500-600 word analysis of an issue regarding any topic relating to the course. The analysis must link to course material and you should engage with people commenting on your analysis – You can also offer a question at the end of your analysis to facilitate discussion.

politics
© 2016 Joule Inc. or its licensors CMAJ, November 1, 2016, 188(16) 1147 D iabetes mellitus is a major health prob – lem worldwide and is associated with in – creased morbidity, mortality, life expec – tancy and health care costs. 1–4 The prevalence of diabetes in Canada has increased more than two – fold over the past decade. 5 Currently, the disease affects almost 2.4  million Canadians, 6 and its management, along with that of associated com – plications, costs more than $9  billion annually. 7 The burden of diabetes is particularly high among First Nations people in Canada, with prevalence rates 3–5 times higher than those among non– First Nations people. 8 Reducing the risk of type 2 diabetes will require a broad set of population-based and indi – vidual-level interventions that target diabetogenic aspects of lifestyle, as well as social determinants of health. The changes required to achieve these objectives will need buy-in from a wide range of stakeholders. Thus, it will be important to com – municate risk in a way that is understood by the general population and by health authorities. Although estimates of incidence and preva – lence provide important information about the burden of a disease in the community, they do not provide adequate information regarding the perspective of risk at the individual level. Life – time risk (the probability of a disease-free indi – vidual developing the disease during his or her remaining lifespan) may be more informative for the general population and for decision-makers. Life-table modelling techniques use incidence and mortality data to estimate the lifetime risk of diabetes. This important assessment of the dis – ease burden of diabetes has been undertaken in a few studies, 9–11 but it has not been done in Can – ada. The need for such estimates is particularly relevant given the higher prevalence of diabetes among First Nations people in Canada. We estimated the lifetime risk of diabetes among men and women in both First Nations and non–First Nations populations using a co – hort of adults residing in a single Canadian province. Lifetime risk of diabetes among First Nations and non–First Nations people Tanvir Chowdhury Turin MBBS PhD , Nathalie Saad MD , Min Jun PhD , Marcello Tonelli MD , Zhihai Ma MSc , Cheryl Carmelle Marie Barnabe MD , Braden Manns MD , Brenda Hemmelgarn MD Competing interests: None declared. This article has been peer reviewed. Accepted: May 2, 2016 Online: Sept. 19, 2016 Correspondence to: Tanvir Chowdhury Turin, [email protected] CMAJ 2016. DOI:10.1503 / cmaj.150787 Background: Lifetime risk is a relatively straight – forward measure used to communicate disease burden, representing the cumulative risk of an outcome during the remainder of an individu – al’s life starting from a disease-free index age. We estimated the lifetime risk of diabetes among men and women in both First Nations and non–First Nations populations using a cohort of adults in a single Canadian province. Methods: We used a population-based cohort consisting of Alberta residents from 1997 to 2008 who were free of diabetes at cohort entry to estimate the lifetime risk of diabetes among First Nations and non–First Nations people. We calculated age-specific incidence rates with the person-year method in 5-year bands. We estimated the sex- and index-age– specific lifetime risk of incident diabetes, after adjusting for the competing risk of death. Results: The cohort included 70 631 First Nations and 2 732 214 non–First Nations people aged 18 years or older. The lifetime risk of diabetes at 20 years of age was 75.6% among men and 87.3% among women in the First Nations group, as compared with 55.6% among men and 46.5% among women in the non–First Nations group. The risk was higher among First Nations people than among non–First Nations people for all index ages and for both sexes. Among non–First Nations people, men had a higher lifetime risk of dia – betes than women across all index ages. In contrast, among First Nations people, women had a higher lifetime risk than men across all index ages. Interpretation: About 8 in 10 First Nations people and about 5 in 10 non–First Nations people of young age will develop diabetes in their remaining lifetime. These population- based estimates may help health care plan – ners and decision-makers set priorities and increase public awareness and interest in the prevention of diabetes. Abstract fi   fi 1148 CMAJ, November 1, 2016, 188(16) Methods Study population All residents of the province of Alberta are eligi – ble for insurance coverage by Alberta Health, and more than 99% participate in this coverage. We included 2 897 299 residents aged 18 years or older (1 436 324 men and 1 460 975 women) who were registered with Alberta Health between Apr. 1, 1997, and Mar.  31, 2008. Each person’s first encounter date with Alberta Health was considered the study entry date. We excluded those who had diabetes at cohort entry. Classification of First Nations status We determined participants’ First Nations status from an indicator variable in the Alberta Health Registry file, which identifies people registered with Aboriginal Affairs and Northern Develop – ment Canada under the Indian Act. A person with a First Nations identifier at any time during the study period was classified as First Nations; all other participants were classified as non–First Nations people. 12 Aboriginal people in Alberta who were not registered within the Indian Act (e.g., unregistered First Nations and Metis) were included in the non–First Nations group. According to the 2011 census, about 52% of the Alberta Aboriginal population is registered First Nations. 13 After Ontario and British Colombia, Alberta has the third largest First Nations population among the provinces and territories of Canada. 14 About half of the population lives on Indian reserves. 15 More than half of First Nations people in Alberta are under 25 years of age, and less than 5% are over 64 years old; the median age is 23 years. 15 Great cultural diversity exists within the Albertan First Nations communities, includ – ing a broad range of spoken languages, the most common being Blackfoot, Cree, Chipewyan, Dene, Sarcee and Stoney. 15 Outcome measure Participants were followed for the development of diabetes after their study entry. The diagnosis of diabetes was based on the previously validated National Diabetes Surveillance System defini – tion. 16 The case definition required 2 or more physician service claims for diabetes (Interna – tional Classification of Diseases, 9th Revision [ICD-9] code 250) within 2 years, or 1  or more hospital admissions with ICD-9 code 250 (before Mar.  31, 2002) or the equivalent ICD-10 (Inter – national Statistical Classification of Disease and Related Health Problems, 10th Revision) codes E10–14 (after Mar. 31, 2002), 16 selected from all available diagnostic codes from the administra – tive data sources. 17 This case definition has been reported to have 86% sensitivity, 97% specificity and 80% positive predictive values for identify – ing individuals with diabetes through administra – tive data sources. 16 Death was determined from the Alberta Health Registry file. Participants were followed from their study index date to the occur – rence of the study outcome, death, out-migration from Alberta or the end of the study period (Mar. 31, 2009). Measurement of cohort characteristics Socioeconomic status was categorized based on Statistics Canada 2001 and 2006 census data. Median neighbourhood household income (in quintiles) and residency (rural or urban) were identified based on census data closest to the study entry date of the participants. 18 A diagnosis of hypertension was determined based on previ – ously validated criteria. 19 We identified other comorbid conditions among physician claims and hospital admission records using validated cod – ing algorithms based on the Deyo adaptation (ICD-9, Clinical Modification [ICD-9-CM] data) and the Quan validation (ICD-10 data) of the Charlson Comorbidity Index. 20 Statistical analysis We used age (in years) as the time scale. The index age categories started at age 20 years and increased by decade to age 60. Risk estimation began at an index age; participants who were younger than the index age of interest at the beginning of the study period entered the analysis when they reached the required age. For exam – ple, for risk estimation at an index age of 20 years, participants aged 20 years and older were included; those who were less than 20  years old at cohort entry began contributing to the risk esti – mation when they attained the age of 20. We estimated the cumulative incidence of diabetes conditional on survival to ages 20, 30, 40, 50 and 60 years. We estimated lifetime risk of diabetes accounting for the competing risk of death. We calculated index-age–specific inci – dence of diabetes and the lifetime risk estimates using a modified technique of survival analysis, 21 as in prior reported analyses. 22,23 In contrast to the conventional Kaplan–Meier survival analysis (which considers individuals who die as cen – sored observations), this modified approach con – siders death as a competing event. All statistical analyses were performed using SAS version 9.1 (SAS Institute). Ethics approval The Conjoint Health Research Ethics Board of the University of Calgary approved the study. fi   CMAJ, November 1, 2016, 188(16) 1149 Results The study cohort included 2 802 845 participants without a history of diabetes, 70 631 (2.5%) of whom had First Nations status ( Figure 1 ). The mean follow-up period was 8.71 (standard devia – tion 3.84) years. The First Nations participants were younger, generally had a higher prevalence of comorbid conditions and were more likely to be in a lower income quintile ( Table 1 ). During a total follow-up of 23 362 108.3 person-years for the participants 20 years and older during the study, diabetes developed in 160 549 participants. The number of person-years of follow-up and the number of events (diabetes and death) across all age groups are presented in Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/ cmaj.150787/-/DC1). Table 2 presents the lifetime risk of diabetes as well as the risk over 10-, 20-, 30- and 40-year time horizons among First Nations and non–First Nations men by index age. The lifetime risk of diabetes adjusted for competing risk of death among 20-year-old men was 75.6% in the First Nations group and 55.6% in the non–First Na – tions group. As expected, there was a graded in – crease in the risk of diabetes over longer time ho – rizons for all index ages in both First Nations and non–First Nations groups. For example, among 20-year-old First Nations men, the risk of diabe – tes was 1.4%, 6.0%, 15.4%, 31.5%, 51.7% and 68.6% over the 10-, 20-, 30-, 40-, 50- and 60- year time horizons, respectively. Table 3 presents the short, intermediate and lifetime risks of diabetes among women in the First Nations and non–First Nations groups. Among 20-year-old women, the adjusted life – time risk was 87.3% in the First Nations group and 46.5% in the non–First Nations group. The lifetime risk of diabetes was lower among women than among men in all index age catego – ries in the non–First Nations group. In contrast, First Nations women had a higher lifetime risk of diabetes than First Nations men in all index age categories ( Tables 2 and 3 ). Again, a graded increase in diabetes risk with increasing time ho – rizon was consistently observed among women in both the First Nations and non–First Nations groups ( Figure 2 ). The lifetime risk estimates of diabetes among men and women by location of residence (urban or rural) are presented in Appendix 2 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj .150787/-/DC1). The estimates among First Na – tions men and women were consistently higher than those among their non–First Nations coun – terparts across both urban and rural locations. In the First Nations group, the lifetime risk of dia – betes was notably higher among those living in Non–First Nations n = 2 732 214 First Nations n = 70 631 Alberta residents 18 yr (1997–2008) n = 2 897 299 Excluded n = 94 454(history of diabetes) Included in study cohort n = 2 802 845 Figure 1: Selection of the study cohort. Table 1: Baseline characteristics of study participants by First Nations status Characteristic % of participants* First Nationsn = 70 631 Non–First Nationsn = 2 732 214 Age, yr, mean ± SD 34.5 ± 12.6 40.7 ± 16.3 Sex, female 49.9 49.5 Comorbid condition Hypertension 3.9 7.5 Cerebrovascular disease 0.7 1.0 Peripheral vascular disease 0.2 0.6 Congestive heart failure 0.8 1.1 Cancer 1.0 1.8 COPD 17.6 9.2 Dementia 0.2 0.5 Myocardial infarction 0.5 0.9 Peptic ulcer disease 4.8 1.9 Rheumatic disease 1.2 0.6 Location of residence Rural 47.7 19.3 Urban 52.3 80.7 Unknown 0.0 0.01 Income quintile 1 (lowest) 42.5 21.6 2 14.7 19.6 3 10.5 18.3 4 7.9 18.0 5 (highest) 9.4 17.8 Unknown 15.1 4.71 Note: COPD = chronic obstructive pulmonary disease, SD = standard deviat ion. *Unless stated otherwise. fi   1150 CMAJ, November 1, 2016, 188(16) rural locations than among those in urban areas. This difference was strikingly prominent among women. For example, 20-year-old First Nations women in rural areas had a lifetime risk of 94.2%, as compared with 80.4% among their counterparts in urban locations. In contrast, non– First Nations men and women in urban locations had slightly higher lifetime risks of diabetes than their rural counterparts. Interpretation We estimated the lifetime risk of diabetes among First Nations and non–First Nations people in a population-based cohort of nearly 3 million people from a provincial health registry. The observed probabilities suggest that about 5 in 10 non–First Nations men and women of young age will de – velop diabetes in their lifetime. The lifetime risk was much higher in the First Nations population (about 7 in 10 men and 9 in 10 women). In our study, men had a higher lifetime risk of diabetes than women of similar age strata in the non–First Nations group. In contrast, women had a higher lifetime risk than men in the First Nations group. This observation likely reflects the fact that the incidence of diabetes is higher among First Nations women than among First Nations men in Canada. 24 That women in First Nations communi – ties are more likely to be overweight or obese than the men, and at a younger age, 25 would explain this disparity to some extent. Also, there are high rates of gestational diabetes among pregnant Aboriginal women who develop type 2 diabetes later in life. 26 Irrespective of urban or rural location of resi – dence, we observed a higher lifetime risk of dia – betes among First Nations people than among non–First nations people. However, in the First Nations group, the lifetime risk was higher among those living in rural communities than among those in urban areas. This difference was striking among First Nations women. Access to care and geographic factors, which have been identified as important determinants of health for indigenous people, 27 may be contributing to the higher observed risk. 28 We also observed that the First Nations group reached a higher risk of diabetes at a much younger age than the non–First Nations group. The cumulative risk of diabetes among young First Na – tions men overtook the lifetime risk among non– First Nations men by about 20  years earlier. Among First Nations women, this happened about 30 years earlier. These findings coupled with the observations that younger people had a higher life – time risk of diabetes than their older counterparts indicates the importance of early mobilization of preventive measures against the development of diabetes among First Nations people. Reports of a similar nature were limited to studies in the United States 11 and Australia. 9 However, the methodologic differences across these studies hinder direct comparison of the esti – mates with our results. In the US study, Narayan and associates 11 used incidence rates and mortal – ity derived from different sources and a Markov chain model to estimate the lifetime risk of diabe – tes. The authors estimated that the lifetime risk of diabetes among people 40 years of age was about 3 in 10. 11 They defined diabetes based on self- reported disease status, which might have under – estimated true diabetes rates. In the Austrialian study, Magliano and associ – ates 9 used the approach of building a multistate life table to estimate the lifetime risk of diabetes in an epidemiologic cohort of 5842 adults. 9 The authors reported that the lifetime probability of Table 2: Age- and sex- specific risk estimates for diabetes among First Nation s and non–First Nations men, by index age Index age, yr Time horizon Risk estimate, % (95% CI) First Nations Non–First Nations 20 10 yr 1.4 (1.2–1.7) 0.6 (0.6–0.7) 20 yr 6.0 (5.6–6.4) 2.5 (2.4–2.6) 30 yr 15.4 (14.7–16.1) 7.4 (7.3–7.5) 40 yr 31.5 (30.3–32.8) 18.1 (17.9–18.3) 50 yr 51.7 (49.9–53.6) 33.5 (33.3–33.8) 60 yr 68.6 (66.0–71.0) 47.8 (47.5–48.1) Lifetime 75.6 (72.6–78.5) 55.6 (55.3–55.9) 30 10 yr 4.7 (4.3–5.0) 1.9 (1.9–1.9) 20 yr 14.3 (13.6–15.0) 6.8 (6.7–6.9) 30 yr 30.8 (29.6–32.1) 17.6 (17.4–17.7) 40 yr 51.5 (49.6–53.4) 33.1 (32.9–33.4) 50 yr 68.6 (66.1–71.2) 47.5 (47.2–47.8) Lifetime 75.9 (72.9–78.9) 55.3 (55.0–55.7) 40 10 yr 10.0 (9.3–10.6) 4.9 (4.9–5.0) 20 yr 27.1 (25.8–28.3) 15.8 (15.7–16.0) 30 yr 48.5 (46.6–50.4) 31.5 (31.3–31.7) 40 yr 66.3 (63.6–68.9) 46.0 (45.7–46.3) Lifetime 73.8 (70.6–76.9) 53.9 (53.6–54.3) 50 10 yr 18.0 (16.8–19.3) 11.1 (10.9–11.2) 20 yr 40.7 (38.7–42.7) 27.0 (26.8–27.3) 30 yr 59.5 (56.7–62.2) 41.8 (41.5–42.1) Lifetime 67.4 (64.0–70.7) 49.9 (49.5–50.2) 60 10 yr 24.8 (22.8–26.9) 16.7 (16.4–16.9) 20 yr 45.4 (42.3–48.5) 32.0 (31.7–32.3) Lifetime 54.1 (50.4–57.8) 40.4 (40.1–40.8) Note: CI = confidence interval. fi   CMAJ, November 1, 2016, 188(16) 1151 diabetes among people 26 years of age was about 3 in 10. 9 They recognized the potential limitation of using a single oral glucose tolerance test to define diabetes in their study and acknowledged the possibility of underestimation of the true risk. Our analysis used a cohort of nearly 3 mil – lion people from a single Canadian province, and diabetes was defined using administrative data sources. We used a survival analysis approach to estimate the lifetime risk of diabe – tes, with a special focus on the difference in risk between First Nations by non–First Nations people. We did not identify prior reports that compared estimates of lifetime risk in an Aboriginal population and a contemporaneous non-Aboriginal counterpart. Although the lifetime risk of diabetes was high in both First Nations and non–First Nations groups, it was higher in the former. These findings are consistent with population-based diabetes reports showing higher incidence and prevalence of diabetes among First Nations people than among non–First Nations people. 24,29,30 Dyck and associates 24 reported that the incidence and preva – lence of diabetes were more than 4  times higher among First Nations women than among non– First Nations women, and more than 2.5 times higher among First Nations men than among non– First Nations men. The reasons that have been attributed to these differences include genetic sus – ceptibility, 31–34 dietary acculturation, 34,35 adoption of sedentary lifestyle 34,36 and increasing prevalence of obesity and metabolic syndrome. 37–39 Overall, the First Nations populations in Canada, and simi – larly other indigenous groups worldwide, are vul – nerable to developing diabetes. It also appears that inequities in the social, cultural, historical, eco – nomic and political determinants of health, lack of access to nutritionally adequate food and barriers Table 3: Age- and sex- specific risk estimates for diabetes among First Nation s and non–First Nations women, by index age Index age, yr Time horizon Risk estimate, % (95% CI) First Nations Non–First Nations 20 10 yr 2.8 (2.5–3.2) 1.2 (1.1–1.2) 20 yr 9.2 (8.6–9.7) 3.5 (3.4–3.6) 30 yr 19.4 (18.6–20.2) 7.1 (7.0–7.2) 40 yr 38.6 (37.3–40.0) 14.7 (14.6–14.9) 50 yr 60.8 (58.7–62.9) 26.0 (25.8–26.2) 60 yr 79.2 (76.3–82.2) 38.0 (37.8–38.3) Lifetime 87.3 (83.7–90.8) 46.5 (46.2–46.8) 30 10 yr 6.4 (6.0–6.9) 2.4 (2.3–2.4) 20 yr 16.8 (16.0–17.6) 6.0 (5.9–6.1) 30 yr 36.2 (34.8–37.6) 13.6 (13.5–13.7) 40 yr 58.6 (56.5–60.7) 24.9 (24.7–25.1) 50 yr 77.3 (74.3–80.3) 37.0 (36.7–37.3) Lifetime 85.4 (81.8–89.0) 45.4 (45.1–45.7) 40 10 yr 10.6 (9.9–11.3) 3.6 (3.6–3.7) 20 yr 30.5 (29.1–31.8) 11.3 (11.2–11.4) 30 yr 53.5 (51.3–55.6) 22.6 (22.4–22.8) 40 yr 72.5 (69.5–75.6) 34.8 (34.5–35.1) Lifetime 80.9 (77.2–84.5) 43.3 (43.0–43.6) 50 10 yr 20.6 (19.3–21.9) 7.7 (7.6–7.9) 20 yr 44.5 (42.2–46.7) 19.2 (19.0–19.4) 30 yr 64.3 (61.0–67.5) 31.5 (31.2–31.8) Lifetime 72.9 (69.1–76.8) 40.1 (39.8–40.4) 60 10 yr 25.5 (23.2–27.7) 11.8 (11.6–12.0) 20 yr 46.6 (43.1–50.1) 24.4 (24.2–24.7) Lifetime 55.8 (51.6–60.0) 33.2 (32.9–33.6) Note: CI = confidence interval. 0 10 20 30 40 50 60 70 80 90 100 20 304050607080Life tim e 40 50607080Life ti me Cum ulative risk of diab etes, % Attained age, yr Att ained age, yr FN menFN womenNon- FN me nNon- FN wo men r y 0 4 e g a x e d n I : B r y 0 2 e g a x e d n I : A Figure 2: Cumulative risk of diabetes with advancing age among First Nat ions and non–First Nations men and women at the index age of (A) 20 years and (B) 40 years. FN = First Nations. fi   1152 CMAJ, November 1, 2016, 188(16) to proper health care play major roles in the diabe – tes epidemic in indigenous populations. 