[Recommendations for the appropriate use of 14 laboratory tests in Québec]. / Recommandations québécoises: usage judicieux de 14 analyses biomédicales.

Ordering certain laboratory tests in a routine medical practice context may be inappropriate because they a) have been replaced with a better test; b) are not indicated for initial testing; c) are part of a panel of tests, or d) cover a broad range of diseases in a nonspecific clinical context. On the other hand, these tests may be useful in the presence of specific clinical indications or in specialty medicine. To improve the appropriateness of ordering laboratory tests, INESSS, in collaboration with an expert committee, has developed a practical tool for the judicious use of 14 laboratory tests, whose inappropriateness for the given indications is raised in the scientific literature.

Summary: use of class 3b and class 4 lasers and intense pulsed light sources for cosmetic procedures in non-medical settings

INTRODUCTION: Body image has always preoccupied people across time and cultures. Today, the search for beauty can be fulfilled with high-power technologies that are relatively easy to use, such as Class 3b and Class 4 lasers and intense pulsed light (IPL) sources. Lasers are devices that amplify light, emitting it in a narrow, coherent optical beam; the beam produced is near-monochromatic, the particles all move in the same direction, and the waves are in phase with one another. Intense pulsed light is based on different physical and technological principles. Unlike lasers, IPL sources emit polychromatic light (non-coherent, between 500 and 1,200 nm), and selected wavelengths are obtained by means of filters. These technologies are used for various cosmetic purposes and applications, including some that clearly come under activities reserved to physicians, while others fall into the grey areas surrounding medicine. Based on the definitions of the different fields of medical activity and on the laws and regulations governing the practice of medicine, this report has limited its scope to examining laser and IPL procedures that do not require medical diagnosis and that may be performed in Québec by operators other than physicians or health professionals, without medical supervision. This report does not purport to determine what does and does not lie within the scope of medicine. Rather, it focuses on the risks inherent in these technologies and on the qualifications required to use them, by taking hair removal as a base case and by dealing more briefly with skin resurfacing and tattoo removal, without ruling on the field of activity to which these practices belong. RESEARCH METHODS: Medline (National Library of Medicine) via PubMed and the Cochrane Library were searched. The grey literature was also examined to take into account the contextual aspects that prompted the request for this report, especially the legal and regulatory provisions framing the use of lasers and IPL by non-physician operators in various countries and regions. In addition, local experts were consulted to validate the contextual evidence and the applicability of the ensuing recommendations. These experts are key actors in the following organizations: Association des dermatologistes du Québec; Collège des médecins du Québec; Comité sectoriel de la main-d'œuvre des services de soins personnels [sector committee on personal services workers]; Ministère de l'Éducation, du Loisir et du Sport; Ministère de l'Emploi et de la Solidarité sociale; and Ministère de la Santé et des Services sociaux. CONCLUSION: Analysis of the scientific and contextual evidence leads to these findings: Class 3b and Class 4 lasers and IPL sources are high-power technologies entailing risks for operators and their customers. The use of these technologies leads to adverse effects that, although minor and transient for the most part, may in some cases be serious; however, scientific evidence does not allow us to determine their frequency or severity, or to link them with the types of professionals using them. Some cosmetic procedures may overlap with activities reserved to physicians when these. procedures are applied to areas of the skin with an underlying medical condition or with the risk of complications requiring medical expertise. Current Canadian safety standards regulate the sale and importation of these devices and their use in health-care facilities, and the safe use of lasers is governed by laws and regulations intended to protect workers' health and safety in all work settings. However, Québec has no law or regulation to protect the health and safety of the public undergoing laser or IPL procedures in non-medical settings. The use of Class 3b and Class 4 lasers and IPL sources is widespread in beauty care centres, but the specific types of devices used are not known. There is no professional order regulating the practice of estheticians or other types of personnel working in the personal services sector and likely to use laser or IPL devices, and the Office des professions du Québec has already denied the application by the Association des électrolystes du Québec to establish a professional order. The Comité sectoriel de la main-d'œuvre des services de soins personnels and the Ministère de l'Éducation, du Loisir et du Sport have already developed their own non-mandatory vocational training programs in laser hair removal, but these programs do not cover other cosmetic laser applications or the use of IPL. The Act respecting Workforce Vocational Training and Qualification (R.S.Q., c. F-5) could fill this regulatory gap in part by standardizing the required occupational skills, establishing vocational training and qualification programs, and determining occupational eligibility requirements for laser or IPL operators working in non-medical settings. In light of these findings, this report is not able to rule either on the safety of laser or IPL procedures by non-physician operators working without medical supervision or on the scope of activities that could be authorized to them in the Québec context. However, given that these technologies present hazards and may lead to adverse effects that are potentially serious when used for cosmetic procedures, and given that there is a serious possibility of interference with the field of medicine, AETMIS has reached the following conclusions, which define the major issues to be dealt with: The boundary between the procedures restricted to the field of medicine and the cosmetic procedures that may be performed by non-physician operators must be clearly established.

