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


  • 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)


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.

OMA/MOH Negotiations: A few suggestions for primary care

With a binding arbitration mechanism finally in place, negotiations between the OMA and the MOH are set to commence in the next month. Sections and districts are being consulted for their priorities in negotiations with the objective of developing a cohesive mandate.

While there will be broad consensus on many high-level issues that stretch across multiple specialties (appropriate funding of system growth, funding to improve physician staffing in under-service remote areas, etc), I want to get a bit more granular to raise some fairly narrow issues that are specific to primary care.

(Disclaimer: I don’t consider these to be anywhere near the most important issues to primary care, but simply a few issues where I think we can see some innovation.)

  1. Fix FHO oversight, and open them back up to all family physicians in all regions

Restricting FHO entry to those in under-serviced areas may have initially seemed like wise policy that would drive physicians to those areas, but instead has resulted in multiple unintended consequences. We have a two-tiered system within primary care of those in a capitation model and those who are stuck in a fee-for-service model which the ministry themselves has decried as antiquated. The difference between the two models is far more than one of finances: it potentially changes the manner in which care is delivered, where capitation incentivizes the physician to innovate, providing alternative methods of care delivery (phone, telemedicine, staff delegation) and removing the incentive to initiate potentially unnecessary visits. When we are dealing with fundamental principles of care delivery, this simply cannot be determined and restricted based strictly on geography. If it’s a good model, it’s a good model in North Bay, it’s a good model in Niagara Falls. But here’s the caveat: we need to fix what is currently happening in some FHOs. FHOs are contracted to provide a minimum number of after-hours clinics, and a small group simply aren’t meeting their obligations, partly answering why we haven’t seen much of an improvement in access despite large investments into FHOs. (I note a “small group”, because I know that the majority of FHO docs who are meeting their responsibilities bristle at any mention that some docs aren’t. If you are doing your mandatory clinics, you are completely exempt from this criticism). Part of the issue is that the ministry hasn’t enforced the requirements, but this can be easily remedied. Start enforcing the rules, and mandate that FHOs transparently advertise their after-hours clinics availability (websites, phone, push e-mails). I won’t comment on specific measures of access during office hours for new or urgent issues, but I think we’re well overdue to see some consistency around this issue across the province.

2. Revising the K030 and Q040 for diabetes management

Family physicians bill a K030 as a visit code for diabetes visits (max 4 per year), and are eligible to bill a Q040 code ($60) once per year “if the physician has rendered a minimum of three K030 services for the same patient in the same 12 month period to which the Q040 service applies”.


Makes sense in theory to improve quality of care, but a few unintended consequences. If a patient comes in for assessment of a unrelated intercurrent illness where diabetes was not reviewed but a physical exam was completed, the physician is essentially forced to bring back the patient for a “diabetic visit” which can just as easily be done over the phone or by other telemedicine means. This leads to unnecessary visits and often inconveniences patients who are stable.

Proposal: Change the K030 into a Q030 tracking code, which can be billed either through provision of in-person or virtual care of all of the features of the Diabetes management Incentive at each visit (except the foot examination and neurologic examination, which should only be required once a year). Three Q030 codes in a 12-month period to be eligible for the Q040 code, which should be increased to the $125 range (matching CHF Q050 code) to properly incentivize physicians to do more virtual care and to properly remunerate the requirements of diabetes care.

3. Complete overhaul of the preventive care bonus program

With all of the innovation taking place in primary care in the province, somehow we are still stuck with the same five metrics for nearly a decade now (influenza vaccination, childhood immunizations, colorectal cancer screening, cervical cancer screening, and mammograms). Kiran et al showed in 2014 that in Ontario, “pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure”. Total bonus payout can be as high as $12,800. Surely we can use that money to actually improve some areas of care. (Disclaimer: I have a compliant practice population and regularly hit all of my maximum targets. Any alteration may actually impact me negatively. But let’s tinker with it anyways.). Here are some ideas:

