You cannot possibly implement any of the accountability measures detailed in points B-L if you reduce the overall payments to FHO physicians. It simply won’t fly, physicians will simply revert to FFS, return to treadmill medicine where every patient is dragged into the office for every small issue, and the entire system will implode before we even get started.

But is there a modification to the capitation rate that can be made? Of course there is, because there are a handful of FHO physicians who have used the capitation rate to allow themselves to spend far less time in the office, since they get paid regardless of their attendance (especially in areas where there are no walk-in clinics to count towards outside use negation). We all know that there are some FHO physicians who are spending very little time in their offices doing direct patient care.

Instead of having an average cap rate of $165 per patient, reduce the cap rate and increase the shadow billing percentage. Attempt to make it a 60/40 split (60% cap, 40% FFS) or 70/30 split. Incentivize physicians to see patient volumes at a slightly higher rate than they are right now, but maintain the overall predictability of the capitation rate. Don’t allow the system to completely collapse by driving all physicians away from the FHO model with an obscene 9% reduction to the capitation rate and no counter-balancing measure.

 

B) Increase to FHO Mandatory Group Size

By April 1, 2019 all PEM groups must be comprised of at least six physicians. This will allow for appropriate coverage and access for patients weekdays, evenings, weekends, and during holidays or short term leaves of absence.

For groups in smaller communities that cannot achieve six person groups, special consideration can be negotiated with the Negotiations Branch of the ministry.

The ministry recognizes that all physicians in a FHO may not be on the same geographic site. Howe ver they should be relatively proximal to facilitate meaningful patient access. All sites must also offer cross coverage to each other and have a shared electronic medical record (EMR). They must offer shared after-hours care for patients rostered to that FHO and coverage for any physician leaves regardless of site.

 

The ministry needs to be careful with this one. There are plenty of high-functioning FHOs across the province with 4-5 physicians that are providing quite good access, and simply do not have the physical space (or interested physicians) to expand to 6 physicians. The special consideration they mention in the proposal should be quite flexible as to not force physicians to abandon entire patient rosters simply because they cannot meet the size requirements.

As for the shared EMR, I agree in principle with the interconnectedness of a shared EMR within a FHO, but we have to understand that there is a significant associated cost (both money and staff time) of transferring across EMR providers. This may be a proposal where existing FHOs are given a period of 5 years or so to meet this requirement, or that they are grandfathered to remain on separate EMRs (with a requirement that they merge should any physician change EMRs or if any vendor goes defunct).

I agree with the requirement of “shared after-hours care for patients rostered to that FHO and coverage for any physician leaves regardless of site”

 

C) Daytime Hours Requirement

For an average roster size of 1,300 patients, groups will provide nine (9) units of care sometime between 0600 and 1700 daily, Monday to Friday. A unit of care is four (4) hours.

During the four hour unit it will be expected that on average services will be provided, face-to-face, to 12 patients.

Since this is a group endeavour, the averaging of the services provided to patients will be measured quarterly (over a three month period) for the entire FHO group.

For FHOs where the average roster size is either above or below 1300 patients, the parties should establish appropriate pro-rated changes to the required daytime Monday to Friday hours.

Also, to ensure that patients have access to the hours of service of their physician’s group, the hours of service will be posted in the office, on-line and shared with the Local Health Integration Network (LHIN).

First, let me say that I understand the underlying motivation here. As I stated earlier, some FHO physicians are simply absent from their office more often than not. And a logical response to that would be to mandate physicians to spend specific time requirements in their offices. (Trust me, I’ve wondered about this same type of proposal many times over the past few years as a possible solution.)

But there are many ways that time requirements can be problematic. How many more units of care will need to be provided if the roster is larger than 1300 patients? I have 2200 patients on my roster, I work Monday-Friday, full-time hours, and have very little ER and outside use. My patients can get in for same-day appointments every day. Will I have to work 11 units a week? 12? What if I am simply efficient at servicing my roster?

If the cap rate from point A is fixed, and points F, G, and H are implemented (with some modifications that I will mention in subsequent sections), the opportunity to game the system nearly vanishes, and physicians who do not show up to work will not be able to meet the FHO requirements (and will make very little money). It will weed the abusers out, and remove the need to start nitpicking hours worked, which will be a nightmare for the ministry/LHIN to police (as they are already failing to police the minimal requirements that already exist with FHOs).

 

D) FHO After Hours Requirement

For an average roster size of 1,300 patients, FHO groups will provide at a minimum one three hour unit of evening care Monday to Friday and three hour units every third Saturday or Sunday, sufficient and convenient to serve enrolled patients.

The required number of units will be prorated either up or down depending on the total group roster.

 

Completely agree. And I’ll go a step further, the weekend requirements should move the Friday evening clinic and include both Saturday and Sunday clinics.

 

E) End the Patient Enrolment Model (PEM) After-Hours Exemption

FHN and FHO groups will no longer be given an exemption from providing after – hours to enrolled patients. The ministry will continue to pay all capitation payments and physicians will fulfill the contractual obligations while meeting the obligation for evening, weekend and holiday coverage as required in the agreement.

Physicians can continue to undertake other clinical work but it will not obviate the group’s requirements for the after hour coverage in the contract.

 

Again, the rationale is there. Many groups have received exemptions from providing after-hours clinics, but while these were likely intended for rural areas to account for physicians who would be working in multiple clinical settings, these exemptions are sometimes being abused by physicians working in urban and suburban settings.

But this proposal would have to be looked at sub-LHIN by sub-LHIN and group by group, as implementing this would be nearly impossible in already under-serviced areas where physicians are already strained to provide the level of care needed for their community. If having them staff an after-hours clinic means no coverage for hospital wards or ERs, then adjustments will absolutely need to be made.

 

F) Requirement for Prompt Access to Appointments for Acute Concerns

Effective April 1, 2019, where a patient’s FHO physician is not available during weekday hours, the FHO will provide a patient presenting with a time-sensitive condition the option of seeing another FHO physician (whether face to face or virtually as clinically appropriate), or as clinically appropriate an allied health provider affiliated with the FHO, on the same or next day, or an after-hours clinic that day or the following day.