Utilisation des lasers de classe 3b et 4 et de la lumière intense pulsée à des fins esthétiques dans un contexte non médical / Use of class 3b and 4 lasers and intense pulsed light for aesthetic purposes in a non-medical context

INTRODUCTION: Body image has always preoccupied people across time and cultures. Today, the search for beauty can be fulfilled with high-power technologies that are relatively easy to use, such as Class 3b and Class 4 lasers and intense pulsed light (IPL) sources. Lasers are devices that amplify light, emitting it in a narrow, coherent optical beam; the beam produced is near-monochromatic, the particles all move in the same direction, and the waves are in phase with one another. Intense pulsed light is based on different physical and technological principles. Unlike lasers, IPL sources emit polychromatic light (non-coherent, between 500 and 1,200 nm), and selected wavelengths are obtained by means of filters. These technologies are used for various cosmetic purposes and applications, including some that clearly come under activities reserved to physicians, while others fall into the grey areas surrounding medicine. Based on the definitions of the different fields of medical activity and on the laws and regulations governing the practice of medicine, this report has limited its scope to examining laser and IPL procedures that do not require medical diagnosis and that may be performed in Québec by operators other than physicians or health professionals, without medical supervision. This report does not purport to determine what does and does not lie within the scope of medicine. Rather, it focuses on the risks inherent in these technologies and on the qualification

Summary: viscosupplementation for the treatment of osteoarthritis of the knee

INTRODUCTION: Osteoarthritis (OA) of the knee is a degenerative disease that frequently results in the need for total knee replacement. This disease has been absorbing an ever-growing share of the human and financial resources of Québec's health-care system. Considered by some to be an alternative to surgery, viscosupplementation involves draining the affected knee then injecting it with hyaluronic acid. The clinical effectiveness of this procedure, which is intended to relieve pain and improve joint mobility, remains controversial. METHODOLOGY: The primary literature search covered a period up to September 30, 2005, with a literature watch until December 2006. Given the large number of secondary studies available, we decided to conduct an assessment of these studies. This assessment scrutinized six meta-analyses considered to be of satisfactory methodological quality. We also reviewed reports published by other health-technology assessment (HTA) agencies on topics such as the budget impact of this treatment on their respective health-care systems. Five economic studies were used to assess cost-effectiveness. Various insurance companies' health coverage policies were also reviewed. CONCLUSIONS AND RECOMMENDATIONS: After examining a series of meta-analyses and assessment reports on the different types of viscosupplements available, we concluded that viscosupplementation offers clinically modest relief from the symptoms of knee OA over a period that could last up to several weeks. It is furthermore a safe short-term treatment. Of note, these conclusions are based on secondary analyses of a multitude of small primary studies of poor methodological quality. Available data did not help distinguish differences in the effectiveness of any one product over the others. It was equally impossible to identify patient subgroups more likely to benefit from this treatment compared with other currently available therapeutic modalities. The cost-effectiveness of this treatment could not be established owing to discrepancies among the clinical data used and the methodological limitations of the economic studies examined. Funding this treatment would lead to a cost increase of some tens of millions of dollars per year and would command significant professional resources at a time when the health system is experiencing a labour shortage. Consequently, AETMIS considers that, given the modest effectiveness of this therapeutic treatment compared with its relatively high cost and the additional professional resources required to administer it, it is not currently justified to contemplate funding viscosupplementation for all patients with OA of the knee. It nonetheless raises the possibility that this product could be offered as a last-resort treatment to patients who do not achieve pain relief from conventional therapies or for whom these are contraindicated. The recommendation not to cover this treatment does not exclude the fact that the MSSS may examine the possibility of exceptionally offering it to people who have failed to achieve pain relief from recognized conventional treatments, as do some other third-party payers. AETMIS therefore recommends that granting agencies should encourage universities to pursue clinical research on viscosupplementation as part of the research areas or programs dedicated to musculoskeletal diseases and focused on either osteoarthritis or chronic pain.

Benefits and costs of immunization of children with pneumococcal conjugate vaccine in Canada.

To estimate cost-effectiveness of routine and catch-up vaccination of Canadian children with seven-valent pneumococcal conjugate vaccine, a simulation model was constructed. In base scenario (vaccination coverage: 80%, and vaccine price: 58 dollars per dose), pneumococcal disease incidence reduction would be superior to 60% for invasive infections, and to 30% for non-invasive infections, but the number of deaths prevented would be small. Annual costs of routine immunization would be 71 million dollars (98% borne by the health system). Societal benefit to cost ratio would be 0.57. Net societal costs per averted pneumococcal disease would be 389 dollars and 125,000 per life-year gained (LYG). Vaccine purchase cost is the most important variable in sensitivity analyses, and program costs would be superior to societal benefits in all likely scenarios. Vaccination would result in net savings for society, if vaccine cost is less than 30 dollars per dose. Economic indicators of catch-up programs are less favorable than for routine infant immunization.

Epidemiological and economic burden of pneumococcal diseases in Canadian children.

BACKGROUND: With the arrival of a new conjugate pneumococcal vaccine, it is important to estimate the burden of pneumococcal diseases in Canadian children. The epidemiological data and the economic cost of these diseases are crucial elements in evaluating the relevance of a vaccination program. METHODS: Using provincial databases, ad hoc surveys and published data, age-specific incidence rates of pneumococcal infections were estimated in a cohort of 340,000 children between six months and nine years of age. The costs of these diseases to the health system and to families were also evaluated using data from Quebec and Manitoba. RESULTS: Cumulative risks were one in 5000 for pneumococcal meningitis, one in 500 for bacteremia and one in 20 for pneumonia, leading to 16 deaths in the cohort. About 262,000 otitis media episodes and 32,000 cases of myringotomy with ventilation tube insertion were attributable to Streptococcus pneumoniae. Societal costs were estimated at $125 million, of which 32% was borne by the health system and 68% was borne by families. Invasive infections represented only 2% of total costs, while 84% were generated by otitis media. CONCLUSION: Pneumococcal infections represent a significant burden for Canadian children and society that could be significantly reduced through immunization.