Computerized clinical decision support to improve stroke prevention therapy in primary care management of atrial fibrillation: a cluster randomized trial.

BACKGROUND: Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care. METHODS: This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines. RESULTS: From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; P = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; P = .024)). CONCLUSION: Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care. TRIAL REGISTRATION: Clinical Trials NCT01927367. https://clinicaltrials.gov/ct2/show/NCT01927367?term=NCT01927367&draw=2&rank=1.

Resource use and cost associated with computerized decision support system and usual care in managing patients with atrial fibrillation: analysis of IMPACT-AF randomized trial data.

BACKGROUND: IMPACT-AF is a prospective, randomized, cluster design trial comparing atrial fibrillation (AF) management with a computerized decision support system (CDS) to usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to compare the resource use and costs between CDS and usual care groups. METHODS: Case costing data, 12-month self-administered questionnaires, and monthly diaries from IMPACT-AF were used in this analysis. Descriptive statistics were used to compare costs and resource use between groups. All costs are presented in 2021 Canadian dollars and cover the 12-month period of participation in the study. RESULTS: A total of 1,145 patients enrolled in the trial. Case costing data were available for 466 participants (41.1%), 12-month self-administered questionnaire data for 635 participants (56.0%) and monthly diary data for 223 participants (19.7%). Emergency department visits and hospitalizations comprised the most expensive component of AF care. Across all three datasets, there were no statistically significant differences in costs or resource use between CDS and usual care groups. CONCLUSIONS: Although there were no significant differences in resource use or costs among CDS and usual care groups in the IMPACT-AF trial, this study provides insight into the methodology and practical challenges of collecting economic data alongside a trial. REGISTRATION: Clinicaltrials.gov (registration number: NCT01927367, date of registration: 2013-08-20).

Rhythm Control Vs Rate Control in a Contemporary Ambulatory Atrial Fibrillation Cohort: Post Hoc Analysis of the IMPACT-AF Trial.

Background: We examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control. Methods: This is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months. Results: A total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS2 scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group. Conclusions: Both rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Contexte: Nous avons examiné les caractéristiques et le devenir de patients ambulatoires contemporains atteints de fibrillation auriculaire (FA) dans le cadre d'une comparaison entre la maîtrise de la fréquence cardiaque et la maîtrise du rythme cardiaque. Méthodologie: Nous avons effectué une analyse a posteriori d'un essai à répartition aléatoire par grappes ( I ntegrated M anagement P rogram A dvancing C ommunity T reatment of A trial F ibrillation [IMPACT-AF]) mené de 2016 à 2018 chez des patients ambulatoires atteints de FA en vue de comparer un outil d'aide à la décision clinique destiné aux omnipraticiens avec les soins habituels. Notre analyse a permis d'établir une comparaison entre les patients pris en charge par une maîtrise de la fréquence cardiaque et ceux pris en charge par une maîtrise du rythme cardiaque lors de leur inscription à l'essai. Les paramètres d'évaluation comprenaient les consultations aux urgences liées à la FA, les hospitalisations imprévues ayant des causes cardiovasculaires et les épisodes hémorragiques à 12 mois. Résultats: Au total, 870 patients ont été inclus dans cette analyse; 99 (11,4 %) faisaient partie du groupe pris en charge par une maîtrise du rythme cardiaque, et 40 % étaient de femmes. Dans le groupe pris en charge par une maîtrise du rythme cardiaque, l'âge moyen était moindre (70 ± 11,4 ans vs 72,7 ± 9,5 ans, P = 0,03), un plus grand nombre de patients présentaient une FA paroxystique (80 % vs 43 %, P < 0,001) et les scores CHADS2 étaient moins élevés. Le taux de consultations aux urgences liées à la FA était plus élevé dans le groupe pris en charge par une maîtrise du rythme cardiaque (17,2 vs 7,3 %, P = 0,003) tout comme le taux de consultations répétées aux urgences (rapport des taux de 3,03, intervalle de confiance à 95 % de 1,99 à 4,52, P < 0,001). Le nombre de consultations répétées aux urgences était indépendamment associé au sexe féminin et à l'inclusion dans le groupe pris en charge par une maîtrise du rythme cardiaque. Conclusions: Des consultations répétées aux urgences ont été notées tant chez les patients pris en charge par une maîtrise de la fréquence cardiaque que chez ceux pris en charge par une maîtrise du rythme cardiaque quoique plus fréquemment chez ces derniers. Nos constats sont de type observationnel. Néanmoins, dans le contexte des lignes directrices actuelles, ils pourraient contribuer à la mise au point d'autres traitements visant à atténuer le fardeau des symptômes tant chez les patients pris en charge par une maîtrise du rythme cardiaque que chez ceux pris en charge par une maîtrise de la fréquence cardiaque et ainsi permettre globalement une meilleure utilisation des soins de santé chez les patients atteints de FA.