FHOs are encouraged to consider including the following illustrative examples as time sensitive conditions:

a) significant new or worsening pain (including pain caused by recent injury),

b) new onset or change in symptoms of infection including fever, rashes, gastrointestinal changes, urinary changes, respiratory changes,

c) exacerbation in chronic conditions (for example back pain, heart disease, lung disease or abdominal or gynecological disease),

d) concerns regarding pregnancy and newborns and infants,

e) decompensation in mental health or substance use, or

f) time sensitive prescriptions that cannot be managed in other ways.

but would not include:

a) annual health exams and preve ntative screening visits,

b) completion of forms (for example tax disability, insurance, school trips/camp), or

c) routine follow up of chronic physical and mental health conditions.

FHOs are encouraged to provide education and training to staff with responsibility for setting appointments related to these time sensitive examples.

 

Completely reasonable. No argument here at all.

 

G) Adjust the Maximum Special Payment (MSP) to Reduce Outside Use (FHO & FHN)

Effective April 1, 2019, a mend the primary care FHN and FHO contracts to change the Maximum Special Payment provision (Access Bonus) to recover negative access bonus payments dollar for dollar.

 

This is likely to be a proposal that is heavily criticized by FHO physicians in the GTA, where their patients are highly mobile and frequently attend walk-in clinics for convenience, while the FHO physician works at an under-utilized after-hours clinic. But while frustrating, the solution can be to de-roster the patient as they are not abiding by the terms of the FHO contract (while still keeping them as a patient). And if many patients are doing this, de-roster the offenders, and open up the roster to more patients.

But to offset the ill will this will create with GTA docs, let’s finally fix the codes that are counting against outside use. Walk-in docs should not be billing A003s on rostered patients. Nor K005 or K013 for non-planned counselling or mental health sessions. And a complex laceration is not something that should be expected to be done, thus should to be negated. And a “consult” done by another family doc who doesn’t have a focus practice designation (*cough* cannabis and pain clinics *cough*) should not be counting toward outside use.

 

H) Inclusion of Emergency Department Usage in Outside Use (FHO & FHN)

Effective April 1, 2019, recover the Emergency Department Best Managed Elsewhere (EDBME) services from the Access Bonus Payment at a service value equal to the A007 and A888 when the ED service is rendered during regular office hours Monday through Friday , 8am – 5pm.

There is no change the current listing of the limited service codes currently considered.

 

Once again, I understand the rationale. Some FHO physicians encourage their patients to attend the ER rather than walk-in clinics when the physician is away, as to not incur outside use negation.

I agree with this proposal but with two important modifications: i) we need to better define EDBME services (done bilaterally with OMA and ministry with what can reasonably be seen in a primary care office) and disseminate these definitions openly, and ii) a mandate must exist to all ERs that if a patient arrives with a problem deemed EDBME, that the patient is informed that their family physician is mandated to be available to see them, and their physician will be charged the value of the ER visit. I know that this will still not provide nearly enough patient accountability, but I think it’s a first step to educating patients about the financial consequences of their care decisions.

 

I) Quality Improvement Plans

Extend the requirement for all primary care physicians to participate in quality improvement activities. This will include the following supports for those in the FHN and FHO:

• All FHNs and FHOs to complete an annual QIP and submit it to HQO similar to other current primary care models such as CHC

• OMA and HQO to work together to develop a QIP model that can be utilized by other primary care mode ls such as FHN, FHG and FFS.

• Each FHN and FHO group should have members (including physicians) with skills in quality improvement (such as provided by the Improving & Driving Excellence Across Sectors (IDEAS) Advanced and Foundations training program)

• Access to data management/ EMR support (such as the Quality Improvement Decisions Support Specialists currently provided to FHTs)

• All individual physicians, regardless of model should receive the HQO Primary Care Practice Improvement Reports. These provide standardized metrics, and audit and feedback supports including practice- and group-level data on these metrics .

 

I like it. (This shouldn’t surprise you if you’ve read any of my other blogs. We do QI in our office for fun, with no formal supports like they receive in FHTs). But this underscores why you simply can’t cut the capitation rate in point A as they have proposed. You can’t expect physicians to do all of this QI work, for less overall money. They will all simply jump to FFS work. Fix the cap rate, get all FHO docs doing great QI work and improve clinical care. Everyone’s happy.

 

J) Add A888A (Emergency Department Equivalent), G590A (Influenza Agent), A002A (18 month well baby visit) to the basket of included codes

Effective April 1, 2019:

A888A to be included as an “ in basket ” included Fee Schedule Code, eliminating incentive for its use. The A888A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value and would continue to be billed in conjunction with the Q012 premium paying at 30% of the fee value.

A002A to be included as an “ in basket ” included Fee Schedule Code. The A002A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value.

G590A to be included as an “ in basket ” included Fee Schedule Code. The G590A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value.

 

Yes, I completely agree that we need to adjust what is in basket and what is out of basket. We want to incentivize family docs to do as much in their offices without referring off to others (expensive consult fees, more fragmentation, etc.).

So sure, put the A888A and A002A in the basket. It will cost us money, I know, but there’s give and take in this negotiation. Don’t remove the influenza vaccine. Pharmacists already make more than family docs to give the vaccine, which has led many family docs to stop giving the vaccine. And since we know that vaccination uptake is much higher when the patient has a positive relationship with the provider, taking influenza vaccinations out of family physicians’ offices (which is what putting it in basket will do) will result in a plunge in the vaccination rate.

And while we’re fixing the baskets, take most procedures out of basket to give family docs incentive to not refer off so frequently. It’s cheaper to have family docs do cryotherapy, punch biopsies, wound repair, joint injections, IUD, etc.; this should be a no-brainer. The current bonus for meeting a certain yearly total of procedures aren’t providing enough of an incentive, as doing very few procedures maximizes that bonus easily, and going above and beyond that threshold doesn’t give additional marginal benefit.