40–43 The increase we observed in the cumulative risk of diabetes across the time horizons for all in – dex age categories among both men and women reflected the contribution of the age time scale that has been reported for other chronic diseases. 44–48 We also observed that the lifetime risk decreased by increasing index age, which is consistent with reports of lifetime risk estimation for other dis – eases. 44–48 The decrease in lifetime risk of diabetes with increasing age reflects the shorter life expec – tancy and period at risk among older participants. Also, at older ages, competing causes of death will increase in importance because older people may not live long enough to develop diabetes, and people susceptible to diabetes might have de – veloped the disease at an earlier age. From the perspective of public health educa – tion, the lifetime risk estimates are beneficial because they are more intuitive than conventional epidemiologic measures such as incidence, preva – lence and relative risk. 49 Problems with statistical numeracy or low quantitative literacy are not uncommon. 50 Furthermore, innumeracy and diffi – culties understanding proportions, ratios and rela – tive risks seem to be general barriers to knowledge translation across all user communities in Canada. Indeed, one study found that patients preferred their health risks to be presented in absolute terms and that their lifetime estimate of risk be given in an “X in 100” format. 51 In addition, merits of reporting lifetime risk estimates have been observed. For instance, the widely publicized life – time risk of breast cancer among American women (estimated to be 1  in 8 [12.6%]) 52 is believed to have influenced the increase in screen – ing mammography for early disease detection. 53 Although lifetime risk lacks the detail and pre – cision needed for individual clinical consultation, the lifetime estimates presented in our study offer a useful and understandable summary of risk in a population. This will be particularly relevant to help researchers and policy-makers appreciate the population burden of diabetes. Limitations The strengths of our study include the use of a pop – ulation-based cohort and data that encompassed diabetes and mortality. However, our reported esti – mates need to be interpreted in light of the limita – tions of this type of methodology. 47,52,54–57 First, life – time risk estimates are population based and reflect average individuals in a population. Although they serve as general guidelines, lifetime risk estimates therefore have only restricted prognostic utility at the patient level, where the lifetime risk would be influenced by individual risk factors for diabetes. Second, lifetime risk estimates assume a fixed age and demographic structure for the general population, as well as stable diabetes incidence rates and mortality. Because studies suggest that the incidence and prevalence of diabetes is increasing over time, the lifetime risk of diabetes may be even higher than reported here. Moreover, the temporal trends in life expectancy, sensitivity of diagnostic tests and the prevalence of risk fac – tors could also alter the lifetime risk estimates of diabetes. Also, our results are based on popula – tion-based data from Alberta; they may not be generalizable to other provinces in Canada. Third, it was not possible for us to recognize unregistered First Nations people, which may caused misclassification of some individuals in the non–First Nations group. Nonetheless, given that most of the First Nations population in Alberta is registered and given the size of the non–First Nations population in our study, we expect this potential misclassification to have minimal impact on the study estimates. Fourth, we did not differentiate between type 1, type 2 and gestational diabetes. How – ever, the major form of diabetes in the popula – tion is type 2 diabetes, which accounts for 90%–95% of diabetes cases in Canada. 6 Conclusion The observed probabilities indicate that 75.6% of First Nations men and 87.3% of First Nations women of young age will develop diabetes in their lifetime. The corresponding risk among non–First Nations people is about 55.6% and 46.5%, respectively. 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HNF-1alpha G319S, a transactivation-deficient mutant, is associated with altered dynamics of diabetes onset in an Oji-Cree community. Proc Natl Acad Sci U S A 2002 ;99:4614 -9. 33. Sellers EA, Triggs-Raine B, Rockman-Greenberg C, et al. The prevalence of the HNF-1 α G319S mutation in Canadian aborigi – nal youth with type 2 diabetes. Diabetes Care 2002 ;25:2202 -6. 34. Young TK, Reading J, Elias B. Type 2 diabetes mellitus in Can – ada’s First Nations: status of an epidemic in progress. CMAJ 2000 ;163 :561 -6. 35. Young TK. The health of Native Americans: toward a biocul – tural epidemiology . New York: Oxford University Press ; 1994 : 145 -68. 36. Ng C, Young TK, Corey PN. Associations of television view – ing, physical activity and dietary behaviours with obesity in aboriginal and non-aboriginal Canadian youth. Public Health Nutr 2010 ;13:1430 -7. 37. Lix LM , Bruce S, Sarkar J, et al. Risk factors and chronic condi – tions among Aboriginal and non-Aboriginal populations. Health Rep 2009 ;20:21-9. 38. Liu J, Young TK, Zinman B, et al. Lifestyle variables, non- traditional cardiovascular risk factors, and the metabolic syn – drome in an Aboriginal Canadian population. Obesity (Silver Spring) 2006 ; 14:500 -8. 39. Pollex RL, Hanley AJ, Zinman B, et al. Metabolic syndrome in aboriginal Canadians: prevalence and genetic associations. Athero – sclerosis 2006 ;184:121-9. 40. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet 2009 ;374 :65-75. 41. Ghosh H. Urban reality of type 2 diabetes among First Nations of eastern Ontario: western science and indigenous perceptions. J Global Citizenship Equity Educ 2012 ;2:158 -81. 42. Ghosh H, Gomes J. Type 2 diabetes among Aboriginal peoples in Canada: a focus on direct and associated risk factors. Pimatisiwin 2011 ;9:245 -75. 43. First Nations Regional Longitudinal Health Survey (RHS) 2002/03 : results for adults, youths and children living in First Nations communities . Ottawa: First Nations Centre ; 2005 . Available : http://fnigc.ca/sites/default/files/ENpdf/RHS_2002/ rhs2002-03-technical_report.pdf (accessed 2016 Feb. 21 ). 44. Turin TC, Kokubo Y, Murakami Y, et al. Lifetime risk of acute myocardial infarction in Japan. Circ Cardiovasc Qual Outcomes 2010 ;3:701 -3. 45. Turin TC, Kokubo Y, Murakami Y, et al. Lifetime risk of stroke in Japan. Stroke 2010 ;41:1552 -4. 46. Seshadri S, Beiser A, Kelly-Hayes M, et al. The lifetime risk of stroke. Stroke 2006 ;37:345 -50. 47. Lloyd-Jones DM , Larson MG , Beiser A, et al. Lifetime risk of developing coronary heart disease. Lancet 1999 ;353 :89-92. 48. Turin TC, Tonelli M, Manns BJ, et al. Lifetime risk of ESRD. J Am Soc Nephrol 2012 ;23:1569 -78. 49. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ 2002 ;324 :827 -30. 50. Schwartz LM , Woloshin S, Welch HG. Risk communication in clinical practice: putting cancer in context. J Natl Cancer Inst Monogr 1999 ;(25):124 -33. 51. Fortin JM, Hirota LK, Bond BE, et al. Identifying patient prefer – ences for communicating risk estimates: a descriptive pilot study. BMC Med Inform Decis Mak 2001 ;1:2. 52. Feuer EJ, Wun LM , Boring CC, et al. The lifetime risk of devel – oping breast cancer. J Natl Cancer Inst 1993 ;85:892 -7. 53. National Center for Health Statistics. Healthy people 2000 review, 1995–96 . Hyattsville (MD): Public Health Service ; 1996 . 54. Seshadri S, Wolf P, Beiser A, et al. Lifetime risk of dementia and Alzheimer’s disease. Neurology 1997 ;49:1498 -504 . 55. Turin TC, Hemmelgarn BR. Long-term risk projection and its application to nephrology research. J Nephrol 2012 ;25:441 -9. 56. Turin TC, Rumana N, Okamura T. Residual lifetime risk of cardio – vascular diseases in Japan. J Atheroscler Thromb 2011 ;18:443-7. 57. Cummings SR, Black DM , Rubin SM . Lifetime risks of hip, Colles ’, or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med 1989 ;149:2445 -8. Affiliations: Department of Family Medicine (Turin), Department of Community Health Sciences (Turin, Manns, Hemmelgarn), Institute of Public Health (Turin, Manns, Hemmelgarn) and Department of Medicine (Saad, Jun, Tonelli, Ma, Barnabe, Manns, Hemmelgarn), University of Calgary, Calgary, Alta. Contributors: Tanvir Turin and Brenda Hemmelgarn con – tributed to the study concept and design. Tanvir Turin and Zhiha Ma performed the data analysis. Tanvir Turin, Mar – cello Tonelli, Braden Manns and Brenda Hemmelgarn inter – preted the results. Nathalie Saad, Min Jun and Cheryl Barn – abe contributed to the interpretation and contextualization of the results. Tanvir Turin drafted the manuscript, and Nathalie Saad, Min Jun, Cheryl Barnabe, Marcello Tonelli, Braden Manns, Zhihai Ma and Brenda Hemmelgarn revised it criti – cally for important intellectual content. All of the authors approved the final version to be published and agreed to act as guarantors of the work. Acknowledgement: This study is based in part on data pro – vided by Alberta Health and Alberta Health Services. The interpretation and conclusions are those of the researchers and do not represent the views of the Government of Alberta. fi  
politics
© 2017 Joule Inc. or its licensors CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 E295 U niversal access to safe, affordable and appropriately prescribed medicines is an important goal of national health care systems. 1 Canadians benefit from universal public coverage of physicians’ services and hospital care; how ­ ever, an estimated 20% of Canadians are uninsured or under­ insured for the cost of prescription drugs used outside hospi­ tals. 2,3 This makes Canada an outlier as the only advanced economy with a universal health care system that excludes uni­ versal coverage of prescription drugs. Although the Canada Health Act ensures universal coverage of medicines used in hospitals, Canada has no national standards for the coverage of prescription drugs used in the community. The federal government provides drug coverage for select populations that account for 2% of prescription drug expenditures in the coun­ try. 4 Provincial and territorial governments offer various public drug plans for people of specific ages, incomes or health statuses that finance between 25% and 41% of prescription drug expendi­ tures in their jurisdictions. 4 Private drug plans — typically obtained through work­related extended health benefits — account for 35% of prescription drug expenditures in Canada. 4 Patients finance 22% of total Canadian prescription drug expenditures out of pocket. 4 Canada’s patchwork of private and public financing of medi­ cines creates clinical and economic problems. About 10% of Canadians report that they cannot afford to take medications as prescribed because of out­of­pocket costs. 5 Such access barriers have been shown to result in worse health outcomes and in­ creased costs elsewhere in the health care system. 6–9 The multi­ payer system for medicines also increases administration costs, creates silo budgeting within the health system and reduces RESEARCH Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada Steven G. Morgan PhD, Winny Li MSc, Brandon Yau BSc, Nav Persaud MD MSc n Cite as: CMAJ 2017 February 27;189:E295­302. doi: 10.1503/cmaj.161082 CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/161082­res See related article at www.cmajopen.ca/content/5/1/E137 ABSTRACT BACKGROUND: Canada’s universal health care system does not include uni­ versal coverage of prescription drugs. We sought to estimate the effects of adding universal public coverage of an essential medicines list to existing pub­ lic drug plans in Canada. METHODS: We used administrative and market research data to estimate the 2015 shares of the volume and cost of prescriptions filled in the community setting that were for 117 drugs on a model list of essential medicines for Canada. We compared prices of these essential medicines in Canada with prices in the United States, Sweden and New Zealand. We estimated the cost of adding universal public drug coverage of these essential medicines based on anticipated effects on medication use and pricing. RESULTS: The 117 essential medicines on the model list accounted for 44% of  all prescriptions and 30% of total prescription drug expenditures in 2015. Average prices of generic essential medicines were 47% lower in the US, 60% lower in Sweden and 84% lower in  New Zealand; brand ­name drugs were priced 43% lower in the US. Esti ­ mated savings from universal public coverage of these essential medicines was $4.27  billion per year (range $2.72  billion to $5.83  billion; 28% reduction) for patients and private drug plan sponsors, at an incremental government cost of $1.23 billion per year (range $373  million to $1.98 bil­ lion; 11% reduction). INTERPRETATION: Our analysis showed that adding universal public coverage of essential medicines to the existing pub­ lic drug plans in Canada could address most of Canadians’ pharmaceutical needs and save billions of dollars annu­ ally. Doing so may be a pragmatic step forward while more comprehensive pharmacare reforms are planned. E296 CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 Cana da’s purchasing power in the global pharmaceutical mar­ ket. 10 As a result, pharmaceutical prices and total per capita ex­ penditures on pharmaceuticals are higher in Canada than in de­ veloped countries with comparable health care systems. 10–13 Universal public coverage of prescription drugs was recom­ mended by the 1964 Royal Commission on Health Services (Hall Commission), the 1997 National Forum on Health and the 2002 Royal Commission on the Future of Health Care in Canada (Romanow Commission). 14 These commissions, and more recent bodies of evi­ dence, suggest that implementing universal public drug coverage that is both comprehensive and evidence based would be the best way to ensure the accessibility, affordability and appropriateness of medicine use in Canada. 15 But a variety of factors have stalled prog­ ress toward such universal pharmacare. 16 Practical considerations are among obstacles to reform. Imple­ menting a comprehensive pharmacare program involves a number of logistical challenges: a national, evidence­based formulary needs to be delineated; prices and supply contracts need to be negotiated; and a greater share of total pharmaceutical expenditure needs to flow through the public program. Although these challenges are not insurmountable, it may be prudent to “start small” by adding uni­ versal public coverage of a carefully selected list of essential medica­ tions to the existing complement of public drug plans in Canada. A similar step toward comprehensive drug coverage for all Canadians was recommended by the 2002 Romanow Commission and the 2016 Citizens’ Reference Panel on Pharmacare in Canada. 17,18 The World Health Organization (WHO) maintains a model list of essential medicines that is meant to be adapted by countries to meet the medicine needs of their populations. 19,20 Medicines on resulting national lists are ones governments commit to mak­ ing accessible because of their importance to patient and public health. 21,22 International evidence suggests that encouraging access to drugs on essential medicine lists can improve patient outcomes and lower costs. 22–28 We sought to estimate the 2015 volume and cost of prescrip­ tions filled in Canada for medicines on, or similar to medicines on, a Canadian adaptation of the World Health Organization’s model list of essential medicines. We also sought to compare the prices of these essential medicines in Canada with their prices within single­payer systems for pharmaceutical coverage that publish data on drug pricing: the US Department of Veterans Affairs, and the national drug coverage systems of Sweden and New Zealand. Finally, we sought to estimate the financial impli­ cations of adding universal public drug coverage of the essential medicines on the model list to the existing complement of public drug plans in Canada. Methods This is a secondary analysis of administrative and market research databases pertaining to the volume and costs of pre­ scriptions for the calendar year 2015. Selection and classification of medicines The essential medicines list used in our study is the CLEAN Meds list, an adaptation of the WHO model list of essential medicines for primary health care in Canada. 29 Our analysis focused on 117 of the CLEAN Meds drugs (hereafter “the essential medicines”) that are available and sold as prescription­only medicines in Canada (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.161082/­/DC1). Although predominantly target­ ing primary health care needs, some medicines on the list are often prescribed by specialists (e.g., treatments for hepatitis and HIV infection, and a biologic drug for inflammatory conditions). We used WHO’s Anatomic Therapeutic Chemical (ATC) Classifi­ cation System to assign medicines to mutually exclusive groups. 30 This allowed us to identify other drugs for which the essential medi­ cines may be suitable substitutes for some patients. We used the chemical subgroups of the ATC system to define relatively close substitutes (e.g., A02BC = “proton pump inhibitors”) and the phar­ macologic/therapeutic subclasses of the ATC system to define broader ranges of substitutes (e.g., A02B = “drugs for peptic ulcer and gastro­oesophageal reflux disease”). We further grouped medi­ cines into 47 broad therapeutic categories for reporting purposes. 31 Data sources We used data from multiple sources, each described in greater detail in Appendix 2 (available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.161082/­ /DC1). From IMS Health, we obtained product­level data describing the number of and total expendi­ ture on all prescriptions dispensed at retail pharmacies in each province during 2015. From the National Prescription Drug Utili­ zation Information System database of the Canadian Institute for Health Information (CIHI), we obtained 2015 data on the number of and total expenditure on prescriptions that were paid, in whole or in part, by public drug plans in all provinces except Quebec. Because the IMS Health data included Quebec but the CIHI data did not, we estimated the public shares of prescription costs for Quebec based on average public shares for the same drug types in all other provinces combined. This may overstate the public proportion of expenditures in Quebec by 7% (Appendix 2). Using methods described in Appendix 2, we obtained prices for the most common dosage forms of each generic drug on the essential medicines list from public formularies in Canada, the United States (US Department of Veterans Affairs), Sweden and New Zealand. Because prices of brand­name drugs listed on national formularies do not include confidential manufacturers’ rebates, we obtained from the US Department of Veterans Affairs a weighted average of net prices of essential medicines available only from brand­name manufacturers in Canada. We converted foreign prices for generic and brand­name drugs to Canadian dollars using 2 methods: exchange rates and gross domestic product (GDP) purchasing power parities. Statistical analysis To measure the baseline volume of prescriptions used, we com­ puted the total number and cost of prescriptions for the essential medicines and all other medicines in 2015. To gauge the poten­ tial scope of clinical needs that the essential medicines may be suitable for, we calculated the number and cost of prescriptions in the same ATC chemical subgroups and the same ATC pharma­ cologic subclasses as 1 or more of the essential medicines. RESEARCH CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 E297 We used economic modelling to estimate the total cost of prescriptions (stratified by province, therapeutic category and source of financing) under a scenario wherein universal public coverage of the essential medicines is added to the existing com­ plement of public drug plans in Canada. The models were based on economic frameworks developed for analyses of the determi­ nants of prescription drug expenditure as a function of the vol­ ume of purchases made, products selected and prices paid for selected products. 