15 minute read
Evidence matters
No Going Back:
Searching for evidence to help navigate the path forward for virtual care
By Krista Kaminski and Barbara Greenwood Dufour
Virtual care is quickly transforming the Canadian health care system. Virtual care can be defined as any interaction between patients and care providers that occurs remotely, using any form of communication or information technology, and that aims to facilitate or improve patient care. Even before the COVID-19 pandemic, Canada’s experience and interest in virtual care had been growing, but the pandemic accelerated the adoption of its use.
For most of us, our first experiences with virtual care happened during the pandemic when health care providers needed to quickly come up with alternative solutions to in-person care. According to an early analysis of Canada’s pandemic response by Health Canada however, “while change was forced upon us by the pandemic it was, in many cases, long overdue.” Virtual care has the potential to improve health care by increasing access to health care and by making health care more convenient for patients.
Now that some health care decision makers have had a few (albeit very brief) moments to catch their breath, they have asked CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – what the evidence says on virtual care. With in-person care resuming, health care providers want to know which services they should continue to offer virtually, and which services are best offered in person.
CADTH has published many reports on various virtual care topics. In one recent report, CADTH searched for and summarized recent evidence-based guidelines on the appropriate use of virtual care. CADTH found 5 guidelines, 3 of which were developed in the context of COVID-19 after the demand for and use of virtual care had increased. The guidelines developed before the pandemic include 1 guideline on the use of remote telecommunications in stroke care and 1 guideline, from the World Health Organization (WHO), on digital interventions for all areas of health. The guidelines developed during the pandemic include 2 on virtual care in rheumatology and 1 on telehealth for oncology.
A recurring theme among all the guidelines is that virtual care should be a complement to, not a substitute for, in-person care. Further, they recommend that virtual care should be considered only when adequate resources and personnel are available and patient privacy can be protected. Multiple guidelines note that it’s not a one-size-fits all approach when using virtual health care with patients.
The guidelines developed during the pandemic reflect the new experiences and insights gained during that time – such as the recommendation that teleconsultation be used for rheumatology patients who must adhere to social distancing restrictions, or the guidance that rheumatologists use telemedicine for patient consultations during medication changes when normal health services are disrupted. One of these guidelines suggests virtual modes as a way to bring medical care to people who are home-bound or those who live in remote areas or underserved communities, which could benefit patient care outside of a pandemic.
For various reasons, some patients prefer not to use virtual care. There may barriers or factors that pose challenges to its use, such as issues with internet access, technical support, and infrastructure.
Users of these guidelines should keep in mind that the quality of evidence they are based on, if reported, is generally low, with consensus-based recommendations made when evidence was lacking. In addition, many of the recommendations might not translate well into Canadian clinical practice given that only 1 of the 5 guidelines is Canadian.
Future guidelines on virtual care that are supported by high-quality evidence are needed. As the research on virtual health care is rapidly evolving, living guidelines (guidelines that are updated as soon as new evidence becomes available) may be useful to decision makers seeking continued direction when using this form of care. In fact, the WHO proposed updating its guidelines as a living document.
One thing is for sure – if virtual care continues to be seen as providing increased convenience, flexibility, and time and cost-savings, patients and health care providers will continue to be interested in its use. CADTH will continue to support health care decision makers by summarizing future evidence on virtual care.
The CADTH report on virtual care guidelines is freely available at cadth. ca/virtual-care-use-primary-care-orspecialty-care-settings. To see all of CADTH’s work in this space, or to find additional reports on telehealth and telemedicine, visit cadth.ca/ digital-health. To learn more about CADTH, visit our website, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region. ■ H
Advancing patient care
with first in Ontario technology
Assessing the nutritional needs of critically ill patients is an ongoing challenge for dietitians. To support meeting the caloric needs of these individuals, Halton Healthcare’s Oakville Trafalgar Memorial Hospital (OTMH) is pleased to be the first hospital in Ontario to be home to a
Q-NRG+ Indirect Calorimeter machine. The machine uses new technology to measure oxygen and carbon dioxide levels in patients’ breath to determine their resting energy expenditure (REE).
“The Indirect Calorimetry is a new method to assess a critically ill patient’s nutrition needs, and give us the information we need to create individualized nutrition care plans for people in the Intensive Care Unit. The needs of these individuals are very different than of other patients,” says Hilda Seyler, Dietitian, Halton Healthcare.
Before the Indirect Calorimetry (IC) device was introduced at Halton Healthcare, the practice was to use predictive equations based on age, weight, height and gender.
Introducing the world’s fi rst 80-cm patient bore and High-V MRI, MAGNETOM Free.Max redefi nes MRI accessibility and opens up new clinical opportunities.