 

K) Eliminate Cumulative Preventative Care Bonus

End the Cumulative Preventative Care Bonus effective April 1, 2019.

Below is a list of the current bonuses and premiums, by category with expenditure amounts for the 2015 – 16 fiscal year :

Cumulative Preventive Care Bonus – (FY15 – 16 $55.0M)

1. Influenza Immunization – target population, patients over age 65

2. Pap smear – target population, women between the ages of 35 and 70

3. Mammogram – target population, women between the ages of 50 and 70

4. Childhood Immunization – target population, patients between ages of 18 months and 2 years

5. Colorectal Cancer – target population, patients between the ages of 50 and 74 years

Colorectal Cancer Screening Premiums

1. FOBT Distribution – All models ($2.947M)

2. FOBT Completion – CCM/FHG/GP Only ($0.031M)

 

The rationale for this one is likely a 2014 study done by Dr. Tara Kiran’s group that showed that “pay-for-performance had little to no improvement in screening rates despite substantial expenditure”. So easy decision, right? Remove the incentive?

Hold on a second. We have a new study from September 2018 in the New England Journal of Medicine out of the UK which showed that removal of financial incentives was associated with an immediate decline in performance on quality measures. So while rewarding performance may not be improving measures, removing the rewards may certainly result in a decline in screening rates.

I realize that from the government’s standpoint, they may feel that they are funding both Cancer Care Ontario (CCO) and family physicians to do the same screening work, but let me be crystal clear. Relying on CCO to drive cancer screening will be a complete disaster. They are still sending cervical screening invitations to patients who have had hysterectomies. They don’t have adequate data on patients who require more frequent screening. And quite simply, patients are less likely to respond to screening invitations from a 3rd party than they are from their family physician.

Here’s a compromise. Keep the total amount of the bonuses, but redistribute. Take out the childhood immunization metric. We are already emotionally pained when parents refuse vaccines, despite our best efforts at communication. Don’t compound our pain through financial penalties. Reduce the maximum payment to each of the remaining 4 metrics. And add some new metrics, rotating them out every few years, based on where the OMA and the government agree that improvements are needed (medication review, pneumococcal vaccination, abdominal aneurysm screening, BMD screening, etc). And we need to change the measurement of the metrics to rewarding process rather than outcome (see my blog here on that topic). Keep things nimble, keep family docs excited about these metrics, give them good EMR tools to do this work, and you’ll see some exciting stuff with how well we step up to the challenge.

 

L) Discount Applied to Services Billed Outside of Enrolling Group

A discount of 25% be applied to the fee value of all services provided to PEM enrolled patients when the service is provided by a physician outside the enrolling group.

The discount to be implemented at the start of the final year of the agreement and ongoing.

 

Not sure I understand the rationale here to be honest. The physician outside the enrolling group (often a walk-in) is simply seeing patients as they come, and has largely no control over whether they are rostered to another physician or not. They have no ability to refuse to see the patient, so I am not quite sure why the walk-in doc is only being paid 75% of the fee when this is largely a product of patient convenience (as the other proposals will ensure the FHO docs is actually available, which they currently aren’t guaranteed to be).

 

So my final message to government. There are plenty of FHO physicians out there doing good work, who are reasonable, and want to find a solution. Put forward a reasonable proposal before you leave an entire generation of family physicians jaded beyond repair. Your arbitration proposal may have been some sort of scare tactic to wake up family docs, but it was unnecessarily harsh. Let’s fix the FHO model, and open them up to all physicians regardless of geography to remove this two-tier system we have right now of FHO and FHG/CCM physicians. Do the work the Liberals couldn’t, and cement a legacy of good quality primary care in Ontario.

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Ontario’s digital immunization strategy….we’re almost there

Along with most of Ontario’s family physicians, I was thrilled to hear the newly-elected Conservative government’s announcement on June 20 that the implementation of the portion of the Immunization of School Pupils Act (ISPA) mandating immunization reporting to public health units would be paused. This legislation was flawed from the outset, and was opposed by both physician groups as well as public health units who all spoke out against it to the Standing Committee of the Legislative Assembly in April/May 2017. The basis for the concern was not opposition to the concept of integration of patient medical records, but rather that in the absence of integration with current electronic medical records, that this would add an unreasonable burden of work to both family physicians and public health units (since without seamless integration with EMRs, physicians would still likely fax records to the health units, duplicating work for both). The previous Liberal government had set an arbitrary implementation date of July 1, 2018, despite the fact that the complete technological solution to implementation has yet to be finalized. With this pause in implementation, we can now work to ensure that the proper supports are in place before immunization reporting becomes mandatory.

So how close are we to a solution? Thankfully a lot of work has already been done in this space, and I will try to give you an explanation of the landscape as we stand right now. I am currently a member of the Digital Health Immunization Repository Clinical Advisory Working Group (DHIR CAWG) as an unpaid member. This working group consists of members which represent the MOHLTC, eHealth Ontario, public health, physicians, nursing, and other stakeholders.

The Digital Health Immunization Repository (DHIR) is the centralized repository of standardized electronic immunization data. This is already in place and operational.

Public health units access the DHIR through an interface called Panorama, which has been operational for many years now. The 36 medical officers of health in the province are the Health Information Custodians (HIC) for the immunization data. It is the public health units that act as the curators of the immunization data before it enters the DHIR to ensure quality control, through a system called the Public Health Information Exchange (PHIX). This quality control is important to avoid patients or providers entering incorrect or duplicate vaccine information.

From the patient’s standpoint:

ICON-Public (Ontario’s Digital Yellow Card) is the online portal where patients can view their immunization data stored in the DHIR, securely submit vaccination information to the DHIR, and receive email notification confirming that information has been accepted into the DHIR. This is operational in 33 of 36 health units right now. To log in, they require their health card number, their Stock Control Number (on back of health card), their date of birth and postal code. They pick a secure PIN which they will need to log-in during subsequent sessions.