32,33 The economic models involved a number of pricing and utili­ zation parameters that we chose on the basis of Canadian and international evidence, as described in Appendix 2 and summa­ rized in Table 1. We report results for scenarios with all model parameters set to base­case scenario values, all parameters set Table 1: Summary of parameters chosen for the economic models of the cost of adding universal public coverage of an essential medicines list to the existing complement of public drug plans in Canada* Parameter ExplanationBase-case scenarioBest-case scenarioWorst-case scenario Direct change in the use of the essential medicines Increased accessibility of essential medicines to Canadians who are currently uninsured or underinsured 34 30% increase in utilization 12% increase in utilization39% increase in utilization Indirect change in the use of the essential medicines Expected product substitutions among patients currently filling prescriptions for drugs similar to the essential medicines 35 Average of 37% of such patients switch Average of 66% of such patients switchAverage of 7% of such patients switch Changes in prices of generic versions of the essential medicines Expected reductions achieved with tendering and other generic pricing tools, gauged on the basis of prices in comparable single ­payer systems: United States (US Department of Veterans Affairs), Sweden and New Zealand 36,37 Median comparator prices Best comparator pricesWorst comparator prices Changes in net prices of brand­name essential medicines Expected price reductions achieved with universal application of negotiated rebates, gauged on the basis of published estimates of prices and rebates, and average net price information for the US Department of Veterans Affairs 38–40 15% lower net prices 20% lower net prices10% lower net prices Changes in prices of drugs not on the essential medicines list Expected changes in the price of drugs not on the essential medicines list No change No changeNo change Standard co ­payment per prescription for the essential medicines Expected co ­payment for standard beneficiaries, set as a maximum dispensing fee that could be lowered if pharmacies competed on price to patient $11 or less, depending on pharmacy $11 or less, depending on pharmacy$11 or less, depending on pharmacy Percentage of prescriptions filled by patients exempted from co ­payments for essential medicines Expected co ­payment exemptions for vulnerable populations (e.g., older people, low­income people, children) as a share of all prescriptions filled for the essential medicines 30% 30%30% Other changes in existing public drug plans in Canada Expected changes in public coverage of drugs not on the essential medicines list None NoneNone Patient savings from shopping at pharmacies with lower dispensing fees Expected patient savings arising from pharmacies competing for business by lowering dispensing fees Not included in estimates Not included in estimatesNot included in estimates Indirect reduction in government cost of extended health benefits for public sector employees Expected government savings from reduced cost of private insurance for public sector employees, which would be equal to about 20% of total private sector savings 41 Not included as government savings in estimates Not included as government savings in estimatesNot included as government savings in estimates Health care system savings from increased adherence to essential medications Expected savings to the broader health care system resulting from increased adherence to essential medicines 6–9 Not included in estimates Not included in estimatesNot included in estimates *Complete details concerning the rationale and data sources for model pa rameters are provided in Appendix 2 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.161082/­/DC1). RESEARCH E298 CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 to best­case scenario values and all parameters set to worst­case scenario values. Results Baseline volume and cost of prescriptions In 2015, Canadians filled an estimated 568.4 million prescriptions at retail pharmacies, at a total cost of $26.2 billion (Table 2). A to­ tal of 377.5 million of the prescriptions were publicly paid, at a total cost of $10.8 billion. The essential medicines accounted for 44% of all prescriptions and 30% of the total cost. They ac­ counted for a slightly higher share (50%) of publicly paid pre­ scriptions and an approximately equal share (31%) of the total expenditure on publicly paid prescriptions. The essential medicines accounted for 50% or more of pre­ scriptions from 15 broad therapeutic categories, including high­prescription­volume drug classes (e.g., drugs for chronic obstructive pulmonary disease and asthma, drugs for ulcers and gastroesophageal reflux disease, noninsulin diabetes medi­ cations and antibiotics). (Results by drug category are available in Appendix 1.) There were no essential medicines listed for 7  treatment categories: hepatitis C, bladder control, infertility, macular degeneration and receptor­positive cancers (endo­ crine therapies). Greater shares of prescription volumes and expenditures were accounted for by the essential medicines combined with drugs that were either chemically or pharmacologically similar to them. Medicines from ATC chemical subclasses that had 1 or more of the essential medicines within them accounted for 77% of total pre­ scriptions filled and 63% of total prescription expenditures. Medi­ cines from ATC pharmacologic subclasses with 1 or more of the essential medicines within them accounted for 90% of total pre­ scriptions filled and 83% of total prescription expenditures. Foreign prices of essential medicines Table 3 summarizes our comparison of the relative price of generic versions of the essential medicines in Canada and in comparable countries. We were able to find comparator generic Table 2: Shares of prescription volume and expenditure accounted for by the essential medicines and other drugs in the same chemical and pharmacologic subgroups in 2015, by province* Variable Province; share of prescription volume or expenditure, %† All BCAB SKMB ON QCNBNSPEI NL Total prescriptions, millions 568.449.941.7 14.915.2 186.8 225.911.412.2 1.98.5 Essential medicines 444843 4344 44 434443 47 43 Essential medicines and other drugs in same chemical subgroups 77 7774 7676 76 797575 78 76 Essential medicines and other drugs in same pharmacologic subgroups 90 8988 8889 91 918888 90 89 Publicly paid prescriptions, millions 377.531.814.0 7.07.2147.9 155.6 5.24.3 0.9 3.7 Essential medicines 505350 4749 52 485048 55 46 Essential medicines and other drugs in same chemical subgroups 83 8278 7980 82 867879 84 78 Essential medicines and other drugs in same pharmacologic subgroups 94 9488 9192 94 969090 93 89 Total expenditure, $ billions 26.22.62.6 0.70.8 10.1 7.40.70.8 0.1 0.4 Essential medicines 303331 3531 28 293232 36 32 Essential medicines and other drugs in same chemical subgroups 63 6563 7066 60 646567 72 68 Essential medicines and other drugs in same pharmacologic subgroups 83 8783 8785 82 828286 86 84 Public expenditure, $ billions 10.81.00.8 0.30.3 4.8 3.00.20.2 0.0 0.1 Essential medicines 313331 3428 30 303635 46 35 Essential medicines and other drugs in same chemical subgroups 61 6561 7065 59 626669 80 70 Essential medicines and other drugs in same pharmacologic subgroups 82 9178 8784 81 828286 89 83 Note: AB = Alberta, BC = British Columbia, MB = Manitoba, NB = New Brunswick, NL = Newfoundland and Labrador, NS = Nova Scotia, ON = Ontario, PEI = Prince Edward Island, QC = Quebec, SK = Saskatchewan. *Calculations are based on data from IMS Health and the National Prescription Drug Utilization Information System database of the Canadian Institute for Health Information (see Appendix 2 for details, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.161082/­/DC1). †Unless stated otherwise. RESEARCH CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 E299 prices for matching dosage forms of 63 of the essential medicines (Appendix 3, available at www.cmaj.ca/lookup/suppl/doi:10 .1503/cmaj.161082/­/DC1). Using 5­year average exchange rates to convert currencies, and weighting products according to Canadian sales volumes, we found that generic versions of the essential medicines were priced 47% lower in the US, 60% lower in Sweden and 84% lower in New Zealand. Results were similar when we used GDP purchasing power parity to convert curren­ cies: 53% lower in the US, 56% lower in Sweden and 84% lower in New Zealand. Several high­volume medicines (including atorva­ statin, pantoprazole, amlodipine, amoxicillin and clopidogrel) were priced at least 70% below Canadian prices in 2 or more comparator countries (Appendix 3). From the US Department of Veterans Affairs, we obtained a weighted­average of relative prices for 16 brand­name drugs that accounted for 91% of Canadian expenditures on all of the essential medicines available only from brand­name manufacturers in Can­ ada. Net of manufacturer rebates, brand­name drugs in the US were priced 43% below Canadian list prices using exchange rate conversions and 49% below Canadian list prices using purchasing power parities. We nevertheless used more conservative estimates of price changes in our economic models (Table 1 and Appendix 2). Cost of universal coverage of the essential medicines For Canada and each province separately, Table 4 lists the esti­ mated change in total (private and public) expenditure on all prescriptions filled in retail pharmacies under our scenarios for adding universal public coverage of the essential medicines to the existing complement of public drug plans in Canada. We estimated that the total expenditure on prescription drugs in Canada would fall by $3.04 billion (range $743 million to $5.46  billion; 12% reduction) under such an expansion of public Table 3: Expenditure-weighted averages of the relative price of generic versions of the essential medicines in Canada and specified comparator countries, May–July 2016 Variable United StatesSwedenNew Zealand Total no. of essential medicines with 1 or more generic equivalent in Canada and comparator country 55 2951 Total expenditure on prescriptions for brand­name and generic versions of essential medicines with 1 or more generic equivalent in Canada and comparator country, Can$ billions 2.98 2.513.22 Expenditure ­weighted average relative price of generic versions of essential medicines, comparator country relative to Canada, % Using 5­year average exchange rates to convert currencies 534016 Using GDP purchasing power parities to convert currencies 474416 Note: GDP = gross domestic product. Table 4: Estimated change in total (private and public) expenditure on all prescriptions filled in retail pharmacies with the addition of universal public coverage of essential medicines on model list, by province Province Population in 2015, millions Actual expenditure in 2015, $ millions Estimated change in expenditure with addition of universal public coverage of essential medicines, $ millions (%) All model parameters set to base-case scenario values All model parameters set to best-case scenario values All model parameters set to worst-case scenario values All 35.726 204 –3043 (–12) –5458 (–21) –743 (–3) British Columbia 4.72649 –320 (–12) –562 (–21) –93 (–4) Alberta 4.22580 –238 (–9) –456 (–18) –35 (–1) Saskatchewan 1.1728 –75 (–10) –134 (–18) –20 (–3) Manitoba 1.3775 –90 (–12) –162 (–21) –22 (–3) Ontario 13.810 148 –1282 (–13) –2238 (–22) –359 (–4) Quebec 8.37364 –804 (–11) –1482 (–20) –158 (–2) New Brunswick 0.8662 –84 (–13) –141 (–21) –30 (–4) Nova Scotia 0.9762 –87 (–11) –153 (–20) –25 (–3) Prince Edward Island 0.296–12 (–12) –20 (–21) –4 (–4) Newfoundland and Labrador 0.5440 –47 (–11) –86 (–19) –10 (–2) RESEARCH E300 CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 coverage. The percentage reduction in total expenditure was about equal across the provinces: ranging in the base scenario from a 9% reduction in Alberta to a 13% reduction in Ontario and New Brunswick. All economic scenarios included a total of more than $6  billion in pharmacy dispensing fees, equivalent to more than $210 000 per pharmacist practising in the community set­ ting in Canada. 42 For Canada as a whole, Table 5 summarizes our estimates of the change in public and private expenditures on all prescrip­ tions filled in retail pharmacies under our scenarios with the addition of universal public coverage of the essential medicines. We estimated that the incremental government cost of adding universal public coverage of the essential medicines would be $1.23  billion per year (range $373 million to $1.98  billion; 11% reduction). The incremental private sector savings from such coverage was estimated at $4.27 billion per year (range $2.72 bil­ lion to $5.83 billion; 28% reduction). Total public expenditure on the essential medicines was estimated at $6.14  billion (range $5.6 billion to $6.6 billion); total public expenditure on medicines not on the essential medicines list, yet currently covered under existing public drug plans, was estimated at $5.85  billion (range $5.53 billion to $6.13 billion). Almost half of the estimated total national savings from add­ ing universal public coverage of the essential medicines ($1.50  billion) came from 7 therapeutic categories of medicine commonly prescribed in primary care: acid­reducing drugs, cholesterol medicines, antihypertensives, antipsychotics, anti­ biotics, antidepressants, and gabapentin and related drugs (Appendix 1). In contrast, about half ($628  million) of the incre­ mental cost to government of covering the essential medicines stemmed from increased public expenditure on just 1 drug: adalimumab (Humira). Interpretation We found that nearly half (44%) of all prescriptions filled at re­ tail pharmacies in Canada in 2015 were for 117 drugs on a model essential medicines list for Canada (the CLEAN Meds list 29). An additional 33% of prescriptions filled were for drugs from the same chemical subclasses as 1 or more medicine from the essential medicines list. We estimated that adding universal public coverage of the essential medicines to the ex­ isting complement of public drug plans in Canada would save patients and private drug plan sponsors $4.27 billion per year (range $2.72 to $5.83  billion; 28% reduction). The incremental government cost of adding such coverage was estimated at $1.23  billion per year (range $373  million to $1.98 billion; 11% reduction). These estimates do not include indirect govern­ ment savings from reduced cost of private drug coverage for public sector employees, patient savings from shopping at pharmacies with low dispensing fees, or reduced demands on  the health system stemming from increased adherence to essential therapies. Our modelling produced financial results similar to those found in the actual implementation of a limited formulary in Sweden. Adherence to the Swedish “Wise List” in Stockholm pri­ mary care sites saved 28% annually (€10 million or Can$14.5 mil­ lion). 43 If our economic models were set up to exclude the cost impact of increases in utilization resulting from insuring previ­ ously under­ and uninsured people (which was not a factor under Sweden’s universal system of drug coverage), they would pro­ duce estimated net savings of 23% ($3.7 billion) within the drug classes directly affected by the essential medicines list modelled for Canada. Our findings are also consistent with a previous study that estimated a comprehensive public drug plan could reduce total annual pharmaceutical expenditure in Canada by $7.3 billion using data from the 2012/13 fiscal year. 41 If our results were scaled to include savings for drugs not on the essential medi­ cines list, the base­case scenario estimates of total annual sav­ ings would be between $6.9 billion and $10.1 billion using data for the calendar year 2015. Reflecting the incremental approach to policy development modelled here, our present estimates of the public cost of adding universal public coverage of essential medicines to the existing complement of public drug plans in Canada are lower than the previous estimates of the public cost of a universal, comprehen­ sive public drug plan. The estimated gross cost to governments (excluding indirect savings on public sector employee benefits) is $1.2 billion for coverage of essential medicines in 2015, as com­ pared with the estimated $3.4 billion for comprehensive public drug coverage in 2012/13. 41 Limitations As a simulation study, our analysis is necessarily based on assumptions concerning changes in drug utilization, product Table 5: Estimated change in public and private expenditure on all prescriptions filled in retail pharmacies with the addition of universal public coverage of essential medicines Source of finance Actual expenditure in 2015, $ millions Estimated change in expenditure on all medicines with universal public coverage of essential medicines, $ millions (%) All model parameters set to base-case scenario values All model parameters set to best-case scenario values All model parameters set to worst-case scenario values Public 10 7601229 (11) 373 (3)1979 (18) Private 15 444–4272 (–28) –5831 (–38)–2721 (–18) Tota l 26 204–3043 (–12) –5458 (–21) –743 (–3) RESEARCH CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 E301 substitutions and prices. We have based our assumptions on available evidence and direct price comparisons described in the Appendix 2. To account for the range of possible outcomes, we present results with all parameters set to best­case scenario values and all parameters set to worst­case scenario values. We were unable to compare net­of­rebate prices in Canada with those in each of the comparator countries in this study. However, from the US Department of Veterans Affairs, we obtained an estimate of the weighted­average net­of­rebate prices for essential medicines available only from brand­name manufacturers in Canada. Those prices were 43% lower than Canadian list prices, which suggests that our assumptions about possible changes in net brand­name prices for the essential med­ icines are conservative (Appendix 2). Finally, we modelled the implications of just one example of an essential medicines list that could be used as a first stage of pharmacare reform for Canada. Changes in the number and type of drugs included on the list will affect financial impacts of expanding drug coverage in this way. Provided that the list in­ cludes 1 or more generic drugs from the high­volume chemical subclasses of medicines that account for most medication use in Canada today (as the CLEAN Meds list does), the financial im­ pacts of coverage of such treatment types will be similar to those modelled here. Expanding coverage to include additional therapeutic categories will broaden the extent of needs met and savings potential from the universal public system, but it will also increase the incremental costs to government of such a program, which would bring this incremental approach to phar­ macare development closer to the comprehensive approach modelled previously. 41 Conclusion Commissions on the Canadian health care system have repeat ­ edly concluded that universal, comprehensive public pharma­ care is the most equitable and efficient means of achieving access to appropriate and affordable care for all Canadians. Our study showed that adding universal public coverage of a model list of essential medicines to the existing complement of public drug plans in Canada could address most of Canadians’ pharma­ ceutical needs and save billions of dollars annually. Doing so may be a pragmatic step forward while more comprehensive pharma­ care reforms are planned. References 1. Bigdeli M, Peters D, Wagner A, editors. Medicines in health systems: advancing access, affordability and appropriate use. Geneva: World Health Organization; 2014. 2. Barnes S, Anderson L. Low earnings, unfilled prescriptions: employer-provided health benefit coverage in Canada. Toronto: Wellesley Institute; 2015. 3. Prescription drug access and affordability an issue for nearly a quart er of all Canadian households. Vancouver: Angus Reid Institute; 2015. 4. National health expenditure trends, 1975 to 2015. Ottawa: Canadian Institute for Health Information; 2015. Available: https://secure.cihi.ca/free_products/ nhex_trends_narrative_report_2015_en.pdf (accessed 2017 Feb. 7). 5. Law MR, Cheng L, Dhalla IA, et al. The effect of cost on adherence to prescrip­ tion medications in Canada. CMAJ 2012;184:297­302. 6. Booth GL, Bishara P, Lipscombe LL, et al. Universal drug coverage and socio­ economic disparities in major diabetes outcomes. Diabetes Care 2012;35: 2257­64. 7. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA 2007; 298:61­9. 8. Kesselheim AS, Huybrechts KF, Choudhry NK, et al. Prescription drug insur­ ance coverage and patient health outcomes: a systematic review. Am J Public Health 2015;105:e17­30. 9. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescrip­ tion drug cost­sharing among poor and elderly persons. JAMA 2001;285: 421­ 9. 10. Gagnon MA. A roadmap to a rational pharmacare policy in Canada. Ottawa: Canadian Federation of Nurses Unions; 2014. 11. OECD health statistics 2016. Paris: Organisation for Economic Co­operation and Development; 2016. 12. PMPRB guidelines modernization: discussion paper — June 2016. Ottawa: Pat­ ented Medicine Prices Review Board; 2016. 13. Lexchin J. Drug pricing in Canada. In: Babar ZUD, editor. Pharmaceutical prices in the 21st century. Cham (Switzerland): Springer International Publishing AG; 2015:25­41. 14. Morgan SG, Martin D, Gagnon MA, et al. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collabora­ tion; 2015. 15. Morgan SG, Gagnon MA, Mintzes B, et al. A better prescription: advice for a national strategy on pharmaceutical policy in Canada. Healthc Policy 2016;12:18­ 36. 16. Morgan SG, Boothe K. Universal prescription drug coverage in Canada: long­ promised yet undelivered. Healthc Manage Forum 2016;29:247­54. 17. Romanow RJ. Chapter 9: Prescription drugs. In: Building on values: the future of health care in Canada — final report. Saskatoon: Commission on the Future of Health Care in Canada; 2002. 18. Citizens’ Reference Panel on Pharmacare in Canada. Necessary medicines: rec- ommendations of the Citizens’ Reference Panel on Pharmacare in Canada. Van­ couver: University of British Columbia; Dec. 5 2016. 19. Medicines in health systems: advancing access, affordability and appro priate use. Geneva: World Health Organization; 2014. 20. WHO model lists of essential medicines. 19th ed. Geneva: World Health Organi­ zation; 2015. 21. Eom G, Grootendorst P, Duffin J. The case for an essential medicines list for Canada. CMAJ 2016;188:E499­503. 22. Wirtz VJ, Hogerzeil HV, Gray AL, et al. Essential medicines for universal health coverage. Lancet 2016 Nov. 4 [Epub ahead of print]. doi:10.1016/S0140­6736 (16) 31599­9. 23. Yakabowich MR, Keeley G, Montgomery PR. Impact of a formulary on personal care homes in Manitoba. CMAJ 1994;150:1601­7. 24. King MA, Roberts MS. The influence of the Pharmaceutical Benefits Scheme (PBS) on inappropriate prescribing in Australian nursing homes. Pharm World Sci 2007;29:39­42. 25. Feely J, Chan R, Cocoman L , et al. Hospital formularies: need for continuous intervention. BMJ 1990;300:28­30. 