As we consider the current pressures on healthcare, the options for where to focus our policy and leadership efforts are numerous and, at times, overwhelming. From health human resources capacity to access to mental health and preventative care to intermittent closures of emergency departments – the outlook is alarming. To help make sense of the situation, our Healthcare Quarterly (HQ) editorial team carefully considers a few areas to focus on in each edition. Over the past few issues, we have highlighted the importance of health equity and the challenges faced by different populations in gaining access to appropriate care and support. We continue to welcome submissions on this topic as we start to shift our focus toward other system priorities, including the mental health crisis in Canada. We are currently exploring a special focus edition on this long-neglected area of the health system and will be inviting submissions on this topic over the coming months.

In this edition of HQ, our focus on the needs of underserved communities includes articles about mitigating health inequities in cancer screening, addressing the impact of a policy shift in Ontario on access to care for uninsured patients and exploring the success of a residential treatment centre for addictions. From there we shift to other topics, including new approaches to funding for radiation services, evaluation of virtual care and addressing ethics in quality improvement and research. We also have our regular featured columns from the Canadian Institute for Health Information (CIHI), the ICES and our colleague Neil Seeman. Finally, it is with some relief that we acknowledge that for this edition, we reviewed only one article on care during the COVID-19 pandemic. While we have many other healthcare concerns on our minds, it is worth a pause and some reflection as we mark this significant milestone for our collective consciousness.

Support for Equity-Deserving Populations

In our first article, Boothby et al. (2023) share their experiences in developing a project to advance health equity in cancer screening. Their project focused on understanding awareness of and barriers to breast, cervical and colorectal cancer screening in low-income communities in urban Calgary. Members of the targeted communities were invited through focus groups to share their perspectives on the reasons for low cancer screening and to engage in problem solving to facilitate improved screening rates. The project also engaged community health workers in exploring outreach strategies designed to better target the needs of the communities. Although this is a localized study, pervasive gaps in cancer screening rates among equity-deserving communities are of concern across Canada, and the learnings from this project have widespread implications.

As we collectively start to move on from the COVID-19 pandemic, we nevertheless felt that it was important to include the article submitted by Katz et al. (2023) on this topic. This piece highlights the impact of changing policy and access to care for uninsured patients from the perspective of those who work on the front line. In 2020, the province of Ontario enacted temporary legislation allowing uninsured patients access to medically necessary hospital services. In April 2023, this temporary legislation came to an end. The Health Network for Uninsured Clients, a growing group of healthcare and social service organizations, shares both its experiences with advocacy and support for uninsured patients during the pandemic and its response to the recent policy changes that have impacted access to care for this population. The authors have provided us with a compelling set of recommendations that will likely invoke reflections on what it means to have a “universal” health system.

In the third article, Cheng and Bloom (2023) describe a residential addictions treatment program specifically designed for women. The authors highlight the need for services that address gender-based differences in care and treatment for substance use. Given the need for greater focus on the substance use pandemic, this article demonstrates how a residential treatment program is providing holistic and evidence-based options for women facing addiction issues. The article concludes with reflections on the growing complexity of mental health and substance use, the societal costs of not taking action and the intersection of policy and systemic issues that need to be addressed.

New Funding Models for Healthcare

In our article on cancer care, Apostolovski et al. (2023) describe their methodology for developing a new funding model for radiation treatment in Ontario. Ontario Health (Cancer Care Ontario) has oversight and accountability for the quality of cancer services across the province. The authors describe the evolution of a quality-based procedure for radiation therapy and the application of a new funding model tied to specific quality-of-care activities. The development of the new funding model engaged clinicians in a consensus-based approach to identify radiation treatment protocols for implementation in 17 different radiation treatment facilities. The methodology used to gain consensus across clinicians provides a model for achieving the spread of other types of clinical best practices in a fiscally constrained environment.

Evaluating Virtual Care

Several articles in recent issues have considered the emerging field of virtual care (Husak et al. 2022; Powis and Krzyzanowska 2022). In this issue, Lunney et al. (2023) provide a useful new perspective with their description of an evaluation framework for virtual care. Evaluation frameworks serve to help plan fully fledged evaluation studies and ensure that these evaluations focus on the most relevant questions. Lunney et al. (2023) offer insightful learnings on the current state of virtual care. Their evaluation framework also provides a useful model for planning evaluations in other sectors of care to ensure that these studies focus on the right questions and have a systems perspective.

Ethical Risks in Human Factors Quality Improvement

Identifying and addressing ethical issues associated with research and quality improvement in healthcare can be daunting. Formal ethics review processes can be time consuming and require specific expertise. Dembicki and Laberge (2023) describe how they used “A pRoject Ethics Community Consensus Initiative” (ARECCI) tool to screen for and address ethical issues in human factors research in healthcare in Alberta. While the article focuses on the application of the tool for human factors projects, the lessons learned and challenges they describe will be of interest to readers working in quality improvement and research more broadly across the healthcare sector.

Quarterly Columns from ICES and CIHI

There have been long-standing concerns about the proportion of Canadians who die in hospital settings (vs. at home) and their access to palliative care, particularly access to appropriate palliative care at home. In this issue of HQ, Reason and Paltser (2023) from CIHI look at newly released information on access to palliative care and gaps in this care. They find that in recent years there have been small improvements in access to palliative care, and show that those in urban areas and those receiving care for cancer receive modestly better access. They note that unevenness and inequities in access to appropriate care persist and often patients and families lack information on services that are available, limiting their ability to pursue better care.

Quinn et al. (2023) from ICES provide an excellent follow-through to the preceding article from CIHI. They describe an innovative care model of regionally organized home-based palliative care for people with heart failure, one that emphasizes alignment with patient values and shared decision making. The collaborative home-based palliative care approach reduced visits to the emergency department, hospital admissions and in-hospital deaths. Their findings also suggest that this more integrated and collaborative care model would hold potential benefits for the delivery of care to patients dealing with other serious chronic diseases.

Quarterly Reflections from Neil Seeman

Finally, we have our quarterly column from Neil Seeman. In this issue, Seeman (2023) reflects on the “Wild West” of health apps, pointing to the lack of integration of these apps with the rest of the healthcare system and the lack of connectivity among the apps themselves. He sees an opportunity for apps that better connect patients with providers and alleviate some of the stresses on our health system. He notes the potential for apps to facilitate social prescribing. Seeman (2023) imagines a day in the future when health apps will “plug together” (p. 15).

In Closing

As always, we welcome feedback from our readers about current or emerging themes of interest. We noted earlier that we are exploring a special edition on the mental health crisis in Canada, with further details on submissions to come. If there are other leadership topics or concerns that you believe we should explore, please send us a note.

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