CANImmunize is a bilingual mobile application where patients can track their immunizations on their smartphone. It gives them information on what immunizations are due or upcoming based on their age, and provides a ton of information about vaccinations, activities for kids, and outbreak information based on geography. The goal is that this will sync with the DHIR (but not clear whether this will be bi-directional or unidirectional).

For clinicians:

ICON-HCP is the online portal where health care providers can view their patient’s immunization data and manually submit vaccination to the DHIR (both vaccinations covered by the IPSA legislation and those outside the legislation). HCPs can also access clinical decision support for which vaccines a patient is due for, which are coming up as due in their forecast, and a future iteration will include specific vaccines for high-risk individuals. HCPs log in to ICON-HCP using their oneID login information. ICON-HCP is currently in a pilot stage was scheduled to be ready for provincial rollout on July 1.

Following me so far?

So while all of the above innovations are fantastic for patients, and necessary for health care professionals without an EMR, ICON-HCP is simply not a practical tool for physicians with an EMR. We have invested significant time and money into having high-functioning EMRs, and to expect us to enter immunization data into our EMR, then to log into a separate portal to enter that same information again, simply is not practical.

What is required is a seamless process, where entering immunization data into the EMR is automatically submitted to the DHIR. OntarioMD is currently working on setting the standards that EMR vendors would need to meet for submitting data to the DHIR, and my understanding is that these standards should be finalized by early fall. The individual vendors would then work on their own solutions for rolling out to physicians. My own personal hope Is that this includes both pushing out of information to the DHIR at the time of vaccination, as well as a pull mechanism for vaccine information from the DHIR, similar to how OLIS operates right now.

Once we have reached a point where vendors have been given sufficient time to implement a functional integration with the DHIR, then the IPSA legislation dealing with mandatory reporting can be un-paused. Those with EMRs will have a functional system to work with, and those without EMRs can use ICON-HCP to submit their immunization data (and yes, they should be required to submit via ICON-HCP; they are being paid to administer vaccines, they cannot silo themselves indefinitely).

One issue I hope is looked at critically is the requirement for express consent from patients for clinicians accessing information from the DHIR. This creates a tremendous barrier for clinicians who are undertaking quality improvement work in their practices to ensure patients are completely vaccinated (running custom searches using EMRs), and many physicians would simply abandon this type of work rather than chase down every single patient to obtain consent. Many physicians do not have an electronic means to contact patients, and either calling patients or bringing them in for consent is simply not practical for practice-wide initiatives.

Overall, I am pleased with the steps the Conservative government has taken to pause the implementation of the mandatory reporting, and I hope they continue to build on the infrastructure work that is so close to providing an integrated electronic immunization system that works for both patients, physicians, and public health units.

B12 for stroke prevention: an exercise in motivated reasoning

Disclosure: I am a member of the Physician Advisory Board and freelance writer for the Medical Post.

I opened my print copy of the Medical Post last month to find this, an article which attempts to make the argument that there is a link between B vitamin deficiency and stroke, and that supplementing with methylcobalamin reduces the risk of stroke.

For anyone familiar with the evidence on this topic, there is absolutely no high-quality evidence to support this claim.

Rather than write a rebuttal, I thought it would actually be clearer to do a line-by-line evaluation of each claim/study cited in the article, and to give the actual context of what the evidence actually shows.

Here we go (the article will be presented in italics):

The first major trial of B vitamins to lower homocysteine for stroke prevention was the Vitamin Intervention for Stroke Prevention (VISP) trial, published in 2004.23 It showed no benefit.

He is absolutely correct. Here’s the link to the JAMA article from 2004. 3,680 patients, multi-centre trial. No effect on vascular outcomes.

Then in 2006 the Norwegian Vitamin Trial (NORVIT) and HOPE 2 trial were published in the New England Journal of Medicine, with an accompanying editorial by Loscalzo, who suggested that the null effects may be due to high levels of unmetabolized folic acid. Following that, the cant became “homocysteine is dead.” 

The NORVIT trial was an RCT 3,749 patients looking at B vitamin supplementation and an outcome of a composite of recurrent myocardial infarction, stroke, and sudden death attributed to coronary artery disease. No benefit.

HOPE 2 randomized 5,522 patients to B vitamins or placebo and found no benefit in the the primary outcome of a composite of death from cardiovascular causes, myocardial infarction, and stroke.

Keep in mind what preceded these studies. Years of observational trials showing that  lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. Thus, one would think that B vitamins should reduce cardiovascular disease. But this is why we do clinical  trials, to see if treatments truly work, not just work hypothetically.

However, the HOPE-2 trial actually showed a 23% reduction of stroke, in a population with better renal function than the other two trials.

In HOPE-2, stroke was not a primary outcome, but was part of a larger composite vascular outcome. There was no reduction in the primary outcome with the intervention of B vitamins. I wish we could ask the HOPE-2 study’s authors whether they think the effect on stroke is meaningful! Oh wait, we can“With regard to the risk of stroke, we observed an absolute reduction of 1.3 percentage points and a relative reduction of 24 percent among patients assigned to the active-treatment group. However, these results must be interpreted with caution. The number of strokes in our study was much lower than the number of coronary events, the confidence intervals around the estimated risk reduction are wide, and the results are not adjusted for the multiplicity of outcomes compared. Also, we found no effect of treatment on transient ischemic attacks. From a biologic perspective, a treatment benefit restricted to stroke would be difficult to explain. Furthermore, the two other large trials of homocysteine-lowering vitamins that have been completed did not show a beneficial effect of treatment on stroke. Therefore, we believe that the apparent beneficial effect of B vitamin supplements on stroke in our trial may represent either an overestimate of the real effect or a spurious result due to the play of chance.” I guess they weren’t impressed either.

An analysis of the VISP trial excluding participants with impaired renal function showed a 34% reduction of stroke/MI/cardiovascular death comparing high-dose vitamins among persons who could absorb B12 well versus low-dose vitamins in persons with lower B12 levels at baseline.

This can be described as “torturing the data until it confesses”. They took the original VISP data, then did a subsequent analysis of whether looking only at normal renal function patients AND excluding those with high and low B12 vitamin levels would result in a lower stroke risk. Doing post-study analyses like this are potentially hypothesis-generating, but cannot be seen as reliable to guide clinical practice.