26. Baker E, Roberts AP, Wilde K, et al. Development of a core drug list towards improving prescribing education and reducing errors in the UK. Br J Clin Pharma- col 2011; 71:190­ 8. 27. Gustafsson LL, Wettermark B, Godman B, et al.; Regional Drug Expert Consor­ tium. The ‘Wise List’ — a comprehensive concept to select, communicate and achieve adherence to recommendations of essential drugs in ambulatory ca re in Stockholm. Basic Clin Pharmacol Toxicol 2011;108:224­33. 28. Hogerzeil HV. The concept of essential medicines: lessons for rich countries. BMJ 2004;329:1169­72. 29. Taglione M, Ahmad H, Slater M, et al. Development of a preliminary essential medicines list for Canada. CMAJ Open 2017;5:E137­43. 30. ATC/DDD Index 2017. Oslo: World Health Organization Collaborating Centre for Drug Statistics Methodology; 2016. Available: www.whocc.no/atcddd ( accessed 2017 Feb. 7). RESEARCH E302 CMAJ | FEBRUARY 27, 2017 | VOLUME 189 | ISSUE 8 31. Morgan SG, Smolina K, Mooney D, et al. The Canadian Rx atlas. 3rd ed. Vancouver: UBC Centre for Health Services and Policy Research; 2013. 32. Morgan S. Sources of variation in provincial drug spending. CMAJ 2004;170:329­ 30. 33. Morgan S. Drug spending in Canada: recent trends and causes. Med Care 2004; 42:635­42. 34. Contoyannis P, Hurley J, Grootendorst P, et al. Estimating the price elasticity of expenditure for prescription drugs in the presence of non ­linear price schedules: an illustration from Quebec, Canada. Health Econ 2005; 14:909­ 23. 35. Morgan S, Gillian H, Greyson D. Comparing tiered formularies and reference pricing policies: a systematic review. Open Med 2009;3:e131­9. 36. Morgan S, Hanley G, McMahon M, et al. Influencing drug prices through formu­ lary­based policies: lessons from New Zealand. Healthc Policy 2007;3:e121­40. 37. Beall RF, Nickerson JW, Attaran A. Pan­Canadian overpricing of medicines: a 6­country study of cost control for generic medicines. Open Med 2014;8:e130­5. 38. Langreth R, Keller M, Cannon C. Decoding big pharma’s secret drug pricing oractices. Bloomberg 2016 June 29. 39. Annual report 2014: Patented Medicine Prices Review Board. Ottawa: Patented Medicine Prices Review Board; 2015. 40. Sawhney R, Gordian M, Behnke N. Pharma: the market access dilemma. New York: Bain & Company Inc.; 2016. 41. Morgan SG, Law M, Daw JR, et al. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187:491­7. 42. Pharmacists in Canada. Ottawa: Canadian Pharmacists Association; 2016. Avail­ able: https://www.pharmacists.ca/pharmacy­in­canada/pharmacists­in­canada ( accessed 2016 Nov. 2). 43. Wettermark B, Pehrsson A, Juhasz­Haverinen M, et al. Financial incentives linked to self­assessment of prescribing patterns: a new approach for quality improve­ ment of drug prescribing in primary care. Qual Prim Care 2009; 17:179­ 89. Competing interests: None declared. This article has been peer reviewed. Affiliations: School of Population and Public Health (Morgan), University of British Colum­ bia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Colum­ bia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont. Contributors: Steven Morgan and Nav Per­ saud conceived of the study. All of the authors contributed to the study design. Nav Persaud and Winny Li obtained research data. Winny Li, Brandon Yau and Steven Morgan con ­ducted the analysis. All of the authors contrib­ uted to the interpretation of results. Steven Morgan and Nav Persaud drafted the paper. All of the authors revised the manuscript for important intellectual content, approved the final version to be published and agreed to act as guarantors of the work. Funding: This study was funded in part by a PSI Graham Farquharson Knowledge Transla­ tion Fellowship from the Physicians Services Incorporated Foundation, by an IMPACT Award from the Ontario SPOR Support Unit and by an operating grant from the Canadian Institutes of Health Research (grant no. DCO150GP). Funding agencies had no role in the study design, analysis or preparation of the paper. Acknowledgement: This study is based in part on CompuScript data (January through December 2015) obtained under license from IMS Health Canada Inc. The statements, find­ ings, conclusions, views and opinions con­ tained and expressed herein are not necessar­ ily those of IMS Health Canada Inc. or any of its affiliated or subsidiary entities. Disclaimer: Nav Persaud is an associate editor for CMAJ and was not involved in the editorial decision­making process for this article. Accepted: Jan. 13, 2017 Correspondence to: Steven Morgan, [email protected] RESEARCH
politics
E568 CMAJ, October 21, 2014, 186(15) © 2014 Canadian Medical Association or its licensors F requent users of health care services rep – resent a relatively small group of patients who account for a disproportionately large amount of health care utilization, including emergency department visits, 1,2 hospital admis – sions and clinic visits. These patients are often of low socioeconomic status, 3,4 have multiple medi – cal, psychiatric and social disorders 5,6 and have a high mortality. 7 Frequent use of the health care system contributes to longer wait times and affects the quality of care. 4,8 Disproportionate use of health care services by a segment of the population has been identified as a challenge in many countries, including Can – ada. 9–12 To encourage less resource-intensive care for frequent users, many efforts have been imple – mented. Some of these interventions, for example, have been designed specifically to transition health care utilization away from the hospital to other set – tings, such as community-based clinics. 13 Much of the literature has focused on frequent users of emergency departments, with less focus on their use of the health care system in general. One systematic review identified a number of studies that assessed the effect of various interven – tions, including care coordination. 14 The authors concluded that case management and multidisci – plinary teams were likely effective interventions to reduce emergency department visits. Emergency department visits typically represent only a fraction of the cost burden on the health care system. There is a need to understand the impact of interventions aimed at reducing overall health care utilization, including hospital admissions. We con – ducted a systematic review and meta-analysis of the effectiveness of quality improvement strategies Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis Andrea C. Tricco PhD, Jesmin Antony MSc, Noah M. Ivers MD PhD, Huda M. A shoor BSc, Paul A. Khan PhD, Erik Blondal BSc, Marco Ghassemi MSc, Heather MacDonald MLIS, Maggie H. Chen PhD, Lia nne Kark Ezer MSc, Sharon E. Straus MD MSc Competing interests: None declared. Disclaimer: Sharon Straus is an associate editor with CMAJ and was not involved in the editorial decision-making process for this article. This article has been peer reviewed. Correspondence to: Sharon Straus, sharon.straus @utoronto.ca CMAJ 2014. DOI:10.1503 /cmaj.140289 Background: Frequent users of health care ser – vices are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta- analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. Methods: We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assess – ing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. Results: We identified 36 RCTs and 14 compan – ion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence inter – val [CI] 0.72–0.91). In subgroup analyses, a sim – ilar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental ill – ness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54–0.89). Interpretation: We found that quality improve – ment strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental ill – ness and reduced emergency department visits among older patients. Our results may help cli – nicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management). Abstract See related commentary, www.cmaj.ca/lookup/doi/10.1503/cmaj.141050  fifi  fi CMAJ, October 21, 2014, 186(15) E569 for care coordination for patients who are frequent users of the health care system. Methods We developed our protocol according to the PRISMA-P (Preferred Reporting Items for Sys – tematic review and Meta-analysis Protocols) statement (available from the authors). Literature search The search strategies were developed by an experi – enced librarian and were reviewed by a second librarian using the Peer Review of Electronic Search Strategies checklist. 15 A comprehensive search of MEDLINE, Embase and the Cochrane Library was conducted from inception until May 5, 2014, and was limited to adults and humans. The MEDLINE search strategy, outlined in Appendix 1 (available at www.cmaj.ca/lookup /suppl /doi:10.1503 /cmaj.140289/-/DC1), was modified for the Embase and Cochrane Library searches with the use of appropriate medical sub – ject headings (available upon request). We also searched trial registries and conference abstracts, scanned the reference lists of included studies and relevant reviews, contacted authors to request other potentially relevant studies, searched the 10 most related citations in PubMed for each included study and searched studies that referenced the included studies in Web of Science (i.e., forward citation searching). Study selection Before screening began, a calibration exercise was conducted to ensure high reliability in cor – rectly selecting articles for inclusion. This exer – cise entailed screening a random sample of 75 citations (titles and abstracts) using Synthesi.SR (a proprietary online systematic review tool developed by the Joint Program in Knowledge Translation at St.  Michael’s Hospital, Toronto). The percentage agreement among these review – ers was quantified. After high agreement was achieved, each citation was screened by 2 authors using the predefined relevance criteria form. Discrepancies were resolved by discussion or the involvement of a third reviewer. The same process was followed for full-text review of potentially relevant articles identified through citation screening. When eligibility of a particu – lar study was unclear, the study’s authors were contacted for additional information. Eligible studies were randomized clinical tri – als (RCTs) that assessed at least 1 of 5 pre – defined quality improvement strategies targeting adult patients (age ≥ 18 yr) who were frequent users of the health care system. The quality Box 1: Description of quality improvement strategies 17 Care coordination Care coordination is the deliberate organization of patient care activit ies between 2 or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resource s needed to carry out all required patient care activities; it is often ma naged by the exchange of information among participants responsible for different aspects of care. 15 • Case management: The coordination of patient care, including diagnosis, treatment and ongoing patient management (e.g., arranging referrals, follow-up of test results, patient education, patient reminders) by an individual other than the primary care clinician. 18 • Team changes: Changes to the primary health care team and how it functions, including routine patient visits with personnel other than th e primary care physician, use of multidisciplinary teams and the expansion or revision of team members’ professional roles. 18 • Promotion of self-management: Providing equipment (e.g., home glucometers for patients with diabetes) or access to resources (e.g., electronic systems for transferring glucose measurements for patients with diabetes) and establishing joint goals to empower patients to manage their disease on their own. 18 • Decision support: Operational process of adjustment for a system that generates regular feedback (from registry data) to clinical teams on guideline compliance or organizational support to facilitate other mechanisms for coordinating care. 19 • Clinical information system: A quality improvement strategy encompassing numerous systems performing a wide variety of functions; distinguished from administrative information systems by the requirement for data entry or data retrieval by clinicians at the point of care. 20 Additional components • Patient navigator: “Guide people through the health care maze, connecting them with the right doctors and helping them gain access to available therapies.” 21 • Outreach activities: Assessment, education or follow-up conducted outside the clinic or hospital, in or near the patient’s home. Other quality improvement strategies • Patient education: Educating patients about their disease, including prevention and treatment strategies. 18 • Patient reminder systems: Reminding patients about upcoming appointments or important aspects of self-care (e.g., glucose monitorin g for patients with diabetes). 18 • Clinician education: Educating clinicians about a particular condition or illness that their patients might face, including strategies for prevent ion and treatment (e.g., based on clinical practice guidelines); may be conducted through conferences, workshops, distribution of educational materials and one-on-one educational outreach meetings (or academic detailing). 18 • Clinician reminders: Reminding clinicians to look up patients’ clinical information or to conduct specific tasks. 18 • Audit and feedback: Generating summaries of clinic’s or individual clinician’s performance, which are transmitted back to the clinician. 18 • Financial incentives: Providing clinicians with financial incentives for reaching pre-established goals or achievements; may also include incentives for patients or system-wide changes in reimbursement. 18 • Continuous quality improvement: Using specific processes to identify quality problems, developing solutions, and implementing and evaluating changes; may include interventions, such as total quality management or plan–do–study–act. 18 • Facilitated relay of information to clinicians: Transmitting clinical information from patients to clinicians by means other than the existing medical record. 18  fifi E570 CMAJ, October 21, 2014, 186(15) improvement interventions of interest, chosen to fill gaps in the “expanded chronic care model” 16 and described in Box 1, 15,17–21 are closely related to care coordination: case management, team changes, promotion of self-management, deci – sion support, and clinical information systems. We also considered the effects of 2 additional components to an intervention: patient naviga – tors and outreach activities. Quality improvement strategies were com – pared with usual care, no intervention or other quality improvement strategies, as listed in Box  1. When more than one control arm was available in the studies, we chose the usual-care arm for inclusion in the analysis. Included stud – ies had to report at least one of the eligible health utilization outcomes, specifically emer – gency department visits, hospital admissions or clinic visits; the proportion of patients was the primary outcome of interest. Studies written in any language, whether published or unpub – lished, and conducted at any point in time were eligible for inclusion. Data collection A data abstraction form was drafted and pilot- tested by 8 of us (A.C.T., N.M.I., H.M.A., P.A.K., E.B., M.G., H.M. and L.K.E.) working indepen – dently on a random sample of 5  articles. Data items we recorded were study characteristics (e.g., setting, type of study design), patient characteris – tics (e.g., population examined, mean age), quality improvement strategies examined and utilization outcomes examined. Two reviewers (A.C.T., N.M.I., H.M.A., P.A.K., E.B., M.G., H.M. or L.K.E.) independently read each article and abstracted the relevant data. Differences in abstraction were resolved by team discussion. Because it is often difficult to classify quality improvement strategies, classification of strategies was performed independently by a systematic review methodologist and a clinician. Conflicts were resolved through discussion. Attempts were made to identify related publications (referred to as companion reports). Study authors were con – tacted via email for clarification of data if neces – sary (e.g., unreported standard deviations for con – tinuous data, mean age of included patients). Appraisal of risk of bias We used the Cochrane Effective Practice and Organisation of Care Risk-of-Bias Tool to assess risk of bias. 22 Each included article was indepen – dently appraised by 2 reviewers (A.C.T., N.M.I., H.M.A., P.A.K., E.B., M.G., H.M. or L.K.E.). Conflicts were resolved by discussion or the involvement of a third reviewer (A.C.T. or S.E.S.). Data synthesis We used a random-effects meta-analysis to com – bine data for outcomes reported in at least 2  RCTs. 16 Mean differences were calculated for studies reporting the average number of visits per patient per month (i.e., continuous outcomes), and relative risks (RRs) were calculated for stud – ies reporting the proportion of patients with visits (i.e., dichotomous outcomes). Funnel plots were created to identify potential publication bias. 23 Before conducting the meta-analysis, we examined 3 types of heterogeneity: clinical (e.g., type of patient population, setting), methodologic (e.g., quality improvement strategy examined) and statistical (e.g., I2 statistic). 24 Our approach for dealing with significant heterogeneity was to conduct appropriate subgroup analyses. We con – ducted post hoc subgroup analyses to determine the influence of the following factors: type of patient (primarily those with mental illness v. those with chronic medical conditions other than mental illness; and age ≥  65 yr v. <  65 yr), and type of frequent user based on the RCT eligibility criteria (at risk of being a frequent user = having a history of inpatient care with other predisposing factors, such as multiple comorbidities or psycho - social morbidity; low utilization = “frequent use” defined as 1 to 2 contacts with the health care system in the past year among patients with mul - tiple comorbidities or psychosocial morbidity; moderate utilization = 3 to 4 contacts with the health care system in the past year; and most fre - quent/severe utilization = ≥  5 contacts with the health care system in the past year). Potentially eligibule reports identifued through literature usearfh n = 11 10b Exfluded n = 10 444 Study design notu relevant n = 9 92 0 Not adult patienuts n = 443 Not a quality imuprovement strategyu n = 41 Trial protofol, ufonferenfe abstraft,u systematif review , letter to the ediutor n = 40 Exfluded n= 61 3 Not adult patienuts n = 322 Study design notu relevant n = 154 Trial p rotofol, fonferenfe uabstra ft, systematif review , letter to the eduito r n = 62 No relevant/ab straftable outfomes u n = 3b Not a quality imuprovement strateg y n = 36 Artifle not retruievable n = 2 Influded in meta-anualysis n = 50 (36 RCTs, 14 ufompanion reports) u Reports retrieved uin full n = 663 Figure 1: Selection of articles for the meta-analysis. RCT = randomized clinical trial.  fifi CMAJ, October 21, 2014, 186(15) E571 Results Search results and study characteristics Of the 11 107 citations identified through the lit - erature search, 663 full-text articles were reviewed. After exclusion of 613 articles for var - ious reasons (Figure 1), we included 36 RCTs (total 7 494 patients) 25–60 plus an additional 14 companion reports. 