High-V MRI – Value beyond barriers High-V MRI takes the power of digitalization and deliberately applies it to a new fi eld strength of 0.55T with inherent clinical benefi ts. High-V MRI combines the best of both worlds to off er a new era in MRI that embraces diagnostic confi dence in daily routine and new clinical opportunities. Diagnostic confi dence for daily excellence Powered by our unique innovations in the fi eld of image acquisition and deep learning based reconstruction MAGNETOM Free.Max delivers excellent diagnostic quality for your standard clinical MRI applications. The world’s fi rst 80 cm patient bore With the world’s very fi rst and only 80 cm patient bore, MAGNETOM Free.Max breaks barriers in patient comfort and accessibility –making the experience a realistic option for claustrophobic, anxious, and more corpulent patients. Infrastructure radically simplifi ed MAGNETOM Free.Max is the world’s most compact whole-body MRI and with DryCool technology it provides a virtually helium-free infrastructure. MAGNETOM Free.Max radically simplifi es infrastructure requirements to break down the barriers imposed by siting constraints.
Redefi ning MRI aff ordability MAGNETOM Free.Max breaks down fi nancial barriers resulting in new opportunities to off er MRI right at the front line of diagnostic services.
“The Q-NRG+ gives me more confidence that the nutrition I’m recommending is accurate and individualized to the patient, because we’re using real-time measurements,” adds Seyler.
Older models of IC devices are typically big and time consuming, usually taking more than an hour to calculate results. Tina Stewart, Clinical Nutrition Manager, says the major benefit of the Q-NRG+ Indirect Calorimeter is that it’s portable and quick. “It only takes 10 to 15 minutes to collect the necessary data, so it’s quite efficient,” she says. “It’s also just slightly larger than a blood pressure machine, and easily mobile.”
The adoption of the Q-NRG+ device has offered a unique connection across teams within Halton Healthcare. Thanks to the collaborative efforts of Dietitians and Respiratory Therapists (RTs), the machine has been successfully integrated into both their practices. With the RTs calibrating the device and using it to measure a patient’s oxygen intake and Dietitians using the calorimeter’s readings to measure the nutrition needs of the patient.
“The Q-NRG+ is very easy to use, very accurate and doesn’t disrupt the clinicians on either side. We RTs are used to ventilators and this machine uses parts similar to what a ventilator uses to measure flow. It’s been a very easy and valuable tool for everyone to use,” explains Margaret Coburn, Respiratory Therapist, Halton Healthcare.
“For acute care this is a great device to have, especially in light of the pandemic, with some patients being ventilated longer,” says Coburn. “This definitely helps us provide better care to our patients because we can fine tune to their individual needs.”
The Q-NRG+ is currently integrated as a patient care option in the OTMH Intensive Care Unit and can be used on any critically ill patient.
The device was purchased through Halton Healthcare’s Innovation Grant, which is an organizational initiative that supports innovative ideas by staff, physicians and volunteers to advance patient care. Halton Healthcare introduced the Innovation Grant program in 2017 and to date has invested approximately $612,000 in more than 70 staff-led initiatives. ■ H
MEDTECH 2022 Canada’s largest epilepsy monitoring unit advances research and diagnosis
Home to the largest Epilepsy Monitoring Unit (EMU) in Canada, London Health Sciences Centre (LHSC) has added new state-of-the-art Electroencephalogram (EEG) machines that will advance epilepsy research and diagnosis. It will provide faster reporting, and clearer, more detailed imagery.
Founded in 1987, the EMU has provided patient-centric care and assessments to more than 10,000 people over three decades. The Centre of excellence has also helped patients with complex epilepsies from around the world, including Holland, Mexico, Spain and Australia. This new static and mobile technology have the functionality to measure electrical activity in the brain. It uses small, metal discs (electrodes) attached to the scalp, which are then communicated through electrical impulses which are active all the time, even during sleep. As the main diagnostic test for epilepsy, an EEG plays a vital role in providing important health care information to patients and their care teams.
“With almost 90 billion neurons, the brain is the most complex human organ in the body, which requires advanced technology and equipment to further ignite research and benefit the patient experience,” said Dr. David Steven, Chair/Chief of Clinical Neurological Sciences. “This new equipment will provide a clearer more accurate picture of what is happening in the brain during a seizure, helping doctors gain crucial information about a patient’s seizures to help guide care options.”
The Centre is a leader in its field and is active in training neurologists and neurosurgeons from around the globe. The department supports world-class research and teaching, with more than 30 neurologists and neurosurgeons coming from various countries.
“Diagnosing and treating epilepsy is a convoluted process,” said Dr. Jorge Burneo, Neurologist Chair/Chief Division of Neurology of the Epilepsy program at LHSC. “With the ability to monitor a larger number of patients, through the implantation of electrodes in the part of the brain associated with the spread of seizures, we will be able to diagnose and treat epilepsy faster. The mobile technology can collect data wherever the patient is in the hospital, which provides more consistent data, ultimately allowing our teams to fully understand the scope of the patient’s unique situation.”
Since September, this $2 million investment in 13 new portable machines has increased the level of data collected among patients, resulting in higher-quality images being captured during the day and at night. Committed to advancing research and finding innovative solutions to health care, the new EEG is an investment that will have lasting impacts on both patients and researchers at LHSC for years to come.