The French Su.Fol.OM3 trial, in a population with even better renal function and a lower dose of B12 (only 20 mcg daily), reported a 43% reduction of stroke. 

Here again, the primary outcome was major cardiovascular events, defined as a composite of non-fatal myocardial infarction, stroke, or death from cardiovascular disease. No benefit was seen in that primary outcome. Now as for that secondary outcome of stroke, I wonder what the authors had to say….why look at that! They did address it! “In our trial, allocation to B vitamins was associated with a 46% reduction in the risk of ischaemic stroke among patients assigned to B vitamins and a trend towards increased cardiovascular mortality, with an unexpected, significant increase in the number of deaths from any cause among patients receiving B vitamins (not specifically linked to cancer). The latter two results must be interpreted with caution, since the number of statistical tests performed on secondary end points was large and the number of events was small, and the confidence intervals around the relative risk estimates are wide.” I cannot say enough about the humility and academic honesty of the authors of these major trials, and it is truly an example of the peer review process working well. Consider how dangerous it would be for researchers to be claiming that every secondary outcome measure is indeed evidence in favour of treatment. Our clinical lives would be chaos with the degree of medical reversal that would ensue with subsequent trials showing conflicting results.

Then in 2010, we reported significant harm from B vitamins including 1,000 mcg/day of B12 (cyanocobalamin) among patients with diabetic nephropathy. Decline in renal function was accelerated by high-dose vitamins, and cardiovascular events were doubled. In 2011 Stampfer and I hypothesized that harm from cyanocobalamin among participants with renal impairment cancelled out the benefit of B vitamins among participants with good renal function.

The JAMA study from 2010 did indeed show that in patients with diabetic nephropathy, B vitamins worsened both eGFR and vascular outcomes. But to assert that somehow implies that B vitamins would thus reduce vascular risk in those without renal disease? There is simply no logic there. Replace B vitamins with NSAIDs. In patients with diabetic nephropathy, NSAIDs are certainly known to worsen both eGFR and vascular outcomes. Following his logic, in patients without renal disease, NSAIDs would then reduce vascular outcomes? That simply isn’t true, and is in fact quite the opposite.

The final piece of the puzzle fell into place with the publication of the Chinese Stroke Primary Prevention Trial, which reported a 25% reduction of stroke with folic acid alone in patients with hypertension receiving enalapril. Among participants with LDL-C >2 mmol/L, the reduction of stroke was 31%.

The study randomized patients to enalapril plus folic acid or enalapril alone, and did in fact find a reduction in stroke risk. But here were the authors with an explanation of why their findings differed from VISP and NORVIT: “In this population without folic acid fortification, we observed considerable individual variation in plasma folate levels and clearly showed that the beneficial effect appeared to be more pronounced in participants with lower folate levels. In comparison, the VISP study was conducted in the United States, a region with folic acid fortification. Mandatory folic acid fortification in North America has had a significant positive effect on the population’s plasma folate levels. The mean folate levels at baseline in the VISP study was about 28 nmol/L (12.4 ng/mL), which was about 50% higher than that in the CSPPT trial. Therefore, it is not surprising that previous folic acid trials conducted in high folate regions generally yielded null results, which were likely due to the “ceiling effect” of folic acid supplementation.” Pretty clear reasoning. Our rates of folic acid deficiency in North America are so low that in Ontario, the government will not actually pay for the test to be performed, because it is of such low value.

Importantly, among participants with impaired renal function, folic acid slowed the decline of renal function and reduced a composite event that included progression to dialysis and mortality. 

Again, another post-hoc analysis aimed at mining a trial for data. You’ll notice that no nephrologists are actively pushing folic acid on their patients for vascular protection.

This means that the problem with the early trials was not unmetabolized folic acid; it was probably due to cyanocobalamin. A meta-analysis of trials stratified by renal function and dose of cyanocobalamin supports that hypothesis.

They looked at the VISP data again! 13 years later! If at first you don’t succeed….

 B vitamins do reduce the risk of stroke, if not MI, but we should be using methylcobalamin or oxocobalamin, not cyanocobalamin. It is important to use B12 in addition to folic acid because of the very high prevalence of metabolic B12 deficiency, which is largely unrecognized.

If you move the goalposts enough times, eventually the field goal will be good.

Only a small fraction of total serum B12 is active (~ 6-20%). This means that a serum B12 in the lower end of the reference range (~ 160-600 pmol/L) may not contain adequate levels of active B12. In order to confirm adequacy of functional B12 it is necessary for the serum B12 to be above 400 pmol/L, or it is necessary to measure holotranscobalamin, or one of the metabolites that becomes elevated in metabolic B12 deficiency: the specific metabolite, methylmalonic acid (MMA), which is not available in most routine biochemistry labs, or total homocysteine (tHcy), which is a reasonable surrogate for MMA in folate-replete patients. Since we have folate fortification of the grain supply, it is reasonable to measure tHcy for this purpose.

None of this is remotely relevant to clinical outcomes. It’s mechanism-based jargon. Testing total homocysteine for what purpose?

Vitamin B12 deficiency is extremely common in the elderly; ~20% of the elderly have inadequate active B12; among vascular patients the percentage is much higher: in my stroke prevention clinic, metabolic B12 deficiency was present in 10% of patients below age 50, and 30% above age 70.

Why does this matter? Not only does B12 deficiency cause neuropathy, myelopathy and dementia; it also raises levels of tHcy, a clotting factor that markedly increases the risk of stroke. High levels of tHcy quadruple the risk of stroke in atrial fibrillation.

Yes, and nothing we have done in North America to reduce homocysteine in isolation has ever done anything to reduce vascular risk. Time to put this theory to bed. Again. Research dollars are a finite resource, and should not be spent chasing this theory any further.