61–74 The studies were published between 1987 and 2014 by researchers in North America ( n = 24), Europe ( n = 8), Australia ( n = 2), Israel ( n = 1) and South Africa ( n = 1) (Table 1). One study was a cluster RCT. The duration of follow-up ranged from 1 to 36 months. The definition of a frequent user of health care services varied across the studies. Some studies included patients who were at risk of being fre - quent users ( n = 11 studies), whereas others included patients with low utilization ( n = 8 stud - ies), moderate utilization ( n = 2 studies) or the most frequent/severe utilization ( n = 15 studies). (Additional study and patient characteristics are shown in Appendix 2, available at www.cmaj . ca /lookup/suppl/doi:10.1503/cmaj.140289 /-/DC1). Most of the studies included patients with a pri - mary diagnosis of mental illness; 14 studies included patients with a chronic medical condition other than mental illness (Table 1). Twelve stud - ies included patients with severe mental health conditions, such as schizophrenia and substance abuse disorders, and 12 studies included patients who were homeless. The mean age of participants ranged from 28.1 to 81.6 years. The studies included from 25% to 77% women (Appendix 2). Care coordination strategies The following strategies were used to improve care coordination: case management ( n = 29 stud - ies), team changes ( n = 21), self- management ( n = 19) and clinical information systems ( n = 1) (de - tails about the strategies are included in Appendi - ces 3 and 4, available at www.cmaj.ca/lookup /suppl/doi:10.1503/cmaj.140289/-/DC1). The number of quality improvement strategies exam - ined per study ranged from 1 to 5 (median 2.5). The intervention included outreach activities in 23 studies and patient navigators in 6 studies. The comparator group received patient education in 1 study or low-intensity case management in 11 studies involving patients with mental illness. Risk of bias results The risk of bias varied widely across the studies (Table 2; Appendix 5, available at www.cmaj.ca /lookup/suppl/doi:10.1503/cmaj.140289 /-/DC1). One study had a high risk of bias on 4 criteria, another had a high risk of bias on 3 criteria, 3 stud - ies had a high risk of bias on 2 criteria, 18 had a high risk of bias on 1 criterion, and the rest of the studies did not have a high risk of bias on any of the criteria. The risk of bias was unclear across many of the criteria. Funnel plots did not reveal evidence of publication bias (data not shown). Effect on emergency department visits After a median duration of 9 months of follow- up, the proportion of patients who visited emer - gency departments did not differ significantly between the intervention and control groups (RR 1.11, 95% confidence interval [CI] 0.65 to 1.90; 6 studies; I2 = 0.85%) (Figure 2; Appendix 6, avail - able at www.cmaj.ca/lookup/suppl/doi:10.1503 /cmaj.140289/-/DC1). The effect was significant only among older patients, with fewer in the intervention group than in the control group visit - ing emergency departments (RR 0.69, 95% CI 0.54 to 0.89; 2 studies; I2 = 0%). In the analysis of studies that reported the mean number of emergency department visits per patient per month, no difference was found between the intervention and control groups after a median duration of 12 months of follow-up (mean difference −0.02, 95% CI −0.06 to 0.03; 7 studies; I2 = 0%) (Appendices 6 and 7, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj .140289/-/DC1). None of the subgroup analyses was statistically significant. Effect on hospital admissions After a median duration of 12 months of follow- up, significantly fewer patients in the intervention group than in the control group were admitted to hospital (RR 0.81, 95% CI, 0.72 to 0.91; 18 stud - ies; I2 = 58%) (Figure 3; Appendix 6). Specific quality improvement strategies that significantly reduced the number of admissions were case management, team changes, promotion of self- management and patient education. Among patients with chronic conditions other than mental illness, significantly fewer patients in the interven - tion group than in the control group were admitted to hospital. No difference was found between the intervention and control groups among patients with mental illness or severe mental illness (e.g., schizophrenia and severe bipolar disorder). Inter - ventions that had a significant effect were those with an outreach component and those aimed at patients with the most frequent/severe utilization rate and those at risk of frequent use. Statistically significant results were not observed with inter - ventions that used patient navigators or those aimed at patients with low utilization rates. In the analysis of studies that reported the mean number of hospital admissions per patient per month, no difference was found between the inter -  fifi E572 CMAJ, October 21, 2014, 186(15) vention and control groups after a median duration of 18 months of follow-up (mean difference 0.00, 95% CI −0.01 to 0.01; 12 studies; I2 = 0%) (Appen - dices 6 and 8, available at www.cmaj.ca /lookup /suppl/doi:10.1503/cmaj.140289/-/DC1). None of the subgroup analyses was statistically significant. Table 1: Study and patient characteristics Study* Country Quality improvement strategy Patients with mental illness Homeless patients Age, yr, mean ± SD Duration of follow up, mo Botha et al., 2014 25 [61] South Africa CM, TC Yes‡ Ye s 32.3 ± 9.9 36 Burns et al., 2014 26 United States CM, SM, PE No No NR 1 Gellis et al., 2014 27 [62] United States FR, CM, SM, PE, CE Ye s No 79.2 ± 7.4 12 Ruchlewska et al., 2014 28 Europe SM Yes‡ Ye s 40.0 ± 11.6 18 Puschner et al., 2011 29 Europe TC, SM Yes‡ Ye s 41.3 ± 11.2 18 Courtney et al., 2009 30 Australia CM, TC, SM, PE Ye s No 78.8 ± 6.9 6 Killaspy et al., 2009 31 [63] Europe CM, TC Ye s No 39.0 ± 11.0 36 Koehler et al., 2009 32 United States TC, CM, PE, SM, CIS No No 78.5 ± 5.5 2 Bellon et al., 2008 33 Europe SM, CQI, CE Yes§ No 48.4 ± NR 15 Lichtenberg et al., 2008 34 Israel CM, TC, SM Ye s No 28.1 ± 11.0 12 Shumway et al., 2008 35 United States CM Yes§ No 43.3 ± 9.5 24 Rivera et al., 2007 36 United States CM Yes‡ Ye s 38.3 ± 12.8 12 Schreuders et al., 2007 37 [64,65] Europe CM, SM Ye s No 52.9 ± 14.8 3 Sledge et al., 2006 38 United States CM, TC, SM No No 51.0 ± 52.8 12 Scott et al., 2004 39 [66] United States TC, PE No No 74.2 ± 7.5 24 Castro et al., 2003 40 United States CM, PE, SM No No 36.4 ± 11.5 12 Laramee et al., 2003 41 United States CM, TC, PE, SM No No 70.7 ± 11.8 2 Harrison-Read et al., 2002 42 Europe CM, TC, SM Yes‡ Ye s 39.2 ± 39.2 24 Kasper et al., 2002 43 United States CM, TC, PE, SM, FI No No 61.9 ± 13.4 6 Katzelnick et al., 2000 44 [67] United States CM, PE, CE Ye s No 45.5 ± NR 12 Burns 1999 45 [68–71] Europe CM, TC, PE Yes‡ Ye s 38.3 ± 11.7 24 Coleman et al., 1999 46† United States CM No No 77.3 ± NR 24 Gagnon et al., 1999 47 Canada TC, SM, CE No No 81.6 ± 6.5 10 Salkever et al., 1999 48 United States CM Yes‡ Ye s 35.7 ± NR 18 Essock et al., 1998 49 [72] United States CM, TC Yes‡ Ye s 41.0 ± NR 18 Stewart et al., 1998 50 Australia TC, CM, PE, SM No No 75.0 ± 10.5 6 Beck et al., 1997 51 United States TC, PE, FR No NA 73.5 ± NR 12 Spillane et al., 1997 52 United States TC No No 38.5 ± 48.2 12 Lafave et al., 1996 53 Canada CM, TC, SM Ye s No 35.8 ± 2.0 12 Quinlivan et al., 1995 54 United States CM Yes‡ Ye s NR 24 Rich et al., 1995 55 [73] United States CM, TC, PE, SM No No 79.2 ± 6.0 3 Rosenheck et al., 1995 56 [74] United States CM, TC Yes‡ Ye s NR 24 Muijen et al., 1994 57 Europe CM Yes‡ Ye s 37.0 ± 11.0 18 Rich et al., 1993 58 United States TC, CM, PE, SM No No 79.0 ± 6.2 3 Bond et al., 1988 59 United States CM Ye s No 34.5 ± NR 6 Franklin et al., 1987 60 United States CM Yes‡ Ye s NR 12 Note: CE = clinician education, CIS = clinical information system, CM = case management, CQI = continuous quality improvement, FI = financial incentives, FR = facilitated relay of clinical information, NR = not reported, PE = patie nt education, SD = standard deviation, SM = self-management, TC = team changes. *Reference numbers in square brackets indicate companion reports. †Cluster randomized clinical trial. ‡Included patients with severe mental health conditions, such as schi zophrenia and substance abuse disorders. §Mental illness was primary diagnosis, but patients may have had othe r comorbidities.  fifi CMAJ, October 21, 2014, 186(15) E573 Table 2: Appraisal of risk of bias of the included studies* Study Random sequence generation Allocation concealment Similar baseline outcome measures Similar baseline characteristics Incomplete outcome data Blinding Contamination Selective outcome reporting Other bias Botha et al. 25 Low Unclear Low Low Low Low High Unclear Low Burns et al. 26 Unclear Unclear Low Low High Low Low Unclear Low Gellis et al. 27 Low Unclear Low Low High Low Low Unclear Low Ruchlewska et al. 28 Low Unclear Low Low Low Low Low Low Low Puschner et al. 29 Unclear Low Low Low High Low Low Unclear Low Courtney et al. 30 Low Unclear Low Low High Low Low Unclear Low Killaspy et al. 31 Low Low Low Low Low Low Low Low Low Koehler et al. 32 Low Low Unclear Low Unclear Low Low Unclear Low Bellon et al. 33 Low Unclear High Low High Low Low Low Unclear Lichtenberg et al. 34 Unclear Unclear Low Low Unclear Low Low Unclear Unclear Shumway et al. 35 Unclear Unclear Low Low High Low Low Unclear Low Rivera et al. 36 Unclear Unclear Unclear Low Low Unclear Low Unclear Low Schreuders et al. 37 Low Low Low Low High Low Low Low Low Sledge et al. 38 Unclear Unclear Low Unclear High Low Low Unclear Low Scott et al. 39 Low Unclear Low Low High Low Low Unclear Low Castro et al. 40 Unclear Low Low Low Low Low Low Unclear Low Laramee et al. 41 Low Unclear Low Low High Low Low Unclear Low Harrison-Read et al. 42 Low Unclear Low Low High Low Low Unclear Low Kasper et al. 43 Unclear Unclear Unclear Low Low Low Low Unclear Low Katzelnick et al. 44 Low Low Low Low High Low Low Unclear Unclear Burns et al. 45 Low Low Low Low Low Low Low Low Unclear Coleman et al. 46 Unclear Unclear Low Low High Low Low Unclear Low Gagnon et al. 47 Low Low Low Low Low Low Unclear Unclear Unclear Salkever et al. 48 Low Low Low Low High High Low Unclear Low Essock et al. 49 Unclear Unclear Unclear High Unclear Low Low Unclear Low Stewart et al. 50 Unclear Unclear Low Low Unclear Low Unclear Unclear Low Beck et al. 51 Low High Unclear High High Low Low Unclear Low Spillane et al. 52 Low Low Low Low High Low Low Unclear Unclear Lafave et al. 53 Unclear Unclear Unclear Low High Low Low Unclear Low Quinlivan et al. 54 Unclear Unclear Unclear Low Low Low Low Unclear Low Rich et al. 55 High High Unclear High High Low Low Unclear Low Rosenheck et al. 56 Low Unclear Low Low Unclear Low Low Unclear Unclear Muijen et al. 57 Unclear Unclear Low Low High Unclear Unclear Unclear Low Rich et al. 58 Low Unclear Unclear Low Low Low Low Unclear Low Bond et al. 59 Unclear Unclear Unclear Unclear High Low Low Unclear Low Franklin et al. 60 Low High Low Low High Low Low Unclear Low Note: High = high risk, low = low risk, unclear = unclear risk. *The risk of bias was assessed with the Cochrane risk-of-bias tool; only the main publications were assessed, not the companion reports.  fifi E574 CMAJ, October 21, 2014, 186(15) Effect on clinic visits After a median duration of 12 months of follow- up, the proportion of patients who made clinic visits did not differ significantly between the intervention and control groups (RR 0.86, 95% CI 0.58 to 1.27; 5 studies; I2 = 91%) (Appendix 6). None of the subgroup analyses was statisti - cally significant. There was also no difference in the mean num - ber of clinic visits per patient per month between the 2 groups after a median of 12 months of follow- up (mean difference −0.08, 95% CI −0.23 to 0.06; 11 studies; I2 = 65%) (Appendices 6 and 9, avail - able at www.cmaj.ca /lookup /suppl/doi:10.1503 /cmaj.140289/-/DC1). None of the subgroup analy - ses was statistically significant. Effect on length of stay After a median duration of 12 months of follow- up, the mean number of days in hospital per patient per month did not differ significantly between the intervention and control groups (mean difference −0.09, 95% CI −0.26 to 0.09; 19 studies; I2 = 0%) (Appendices 6 and 10, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj .140289/-/DC1). None of the subgroup analyses was statistically significant. Interpretation We found that quality improvement strategies focused on the coordination of care reduced hos - pital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. The strategies were not effective in reducing the use of health care services among patients with mental illness. This lack of effect may have been because 7 of the 11 studies involving patients with mental illness had a care coordination strategy (a form of case manage - ment) as part of their control intervention. Of the interventions examined, team changes, case management and promotion of self- management had significant effects on reducing hospital admissions. Patient education, which is not one of the care-coordination quality improve - ment strategies based on Wagner’s model, 16 also significantly reduced hospital admissions. Patient education and promotion of self- management are likely less resource intensive than case manage - ment interventions are, 17 which suggests that qual - ity improvement strategies targeting patients (as opposed to clinicians) might be an efficient use of resources. Indeed, in other systematic reviews, pa - tient education and promotion of self-management were found to be highly effective in improving diabetes care. 75,76 A previous systematic review assessed the effect of various interventions on frequent users and found that case management and multidisci - plinary teams were likely effective in reducing emergency department visits. 14 The authors did not conduct a meta-analysis or examine utiliza - tion beyond the emergency department. We observed statistically significant reductions in emergency department visits among older patients, but not specifically for interventions involving case management or team changes. Limitations We identified several limitations in the literature included in our analysis. First, similar to other studies of complex interventions, 77 studies in - cluded in our meta-analysis reported few details about the intensity and “dose” of quality im - Study Treatment n/N Contro l n /N RR (95%CI) Scott et al. 39 51/146 78/149 0.67 (0.51 to 0.87) Courtney et al. 30 14/49 20/58 0.83 (0.47 to 1.46) Burns et al. 26 20/110 42/313 1.35 (0.83 to 2.20) Koehler et al.32 6/20 9/21 0.70 (0.30 to 1.61) Ruchlewska et al . 28 22/70 25/73 0.92 (0.57 to 1.47) Franklin et al. 60 35/213 7/204 4.79 (2.18 to 10.54) Overall Heterogeneity: I 2 = 85% 1.11 (0.65 to 1.90) 0.251.0 4.0 RR (95% CI) Decreased risk Increased risk Figure 2: Effect of quality improvement strategies for coordination of c are on emergency department visits. Relative risks less than 1.0 indicate a decreased risk of an emergency department visit. CI = confi dence interval, RR = relative risk.  fifi CMAJ, October 21, 2014, 186(15) E575 provement strategies, as well as further details re - garding delivery. The Standards for Quality Im - provement Reporting Excellence (SQUIRE) guidelines have been developed to improve the reporting of quality improvement strategies, 78 which will be of benefit to future meta-analyses such as ours. Second, in some studies, the dura - tion of intervention may have been too short (e.g., 1 mo) to show any significant impact. Third, the duration of follow-up (as little as 3 mo) was also short in some studies. Fourth, the defini - tion of a frequent user was inconsistent across the studies. Finally, most of the included studies had unclear or inadequate concealment of the alloca - tion sequence and a high risk of bias owing to in - complete outcome data. Our systematic review process also had some limitations. First, although we searched for unpublished studies, none was identified. How - ever, the funnel plots compiled for the meta- analyses of more than 10 RCTs showed no evi - dence of publication bias. Second, this was a challenging area to search, and many of the included studies did not use adequate search terms to allow their identifi - cation. We conducted supplementary searches to surmount this issue (e.g., forward citation searches, manual searches of related articles), but we may have missed relevant studies. Third, our analysis was limited because the quality improvement strategies were complex and difficult to classify consistently. For exam - ple, some of the strategies were interconnected, such as patient education and promotion of self- management, or case management and team changes. However, we conducted a sensitivity analysis of our classification of the strategies, and our results did not change. Fourth, because of the dearth of data, we were unable to perform more sophisticated analyses, such as meta-regression analysis. As such, we did not control for all potential confounding fac - tors or effect modifiers. Also, there was a small number of studies included for some outcomes (e.g., emergency department visits, clinic visits), which may have led to the nonsignificant effect. As well, the results of the subgroup analyses should be interpreted with caution because of the risk of type 2 statistical error owing to the small number of studies included. Study Treatment n/N Control n/N RR (95%CI) Beck et al. 51 35/160 47/161 0.75 (0.51 to 1.09) Botha et al. 25 13/32 18/24 0.54 (0.34 to 0.87) Burns et al.45 210/353 228/355 0.93 (0.82 to 1.04) Franklin et al.60 62/213 38/204 1.56 (1.10 to 2.23) Lafave et al. 53 13/24 37/41 0.60 (0.41 to 0.88) Puschner et al.29 108/241 103/250 1.09 (0.89 to 1.33) Rich et al . 55 41/142 59/140 0.69 (0.50 to 0.95) Salkever et al. 48 27/91 25/53 0.63 (0.41 to 0.96) Rich et al . 58 21/63 16/35 0.73 (0.44 to 1.20) Kasper et al.43 47/102 55/98 0.82 (0.62 to 1.08) Courtney et al .30 13/49 27/58 0.57 (0.33 to 0.98) Castro et al. 40 20/50 25/46 0.74 (0.48 to 1.13) Burns et al.26 17/110 56/313 0.86 (0.53 to 1.42) Koehler et al.32 6/20 9/21 0.70 (0.30 to 1.61) Ruchlewska et al .28 24/70 33/73 0.76 (0.50 to 1.14) Laramee et al. 41 49/131 46/125 1.02 (0.74 to 1.40) Stewart et al.50 24/49 31/48 0.76 (0.53 to 1.08) Lichtenberg et al . 34 71/122 74/95 0.75 (0.62 to 0.90) Overall Heterogeneity: I 2 = 58% 0.81 (0.72 to 0.91) 0.251.0 4.0 RR (95% CI) Decreased risk Increased risk Figure 3: Effect of quality improvement strategies for coordination of c are on hospital admissions. Relative risks less than 1.0 indicate a decreased risk of admission to hospital. CI = confidence interval, RR = relative risk.  fifi E576 CMAJ, October 21, 2014, 186(15) Fifth, many of the meta-analyses had substan - tial heterogeneity, which was to be expected given the number of quality improvement strate - gies assessed, the variety of patient populations examined and the inconsistent definitions of usual care used across the studies. The high het - erogeneity may indicate that the results should be interpreted with caution; however, heteroge - neity was substantially lower in most of the sub - group analyses (e.g., by type of quality improve - ment strategy). Sixth, we did not examine patient-centred outcomes, such as patient experience and quality of life, because the target for our research was health system outcomes. Seventh, we were unable to examine contex - tual factors that would have been relevant to our objective, such as socioeconomic status, appro - priateness of care and access to a primary care physician, because they were not measured con - sistently across the studies. Finally, we abstracted some data on costs but were unable to summarize this in a meaningful manner, because this information varied widely by context. Conclusion We found that quality improvement strategies focused on the coordination of care reduced hos - pital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older pa - tients. Novel strategies are required for patients with mental health conditions. 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The effectiveness of clinical guideline implementation strategies — a synthesis of systematic review findings. J Eval Clin Pract 2008;14:888-97. 77. Shepperd S, Lewin S, Straus S, et al. Can we systematically review studies that evaluate complex interventions? PLoS Med 2009;6:e1000086. 78. Davidoff F, Batalden PB, Stevens DP, et al. Development of the SQUIRE publication guidelines: evolution of the SQUIRE proj - ect. Jt Comm J Qual Patient Saf 2008;34:681-7. Affiliations: Li Ka Shing Knowledge Institute (Tricco, Ant - ony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael’s Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women’s Col - lege Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont. Contributors: Andrea Tricco contributed to the study con - cept and design, helped obtain funding for the study, screened citations and full-text articles, abstracted data, helped analyze the data and interpreted the results. Jesmin Antony screened full-text articles, abstracted data and appraised study quality. Noah Ivers abstracted data,  fifi E578 CMAJ, October 21, 2014, 186(15) appraised study quality and interpreted the results. Huda Ashoor abstracted data and appraised study quality. Paul Khan, Erik Blondal and Marco Ghassemi screened citations, abstracted data and appraised study quality. Lianne Ezer screened citations and abstracted data. Heather MacDonald screened citations and full-text articles and abstracted data. Sharon Straus contributed to the study concept and design, helped obtain the funding and interpreted the results. Andrea Tricco and Sharon Straus drafted the manuscript, Lianne Ezer helped write the background section and introduction, and all of the authors critically revised the manuscript and accepted the final version submitted for publication. All of authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the analyses. Funding: This project was funded by the Building Bridges to Integrate Care (BRIDGES) initiative, through the Ontario Min - istry of Health and Long-Term Care. The funding group had no role in the study design, the collection and analysis of data, the decision to publish or the preparation of the manuscript. Andrea Tricco is funded by a Canadian Institutes of Health Research/Drug Safety and Effectiveness Network (CIHR/DSEN) New Investigator Award on Knowledge Syn - thesis Methodology. Noah Ivers holds fellowship awards from the CIHR and from the Department of Family and Community Medicine, University of Toronto. Sharon Straus is funded by a CIHR Tier 1 Research Chair in Knowledge Translation. Acknowledgements: The authors thank Laure Perrier for conducting, and Becky Skidmore for peer reviewing, the liter - ature search; Mariam Tashkandi, Erin Lillie and Charlene Soobiah for screening some of the citations; Jennifer D’Souza for locating full-text articles; and Wing Hui and Judy Tran for formatting the tables and text in the submitted manuscript.  