Lessons learned from Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): a pragmatic clinical trial of computerized decision support in primary care.

BACKGROUND: Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) was a pragmatic, cluster randomized trial assessing the effectiveness of a clinical decision support (CDS) tool in primary care, Nova Scotia, Canada. We evaluated if CDS software versus Usual Care could help primary care providers (PCPs) deliver individualized guideline-based AF patient care. METHODS: Key study challenges including CDS development and implementation, recruitment, and data integration documented over the trial duration are presented as lessons learned. RESULTS: Adequate resources must be allocated for software development, updates and feasibility testing. Development took longer than projected. End-user feedback suggested network access and broadband speeds impeded uptake; they felt further that the CDS was not sufficiently user-friendly or efficient in supporting AF care (i.e., repetitive alerts). Integration across e-platforms is crucial. Intellectual property and other issues prohibited CDS integration within electronic medical records and provincial e-health platforms. Double login and data entry were impediments to participation or reasons for provider withdrawal. Data integration challenges prevented easy and timely data access, analysis, and reporting. Primary care study recruitment is resource intensive. Altogether, 203 PCPs and 1145 of their patients participated, representing 25% of eligible providers and 12% of AF patients in Nova Scotia, respectively. The most effective provider recruitment strategy was in-office, small group lunch-and-learns. PCPs with past research experience or who led patient consent were top recruiters. The study office played a pivotal role in achieving patient recruitment targets. CONCLUSIONS: A rapid growth in healthcare data is leading to widespread development of CDS. Our experience found practical issues to address for such applications to succeed. Feasibility testing to assess the utility of any healthcare CDS prior to implementation is recommended. Adequate resources are necessary to support successful recruitment for future pragmatic trials. CDS tools that integrate multiple co-morbid guidelines across eHealth platforms should be pursued. TRIAL REGISTRATION: ClinicalTrials.gov NCT01927367. Registered on August 22, 2013.

Patient-Reported Outcomes and Patient-Reported Experience of Patients With Atrial Fibrillation in the IMPACT-AF Clinical Trial.

Background The IMPACT-AF (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation) trial is a prospective, randomized, cluster design trial comparing atrial fibrillation management with a computerized clinical decision support system with usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to assess and compare patient-reported health-related quality of life and patient-reported experience with atrial fibrillation care between clinical decision support and control groups. Methods and Results Health-related quality of life was measured using the EuroQol 5-dimensional 5-level scale, whereas patient-reported experience was assessed using a self-administered satisfaction questionnaire, both assessed at baseline and 12 months. Health utilities were calculated using the Canadian EuroQol 5-dimensional 5-level value set. Descriptive statistics and generalized estimating equations were used to compare between groups. Among 1145 patients enrolled in the trial, 717 had complete EuroQol 5-dimensional 5-level data at baseline. The mean age of patients was 73.53 years, and 61.87% were men. Mean utilities at baseline were 0.809 (SD, 0.157) and 0.814 (SD, 0.157) for clinical decision support and control groups, respectively. At baseline, most patients in both groups reported being "very satisfied" with the care received for their atrial fibrillation. There were no statistically significant differences in utility scores or patient satisfaction between groups at 12 months. Conclusions Health-related quality of life of patients remained stable over 12 months, and there was no significant difference in patient satisfaction or utility scores between clinical decision support and control groups. Registration information clinicaltrials.gov. Identifier: NCT01927367.