  • Take a small portion of the existing bonus money and leave it to reward the existing five metrics, but change the measured outcome from “test or treatment completed” to “test or treatment was offered to patient” and implement a tracking code for each. Make the threshold 95% compliance to obtain the bonus. Childhood immunizations discussions must occur in person, the other 4 interventions can be done virtually (batch email, snail mail, phone, etc). This will enable informed, patient-centred decision making, and will eliminate the tension between physicians and patients when patients refuse an intervention that may affect the physician’s income. If the bonuses for these metrics are completely eliminated, I do fear that we may see a significant decline in screening and immunization rates, as many patients complete these interventions because of their relationship with the primary care physicians (and would not be as compliant if Cancer Care Ontario or public health departments were the only bodies encouraging the interventions).
  • Develop an advance care planning framework (workbook, custom form, etc.), and establish bonus money thresholds for percentage of patients 65+ years of age for whom the established framework has been either completed or offered (for patients who refuse to engage in discussion). Codes should be established for both the visit where this discussion occurs, as well as making the bonus sufficiently generous given the large number of patients this initiative will encompass.
  • Dedicate the majority of incentive money towards EMR maturity programs, specifically a focus on rewarding data integrity and standardization over a 3-year period. Identify priorities (linking problem lists to ICD-codes according to defined algorithms, appropriately labelling data elements including lab results, imaging, immunizations, vitals, etc). There are massive disparities across the province in how effectively and consistently physicians are entering their data, and an incentive program would reward physicians who have 1) invested in an electronic medical record and 2) are interested in working towards maximizing the potential of their EMR to improve quality of care in their practices. Future agreements can focus on specific renumeration for participation in quality improvement initiatives using their high-quality data.

4. Tighten up house call restrictions

We have seen some entrepreneurs in the GTA create companies that offer the convenience of physician house calls. While of course I support the availability of house calls to all Ontarians, some of these programs risk putting simple patient convenience ahead of continuity of care, as well as markedly increasing health care costs with otherwise mobile patients costing the system 3-7 times the cost of a regular office visit. A few simple suggestions:

  • Strict enforcement that house calls are only available to patients who are physically disabled and unable to attend an office visit in person. Lack of adequate transportation and convenience (e.g. parent with febrile child would not qualify). This must be clearly advertised by these companies, the patient’s disability must be clearly documented for auditing purposes, and patients who do not qualify should be able to pay out of pocket for the total cost of these convenience house calls.
  • For patients requesting house calls who are rostered to a physician group, any house call physician outside of that group must 1) have prior consent to see the patient or 2) make an attempt to contact the on-call physician of that group to ensure that they are not able or willing to see the patient.

5. Change the billing framework for “physicals” and “Periodic health examinations”

In the last agreement, for patients without a chronic disease, any “checkup” or “physical” would become known as a “Periodic Health Visit”, code K130/131/132 to be billed at $50.00. (For those without chronic disease, this was a marked reduction from the A003, a general assessment, billed at $77.20 (pre-unilateral action)).

Here’s my radical suggestion, in keeping with the Choosing Wisely campaign: Change the K130/131/132 to a Periodic Health Review, billed at $30 once per 12 months, which can be done either in-person (in conjunction with a visit code) or virtually. The review will simply include a questionnaire including all of the history-taking components of the Preventive Care Checklist, with no required physical examination component. Patients can either monitor their own BP and weight to be recorded in the EMR, or they can stop into the office to have this measured (recording these vitals once yearly would be required to bill the K130/131/132). A003 will still be able to be billed for patients for a physical for follow-up of a cancer diagnosis or other life-threatening illness requiring a head-to-toe exam (eg. CKD patients should have a focus physical exam at regular appointments, and thus do not require an annual A003). If patients who do not meet the criteria request any hands-on annual physical examination, this should be not OHIP covered, and available to patients at OMA rates.



Crazy ideas, I know. We’ll see what happens with the negotiating parties.

Cheaper PPI options: An EMR QI exercise

Back in December 2016, I was doing some work around proton pump inhibitor (PPI) costs in Ontario and did some digging into my EMR data to see what savings could be found.

Here was my Twitter thread about the topic.