fifi politics Keywords: Canada’s Obligations; Discrimination against women; United Nations; Aboriginal women; Indigenous peoples; Indigenous theory; Canada; Canadian government; CEDAW; UNDRIP; Violence against women; Rurality; Rural communities; Human rights; Sex work; Equality Introduction Although Canadians are largely familiar with the ongoing struggle of Aboriginal peoples’ equality, and there exists so much collective community grieving, there is often little focus on the domestic and international legal obligations that the Canadian government repeatedly neglects. International obligations include the United Nations Declaration on the Rights of Indigenous Peoples [1], ratified and finally supported by Canada in 2010. The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) [2] is also important in helping to eradicate gender-based discrimination; this statute represents Canada’s international obligations to women generally, but is particularly relevant to the discrimination faced by Aboriginal women. CEDAW will be of particular focus throughout the discussion. Specifically, Articles 6 and 14 will set the framework and context to how issues of both “prostitution” (sex work) and rural communities disproportionately impact Aboriginal women and their families. Next, other aspects of CEDAW will be examined, including Article 18, which requires regular progress report submissions by state parties to the Secretary-General of the United Nations. Finally, Canada’s compliance with Articles 6, 14 and 2 will be examined in detail, including an examination of the reply list of issues and questio ns from the Committee on the Elimination of Discrimination against Women (the “Committee”) pursuant to Article 20. Detailed, critical analyses of Canada’s obligations under CEDAW, through examination of selective Articles of the Convention, will help form a central conclusion: the federal government of Canada has failed to implement a national action plan to address the systemic problems of violence, discrimination, murder, and disappearance of Aboriginal women and girls [3]. Government omissions include: inadequate police training, inconsistent data collection of the number of missing and murdered women, and lack of jurisdictional coordination, among other shortsightedness. These omissions and oversights mean Canada has not fulfilled its international human rights obligations to investigate the hundreds of missing Aboriginal women. The Canadian government has steadfastly refused to investigate, identify, and address the problem, and has willfully contributed to the tragedy through politically “convenient,” partisan-centered decision-making. The neglect this community has faced has had, and without immediate action will continue to have, long-lasting and harmful social, environmental, health, and financial costs, as well as negative cultur al and social ramifications for Aboriginal women, their communities, and all Canadians. Historical Overview: Discriminatory Treatment against Aboriginal Peoples and Aboriginal Women An opinion editorial written by Liberal Member of Parliament Carolyn Bennett illustrates a grim picture: in 2012, the federal government’s Department of Aboriginal Affairs and Northern Development spent $106 million on litigation, more than any other department and double the amount spent by the Canada Revenue Agency [4]. This statistic is shocking when considering the very pertinent concerns surrounding the status of Aboriginal women and Canada’s obligations under CEDAW. The vast funding allocated *Corresponding author: Matthew P Ponsford, LLM (Master of Laws) Candidate, McGill University, Canada, Tel: 514-398-8411; E-mail: [email protected] Received December 31, 2015; Accepted January 20, 2016; Published January 27, 2016 Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170 Copyright: © 2016 Ponsford MP. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unr estricted use, distribution, and reproduction in any medium, provided the original author and source are credited. A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women Matthew P Ponsford* JD, BSc, LLM (Master of Laws) Candidate, McGill University, Canada Abstract Standing on Canada’s Parliament Hill, meters from the historic Centennial Flame, Canadians witnessed another year of commemoration, representing the many missing and murdered Aboriginal women across Canada. Stories of loss and hope, grief and frustration, filled with song and dance and spoken word, left many standing in a mesmerizing stare; they were moved by powerful words, but remained speechless. The event was one of the annual Sisters in Spirit Vigils to honor lost sisters, wives, daughters, and aunts, among friends, families, activists, and supporters, who have fought in their communities for so long. Families and leaders have lobbied governments for decades, facing the reality of the Canadian government’s inaction and omissions relating to the investigation of hundreds of missing and murdered Aboriginal women. Families and leaders are faced with the dissatisfactory inaction that has persisted too long at the cost of so many. And despite countless setbacks and hardships endured, Aboriginal voices and allies calling for action remain strong. Open Access Research Article Journal of Civil & Legal Sciences Journal of Civil & Legal Sciences ISSN: 2169-0170 Ponsford, J Civil Legal Sci 2016, 5:1 http://dx.doi.org/10.4172/2169-0170.1000170 Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 2 of 7 toward Aboriginal litigation demonstrates what is perceived to be the government’s strong opposition to full equality for all Canadian citizens. Aboriginal women in Canada have historically suffered widespread gender-based discrimination and oppression. Finding Dawn, a documentary written, directed, and narrated by Métis filmmaker Christine Welsh, sheds light on the hundreds of Aboriginal women who have gone missing or who have been murdered in Canada over the last twenty years [5]. The film highlights the complex historica l, social, political, and economic factors that have contributed to the abuse, neglect, and ill treatment associated with Aboriginal women in Canada. Repeatedly, interviews and stories in the film emphasize the desperate need for change. From the “Highway of Tears” on Highway 16 in northern British Columbia, the Women’s Memorial Walk in Vancouver, “skid row” in Vancouver’s Downtown Eastside, and unsolved murders in Saskatoon, the mistreatment of Aboriginal women proves to be vast and appalling. Dawn Crey, the central character featured in the film, was placed in foster care as a young child following her father’s tragic death. She later entered into a life of drugs and prostitution in Vancouver’s Downtown Eastside. Approximately half of the missing women in this area are Aboriginal and they share a common struggle: living in poverty. These women do not have adequate access to education or employment, even though equal access is guaranteed under Articles 10 and 11 of CEDAW. In fact, the 2006 Census illustrates Aboriginal women are less likely than non-Aboriginal Canadians to be part of the paid work force. Aboriginal women 15 years of age or older had an employment rate of 51.1% compared to 57.7% of non-Aboriginal women who were employed [6], and unemployment rates for Aboriginal women are often double that of non-Aboriginal women. It is disgraceful that the Canadian government has failed to take accountability to ensure Aboriginal women are valued and respected. Jim Silver, author of “Building a Path to a Better Future,” states that Aboriginals are “lacking in self-confidence, self-esteem and a sense of self—worth-the result of having internalized the colonial ideology— and are in need of healing [7].” Dealing with these disadvantages and unfair burdens has huge costs, as evident by Aboriginal suicide rates that are three to six times higher than the national average [8]. In particular, the suicide rate for First Nations women is 35 per 100,000 compared to 5 per 100,000 for non-Aboriginal women. M ental health challenges and depression have other far-reaching consequences. In the film, Janice Acoose, a Saskatchewan Professor, acknowledges that i t was the social environment she lived in that was responsible for sending her to Regina’s “skid row” on South Railway Street. She stated that the city “was a place of hope” and offered her something different than the reserve. It is the lack of social programs that is at the root of much o f the inequality that exists for Aboriginal women like Crey and Acoose; it is the vicious cycle of neglect and mistreatment that has resulted in th e marginalization and social exclusion of Aboriginal women. The often-demoralizing social status of Aboriginal women is another important aspect of the mistreatment and violence directed toward them. Aboriginal women are treated in an inferior manner and with less self-worth compared to non-Aboriginal Canadians. Ernie, Crey’s brother, is featured in the film and has been an outspoken a ctivist. He believes that the investigation into his sister’s disappearance would have been better financed and coordinated if the victim, his sister, were non-Aboriginal. This pattern of differential treatment is evide nt through anecdotal records and has been widely documented, including a 2009 comparative study [9]. To understand the discrimination faced by Aboriginal women today, it is important to acknowledge that discrimination against Aboriginal people has occurred on numerous occasions in Canada, often under the incontestable view of the Canadian government. For example, in the nineteenth century, the Canadian government took part in “aggressive cultural assimilation,” resulting in the remov al of about 150,000 Aboriginal, Inuit and Métis children from their communities. This tragedy is known widely as the Indian Residential Schools [10]. Although some former students have received minor compensation, the government cannot compensate the victims for isolating these children from their families, traditions, and culture. Prime Minister Stephen Harper, of the Conservative Party of Canada, released an official, historic government apology on June 11, 2008, but little action has been taken since. Following the apology made on behalf of the Government, the Truth and Reconciliation Commission of Canada [11] was launched following the largest class-action lawsuit in Canadian history—the Indian Residential Schools Settlement Agreement. The Assembly of First Nations agreed to the establishment of the Truth and Reconciliation Commission that began with a five-year, $60 million budget. However, work on the final report remained, and so the mandate was extended by one year, until June 30, 2015 [12]. The Honorable Bernard Valcourt, Minister of Aboriginal Affairs and Northern Development, stated: “Our government remains committed to achieving a fair and lasting resolution to the legacy of Indian Residential Schools, which lies at the heart of reconciliation and the renewal of the relationship between Aboriginal people and all Canadians.” Revelations into the inexcusable discrimination faced by Aboriginal peoples continues. Recently, government documents uncovered by Ian Mosby of the University of Guelph exposed the shocking practice of widespread nutritional experiments conducted by Canadian government bureaucrats during the 1940s, following the Second World War. The deplorable execution of these experiments was occurring during a period of “scientific uncertainty around nutrition [13].” At least 1,300 Aboriginals were involved, including many children. A spokesperson for the Minister of Aboriginal Affairs and Northern Development stated the news was “abhorrent and completely unacceptable.” Following the shocking revelations, First Nations leaders demanded an apology for the nutritional experiments [14]. Shawn Atleo, National Chief of the Assembly of First Nations, demanded the government take responsibility and acknowledged ongoing food security problems that disproportionately impact Aboriginal children. It is hoped that other government documentation will be made publicly available. The disgraceful pattern of Aboriginal children and women being treated as “less than” and “second class” is an all too comm on pattern seen in many social contexts throughout Canadian history. In Finding Dawn, Fay Blaney, an advocate for native rights nationally and internationally, states that she believes an attitudinal shift needs t o take place; her comments included the idea that Aboriginals have been perceived as “nothing and only good for prostitution.” She preache s that Aboriginal women deserve respect and need to reclaim some of their traditions, land, and culture. It is evident that improved public health and social policy, directed specifically at Aboriginal women, i s desperately needed. With these improvements, Aboriginal women will be better able to improve their way of life and to restore their human dignity; but these improvements cannot happen without the Canadian government’s full realization and implementation of its international human rights obligations. Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 3 of 7 Introduction to the Convention on the Elimination of All Forms of Discrimination against Women The Convention on the Elimination of All Forms of Discrimination against Women was adopted by the United Nations General Assembly on December 18, 1979, open for signature on March 1, 1980, and entered into force on September 3, 1981, faster than any other human rights convention [15]. As of December 2013, there were 99 signatories and 187 parties to CEDAW [16]. Canada signed CEDAW on July 17, 1980 and ratified the Convention on December 10, 1981. The Convention consists of a preamble, six parts, and thirty articles. Issues addressed within CEDAW include: equal representation of women in government and international organizations (Article 7), the elimination of discrimination against women based on marriage and family relations (Article 16), policy pursuits by state parties to ensure women’s equality (Article 2), and equal rights to education for women (Article 10). CEDAW advocates for equal rights of men and women by building on the impermissible grounds of discrimination based on sex enshrined in the Universal Declaration of Human Rights (Article 2) [17], the International Covenant on Civil and Political Rights (Articles 2, 4, 24, 26) [18], and the International Covenant on Economic, Social and Cultural Rights (Article 2) [19]. Discriminatory grounds based on sex are also present in the Canadian Charter of Rights and Freedoms (Sections 15(1)(2), 27) [20]. Articles 6 and 14 of the Convention on the Elimination of All Forms of Discrimination against Women It is important to recognize that beyond gender-based discrimination, in Canada, further discrimination is experienced by women of Aboriginal status. Specifically, Articles 6 and 14 will inform the discussion. These Articles receive limited attention in the context of the involvement of Aboriginal women in the sex industry, a decision often rooted in historical poverty and wider problems faced by Aboriginal women in rural communities. Article 6 states: “States Parties shall take all appropriate measures, including legislation, to suppress all forms of traffic in women and exploitation of prostitution of women.” In Canada, the exploitation of “prostitution” of wom en is particularly troubling given that Aboriginal women report much higher rates of violence and abuse when working in the sex industry compared to non-Aboriginal women [21]. Article 14(1) states: States Parties shall take into account the particular problems faced by rural women and the significant roles which rural women play in the economic survival of their families, including their work in the non-monetized sectors of the economy, and shall take all appropriate measures to ensure the application of the provisions of the present Convention to women in rural areas. Missing and murdered Aboriginal women are not always part of rural communities in Canada, but for many rural Aboriginal women, the challenges they face compared to those living in urban environments are substantial. Challenges include reduced access to education and employment compared to non-Aboriginal women. 40% of Aboriginal women did not graduate high school in 1996, and although that number dropped to 27% in 2006, the rate of non- Aboriginal high school dropouts for women was 22% and 12% in 1996 and 2006 respectively [22]. That means, as of 2006, 88% of non- Aboriginal women graduated high school compared to only 73% for Aboriginal women. The comprehensive report from the Canadian Centre for Policy Alternatives also demonstrated that although rural reserves comprise only 9% of non-Aboriginal workers, those individuals earn 88% more than Aboriginal peoples. The authors unequivocally conclude: “the data clearly shows that non-Aboriginal Canadians make more than their Aboriginal counterparts whether working on reserve, off reserve, or in urban, rural, or remote communities.” The impact of rurality on Aboriginal women’s lives continues to be important. Recently, on October 7, 2013, the Committee on the Elimination of Discrimination against Women (the “Committee”), created through Article 17, held a general discussion on rural women in Geneva [23]. The report aimed to “provide appropriate and authoritative guidance to States Parties on the measures to be adopted to ensure full compliance with their obligations to protect, respect and fulfill the rights of rural women.” NGOs were invited to provide submissions before the discussion. Human Rights Watch (HRW) submitted highlights of their work related to rural women and girls, noting: “we have documented, for example, police abuse of indigenous and rural women and girls in northern British Columbia, Canada [24].” The presence of Canada in this submission, among other countries, emphasizes the attention this issue is garnering internationally. HRW’s submission alluded to their comprehensive report entitled “Those Wh o Take Us Away,” published in February 2013, underlining the failure of law enforcement and police personnel, particularly the dysfunctional relationship between the Royal Canadian Mounted Police (RCMP) and the families of Aboriginal women and girls in northern, rural British Columbia [25]. Intersecting Marginalization: Rurality, Sex Work, and Aboriginal Women’s Equality There is greater disparity in income levels of Aboriginal women in rural communities compared to aboriginal men. In situations of significant and often dire levels of systemic poverty, the intersect ing marginalization of Aboriginal women and sex work begins to surface. A comprehensive report published in 2010 and entitled “Challenges: Ottawa-Area Sex Workers Speak Out” is the basis for a case study related to Aboriginal women and sex work. The report stems from a community-based research initiative focused on the labor site challenges, safety, security, and well-being of sex workers, and interactions between sex workers and police and law enforcement. The report also focuses on the social stigma and intersecting marginalization of sex workers, including the “well-documented oppression and disadvantage experienced by Aboriginal people, homosexual men and women, transgender people and drug users.” Intersections of class, socioeconomic status, gender, ableism, and economic resource distribution are explored, formulating discussions of the “question of choice [to engage in sex work].” The report’ s findings are based on interview exchanges with 37 Ottawa-based sex workers, including four Aboriginal women and one Aboriginal transgender woman. The sample used for Aboriginal women sex workers is relatively low, but the consensus among the five participan ts is noteworthy. For example, four of five Aboriginal sex workers (80%) described experiences of violence and abuse compared to 15 of 32 (47%) of non-Aboriginal sex workers. Intersecting Marginalization: Poverty, Sex Work, and Aboriginal Women’s Equality A disproportionate number of Aboriginal women are involved in sex work and bear the burden of poverty, including women in Vancouver’s notorious Downtown Eastside. It is important when critically analyzing Canada’s obligations under CEDAW to examine how poverty, the Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 4 of 7 social status of Aboriginal women, and their involvement in sex work, intersect and profoundly contribute to government inaction related to the investigation of the hundreds of missing Aboriginal women. Culturally relevant social support services are especially important for Aboriginal women like Alice, a street-based sex worker who powerfully articulates the implications of her intersecting struggle: It is especially true because I am Aboriginal. We’re a minority who has very big issues. I am a residential school survivor and it’s such a huge barrier. And I often see a difference, like, sometimes I tell m yself “If I was a White woman, this would not be happening to me.” As an Aboriginal woman, I am automatically nothing but trash, you know, I don’t like being considered that way. I feel that from the community as whole, it’s racism, and then the judgment of being a sex worker. I am a minority and I get treated differently [emphasis added]. Security and Safety: Aboriginal Women and Sex Work In Canada, the mistreatment of Aboriginal women like Alice who engage in sex work is exacerbated by an ongoing constitutional challenge of Canada’s prostitution laws, where in October 2009 three Ontario sex workers of Sex Professionals of Canada, applicants Amy Lebovitch, Terri-Jean Bedford, and Valerie Scott, argued that current prostitution laws threaten their Section 7 Charter rights to life, liberty and security of the person, and freedom of expression rights under Section 2. On September 28, 2010, Justice Susan Himel of the Ontario Superior Court of Justice struck down Sections 210, 212(1)(j) and 213(1)(c) [26], a decision which was later appealed by the Canadian government to the Court of Appeal for Ontario [27]. On March 26, 2012, the appellate court’s decision was issued, demonstrating the Crown’s successful limitation of Section 7 freedom of expression rights for communicating for the purposes of prostitution. After leave to appeal was granted, the Supreme Court of Canada heard arguments on June 13, 2013. The Supreme Court has since released a decision, Bedford v Canada (AG), 2013 SCC 72. The verdict will have far-reaching implications for Aboriginal women’s security and safety. Unfortunately, Aboriginal women are over-policed like other Aboriginal peoples in Canada, including three out of the five Aborigin al sex workers included in the study who were criminally charged for soliciting; four of these individuals also experienced physical violence and “police abuse of power.” It is clear that the Criminal Code [28] provisions reviewed by the Supreme Court of Canada will have significant impacts on the intersection between Aboriginal women sex workers and the criminal justice system, as well as Canada’s obligations under Article 2(C)(D)(E) to “ensure the protection of women aga inst any act of discrimination.” Violations of