Canada's Evolving Medicare: End-of-Life Care.

A challenging issue in contemporary Canadian Medicare is the evolution of end-of-life care. Utilizing data from the 2016 and 2018 Health Care in Canada (HCIC) surveys, this paper compares the support and priorities of the adult public (n = 1500), health professionals (n = 400), and administrators (n = 100) regarding key components for end-of-life care just prior to and post legalization of medical assistance in dying (MAiD) in Canada. In 2016 and 2018, the public, health professionals and administrators strongly supported enhanced availability of all proposed end-of-life care options: pain management, hospice and palliative care, home care supports, and medically assisted death. In 2018, when asked which option should be top priority, the public rated enhanced medically assisted death first (32%), followed by enhanced hospice and palliative care (22%) and home care (21%). Enhanced hospice and palliative care was the top priority for health professionals (33%), while administrators rated enhanced medically assisted death first (26%). Despite legalization and increasing support for MAiD over time, health professionals have increasing fear of legal or regulatory reprisal for personal involvement in medically assisted death, ranging from 38% to 84% in 2018, versus 23% to 42% in 2016. While administrators fear doubled since 2016 (40%-84%), they felt the necessary system supports were in place to easily implement medically assisted death. Optimal management of end-of-life care is strongly supported by all stakeholders, although priorities for specific approaches vary. Over time, professionals increasingly supported MAiD but with a rising fear of legal/regulatory reprisal despite legalization. To enhance future end-of-life care patterns, continued measurement and reporting of implemented treatment options and their system supports, particularly around medically assisted death, are needed.

Access and quality of health care in Canada: Insights from 1998 to the present.

This article reviews perceptions of Canada's public and health professionals regarding access and quality of healthcare. Principal data sources were 13 sequential Health Care in Canada (HCIC) surveys, from 1998 to 2018. Over time, the data series reveals that an increasing majority of the public report receiving quality care, rising from a national average of 53% in 2002 to 61% in 2018. Regionally, the variation in quality care has been relatively narrow, ranging from 52% in the Atlantic and Prairie provinces to 65% in Ontario in 2018. Professionals' ratings for delivery of quality care in 2018 were slightly higher than the public, averaging 65% and ranging from 58% among nurses to 72% and 74% among physicians and administrators. Despite the favourable ratings received for quality of healthcare, a persistent and growing issue in all regions of the country is concern around timely access to care. In 1998, 4% of the public rated prolonged wait times as a concern; in 2018, 43% rated it as their greatest concern. Regionally, the variation in 2018 ranged from 34% in the Atlantic provinces to 49% in Alberta. This concern about timely access involves all major components of healthcare delivery and is anticipated to worsen. Proposals to improve timely access have been suggested, with interdisciplinary, team-based care being the most strongly supported proposal. The Canadian Medicare system is currently recognized as a valued component of our national identity. However, sub-optimal access continues to undermine quality of care. In the absence of improved access, healthcare quality and outcomes will also remain sub-optimal.

Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool.

BACKGROUND: Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care. METHODS: Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis. RESULTS: No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months. CONCLUSIONS: IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.

Medicare's Evolution: National Pharmacare and Shared Leadership.

Repeated Health Care in Canada (HCIC) surveys over the past two decades have consistently reported that the adult public and clinical and administrative health professionals consider medicare to be successful in terms of quality of care, despite a growing concern that timely access to care remains challenging. These key stakeholders have also recently signalled that major change strategies are likely necessary for continuing success. In the 2018 survey, both the public and professionals ranked highest the creation of a national comprehensive pharmacare plan, entirely funded by the federal government, or with federal funding for those not currently covered by existing pharmaceutical plans. The majority of the public and health professionals in 2018 were also remarkably concordant regarding preferred leadership for designing, instituting and managing a national pharmacare program. The public's priority, supported by 50% of the adult population, was shared leadership involving governments, medical academia and the pharmaceutical/biotech industries, followed by government leadership at 33%. Among professionals, preference for shared leadership averaged 60% and governmental leadership averaged 33%. Based on these data, restriction of pharmacare's leadership exclusively to any single stakeholder raises concern of a critical lack of support for success. A coalition of governments, research hospitals/health authorities and the pharmaceutical/biotech industry - the highest-ranked candidates as potential leaders - would likely provide the best chance to garner the majority of public support and enhance the chances of success in the short and long terms. In summary, the addition of universal pharmacare to medicare's existing healthcare portfolios is an attractive strategy to advance Canadian healthcare and outcomes. The federal government has taken the initial step. Recruitment of additional leaders sharing aspiration, inspiration and experience to optimize pharmacare's development and measure its outcomes is needed. Things can be better.