In short, I identified 414 of my patients on a PPI, 314 (76%) of which were on rabeprazole or pantoprazole, the two cheapest options. I calculated the potential monetary savings by switching every patient in my practice who is on a more expensive PPI (esomeprazole, lansoprazole, omeprazole, dexlansoprazole) to generic rabeprazole; projected tally would be $22,340 over the course of a year. Not an insignificant sum.

It’s one thing to project a cost savings. But would it actually work?

I embarked on a very simple intervention in January 2017. Using my EMR (Telus PS Suite), I created a reminder that would place the note “Consider switch to cheaper PPI” on the chart of every patient on esomeprazole, lansoprazole, omeprazole, dexlansoprazole, or pantoprazole.


That reminder would appear on their chart, and would prompt a discussion at their next appointment about a potential trial of rabeprazole.


(I am intentionally omitting the issue of de-prescribing from this analysis, as de-pescribing PPIs has been another important undertaking in my practice, yet this analysis was strictly looking at looking at cost-saving from cheaper PPIs. The above reminder did prompt many instances of de-prescribing, but these were not as easily quantifiable retrospectively. In addition, I bristle at the idea of openly quantifying and applauding the cost savings from de-prescribing, as it would rightfully raise the question in patients’ eyes whether we are de-prescribing out of concern for their health, or simply to save money. This analysis looks at cost-savings from switching from one PPI to another, the goal of which is to produce no clinical negative change).

Of the patients who were engaged in a discussion, many were found not to be appropriate for a rabeprazole trial, either because of intolerance or lack of efficacy from previous trials of rabeprazole. Other patients were not open to a trial because of lack of interest in “rocking the boat” or because of an upcoming trip and concern about impacting travel insurance.


28 patients (some private pay, some publicly-funded) who required ongoing PPI therapy (due to ongoing indication or due to previous failure with PPI wean) agreed to a rotation to rabeprazole as a trial. 7 patients described a clinical worsening of symptoms (most within the first two weeks), and requested to be put back onto their initial PPI (5 patients on lansoprazole, 1 on pantoprazole, and 1 on omeprazole).  21 patients saw no clinical change, and those 21 have been found to be stable at the 3-month mark post-rotation (11 on lansoprazole, 4 on omeprazole, 4 on esomeprazole, and 2 on pantoprazole).

The cost savings were as follows (using rabeprazole 20mg tablet, $0.24/pill):

  • Esomeprazole – $1.86 per pill ($1.62 savings/d, $591.30/yr per patient)
  • Omeprazole – $0.41 per pill ($0.14 savings/d, $51.10/yr per patient)
  • Lansoprazole – $0.50 per pill ($0.26 savings/d, $94.90/yr per patient)
  • Pantoprazole – $0.30 per pill ($0.06 savings/d, $21.90/yr per patient)

Total yearly savings from these 21 patients now stable on rabeprazole: $3657.30

A few things to take away from this:

  1. This was a ridiculously simple intervention, and took me virtually no time to create the reminder or to have those discussions with patients.
  2. This should be a wake-up call to the Ministry of Health on the importance of working with physicians on finding efficiencies in our system. Physicians know where these efficiencies are, so allow innovation and creativity, reward it appropriately, and we’ll find the money.
  3. It is critical that the first script for the rabeprazole be of short duration (I prescribed two weeks), otherwise 3 months of wasted pills for the 25% failure rate would have erased some of the cost savings.
  4. Most practices will likely see greater savings than I achieved in my practice, as I have been consciously working to prescribe exclusively rabeprazole for some time now. Even if you assume my prescribing rate to be on par with the Ontario average (2200 patients), extrapolating this out to Ontario’s population of 13.6 million, this simple intervention would amount to a provincial total of $22.6 million.
  5. Note that most of the savings were found in switching patients from esomeprazole. Please don’t use it unless you are absolutely handcuffed. It is insanely expensive compared to others in the class.

All of us have these opportunities in our practices for small interventions that we may actually find some element of satisfaction in evaluating, especially with the power of a well-functioning EMR behind us.

ACE-inhibitors/ARBs in diabetics: Evidence doesn’t support the CDA guidelines

As part of my work on a provincial committee, the issue came up recently regarding a quality metric evaluating proportion of all diabetic patients aged >55  who are being prescribed an ACE-inhibitor or ARB. When it was pointed out that the evidence supporting this specific metric is weak, the response was that this recommendation is part of the Canadian Diabetes Association Clinical Practice Guidelines, and that for a committee to go against an established guideline would be difficult.