Guarding against pseudoscience at Western University

As a member of the faculty at Western University, I was absolutely thrilled that last weekend’s Homecoming featured a panel discussion on the topic of pseudoscience. The panel consisted of: Dr. Jen Gunter, an obstetrician-gynecologist, Western alumnus, and prominent online voice for science-based medicine; Dr. Marina Salvadori, a local pediatric infectious disease specialist and passionate vaccine advocate; Mark Speechley, PhD and Dr. Saverio Stranges from the Department of Epidemiology and Biostatistics.

The talk was engaging, dealing with issues ranging from our society’s move away from appreciating the value of expertise, to vaccine denialism, to celebrity promotion of pseudoscientific products. My only quibble was with the short duration, as one hour was only a fraction of the time needed to tackle such a pressing topic, but hey, it’s Homecoming weekend, every minute is valuable.

So after a terrific talk, I waiting in line to greet Dr. Gunter (my Twitter buddy!) and Dr. Salvadori (who saved my cousin’s life in 2008, long story…) when, to my left, a fairly irritated man was needling Dr. Speechley with the demand that he “define pseudoscience for him”. Dr. Speechley politely explained that a definition could include beliefs and practices that appear scientific, but are not. The man was not satisfied, and repeatedly demanded a more specific definition. I couldn’t help but interject myself into the discussion, so I elaborated a bit further as to what a definition could entail. Again, he was not satisfied with our explanations. I sensed that he was clearly not interested in an actual discussion, but was rather trying to troll us into some ideological debate he wanted, so I asked him what he did for a living, to try and get a sense of where the heck he was coming from. He refused to answer. Giant red flag.

Before I had even a second to think of what to say next, he had moved on rapidly to explaining to us how he personally used homeopathy, and used it for all of his family, and who were we to tell him what works and doesn’t work.

There it was. The sacred cow. His love of homeopathy. Of course.

The rest of our conversation was a failed attempt at explaining to him that he and his family are free to pursue whatever treatments they desire, but he crosses a line when he attempts to convey to others that pseudoscientific treatments are based on any sound science. Oh, and I finally managed to get him to tell me what he did for a living. He’s an ENT surgeon. Frightening.

So where does that leave us? After an hour of kumbaya about science and fighting pseudoscience, this discussion brought me right back down to earth with the realization that pseudoscience is right in our midst on a daily basis, even promoted by those who we assume should know better.

There wasn’t any time for any questions to be taken from the audience, but here is the comment I wanted to deliver:

There was a lot of discussion during the talk about the role of health care professionals and the government in terms of education and policy around science, but we need to realize the important role that academic institutions like Western can play in terms of leadership in battling pseudoscience. Sadly, we have seen a proliferation of institutions in North America providing legitimization for pseudoscientific practices: UC Irvine accepting a $200 million gift to launch an “integrative health” institution, the fact that most American hospitals have a department dedicated to “integrative medicine”, and even the University of Toronto has its own “Centre for Integrative Medicine”. There is absolutely nothing from stopping Western from being the next university to fall prey to this trend. There has long been a course in the 4th year medicine curriculum about Complementary and Alternative Medicine, taught by “alternative practitioners”, with the students not provided with an ounce of scientific skepticism about these practices (as faculty, I provided an open lecture this year to any interested medical students, entitled “Scientific Skepticism in Medicine”). Western’s Departments of Health Sciences and Kinesiology have offered a course in “Integrative Health“, which….well just look at the syllabus. It’s horrifying.

To administrators who simply shrug and question what the magnitude of harm there could possibly be in allowing unscientific concepts to proliferate an institution, let me remind you of the institutional embarrassment that these individuals and concepts can bring to an institution. Do you think Yale was pleased at being referenced along Dr. Oz during his testimony before congress? Do you think the Cleveland Clinic had a few regrets about the fact the medical director of their Wellness Institute created an online firestorm after his blog that regurgitated anti-vaccine talking points? Do you think UBC is happy that two anti-vaccine researchers have made national headlines for having a paper retracted for the second time over accusations of fraudulent data?

There are consequences to allowing pseudoscience to flourish, because when there is the inevitable embarrassment, health professionals like myself will lay the blame at the feet of those in power who did not stand up for science.

Let’s be international leaders at Western, bucking the ongoing trend towards quackery, and setting a new standard for creating a health community dedicated to science-based medicine.

OMA/MOH Negotiations: Part Deux

My last blog post raised a few very specific ideas within primary care that I hope to see addressed in the upcoming negotiations between the OMA and the Ministry of Health.

While I love practical minutiae, I think it’s also important to step back and address some of the larger issues of how primary care is organized and funded.

First it is vital to clearly delineate the accountabilities within the system, which are currently blurred to the point of being non-existent. From a funding standpoint (for care deemed clinically necessary, third party care excluded), there should only be two lines of accountability, one between the insurer (government) and policy holders (patients), and the other between the insurer and care providers (physicians). Patients should not be financially accountable to physicians, nor vice versa, and their relationship should be strictly clinical. I’ll explain later why this is important.

Patients in Ontario (and Canada, for that matter), generally do not fully understand the fact that their taxes are paying into a health insurance policy, and that like any insurance policy, there are benefits, expectations, and restrictions to the type of care that their insurance covers. I don’t blame patients for this. The fault for this lack of clarity lies with the insurer (government), who is understandably fearful of the political ramifications of being seen to “restrict” care by enforcing any semblance of limitation on “insured care”. Second opinions, two visits for the same issue in one day, anything goes!  But can you imagine Anthem or Aetna in the US demonstrating this type of ambiguity with what their  policies cover? Tax payers don’t want to pay more taxes to cover increasing costs, so we need to have open discussions around what is medically necessary and appropriate. Clear answers are needed to the question of what does the insurer guarantee to patients, and what expectations are there of patients. Physician organizations can and should be engaged to provide their objective expertise to guide what should be covered by a provincial insurer, but the reason that there can be no physician-patient financial accountability is that physician recommendations and behaviour may be seen as being influenced by financial motives.