Non-Adherence to Prescribed Therapies: Pharmacare's Existential Challenge.

Pharmacare, a recently proposed addition to Canada's universal medicare program, has become a prominent topic in the public discourse, but funding and leadership have not been established. Repeated Health Care in Canada (HCIC) surveys of the adult public and a broad spectrum of health professionals reveal very strong support for a national system that is easy to access and covers all prescribed pharmaceuticals. Although the practical details of universal pharmacare remain to be established, there is strong support among the public and professionals as well as increasing federal government interest in moving forward and ultimately implementing pharmacare. At the same time, HCIC surveys indicate that a high percentage of patients do not take their medications as directed, both for acute and chronic illnesses. The data suggest that pharmacare's success will be severely challenged by this. Of the four major challenges preventing usual care from being the best care - suboptimal access, non-diagnosis, non-prescription and non-adherence - risk from some form of non-adherence is often ranked first by care professionals. The most commonly reported reasons for non-adherence in clinical settings are patients' forgetfulness and how they feel in the moment on any given day. Costs of therapy, lack of understanding or poor knowledge transfer between prescribers and patients regarding therapeutic risks and benefits are rarely cited causes for poor adherence. These findings from the 2018 HCIC survey are not new. They are very consistent with measurements in the 2016 and other previous HCIC surveys. They do, however, raise practical challenges for the creation and ongoing management of universal pharmacare. Specifically, a patient-centred care component designed to improve non-adherence to prescribed therapies is needed. Ideally, it should include a measurement and feedback component on adherence that shares data with and between patients, health professionals and payers. Things can be better.

Canada's Evolving Medicare: Patient-Centred Care.

Canada's universal healthcare program, medicare, continues to evolve. An area of care that has gained increasing attention over the past several years is the general concept and specific components of patient centricity in healthcare delivery. This paper compares key measures of patient-centred care practices recorded in the 2013 and 2016 Health Care in Canada (HCIC) surveys, with the most recent preferences of the public and health professionals obtained in the 2018 HCIC survey, including priorities for improved future care. Timely access and caring care were the public's top-supported components of patient-centred care in the 2013 and 2016 HCIC surveys. In the 2018 HCIC survey, the Canadian public's overwhelming choice as the top-priority component of patient-centred care continued to be care readily and timely accessed, provided in a caring and respectful environment and based on need versus the ability to pay. In contrast, the public's lesser-supported option in all surveys was measurement and stakeholder feedback of actual care and outcomes. Among professionals in 2018, timely access and caring care were also rated as the top characteristics of patient-centred care, followed by care supported by research and expert opinion. Also similar to the public, Canadian healthcare professionals in 2018 rated measurement and feedback of delivered care and outcomes at the bottom of their support list. When the public and professionals were asked in the 2018 survey to prioritize their implementation choices for enhanced patient-centred care going forward, both stakeholder groups chose timely access as their first priority. Measurements and feedback of care and outcomes were rated at the lower end of choices in both groups in 2018. In summary, among key stakeholders, healthcare that is not readily and timely accessed remains the perceived greatest impediment to achievement of patient-centred care in contemporary Canadian medicare. The continued reality of undue delay in accessing healthcare in Canada is disturbing. A companion risk going forward is that all other components of patient-centred care will retreat to a level of irrelevance. Measurement and feedback of care, particularly its timeliness of access and outcomes, are necessary to monitor progress, stimulate innovation and ensure the success of Canadian medicare. Things can be better.

Healthcare in Canada: Choices Going Forward.