Article 2(C)(D)(E) of the Convention on the Elimination of All Forms of Discrimination against Wo m e n Although the Supreme Court of Canada heard an appeal regarding the safety implications of sex work in Canada related to current Criminal Code provisions, Article 2(C)(D)(E) obliges state parties, of which Canada is a signatory, to “condemn discrimination against women in all its forms,” which extends to the inclusion of Aboriginal women sex workers in addition to Aboriginal women more broadly. In Canada, “johns” (a sex worker’s client) and police and law en forcement personnel subject Aboriginal women to sexual and physical exploitation at much higher rates compared to non-Aboriginal women. Sexual and physical mistreatment is unacceptable no matter the circumstance or gender, but is particularly prevalent when examining Aboriginal women’s safety and security. The Canadian government must investigate the abuse and murders of Aboriginal women regardless of current “prostitution” laws or political ideologies. Particularly, Article 2(C)(D)(E) requires state parties: (c) To establish legal protection of the rights of women on an equal basis with men and to ensure through competent national tribunals and other public institutions the effective protection of women against any act of discrimination; (d) To refrain from engaging in any act or practice of discrimination against women and to ensure that public authorities and institutions shall act in conformity with this obligation; (e) To take all appropriate measures to eliminate discrimination against women by any person, organization or enterprise [emphasis added]; The Canadian government’s irresponsible approach to ensuring Aboriginal women’s safety and security is clear; the federal governme nt has refused to establish a national inquiry into missing and murdered Aboriginal women, many of whom have gone missing or been murdered due to involvement in sex work, or targeted because of their perceived or self-identified ethnicity. National Inquiry into Missing and Murdered Aboriginal Wo m e n For decades, innumerable civil society organizations, nongovernmental organizations, municipal, provincial and federal politicians, community leaders, First Nations organizations (including the Assembly of First Nations), United Nations experts, and countless others, have called for a national inquiry into the hundreds of missing and murdered Aboriginal women in Canada. Discrimination and violence against Indigenous women has been well documented. The record and personal stories of these missing and murdered women, Canada’s “stolen sisters,” are indisputable. Organizations such as Amnesty International Canada [29] have researched and published extensively about governmental obligations to adopt measures “to guard against private individuals committing acts which result in human rights abuses.” Accountability by state parties includes the need to ensure adequate police training, consistent data collection of the number of missing and murdered Aboriginal women, and jurisdictional coordination, internationally mandated practices of which Canada is a signatory. The Canadian public, international human rights experts and bodies, as well as provincial and territorial leaders, all support a comprehensive review of violence against Aboriginal women across the country. In fact, ahead of the Council of the Federation meeting in July 2013, every provincial and territorial leader among Canada’s ten provinces and three territories publicly supported an inquiry on missing and murdered Aboriginal women [30]. The Native Women’s Association of Canada has been calling for an inquiry for the past thirteen years. In part, these leaders believe national-level coordinati on is required in order to compare and contrast jurisdictional similarities or distinctions. There is a plethora of research and evidence to support this approach, not the least of which is Canada’s obligations under Article 2(C) of CEDAW to establish legal protections through national tribunals. Provincially, an Order in Council established the Missing Women Commission of Inquiry in British Columbia on September 27, 2010 [31]. The Terms of Reference states the Inquiry’s mandate is to: Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 5 of 7 (a) Inquire into and make findings of fact respecting the conduct of the investigations conducted between January 23, 1997 and February 5, 2002, by police forces in British Columbia respecting women reported missing from the Downtown Eastside of the city of Vancouver; (b) Inquire into and make findings of fact respecting the decision of the Criminal Justice Branch on January 27, 1998, to enter a stay of proceedings on charges against Robert William Pickton of attempted murder, assault with a weapon, forcible confinement and aggravated assault; (c) Recommend changes considered necessary respecting the initiation and conduct of investigations in British Columbia of missing women and suspected multiple homicides; and (d) Recommend changes considered necessary respecting homicide investigations in British Columbia by more than one investigating organization, including the co-ordination of those investigations. Although numerous reports from the Commission have been released, a national inquiry would ensure jurisdictional coordination, effective analyses of ineffective and discriminatory police practice s, and a more accurate sense of the scale of the problem. As of October 2015, there were nearly 1,200 documented cases of missing and murdered Aboriginal women and girls, according to the Royal Canadian Mounted Police. Provincial and territorial leaders do not, cannot, and must not claim sole responsibility; instead, they must aim to work with the federal government and Aboriginal communities to address the problem collaboratively, while recognizing solutions may be adapted to the particular needs of various communities across Canada. Canada’s Periodic Report to the Secretary-General of the United Nations Article 18 of CEDAW requires Canada and other state parties to submit a report outlining the progress made toward the principles of CEDAW. Article 18 states: A. States Parties undertake to submit to the Secretary-General of the United Nations, for consideration by the Committee, a report on the legislative, judicial, administrative or other measures which they have adopted to give effect to the provisions of the present Conventio n and on the progress made in this respect: (a) Within one year after the entry into force for the State concern ed; (b) Thereafter at least every four years and further whenever the Committee so requests. B. Reports may indicate factors and difficulties affecting the degree of fulfillment of obligations under the present Convention. Canada’s eighth reporting cycle to the UN Secretary-General was due December 1, 2014; reporting cycles six and seven were combined, submitted and published on August 17, 2007 [32]. This 186-page report, covering the period from April 1999 to March 2006, will form the discussion [33]. Although prostitution is not a criminal offence in Canada, the report fails to mention the measures taken to protect vulnerable and marginalized Aboriginal women who engage in sex work, particularly in rural communities. The discussion of Article 6 focuses on trafficking and exploitation of women and girls generally; this appears to be the correct interpretation of the statute. However, although the suppression of “trafficking” of women into Canada appears to be in alignment with the legislation and policies adopted by the Canadian government, the term “exploitation” is narrowly applied. The application of the term includes prohibitions against the sexual exploitation of children. The Canadian government has not recognized the disproportionate number of Aboriginal women who may “choose” to engage in sex work but are nonetheless subject ed to exploitative behavior. This includes the basic premise that Aborigi nal women may be exploited by both Aboriginal and non-Aboriginal men through unfair, sexually exploitative, violent, abusive, and sometimes homicidal encounters, at the hands of “johns,” or others, who expl oit them. Although Canada’s periodic report acknowledges eight times higher spousal homicide rates for Aboriginal women compared to non- Aboriginal women, Canada’s political stance surrounding prostitution laws may have diluted the attention these marginalized women may otherwise have received. UN Periodic Review and Canada’s Compliance with Articles 6 and 14 of CEDAW In March 2008, the Committee on the Elimination of Discrimination against Women met and replied to Canada’s combined sixth and seventh periodic submission, as per Article 20, issuing a list of considerations [34]. The Committee highlighted the need for additional information pertaining to Aboriginal women and their communities, noting patriarchal attitudes permeating Canadian society: Stereotypes and education Please inform the committee whether activities to promote Aboriginal women which are funded by the Government … include awareness-raising programmes aimed at sensitizing Aboriginal communities about women’s human rights and combating patriarchal attitudes, practices and stereotyping roles [emphasis added]. The Committee continued to inquire about public education programmes used in Newfoundland and Labrador to combat stereotypes, asking if similar culturally sensitive programming would be implemented in other provinces and territories; this relates to the need for jurisdictional collaboration and the sharing of best practices inter-provincially and inter-territorially in a systematic fashion, a request many politicians have expressed. The Committee does not comment explicitly on exploitation of prostitution, instead focusing on trafficking of women, but their discussion of patriarchal attitudes is important and will help Canada address widespread gender and stereotype-based discrimination that places Aboriginal women at increased danger. The overrepresentation of Aboriginal women in the prison system, and the high level of violence and abuse directed toward them, was also highlighted. The Committee requested sex-disaggregated data of the gender impact of anti-poverty measures for minority groups, including Aboriginal women. This is important because the levels of poverty Aboriginal women face often impacts their involvement in sex work to support themselves and their families, and sex work places women at an increased risk of abuse and disappearance. Unfortunately, Canada’s reply to the list of these issues was inaccessible through the United Nations database; however, the Committee’s reply is significant bec ause over half of the submission deals specifically with Aboriginal women’ s equality, including their representation in governance and legislative processes by means of election to public office. Again, it is a testame nt to the attention Aboriginal women’s issues in Canada is amassing internationally because of government inaction and omissions. Article 14, relating to challenges faced by rural women, specifically Aboriginal women, was not directly discussed in the Committee’s six- Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 6 of 7 page reply. It would have been helpful for the Committee to address Aboriginal women’s roles in the “non-monetized sectors of the economy,” as Article 14 stipulates, although there was brief mention of the affordability of childcare and benefit levels for parental leave, to encourage men to equally contribute to family life and responsibilities. It is interesting to note that Canada’s submission mentioned rural challenges facing minorities, including Aboriginal women, more than the Committee’s reply, which may suggest compliance of this provision . Canada mentioned the Domestic Violence Action Plan, pertaining to Article 3 of CEDAW, and recognized the increased risk of domestic violence directed toward Aboriginal rural women who have limited access to support services, shelters, and crisis centres due to geograph y and culture. However, the government seems to engage in short-term commitments to discussions pertaining to Aboriginal women, such as the March 2006 policy forum on Aboriginal Women and Violence, rather than implementing a long-term, streamlined, coordinated national tribunal, in compliance with Article 2 of the Conven tion. Intersecting CEDAW Provisions Impacting Aboriginal Women’s Equality Issues of sex work and rurality facing Aboriginal women formed the basis of the analyzing framework of CEDAW throughout the discussion; however, there was minimal discussion directly related to Articles 6 and 14 in Canada’s periodic submission to the Committee and the Committee’s reply. This may be explained by intersecting CEDAW provisions with other Articles within the statute. For example, systemic issues of poverty affecting Aboriginal women (Article 11), access to childcare and maternity services (Article 5), gender equitable parenti ng (Article 11), among other issues previously addressed, contribute to the exploitation of sex workers and a heightened rural-urban support services divide. The correction and improvement of these issues inextricably reinforces the principles contained in Articles 6 and 14. Article 2: UN Periodic Review and Canada’s Failure to Establish a National Inquiry The remainder of the discussion will focus on Canada’s compliance with Article 2 of the Convention, namely Canada’s obligations to investigate the hundreds of missing and murdered Aboriginal women. It is shocking that the words “murder” and “murdered” appear a mere three times within the 186-page periodic report from Canada; these words occur only twice in the context of Aboriginal women homicide. The word “missing” as it relates to Aboriginal women is mentione d fourteen times. These numbers are symbolic because it demonstrates the lack of attention the Canadian government has for missing and murdered Aboriginal women. In the report, the government references $5 million in funding contributed to the Sisters in Spirit Initiative from 2005 to 2010, a campaign of the Native Women’s Association of Canada. In part, the funding supported quantifying the number of missing and murdered Aboriginal women, which has been challenging, but the initiative should be a government-mandated priority. Second, the report mentions the Government of Saskatchewan’s 2005 initiative to (1) increase police resources directed toward missing women investigations; (2) evaluate and redevelop police policies; and (3) strengthen partnerships with police, government, communities, and families of missing persons. The Missing Persons Task Force was regionally focused, and not a national tribunal as Article 2(C) implies. British Columbia’s Hate Crimes Team is also mentioned briefly, which simply named the Missing Women Taskforce, with no further elaboration or insight of what this taskforce entails. The $5 million funding, Saskatchewan case study and “Missing Women Taskforce” are the only insights the Canadian government provided to the Committee. There was absolutely no mention of a national inquiry, tribunal, or investigative body within the 186-page report. It seems, without question, that Canada has not only failed to take action as required by international law, but has also failed to even acknowledge the alarming problem at the request of respected United Nations agencies. Although the principle of equality for both men and women is enshrined in the Canadian constitution, as required by Article 2(A), “the practical realization of this principle” has not been met. Legislative frameworks prohibiting discrimination against women do exist as per Article 2(B)(F)(G); albeit the existence of such legislation does not mean compliance with enacted principles. Further, Canada is in clear violation of Article 2(C), refusing to establish a national inquiry in the form of a tribunal. Canada has failed to conduct a nationwide investigation of systematic, discriminatory police practices against Aboriginal women as per Article 2(D), “to ensure that public authorities and institutions shall act in conformity with this obligation.” Finally, Canada has not taken “all appropri ate measures” to ensure the eradication of discrimination against women by “any person, organization or enterprise” as per Article 2(E); in fact, it has taken very few, regional measures, selectively funding Aboriginal women’s rights initiatives generally, without directly addressing the tragedy of missing and murdered women. Conclusion: Moving Forward Together—Struggles, Hope and Cautious Optimism The purpose of emphasizing Article 6 through the lens of a local Ottawa-based sex workers advocacy group (POWER), and in discussing Article 14, was to direct attention to the stigmatic assumptions underlying rural Aboriginal women and those who engage in sex work, which contributes to vast social judgment by both Canadians and the government. It is difficult to quantify the number of Aboriginal women who have gone missing or been murdered as a result of involvement in sex work or living on isolated rural reserves and communities. The commonality is that these issues contribute to the social exclusion of Aboriginal women, reinforce recurrent themes of power and privilege, and remind us of the intersections of class, poverty, ethnicity, and gender. It was disconcerting to examine the Convention and recognize the scale of Canada’s incompliance. Government inaction is not only disgraceful to missing Aboriginal women, but a troublingly, brazen disregard to women’s families, friends, and allies who have repeatedl y sought justice for missing and murdered Aboriginal women. A fundamental theme throughout Finding Dawn was hope. It is now time Canadians take a united, assertive stand, and voice to the government the dire need for change and responsible leadership. As the struggle continues, collaboration on Aboriginal women’s issues will hopefully improve the quality of life for daughters, sisters, aunts, friends, and mothers of missing and murdered Aboriginal women across Canada. We must honor Aboriginal women who have been tragically murdered, and vow to search for those still missing; in fact, international law obliges the Canadian government to undertake no less. Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi: 10.4172/2169-0170.1000170 Page 7 of 7 References 1. (2007) United Nations Declaration on the Rights of Indigenous Peoples. 2. (1979) Convention on the Elimination of All Forms of Discrimination against Women. 3. (2012) Native Women’s Association of Canada (NWAC), Missing and Murdered Aboriginal Women and Girls in British Columbia, Canada. 4. Bennett C (2013) See You In Court: An Expensive, Time-Consuming Wrong- Headed Strategy. 5. Christine W (2006) Finding Dawn. 6. Donnell V, Wallace S (2015) First Nations, Métis and Inuit Women. 7. Silver J (2006) Building a Path to a Better Future: Urban Aboriginal People. Black point, Nova Scotia: Fernwood Publishing. 8. (2013) Health Canada, First Nations and Inuit Health, Mental Health and Wellness. 9. Cohen IM, Plecas D, McCormick AV (2013) A Comparison of Aboriginal and Non-Aboriginal Missing Persons in British Columbia Where Foul Play has not been Ruled Out. 10. (2008) Prime Minister Harper offers full apology on behalf of Canadian s for the Indian Residential Schools system. 11. (2008) Truth and Reconciliation Commission of Canada. 12. (2013) Statement by the Honourable Bernard Valcourt on the Mandate of the Truth and Reconciliation Commission. 13. Bob W (2013) Canadian government withheld food from hungry aboriginal kids in 1940s nutritional experiments, researcher finds. 14. (2013) First Nations Leaders demand apology for nutritional experiments. CBC News. 15. (2008) UN Women, Convention on the Elimination of All Forms of Discrimination against Women. 16. (2013) United Nations Treaty Collection, Convention on the Elimination of All Forms of Discrimination against Women. 17. (1948) Universal Declaration of Human Rights. 18. (1966) International Covenant on Civil and Political Rights. 19. (1966) International Covenant on Economic, Social and Cultural Rights. 20. (1982) Canadian Charter of Rights and Freedoms, Part I of the Constitution Act, Schedule B to the Canada Act. 21. Bruckert C, Chabot F (2010) Challenges: Ottawa-Area Sex Workers Speak Out. 22. Wilson D, Macdonald D (2010) The Income Gap Between Aboriginal Peoples and the Rest of Canada. 23. (2013) Committee on the Elimination of Discrimination against Women. United Nations Office of the High Commissioner for Human Rights. 24. (2013) Human Rights Watch, HRW Submission to CEDAW Committee on Rural Women. 25. (2013) Human Rights Watch, Those Who Take Us Away: Abusive Policing and Failures in Protection of Indigenous Women and Girls in Northern British Columbia, Canada. 26. (2010) Bedford v Canada (AG), ONSC 4264, 330 DLR. 27. (2012) Bedford v Canada (AG), ONCA 186, 109 OR. 28. Criminal Code, RSC 1985, c C-46. 29. (2004) Amnesty International Canada, Canada’s Stolen Sisters: A Human Rights Response to Discrimination and Violence against Indigenous Women in Canada. 30. (2013) Premiers call for inquiry on missing aboriginal women. The Globe and Mail. 31. (2011) Missing Women Commission of Inquiry, Reports and Publications. 32. (2011) United Nations Office of the High Commissioner for Human Rights, Ratification, Reporting & Documentation for Canada. 33. (2007) Convention on the Elimination of All Forms of Discrimination against Women, UNOHCHR, 42d Sess, UN Doc CEDAW/C/CAN/7. 