The full CDA Clinical Practice Guidelines were last updated in 2013 (partial updates in 2015, February 2016, and November 2016), including the section specific to vascular protection in people with diabetes. Here is the recommendation around ACE-inhibitors/ARBs:


The efficacy for ACE-inhibitor/ARB use in established macrovascular disease was established back in 2000 with the HOPE trial. No argument there. Same with patients with diabetes and kidney disease (including microalbuminuria) from the RENAAL trial showing losartan improved proteinuria and renal outcomes.

I want to focus on the first half of point #2, where they recommend ACE-inhibitors for all patients 55 or older “with an additional risk factor”. From the HOPE definition, these risk factors would include hypertension, cigarette smoking, elevated total cholesterol levels, low HDL levels, or microalbuminuria.

Should ACE-inhibitors be the preferred treatment for hypertensive diabetics without cardiovascular or kidney disease? Not quite. The 2017 CHEP Guidelines reviewed the evidence and found that thiazide/thiazide-like diuretics and dihydropyridine CCBs would also be appropriate choices in this population (Section XII, Point #3). American guidelines from JNC 8 came to a similar conclusion (Recommendation #6). Here’s a systematic review from the BMJ from 2016 on the topic.

The most relevant question to me is, should patients with diabetes with no history of cardiovascular disease, no history of hypertension, and no end-organ damage, be prescribed an ACE-inhibitor? Simply on the basis of having hyperlipidemia or cigarette smoking?

The HOPE study population was a mix of patients with established cardiovascular disease and those who where 55 or older with one of the above mentioned risk factors. While a benefit was found to ACE-inhibition in the study population as a whole, here were the confidence intervals for those with and without cardiovascular disease:


As you can see, it is very difficult to make any conclusions about the “no cardiovascular disease” group. Point estimate around 0.8, but very wide confidence intervals. One could argue that the point estimate could be hypothesis-generating, but certainly no more than that in terms of guiding whether these patients should be all prescribed ACE-inhibitor/ARB therapy.

The guidelines also cite a “recent meta-analysis indicates that ACE inhibitors and ARBs reduce CVD events in normotensive individuals with and without diabetes” and “accordingly, the use of ACE inhibitors or ARBs for vascular protection with persons with diabetes ≥55 years or with any evidence of organ damage is recommended, even in the absence of hypertension”.

But hold on a second. What did this meta-analysis show? Or should I ask, what studies did this meta-analysis look at? 13 studies in total: 3 studies including only those with heart failure (SOLVD, SAVE, and TRACE), the RENAAL trial (patients with nephropathy), PROGRESS (patients with stroke or TIA), CAMELOT (those with angiographically documented CAD and elevated DBP), EUROPA (stable CAD patients), DIABHYCAR (patients with microalbuminuria), DREAM (dysglycemia, no frank diabetes), TRANSCEND (established atherosclerotic disease or end-organ damage), PROFESS (history of ischemic stroke), ACTIVE-I (history of atrial fibrillation), and the above-mentioned HOPE trial.

So the only study in this meta-analysis that included the patients from our relevant clinical question (diabetes with only hyperlipidemia or smoking as a risk factor) is the HOPE trial, which we already showed we cannot look to for a definite answer on this. None of the other trials cited by the CDA Guidelines looked at ACE-inhibitor/ARB use in our subset of patients.

Why is this relevant? In my practice alone, of 220 patients with diabetes, I have 40 patients who either smoker or have hyperlipidemia, and who have no history of cardiovascular disease, no microalbuminuria, and are not on an ACE-inhibitor/ARB for hypertension. The current guidelines suggest that all 40 of these patients should be on treatment, despite the evidence not supporting this claim. This is not a minor clinical issue. And to compound this problem, we have provincial and local organizations uneasy about contradicting these guidelines, and feeding data to physicians with the intent of altering prescribing rates.