The overarching purpose of serial Health Care in Canada (HCIC) surveys of the adult Canadian public and a broad spectrum of healthcare professionals over the past two decades has been the development of an evidence-based map to inform strategic and clinical decisions to improve care and outcomes for Canadians. Recent surveys reveal a growing concern that medicare may require complete rebuilding or major strategic repairs. On the other hand, a majority of stakeholders perceive continuing underlying quality in our clinical care and look forward to both system- and patient-centred initiatives to improve future care. Currently, the most strongly supported strategic improvement target among the public and professional caregivers is enhanced availability of less expensive prescription medications. With regard to practical implementation of this strategy, the public's (39%) and healthcare professionals' (39-54%) preference was institution of a nation-wide pharmacare plan, funded by a federal tax. There was also pan-stakeholder concordance around the two least favoured potential strategies: increasing taxes and shifting money from other funded services. In terms of improving clinical care, the public and all professional groups were also concordant in most strongly supporting increases in home and community care services, disease prevention/wellness education and use of non-physician care providers and electronic health records. There was also remarkable concordance regarding who is most responsible for implementing these preferred innovations: research hospitals/health authorities, government funding agencies and pharmaceutical/biotech industries. In summary, contemporary Canadian public and health professionals agree on key strategic and practical priorities to improve future care and outcomes. Moreover, they concur on who should lead their implementation. This public/professional concordance supporting evidence-driven choices and leadership for improving care is not common. It is, however, an opportunity, providing a call to arms for other stakeholders, particularly governments and industry, to recognize the opportunity and their leadership expectations and to act upon them. Things can be better.

Optimizing primary care management of atrial fibrillation: The rationale and methods of the Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) study.

The Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) is an investigator designed, prospective, randomized, un-blinded, cluster design clinical trial, conducted in the primary care setting of Nova Scotia, Canada. Its aim is to evaluate whether an electronic Clinical Decision Support System (CDSS) designed to assist both practitioners and patients with evidence-based management strategies for Atrial Fibrillation (AF) can improve process of care and outcomes in a cost-efficient manner as compared to usual AF care. At least 200 primary care providers are being recruited and randomized at the level of the practice to control (usual care) or intervention (eligible to access to CDSS) cohorts. Over 1,000 patients of participating providers with confirmed AF will be managed per their provider's respective assignment. The targeted primary clinical outcome is a reduction in the composite of unplanned cardiovascular (CV) or major bleeding hospitalizations and AF-related emergency department visits. Secondary clinical outcomes, process of care, patient and provider satisfaction as well as economic costs at the system and patient levels are being examined. The trial is anticipated to report in 2018.

Public and Professional Insights on End-of-Life Care: Results of the 2016 Health Care in Canada Survey.

A new dimension has been added to Canadian Medicare ߝ exemption from prosecution for physicians, nurse practitioners and assistants providing medical assistance in dying for competent and informed adult patients with a grievous and irremediable medical condition causing intolerable physical or psychological suffering, irreversible decline in capabilities and reasonably foreseeable natural death. To define stakeholders' perceptions on all contemporary end-of-life care options, we analyzed data from the 2016 Health Care in Canada Survey comprising representative samples of the adult public (n = 1,500), physicians (n = 102), nurses (n = 102), pharmacists (n = 100), administrators (n = 100) and allied health professionals (n = 100). Among the public, enhanced pain management, hospice/palliative care and home/family care were all supported at, or above, the 80th percentile; medically assisted death was supported by 70%. Among all professionals, hospice/palliative care, pain management and home care garnered >90% support; support for medically assisted death ranged from 58% (physicians) to 79% (allied professionals). In terms of priority to implement available options, medically assisted death was rated first by 46% of the public, overall, and by 69% of the sub-group who strongly supported it, followed by enhanced pain management (45%) and home care (42%). Among professionals, top implementation priorities (range: 57ߝ61%) were: enhanced pain management, hospice/palliative care and home care support. Priority for medically assisted death ranged between 25% and 41%, although among professionals who strongly supported it, it was their top priority (52%). When asked to balance patients' right to access assisted death, versus some professionals' reluctance to provide it, 42% of the public and the majority of professionals thought providers should be allowed to opt out if they referred patients to another willing provider. And many professionals perceive some risk of either legal or regulatory reprisal if they assist in patients' deaths. In summary, there is substantial contemporary support for all components of end-of-life care among all stakeholders. However, non-lethal care modalities remain generally preferred, perhaps, at least in part, because medical professionals have a pervasive concern of going in harm's way by participating in assisted death, or by refusing. Things can be better.