34. (2008) Canada, UNOHCHR, 42d Sess, UN Doc CEDAW /C/CAN/Q/7. Citation: Ponsford MP (2016) A Critical Examination of Canada’s Obligations Under the Convention on the Elimination of all Forms of Discrimination against Women and the Government’s Actions and Omissions in Relation to the Investigation of the Hundreds of Missing Aboriginal Women. J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170 OMICS International: Publication Benefits & Features Unique features: • Increased global visibility of articles through worldwide distribution and indexing • Showcasing recent research output in a timely and updated manner • Special issues on the current trends of scientific research Special features: • 700 Open Access Journals • 50,000 editorial team • Rapid review process • Quality and quick editorial, review and publication processing • Indexing at PubMed (partial), Scopus, EBSCO, Index Copernicus and Goog le Scholar etc • Sharing Option: Social Networking Enabled • Authors, Reviewers and Editors rewarded with online Scientific Credits • Better discount for your subsequent articles Submit your manuscript at: www.omicsonline.org/submission Volume 5 Issue 1 1000170 J Civil Legal Sci ISSN: 2169-0170 JCLS, an open access journal politics ©2015 8872147 Canada Inc. or its licensors CMAJ, August 11, 2015, 187(11) E347 O n Feb. 19, 2014, armed fighters entered the Malakal Teaching Hospital run by Médecins Sans Frontières in South Sudan, robbed patients and their families of cash and mobile phones, and shot those who had noth - ing to give, killing 14 patients who were lying in their hospital beds. 1 In Syria, not only has the neu - trality of medical personnel, hospitals and patients been ignored, these individuals and facilities have become strategic targets in a systematic campaign of violence that, according to the United Nations, has seen “… government forces and affiliated militias interfere with and instrumentalise medical care to further strategic and military aims.” 2 These acts of brutality are two examples of a global problem for which there are few solutions: in many parts of the world, health care is in danger. Armed conflicts, internal disturbances and other types of unrest create a generalized state of insecurity that often makes maintaining a mini - mally functional health system nearly impossi - ble. Health facilities are destroyed, looted or forced to close or become isolated from the pop - ulations they serve. 3 Patients may be attacked or robbed, and health workers threatened or kid - napped. 4 Policies and laws may be enacted to criminalize or restrict the provision of medical care to those opposing the state. 5 Ambulances are frequently delayed or are targets of attacks and hijackings, which limits the effectiveness of referral systems. 6 There have been growing calls to strengthen the right to health in conflict, and for non-state actors to be held accountable for attacks on health workers through existing human rights mechanisms. 5 The Geneva Conventions, custom - ary international humanitarian law and other treaties include provisions that clearly identify attacks on health workers and patients as a viola - tion of international law. Regrettably, these are routinely ignored or are not translated into national legislation in the countries where these acts occur. 7 Meanwhile, several international bodies have passed resolutions attempting to strengthen these mechanisms, including the 2011 United Nations Security Council resolution 1998, which declared hospitals off limits for armed groups and military activities and allows public reporting of the parties who attack them. 8 Civil society coalitions, such as the Safeguarding Health in Conflict Coalition, have demanded monitoring, reporting and accountability for such attacks, while raising the issue politically and within academic communities. These interventions are necessary, but more must be done. Attacks on health systems often have a strategic advantage as a tactic of war, are rarely prosecuted nationally and may even have been committed by the government that would, theoretically, be prosecuting them. Invoking the jurisdiction of the International Criminal Court in prosecuting these attacks may, therefore, be appropriate in these circumstances. 9 For humanitarian agencies operating in vio - lent settings, the available interventions are challenging: openly reporting attacks places them at risk of reprisal; barricading or reinforc - ing hospitals to become fortresses is inconsis - tent with the need to be accessible and to be viewed as a community, rather than a military, asset; arming humanitarian agencies blurs the boundaries between the militarization and neu - trality of aid; and not operating in conflict zones denies the world’s most vulnerable people of basic health services. Ensuring the security of health care in conflict settings: an urgent global health concern Jason W. Nickerson RRT PhD Competing interests: Jason Nickerson has worked as a consultant for the United Nations, nongovernmental organizations and the Canadian government in various conflict settings. This article has been peer reviewed. Correspondence to: Jason Nickerson, [email protected] CMAJ 2015. DOI:10.1503 /cmaj.140410 • Attacks on health workers, health facilities and patients are a common threat to medical care in conflict zones. • The Geneva Conventions, customary international humanitarian law and other treaties clearly identify attacks on health workers and patients as a violation of international law. • However, the recommendations of such bodies are poorly enforced in many jurisdictions. • Carefully collected data are needed to further our knowledge of attacks and to inform the development of countermeasures to improve programs in different settings and contexts. Key points CMAJ Podcasts: author interview at soundcloud.com/cmajpodcasts/conflict-he alth All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Can adian Medical Association. fifl fi E348 CMAJ, August 11, 2015, 187(11) The use of military forces to protect civilians and humanitarian agencies has garnered particu - lar attention over the past decade through the controversial concept of the “responsibility to protect,” or R2P. This concept is controversial for several reasons. Chief among them are the lack of automatic or consistent protection from foreign military forces, and the resistance by many humanitarian agencies to support R2P on the basis that it compromises their neutrality and impartiality by providing legitimacy to the objectives of one of the warring parties. 10 A clear need exists to strengthen an under - standing of the nature and causes of violent events directed toward health care providers, and the interventions that have been effective in miti - gating them. The International Committee of the Red Cross has taken the lead on this, conducting a two-year, anonymized, 16-country study that documented 1342 reports of 655 separate events of violence or threats affecting health care. 4 The committee then convened stakeholder meetings to identify best practices and potential solutions for ensuring the continued provision of medical care in conflict zones. In 2012, the World Health Assembly passed a resolution (WHA65.20) call - ing for the World Health Organization to improve the systematic documentation of these attacks and to generate an evidence base for greater protection and advocacy. 11 In addition to the systematic reporting of the scope and incidence of violent attacks and threats directed toward health workers, a more nuanced understanding of the nature and causes of these events is needed to better contextualize their impact and the appropriate responses. Operational research to systematically describe the impact of violent events on patients, health workers and health systems is needed to under - stand more precisely what occurs and what inter - ventions have been implemented to mitigate these effects, both successfully and unsuccess - fully, as well as their implications. Developing a detailed understanding of what takes place at checkpoints or during armed entries to hospitals, for example, provides a needed context through which interventions can be assessed. The synthe - sis of these experiences is essential for weighing the risks and benefits of interventions. Although some interventions may be easily implemented, such as placing plastic sheeting on windows to absorb shrapnel from bomb blasts, other inter - ventions such as decisions to stockpile medicines have associated risks (e.g., looting). More than merely documenting experiences, what is needed is the development of a decision aid based on pragmatic anecdotal, experiential and often unpublished evidence to guide the main- tenance of the essential functions of health systems during violent events. This must be matched by strong advocacy and engagement of civil society organizations to ensure that those who commit crimes against health workers and patients are held to account. The medical community must pressure governments to pursue international justice and demand accountability for war crimes against medical workers, in solidarity with colleagues and patients whose safety is directly at risk. References 1. Medical care under fire in South Sudan . Toronto: Médecins Sans Frontières Canada; 2014. Available: www.msf.ca/en/article/ medical-care-under-fire-south-sudan (accessed 2014 Mar. 24). 2. Assault on medical care in Syria [A/HRC/24/CRP.2]. Geneva: United Nations Human Rights Council; 2013. Available: www.ohchr.org/EN/HRBodies/HRC/RegularSessions/Session 24 /Documents/A-HRC-24-CRP-2.doc (accessed 2014 Mar. 17). 3. Dewachi O, Skelton M, Nguyen V-K, et al. Changing therapeu - tic geographies of the Iraqi and Syrian wars. Lancet 2014;383: 449-57. 4. Health care in danger: a sixteen-country study . Geneva: Interna - tional Committee of the Red Cross; 2011. Available: www.icrc .org /eng/resources/documents/report/hcid-report-2011-08-10.htm (ac - cessed 2014 Mar. 24). 5. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health . Geneva: United Nations Human Rights Office of the High Commissioner for Human Rights; 2014. 6. Coupland R. Security of health care and global health. N Engl J Med 2013;368:1075-6. 7. Rubenstein LS, Bittle MD. Responsibility for protection of med - ical workers and facilities in armed conflict. Lancet 2010;375: 329-40. 8. Resolution 1998 (2011) [S/RES/1998(2011)]. Geneva: United Nations Security Council; 2011. Available: www.un.org/en/ga /search/view_doc.asp?symbol=S/RES/1998(2011) (accessed 2014 Mar. 17). 9. Protection of health workers, patients and facilities in times of violence . Baltimore: Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health; 2013. Available: www.jhsph.edu/research/centers-and-institutes /center-for-public-health-and-human-rights/_pdf/BellagioReport -03192014.pdf (accessed 2014 Aug. 20). 10. Weissman F. Not in our name: why Médecins Sans Frontières does not support the “responsibility to protect.” Crim Justice Ethics 2010;29:194-207. 11. WHO’s response, and role as the health cluster lead, in meeting the growing demands of health in humanitarian emergencies [Resolu - tion WHA65.20]. Sixty-fifth World Health Assembly; Geneva; 2012 May 21–26. Available: http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_R20-en.pdf (accessed 2015 Apr. 21). Affiliation: Bruyère Research Institute, Ottawa, Ont. fl  politics E440 CMAJ | MARCH 20, 2017 | VOLUME 189 | ISSUE 11 © 2017 Joule Inc. or its licensors R ecent attention to the role that social entrepreneurship could play in addressing acute health care challenges 1 reminds us that addressing the socioenvironmental factors that influence the physical, mental, social and spiritual components of health and well-being 2 requires similarly innovative and imagina- tive responses. Social enterprises are a potentially useful and economically viable strategy to this end. These are organiza - tions that engage in commercial trade for a social purpose — most often to address one or more aspects of social vulnerability  — rather than for the personal financial enrichment of owners or shareholders. Examples of Canadian social enter- prises include Manitoba Green Retrofit, a social enterprise that takes on small con- struction projects, environmental retrofits and treatments for bedbug infestation in Winnipeg’s low-income housing neigh- bourhoods, while at the same time pro- viding job skills training and employment to local residents that creates a sense of place and community belonging; Park- dale Green Thumb Enterprises in Toronto, a horticulture business that employs peo- ple living with serious mental illness to design green spaces and provide grounds - k eeping services for nonprofit organiza- tions, low-income housing, hospitals, the private sector and community groups; and Inside Art, a cooperative run by inmates at Mountain Institution in British Columbia, a medium security prison. By engaging incarcerated individuals in cre- ating art and making business decisions about their cooperative business model, this social enterprise has helped persons excluded from society to contribute to correctional programming, learn new skills and build confidence. A WISE approach to health? Abundant “lay knowledge” 3 exists that shows the influence that social enterprise can have on individual valorization, social capital and civic engagement of society’s most disenfranchised, giving credence to the notion that social enterprise and social entrepreneurship could potentially have an influence on the social determinants of health. 4 A recent systematic review of social enterprise–led activity on health and well- being 5 found evidence (albeit limited) of positive impacts on mental health, self- reliance/self-esteem and health behav - iours, reductions in stigma and the build- ing of social capital; all are important determinants of health. Most of the studies examined in that review focus on a particu- lar type of social enterprise that aims to create employment for vulnerable people who are profoundly disadvantaged in accessing the mainstream labour market. This includes people who are chronically unemployed, leaving long-term institu- tional care, living with serious mental health issues, chronic health conditions or physical disabilities; in other words, fac- tions of society that are most at risk for poor health outcomes and most likely to experience inequity in access to traditional health services. The focus of such “Work Integration Social Enterprises” (WISEs) is to provide transitional or permanent employment, and/or entrepreneurial Action on the social determinants of health through social enterprise n Cite as: CMAJ 2017 March 20;189:E440-1. doi: 10.1503/cmaj.160864 A few of the workers at Parkdale Green Thumb Enterprises. Courtesy of Toronto Enterprise Fund HUMANITIES | MEDICINE AND SOCIETY CMAJ | MARCH 20, 2017 | VOLUME 189 | ISSUE 11 E441 opportunities in a supportive, empowering and community-based environment. 6 One particular at-risk group of long- standing concern to both the health and welfare sectors is youth with mental health problems who live on the street. A tradi- tional (pathogenic) approach to engaging with this group might address common pre- senting symptoms, such as injuries from physical violence or abuse, physical and emotional impacts of self-medication and abuse of illicit substances. Programs such as needle exchanges might seek to address individual risk factors and/or wider harm (including to society) from illegal or harmful behaviours. Although we are not criticizing such approaches, there is good evidence that a holistic, social enterprise–led approach to working with this population can deliver positive results, and prevent manifestation of such symptoms. For exam- ple, Ferguson 7 described a social enterprise in which young people with mental illness living on the streets of Los Angeles were employed to design, manufacture and sell clothing items popular with youth. Their employment prospects and clinical out- comes were improved through peer mentor- ing, vocational training and training in small business skills, and integrated with the pro- vision of clinical and harm reduction services. Challenges showing impact Despite many examples of good news, evi- dence to support that social enterprises such as WISEs do work (in particular, evi- dence that meets the standards that public health officials currently require) remains scarce. Assessing the health and well-being benefits of WISEs presents numerous chal- lenges to researchers and to policy-makers. We have seen that randomized controlled trials  — the gold standard in public health evaluation — are often unsuitable for a vari- ety of reasons, including the expense, small sample sizes and ethical reasons relating to the types of populations that social enter- prises traditionally work with. Although some promising groundwork has been laid to move this research agenda ahead in recent years, some key issues remain. For one, WISEs are highly idiosyncratic, often based upon population-specific needs and business-specific goals and visions. To date, there is a lack of agreement on core organizational, structural and process ele- ments that define WISE, while respecting the need for business diversity across a range of business features such as the products/services offered, hiring practices, and level of involvement of the marginal- ized population in business development and operations. This variability, combined with the multiple health determinants that are affected by WISE participation, make this a highly complex intervention that must be carefully unpacked to better understand the causal pathways, and how the variables embedded in the social deter- minants can (potentially) be identified and measured in ways that are both valid and conceptually meaningful. Therefore, there is a clear need to heighten theoretical understanding of how WISEs affect health and health equity; iden- tify WISE business implementation pro- cesses and practices that contribute to pop- ulation health and health equity; and advance this emerging field of scientific enquiry through identification of feasible research designs to meaningfully explore the impact of these enterprises on health and health equity. Application of realist evaluation principles 8,9 may help guide sci- entific inquiry in this regard: supporting researchers to answer developmental-stage questions concerning the contextual factors that support positive outcomes, and the theoretical processes leading to change. Such a line of inquiry will help lay the groundwork necessary for future rigorous research on this highly complex form of intervention. Furthermore, we need to influ- ence and encourage policy-makers and research funders to think imaginatively  — not only in terms of what actually consti- tutes a public health intervention, but also about how community-led activity could be better supported and integrated with tradi- tional health service approaches to form a wider societal response to addressing the social determinants of health. The public health contributions of those who work to address social vulnerabilities in their local communities, but who oper- ate outside of formal health systems, deserve to be acknowledged and better understood if we are to address longstand- ing issues of public health concern. Michael J. Roy PhD Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK Rosemary Lysaght PhD , Terry M. Krupa PhD School of Rehabilitation Therapy, Queen’s University, Kingston, Ont. References 1. Lim YW, Chia A. Social entrepreneurship: improv- ing global health. JAMA 2016;315:2393-4. 2. Gewurtz RE, Moll SE, Letts LJ, et al. What you do every day matters: a new direction for health promotion. Can J Public Health 2016; 107:e205-8. 3 . Popay J, Williams G , Thomas C, et al. Theorising inequalities in health: the place of lay knowledge. Sociol Health Illn 1998;20:619- 44. 4. Roy MJ, Donaldson C, Baker R, et al. Social enter- prise: New pathways to health and well-being? J Public Health Policy 2013;34:55-68. 5. Roy MJ, Donaldson C, Baker R, et al. The poten- tial of social enterprise to enhance health and well-being: a model and systematic review. Soc Sci Med 2014;123:182-93. 6. Krupa TM, Lysaght R, Brown J, et al. Environ - mental scan of social businesses. In: The aspiring workforce — employment and income for people with serious mental illness. Ottawa: Mental Health Commission of Canada; 2013:46-70. Avail- able: www.mentalhealthcommission.ca/English/ initiatives/11895/aspiring-workforce (accessed 2016 July 19). 7 . Ferguson KM. Merging the fields of mental health and social enterprise: lessons from abroad and cumulative findings from research with homeless youths. Community Ment Health J 2012;48:490- 502. 8. P awson R, Tilley N. Realistic evaluation. Thou- sand Oaks (CA): Sage; 1997. 9 . Fletcher A, Jamal F , Moore G , et al. Realist complex intervention science: applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions. Evaluation (Lond) 2016; 22 :286- 303. This article has been peer reviewed. This work was supported by the Medical Research Council, and the Economic and Social Research Council (grant no. MR/L003287/1). HUMANITIES politics Finding Connections Assignment For this assignment, students will complete the following steps. Your written submission should be 12 point font and approximately 250 words in length. While you may use point form in the article summary, your analysis must be in sentence/paragraph form. No late assignments will be accepted without a medical note. Steps: Social psychology is about how individuals think, feel and behave in social settings and, therefore, we are constantly making observations related to topics social psychology (e.g., role-playing, compliance, loneliness, socialization, group-think, etc,). For this assignment, you need to find an article that connects to a concept in social psychology (e.g., Huffington Post, Globe and Mail, New York Times, Macleans, The Atlantic, or a “popular press” magazine”) Then, write a summary of the key points in the article; and analyze the relationship between the concepts in the article and social psychology. Prepare questions or an activity to engage the