With roots going back a century and a half, London Health Sciences Centre (LHSC), is an award-winning, research-intensive acute tertiary and quaternary teaching hospital, one of only 14 such hospitals in Ontario. LHSC is also home to Children’s Hospital, one of just four acute tertiary care paediatric hospitals in the province. Our unique place in the health system positions us well to inform and advise on provincial, national and international health policy. We are the cornerstone of care for many specialized programs and services in Western Ontario. And, as a major provider of emergency care and through our community hospital mission, we also care for the more than 400,000 people who call London home as well as many in surrounding communities. With Ontario’s health system continuing its transformation, LHSC has an opportunity to inform it and to place itself at the locus of the regionalized health system by virtue of its size, specialized capabilities, research and education capacity and its current regional footprint. LHSC’s formal relationship and strong bond with Western University provide a mechanism for collaboration to enable the delivery of high-quality care through a process of continuous learning and research. At its core, the affiliation is a reciprocal relationship that leverages the learning, teaching and care environments of both Western University and LHSC. LHSC is a 15,000 person strong team of physicians, staff and volunteers – collaborators, innovators and pioneers, meeting the care needs of those we serve and charting a course for the future. ■ Ht
Dr. Jorge Burneo and Dr. David Steven.
MEDTECH 2022 Inflation and supply chain woes in healthcare:
Working together to find solutions
By Nicole DeKort
Canada’s hospitals are under tremendous pressure. Wave after wave of COVID-19, health staffing shortages and an immense surgical and procedural backlog have dominated headlines for months. Governments and healthcare systems across the country are responding and investing in hospital infrastructure, developing significant recruitment and retention plans and rethinking the best way to cut waiting times.
Behind the scenes though, a new challenge has hit our healthcare system: a shortage of medical supplies and devices. This has caused difficulties for healthcare providers during an already highly demanding time.
Global supply chain issues have affected all sorts of devices. The COVID-19 pandemic and other global events, such as the war in Ukraine, have resulted in increases in the cost of fuel and raw materials. These and many other factors including global staffing shortages are driving up prices.
Consumers are well aware of the increases in food prices and have seen the challenges associated with buying new cars and electronics, but less noticed have been the consequences for the manufacturers and suppliers of medical devices and supplies.
According to the CD Howe Institute, prices for plastics and resin, which are critical components of broadly used medical supplies including needles and syringes have doubled, transportation costs have tripled and the prices of other raw materials such as metal have increased by more than 30 per cent. The result is skyrocketing costs to produce and supply medically necessary devices ranging from IV bags and gauze, to stents, hip and knee replacements and pacemakers.
Medical supply contracts in Canada are far less flexible than their global counterparts. Manufacturers and suppliers are locked into contracts for five to seven years at fixed prices, which means, unlike in other sectors, manufacturers and suppliers are often unable to simply adjust their prices in real time to reflect the impact of these macroeconomic and geopolitical market forces.
Our industry is working hard every day to ensure that our healthcare partners have the necessary devices and supplies to continue to provide high-quality care to Canadians.
But, unless governments and purchasing organizations work with suppliers on solutions to reflect this current supply chain crisis, manufacturers and suppliers are looking at continuing to supply these devices at significant losses. This is simply unsustainable.
In March 2022, Medtech Canada released our position paper outlining four key recommendations for governments to tackle the effects of the global shipping and supply chain crisis, and its potentially detrimental impacts on patient care.
In the case of scarce supply, governments need to work with manufacturers to ensure that the Canadian health care system has access to the devices and supplies we need to support patients.
One of the latest examples of this is epidural catheters used to manage pain during labour and c-sections. Product shortages can contribute to even longer wait times – a problem when we are already dealing with record surgical backlogs – and dramatically poorer health outcomes for Canadians.
To help address supply chain challenges jurisdictions across Canada, we need to be more flexible in contracting systems for medical devices and supplies. We can and should provide greater clarity to suppliers around product need forecasting, improve contingency planning for future geopolitical events, as well as consider incentives to promote greater domestic manufacturing. However, these solutions will not be put in place overnight, and the problem is immediate and urgent.
Just as it would be beneficial to industry to have data on health system demand forecasting, we also understand that our industry needs to do its part to ensure that our healthcare and government partners are informed about foreseeable product shortages. Medical device companies provide information with Health Canada when shortages occur, and the regulator posts these shortages publicly on its website. We’ve also been engaging with government purchasing departments and group purchasing/shared service organizations to share information. We were pleased to learn at our recent annual conference that Health Canada would soon be convening a Medical Device Shortage Multi-Stakeholder Committee, which should also be beneficial to foster communication nationally and ensure efforts aren’t being duplicated.
While that work is being done to communicate about shortages, government investments are needed to help ensure that they don’t occur in the first place. Just as we have seen investments in other areas to stabilize the health system, we need investment in medical devices and supplies to help ensure that our healthcare partners can deliver the quality and timeliness of care that Canadians expect.
With the health system backlog resulting from the pandemic, Canadian patients have suffered enough from long wait times and limited access to the critical medical services they need. Medical devices and supplies are critically important to providing the quality of care we rightly expect in Canada.
We can’t ignore these supply chain issues and we urge governments to come together with the sector to ensure that our health care system not only has the capacity – but also the necessary supplies – to support Canadian patients. ■ H