Patient-Centred Care in Canada: Key Components and the Path Forward.

Canadians' health and its care continue to evolve. Chronic diseases affect more than 50% of our aging population, but the majority of public and professional stakeholders retain a sense of care quality. An emergent issue, however, is generating an increasingly wide debate. It is the concept of patient-centred care, including its definition of key components, and efficacy. To advance the evidence base, the 2013-2014 and 2016 Health Care in Canada (HCIC) surveys measured pan-stakeholder levels of support and implementation priorities for frequently proposed components of patient centricity in healthcare. The public's highest rated component was timely access to care, followed by perceived respect and caring in its delivery, with decisions made in partnership among patients and professional providers, and within a basic belief that care should be based on patients' needs versus their ability to pay. Health professionals' levels of support for key components largely overlapped the public's levels of support for key components, with an additional accent on care influenced by an evidence base and expert opinion. In terms of priority to actually implement enhanced patient-centred care options, timely access was universally dominant among all stakeholders. Caring, respectful care, also retained high implementation priority among both the public and professionals, as did care decisions made in partnership, and, among professionals, care driven by research and expert opinion. Low priorities, for both the public and professionals, were the actual measurements of patient-centred care delivery and its impact on outcomes. In summary, there is remarkable concordance among all stakeholders in terms of favoured interventions to enhance patient-centred care, namely, timely access, caring, partnering and communicative delivery of evidence-based care. Unfortunately, the lack of contemporary imperative around the value of measuring and reporting actual use and outcomes of favoured interventions means uncertainty of their efficacy will persist for the foreseeable future. Things can be better.

Searching for Best Direction in Healthcare: Distilling Opportunities, Priorities and Responsibilities.

Canada's health and its care are evolving. Evidence from serial Health Care in Canada surveys of the public and health professionals over the last two decades reveal a persistent sense of care quality, despite an aging population, decreasing levels of good and excellent health, increasing prevalence of chronic illnesses; and sub-optimal access to timely and patient-centred care. Stakeholders are, however, somewhat pessimistic and many sense complete rebuilding, or major changes, may be necessary. To improve access, the primary health concern of all Canadians - increasing medical and nursing school enrolment, and requiring professionals to work in teams - have attracted increasingly high support from both the public and professionals. However, physicians' support lags behind that of nursing, pharmacy and administrative colleagues; and, currently, only a minority of patients and professionals are actively involved in team care programs. Another example in which high levels of support may not necessarily translate into priority implementation of promising interventions is the realm of patient-centred care. The public and all professionals report a very high level of general support for care provided in a caring and respectful manner. However, while the public rank it second in implementation priority, following timely access, the majority of professionals rank it only fourth. By contrast, there is remarkable pan-stakeholder concordance around interventions to improve the overall health system, with the majority of public and professional stakeholders rating the creation of national supply systems as their top priority to expedite the clinical and cost efficiency of new treatments. There is a similar pan-stakeholder concordance around priority of responsibility to drive innovations, the top three being: federal/provincial governments; research hospitals/regional health authorities; and the pharmaceutical industry. In summary, Canadians are at a healthcare crossroads. Population health is decreasing, chronic diseases are increasing and desire for timely access to patient-centred, team-delivered and technology-supported care remain top concerns. Despite some disconnects between theoretical support for, and priority to implement, promising innovations, there is universal support to optimize resources to make things better. And there is concordance around the leadership best suited to lead innovation. Things can be better.

Contributions and Challenges of Non-Professional Patient Care: A Key Component of Contemporary Canadian Healthcare.