And the provider-physician accountability? Not as clear as you would expect. Should be pretty simple, too. Agree to a framework of what is covered by the insurer, what the expectations are of physicians, and compensate appropriately for the insured care that is provided. But rather than having a strict framework guide physician activity, we often have physician entrepreneurs stretching the boundaries of what the current loose framework intended. House calls for non-disabled patients, specialist clinics that bring stable patients back repeatedly for routine follow-up with expensive imaging tests, and niche clinics opening up for any new market that they identify (eg. “biochemistry nutrition clinics”, “functional medicine clinics”, “cannabinoid medicine clinics”, etc.). With many of these clinics, the horse is coming before the cart. The physicians have a OHIP billing number, and it’s essentially a blank cheque to bill the government for any semi-clinical interaction with patients, until the CPSO or the ministry deems the clinic’s practices egregious enough to intervene (which is rare).

So where am I going with this? I have a fairly radical plan for how primary care funding could be re-organized.

First we need to address the issue of the “access bonus” for those in a FHO model with negation for family physician billings outside of their FHO. The initial rationale for the concept was innovative: use the outside billings as a surrogate marker for the degree of access FHO physicians are providing. With better access, patients should be seeking care elsewhere less frequently. Unfortunately, it has proven to be a poor surrogate in many areas of the province, including areas without a walk-in clinic (ER visits don’t contribute to negation, physicians get their total access bonus regardless of actual access) and the GTA where commuting patients will seek convenient care at a walk-in rather than attending the after-hours clinic their FHO is providing (FHO provides the access, still gets negated). But apart from the inequality of the system, this mechanism is fundamentally flawed because it violates one of the principles of accountability I raised earlier. Lines of financial accountability should not exist between patients and physicians. In the case of the access bonus, it has strained many physician-patient relationships as physicians have often clumsily attempted to educate patients about what the access bonus/negation issue entails, while the patient hears “You are costing me money by seeking health care”.  This is not healthy for these relationships. We need a new system.

Here we go.

First, take the FHO/FHG/FNH models and replace them with two capitation “tracks” that family physicians can decide between for their practice. Track 1 would see 80% of their income from capitation fee, with a 20% fee-for-service shadow billing for patient encounters. Track 2 would see a 60/40 split. Depending on which Track a physician chooses, they would be locked in for 3 year periods (the math involved in switching between tracks more frequently would be a nightmare). Capitation figures would be adjusted based on a formula of patient complexity, the data of which would be taken from the accurate EMR coding of patient problems (with agreed-upon standards of what makes a patient eligible to be given a certain diagnosis/problem).

Next, when a patient is rostered to a family physician, within a 30km radius of their provider they are only insured to see their provider group. If a patient chooses to seek care at a walk-in or other family physician within that 30km radius, it would not be an OHIP-insured service, while outside of that radius it would be insured (on vacation, visiting family, work, etc.). There would have to be point-of-care OHIP validation available in real-time for walk-in providers to determine whether the patient visit would be insured or would be patient-pay. For those without valid OHIP cards who present for care, there would also have to be a live ministry-run system available for dealing with issues of coverage during all clinic hours.

If a patient repeatedly is seeking care outside of their provider network/radius, it is the INSURER (the province) that then can de-roster the patient and make that patient a “fee-for-service patient” (that is, each service covered by OHIP is paid as fee-for-service, not covered by capitation rates). The ministry would then be incentivized to attempt to find the patient a primary care group that is closer to the patient’s geographic area, as the province does like the relative cost-certainy that capitation models bring.

For physicians in these new capitation “tracks”, there would be NO cap on fee-for-service billings provided to patients who have been excluded from capitation by the ministry, as the fact that they are “fee-for-service patients” is out of their hands (there is currently a cap on these billings for capitated physicians).

There would also be no further clawback on access bonus payments. The payments would all be made in full to all physicians, but with strict accountability for after-hours clinic availability (7 days a week, 3 hours/d), and adequate patient access for new-onset complaints (3rd next available appointment within 24 hours). For those in rural areas, providing scheduled after-hours care through emergency departments would be allowable if negotiated directly with the LHIN. If physicians are found not to be meeting the access requirements, there would be a tiered warning system, with repeated violations ultimately resulting in termination of their capitation contract, reverting the physician to an exclusively fee-for-service model. Some physicians may see these requirements as oppressive, but if we are going to create a model whereby payments are essentially guaranteed and patients are restricted from seeking care elsewhere, we must provide them with impeccable access to our services.

(There would also have to continue to be a significant financial advantage for physicians to be in a capitation “track” model over a fee-for-service model to provide the incentive to stay within the organized capitation system.)

Patients themselves can opt to be “fee-for-service patients” within a practice and the province, but then would not be guaranteed the provisions of access to after-hours clinics or the 24-hour clinic appointment guarantee.

So there’s my preliminary framework. Lots of work still to be done (and I’m sure exceptions and situations I haven’t considered), but I hope we can start moving our system forward with some new innovations, because the current blurred lines of accountability are frustrating both patients, physicians, and the government.

AAA screening in older males: Should we?

Last week, a Danish group made headlines with their Lancet study showing that “Triple-screening” older men for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), and hypertension reduced 5-year mortality by 7%.

This was seen as validating the current Canadian guidelines that call for all males 65-75 years old to undergo a one-time ultrasound to rule out a AAA, in addition to women with risk factors (smoking history, family history of AAA, or cerebrovascular disease).

So, is it time to move forward with a formal population-based screening program? Let me provide some food for thought using some of my own practice data.

In the Danish study, 21% of the subjects were active smokers at baseline. In my practice 10 of 154 (6.5%) men 65-75yo are smokers (3 of the 10 smokers smoke only cigars or pipes infrequently, and 3 men in the cohort have no smoking data available). We know that smoking is the strongest risk factor for development of AAA, as current smokers are 7.6 times more likely to have an AAA than nonsmokers, and even ex-smokers are 3.0 times more likely to have an AAA than nonsmokers. Screening a population where smoking is less prevalent will provide far less of a mortality benefit than was seen in the Danish population, with a larger number needed to screen.