I would suggest that the Canadian Diabetes Association Clinical Practice Guidelines Expert Committee re-evaluate their stance on the issue of ACE-inhibitor/ARB use in patients 55 and older with one additional risk factor (without macrovascular disease or end-organ damage) given the paucity of evidence supporting their current recommendation.

Anti-vaccine advocates present on Bill 87: Torrents of misinformation

Bill 87 has been controversial for a number of reasons. One of the only pieces of the bill that everyone has seemingly agreed on is the requirement that any parent refusing vaccines for their child based on conscience of religious belief must attend a mandatory education session held by public health.

Reasonable, no? Who could possibly disagree with this?

The anti-vaccine crowd, of course. Each of the first three committee meetings of the Standing Committee on Bill 87 has featured a speaker delivering an oral submission rife with myths and misinformation on vaccines, aimed at swaying the legislature to remove the amendment.

Before I get into the specifics of their presentations, I want to deliver a very clear message to the members of this Standing Committee and to all of our political leaders. Your roles as elected officials involve seeking out expertise and using their information to guide public policy. Public health officials, physicians, and other health professionals have specific expertise that must be utilized, and decisions cannot be influenced by those who push misinformation, conspiracies, and who adhere to no scientific or academic standards.

Here are the presentations from April 12 and April 26. Those who spoke out against vaccines were Elisabeth Hall, Gisele Baribeau (Concerned Parents of London and Area – on Vaccines), and Heather Fraser (Vaccine Choice Canada).

Ms. Hall told her story of her two daughters with chronic eczema, psoriasis, asthma, allergies, tics, IBS and “chronic breathing issues”. She described (in her own words) “starting down the rabbit hole” of researching vaccines and “began to understand that vaccine injury is real”. She stated that “parents who are choosing to follow a different schedule than the recommended schedule are very well educated individuals with a high level of education”.

Let quote Tom Nichols’ from his terrific book “The Death of Expertise”:

The parents most likely to resist vaccines, as it turns out, are found among educated San Francisco suburbanites in Marin County. While these mothers and fathers are not doctors, they are educated just enough to believe they have the background to challenge establish medical science. Thus, in a counterintuitive irony, educated parents are actually making worse decisions than those with far less schooling, and they are putting everyone’s children at risk.

She adds “It appears the purpose for these education sessions could have an ulterior motive behind it.” Yes, the motive is to improve the health literacy of the population and to increase vaccine coverage in our community. No one is hiding this. She likely believes that any actual facts presented at these sessions are “coercion”, while in reality they would be providing citizens with high-quality medical information as is our duty as health educators.

She then engages in a horrifying back and forth with NDP Health Critic and MPP France Gelinas about checking for antibody titres. Warning to immunologists, infectious diseases experts, and frankly anyone with any expertise in this field. You will need a good dose of Gravol to get through this…

Mme France Gélinas: This is an interesting concept. Frankly, I never thought about that, that somebody would already have the immunity through some of the mandatory vaccines. Do you know of any other jurisdictions that do that, that test people before they have a universal vaccination program?

Ms. Elisabeth Hall: No. Nobody does a routine titre test, something where it’s a regular test, like you go to the doctor’s and you do a pap smear or something. You know you’re supposed to do that every couple of years at a certain age. We’re not routinely checking at all. In fact, I called OHIP and I asked them if the titre test was covered by OHIP, because I wanted to know if it was free and covered or if I had to pay for it. They did not know what a titre test was, so then they told me to call my doctor.

That’s how rare this test is. As you can see, not many people know about it. But if we are routinely checking for titres, we can see if the vaccine is working, because we know that sometimes vaccine manufacturers have maybe set an efficacy of 95% but then they came back and said a couple of years later, “Oh, sorry, it was only 60%.”

We can see that titre tests would be very important if you want to actually protect a community and protect individuals, because antibodies can transfer through breast milk. They can also come into contact—there have been people who have had titre tests who have never actually experienced the symptoms of the disease and had the antibodies for the disease.

Mme France Gélinas: Did you go to your family physician? Did you ask—if you were to be referred, is it covered?

Ms. Elisabeth Hall: Yes, it is covered.

Mme France Gélinas: But we’re not using it because nobody knows about it.

Ms. Elisabeth Hall: Exactly.