The Canadian public is aging. Population levels of excellent, or very good, health are decreasing, and the prevalence of chronic diseases is increasing. Timely access to caring and respectful care from health professionals, with supporting information transfer, are key qualities in patients' sense of centricity and hope for best outcomes. Data from the 2013-2014 Health Care in Canada (HCIC) survey reveal, however, that 38% of such patients do not always, or often, access this support. The lack of timely access may be one underlying driver for non-professional caregivers to contribute to the care, as well as the personal and financial management, of family members or friends with chronic disease. Previous HCIC surveys, in 2005, 2006 and 2007, reported non-professional caregivers' prevalence in the adult public at 21, 23 and 26%, respectively, compared with 19% in the 2013-2014 survey. In all the surveys, a notable feature of non-professional care providers has been their universality of contribution, across age, sex, geography and time. Caregivers pay, however, a price. They have a lower level of self-related health, a higher incidence of chronic illness and net-negative impacts on relationships, career and finances, including use of personal savings (53%) and necessity of quitting their job (12%). Conversely, they infrequently claim available tax (12%) or compassionate care (11%) benefits. Interestingly, non-professional caregivers work in team-care settings with health professionals more frequently (29%) than patients in the general population with chronic illnesses (18%). Nonetheless, their current levels of always, or often, receiving assisting support (46%) and information (53%) from health professionals are lower than the respective results reported by the general public (65% and 68%). In conclusion, non-professional patient care in Canada is a common, longstanding and not-for-profit enterprise. It is more likely driven by altruistic caring or sense of duty that balance, or overwhelm, its associated personal, medical and financial burdens. In the short term, practical opportunities for enhancement include broader recognition of caregivers' contributions, their improved access to professional support and communication and wider use of available governmental financial support. All are likely to enhance both patient-centred care and lessen the practical burdens of caregivers. Things can be better.

Stakeholder surveys of Canadian healthcare performance: what are they telling us? Who should be listening? Who should be acting, and how?

Eleven Health Care in Canada (HCIC) surveys, spanning 1998-2014, offer a comprehensive overview of the changing perceptions of physician, nurse, pharmacist, administrator and public stakeholders of the nation's health status, its burden of illness and its quality and cost of care. Overall, there persists a universal sense of quality in our health system--despite evidence that national health status is declining, chronic illnesses are increasing, patients' timely access to care and ability to afford care are diminishing and all these indicators are predicted to worsen over time. Among the public and health professionals, key priorities for improving future patient care are increasing professional schools' output and team-based care, along with enhanced use of national supply systems to reduce costs of care. Among HCIC survey partners, the overarching goal has been, and remains, the utilization of knowledge gained from the surveys to facilitate evidence-driven health policy and improved patient care and outcomes. Practical foci are the development of knowledge translation (KT) activities and assessment of their impact. This paper outlines current initiatives to track reach of member and non-member audiences for HCIC information; to ascertain how they perceive and value the various KT messages, vehicles and metrics; and to potentially identify a hierarchy of efficacy for impact factors. The primary objective is to inform future HCIC survey design and reporting, especially identification of KT vehicles and venues that are most effective in terms of reach and impact in facilitating understanding of, and subsequent action around, the knowledge generated.

Partnership and measurement: the promise, practice and theory of a successful health social networking strategy.

Patient health management (PHM) was launched as a promising paradigm to close care gaps, the inequities between usual and best care, for whole patient populations. PHM's core premise was that interventions of multidisciplinary, community-oriented partnerships that used repeated measurement and feedback of provider practices, clinical and economic outcomes and general communication of relevant health knowledge to all stakeholders would continuously make things better. This article reviews the evolution of PHM from its genesis in a series of casual hospital-based networks to its maturation in a province-wide, community-focused, clustered-lattice social network that facilitated the improved clinical and cost-efficient care and outcomes of whole patient populations. The factors underlying PHM's clinical and cost efficacy, specifically its patient-centric social networking structures and integral measurement and knowledge translation processes, offer continuing promise to optimally manage the care of our increasingly aged patient populations, with their high burden of chronic diseases and disproportionately large care gaps. In an era when patients are demanding and leading change, and governments are struggling fiscally, PHM's clinical efficacy and cost-efficiency are especially resonant. Things can be better.