In response to the Canadian guidelines, I have made an effort in my practice to increase AAA screening rates over the past few years, with 113 of 157 (72.0%) men 65-75yo completing an ultrasound screen. Of the 113, only 2 have a AAA, which is significantly lower than the 3.3% AAA rate seen in the Danish study. Lower smoking rates overall likely translating to the lower rate of AAA.

Looking at all age groups, 14 of my patients have a current or past AAA (7 men, 7 women). 10 of the 14 are former smokers, and none are current smokers. 12 of the 14 are over the age of 75.

The number needed to screen for men >65yo to prevent one AAA related mortality is 769, but this includes both smokers and non-smokers which are likely inflating the numbers. If we are going to implement a program, let’s start with the high-yield groups of smokers/ex-smokers first where we know we will see a see the biggest benefit.

Ontario Osteoporosis Strategy Technical Report – My practice-level data/insight

The Ontario Osteoporosis Strategy recently released its technical report which I encourage all family physicians, endocrinologists and orthopaedic surgeons to read. The report takes data from ICES and CIHI and brings to light some interesting province-wide and LHIN-wide trends in osteoporosis screening.

The main takeaway for me from the report is that the current system is doing a generally poor job of screening patients for osteoporosis. Top level points include:

  • In 2014/15 only 13% of men and 28% of women aged 68-70 had received a BMD in the past 5 years

osteolhin2

  • In 2014/15, there was a three-fold difference between high and low rates for standardized BMD testing following a hip fracture (low of 11.9 in Erie St. Clair; high of 38.6 in Toronto Central)

osteoLHIN.png

It goes without saying, but there is an awful lot of improvement when you look at that table. Many eligible patients not being screened at all, and many not receiving appropriate care post-fracture.

But before every LHIN jumps out of their seat wanting to improve this as a quality metric, we need to step back and practically evaluate which groups would truly benefit from screening.

The 2010 Canadian clinical practice guidelines recommend screening all individuals >= 65 years old (men and women) for osteoporosis. The Osteoporosis Self-Assessment Tool is a validated screen that is useful in determining which patients would warrant a BMD. The formula is Weight (kg) – Age (years), and if <10, increased risk of osteoporosis and BMD is warranted.

How do these two approaches to screening compare in a real-life setting? I looked at my practice-level data and will share the insights here.

In a practice of 2200 patients, 243 women >= 65yo were identified, 224 of whom have had at least one lifetime BMD (92%). 250 men >= 65yo were identified, 107 of whom have had at least one lifetime BMD (43%).

l went through my patient data and analyzed which patients have a calculated OST < 10 and would qualify for BMD screening, sorted by age cohort.

First, the men (11 patients were excluded because of no recorded weight):

65-69yo: 9/75 have an OST <10 (12%)

70-74yo: 24/61 (39%)

75-79yo: 23/37 (62%)

80-84yo: 26/31 (84%)

>=85yo: 31/31 (100%)

And the women (21 patients were excluded because of no recorded weight):

65-69yo: 34/52 have an OST <10 (65%)

70-74yo: 38/59 (64%)

75-79yo: 29/38 (76%)

80-84yo: 32/33 (97%)

>=85yo: 47/47 (100%)

In total, 45% of men >=65yo would qualify to be screened with BMD according to the OST, and 77% of women >=65yo would qualify.

Certainly looking at the male data, it appears that using the age 65 cut off is a very crude screen and may lead to over screening with BMD. But what about the most important outcome, which men actually required treatment for osteoporosis as a consequence of screening those >=65yo? (using Mayo Clinic resource as shared decision-making tool)

I identified 14 male patients in my practice who are currently being treatment for osteoporosis (either with bisphosphonate or denosumab): 10 patients >=65yo, 6 patients 50-64yo, and 1 patient <50yo. Interestingly, only one of the 14 patients was identified as having osteoporosis through the >=65yo screening program. The remainder were identified as requiring a BMD because of other risk factors:

– 5 with compression fractures (2 of whom have alcohol use disorder)

– 2 on prednisone

– 2 with rheumatoid arthritis

– 1 with Parkinson’s

– 2 with alcohol use disorder

– 1 with Prader-Wili

Out of 107 men >=65yo who received at least one lifetime BMD, only ONE patient lacking any other risk factors apart from age warranted (and agreed to) treatment for osteoporosis.

A few points to consider:

  • If we are going to target osteoporosis screening as a quality metric to improve, I think it behooves us to isolate screening in women >=65yo as the actionable, measurable metric, rather than including both men and women in the cohort. Screening all men >= 65yo will not be a cost-effective intervention, as it will not identify a significant number of men who will actually warrant treatment, and will instead result in many completely fruitless BMDs, at a cost of millions of dollars to the system. While likely not measurable as a widespread metric, the preferred approach to screening in men should be risk factor-based, with a particular focus on screening men with a history of corticosteroid use, alcohol use disorder, RA, those on aromatase inhibitors, and those with a previous fragility fracture (and screening men with chronic back pain with plain x-ray to rule out compression fracture).
  • The OST should be encouraged as the initial screening evaluation prior to BMD, and that it be highlighted to physicians that 100% screening compliance is not the suggested target in women >=65yo (only 77% were eligible according to OST in my patient population).
  • The technical report mentioned that of those on treatment for osteoporosis, 38% of individuals received a follow-up BMD within 2 years. While the report frames this as a proportion that should be increased, I would take the opposite approach to this data. Ordering a repeat BMD within the first 2 years of treatment for osteoporosis is rarely indicated as the results should not often change treatment. Any change in the BMD within 2 years of starting treatment is just as likely to be inherent variability in the test as compared to a meaningful change due to treatment. We should be targeting that 0% of patients receive a follow-up BMD within 2 years of starting treatment.

Certainly there is tremendous room for improvement in how we are systematically screening for osteoporosis in Ontario, especially in those who have already experienced a fragility fracture and in women >=65yo. We must, however, also ensure that any widespread quality improvement efforts must be rational in who it targets and careful to avoid over screening in extremely low-risk populations, such as men who lack any risk factors other than age.