Mme France Gélinas: How did you come to know about that?

Ms. Elisabeth Hall: I’ve been researching for a year and a half consistently, almost every day for, like, three hours.

Mme France Gélinas: It took a lot of work.

Ms. Elisabeth Hall: Yes, many sleepless nights.

Mme France Gélinas: Did you have such a test done on your children?

Ms. Elisabeth Hall: I haven’t done a test, no, because they’re fully vaccinated—and they were injured by vaccines. So I haven’t done a test yet, but I probably will, just to see if the vaccines actually even worked.

Mme France Gélinas: Very interesting. Thank you.

“Nobody does a routine titre test”. Yes we do. Regularly. She called OHIP and they didn’t know what a titre test was. Who was she speaking to? A secretary? The janitor? What is that supposed to prove? “Not many people know about it”. This is a straw man fallacy to end all straw man fallacies. Everyone knows about titres. Everyone orders titres. This is not a new thing. But here’s where she is totally off base. She is subtly implying that we should order titres on children before giving them vaccines. Here’s the problem with that. If you check a titre after giving one dose of MMR, you may see a positive titre and be falsely led into thinking that you don’t need a booster. Your immunity will quickly drop off and you will soon be left unprotected. We check them in certain cases in adults to avoid immunizing if not necessary, but this is not applicable to children.

“I’ve been researching for a year and a half consistently, almost every day for, like, three hours.” Googling frantically and looking for information that specifically supports your prior belief system is not researching. It’s confirmation bias. And I must say that I am incredibly disappointed in MPP Gelinas for feeding directly into the conspiratorial narrative that Ms. Hall was creating.

MPP John Fraser gave Ms. Hall the most opposition, defending the need for health protection. Ms. Hall then adds “If someone wants an exemption, they have to have maybe had an injured child that’s—maybe their family history has the MTHFR gene that enables them to detox from toxins. They might have this gene, and they might want a medical exemption.” Someone bringing up the MTHFR is a big pseudoscience flag, as it’s being used by the alternative medicine community to explain away just about any health concern. Here’s a terrific summary of the MTHFR issue from Skeptical Raptor.

Heather Fraser from Vaccine Choice Canada spoke about her experiences with her son with eczema, asthma, and peanut allergies, and attributed them to vaccines. She authored a book, The Peanut Allergy Epidemic where she “explains that vaccination is the precipitating cause of this pediatric epidemic” (again, there is no evidence to support this claim). She holds an MA in Art History, BA in Art History & Criticism and a degree in Education, Visual Art & English. No expertise in medicine, public health, immunology, or infectious diseases. But here is the pièce de résistance. Her book’s foreword was written by Robert F. Kennedy Jr. Yes, the same Robert F. Kennedy who was recently announced by Donald Trump to coordinate a vaccine safety commission for the president. RFK Jr. has long been criticized for his anti-vaccine views, including continuing to push the disproven claim that MMR is linked to autism. Here is a great article from Scientific American detailing RFK Jr’s questionable past.

She cites Dr. Peter Vadas to support her position that vaccines can lead to allergy. She is likely referring to this video from 2001. What she conveniently omits is that Dr. Vadas has since been very clear on his position of the safety of vaccines, and his comments have been repeatedly taken out of their context.


She goes into detail about adverse event reports that has seen, listing all of the reported conditions in an attempt to strike fear into the legislators. There are significant problems with using reporting systems as a measure of vaccine safety, as Scott Gavura details in this article. Most of the cases of vaccine injury she cites are likely an example of the post hoc ergo propter hoc fallacy, which states “states “Since event Y followed event X, event Y must have been caused by event X.” e.g. The rooster crows immediately before sunrise; therefore the rooster causes the sun to rise.

It is easy for me to go through their presentations line by line and point out their scientific and logical flaws, but my hope is that politicians and the public can familiarize themselves with the patterns and techniques used by the anti-vaccination movement to be able to quickly recognize these fallacious arguments. None of their arguments are new, they simply recycle the same talking points that have been corrected and disproven time after time.

So again, a message to our elected officials. I understand that you are trying to remain diplomatic during these types of proceedings, but you cannot allow blatant misinformation to go unchallenged in a public forum. You must stand up for facts, science, and intellectualism.

OMA Council: Motions, motions, motions

There was no shortage of drama and excitement around this weekend’s OMA Council, the main events of which you can likely read about elsewhere on the blogosphere.

I want to focus on a slightly more mundane issue, but one which I think is vital to the success of future Councils and for continued engagement of Council delegates.

First a bit of background. At Spring and Fall Council, individual delegates to Council are encouraged to submit Members’ Period Motions for Council to vote on, which if passed, would then be advisory (not binding) to the Board of Directors. Prior to being presented, the motions are reviewed by the Resolutions Committee who provide advice on phrasing, content, and whether the motion is deemed out of order for procedural reasons.

At previous Councils, the number of motions put forward had been modest, and there had been relatively no issue in getting through all of the motions. With so many new and engaged delegates to this Council, the number of motions approached 80. To put this in perspective, during the time set aside at this Council specifically for motions (which was similar time to past Councils), we managed to get through 38 motions. There was hope that time could be found at the end of Council to get through additional motions, but unfortunately despite the Chair’s best efforts to move the program along, the remainder of the motions were not heard.

It truly wasn’t anyone’s fault that the motions weren’t heard, it was simply a perfect storm of unprecedented interest in putting forward motions coupled with a busy program updating Council delegates on a chaotic period since the spring.

That being said, although no one is to blame for the situation, we need to course correct in advance of the next Council meeting. Close to 40 motions were unheard during this meeting, put forward by physicians who felt them important enough to be heard and who will likely feel they may still be relevant at Fall Council. Add those to the avalanche of new motions likely to be generated between now and then, and we’re quickly creating our very own organizational waiting list. So very Canadian of us.

So what to do?

First we need to reflect on what has spurred the interest in motions, and what the true intent of some of these motions are. Are they regarding an issue the delegate has raised unsuccessfully and repeatedly through existing OMA channels, and is looking for a Council stamp of approval to spur the Board to action? Is it an issue that is more symbolic? Is it an issue that the delegate thought of while in the shower on Saturday morning and thought it would be a good idea to see what Council thought? While we shouldn’t stifle debate or engagement, given the limited time that we have as a Council, it may be appropriate to give delegates some guidance on alternative strategies to moving an issue forward rather than putting forward a motion.

The number of motions is at least in part a symptom of delegates’ sense (correct or not) of not being listened to by the OMA, and that the Council floor is their opportunity to have their voice heard and ideas evaluated by colleagues. Consideration has to be given to dedicating a section of the current online forums to idea generation and board/delegate member feedback on those ideas. I know that a few delegates set up an online group for Council delegates to discuss motions openly prior to Council, but I wonder whether the OMA should be setting up a similar platform for discussion and board evaluation and uptake between Council meetings to drive down the biannual swell of interest.

Another issue that has to at least be given consideration is to limit the number of total motions any specific delegate can put forward. There were no motions that I specifically found superfluous, but I think in a time where there is this much interest, we need to consider equity in allowing as many delegates as possible to put forward their best motions.

My last point is around the presentations themselves, and the discussion from delegates that followed. In this new era of engaged membership (the Chair himself remarked that he could not recall so many delegates staying until the end of the meeting), it behooves the Chairs of each committee to deliver a well-prepared, concise presentation to maximize the time for other issues. I would humbly suggest that the Health Policy presentation be moved out of the Sunday afternoon slot, as virtually no one in that room had the stamina to discuss what should be one of the most important topics of the weekend. Delegates should also be reminded that whenever possible, discussions that can be held privately should be held privately for the sake of efficiency. Consideration should also be given to alternating committee presentations with Member’s Motion Periods to sustain the attention of delegates (credit Dr. Deepa Soni for this idea).

I am confident that we will see many of these changes adopted prior to Fall Council, as the Chair and Vice-Chair were clear that they were looking for feedback from delegates. While I don’t want to see the pendulum swing too far such that the entire Council is spent deliberating hundreds of motions, I think we could make some definite progress in terms of efficiencies to ensure that the motions that need to be heard at Council get the audience they deserve.

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.