The emergence of the now provincially and globally dominant SARS-CoV-2 Omicron variant demands a reassessment of the diagnostic performance of rapid antigen tests. Rapid antigen tests are less sensitive for the Omicron variant compared to the Delta variant in nasal samples, especially in the first 1-2 days after infection. However, rapid antigen tests can more reliably detect infectious cases of the Omicron variant in combined oral-nasal samples. Individuals can collect these samples by initially swabbing both cheeks, followed by the back of the tongue or throat, and then both nostrils. In light of currently very high SARS-CoV-2 transmission rates in Ontario and the limited sensitivity of rapid antigen tests for the Omicron variant, a single negative rapid antigen test result cannot reliably rule out infection; a single negative test result is not conclusive and should not be used as a green light for abandoning or reducing precautions. Conversely, in this context, an individual with a positive rapid test result should be considered and managed as a case of COVID-19 and should immediately isolate; additional confirmation by polymerase chain reaction (PCR) is not necessary in most settings. If asymptomatic testing strategies are considered, rapid antigen tests need to be performed frequently to be effective. When using ‘Test-to-Stay’ strategies as an alternative to large-scale isolation, asymptomatic close contacts of a positive case need to do rapid antigen testing daily. When using ‘Voluntary Asymptomatic Screen Testing’ strategies, asymptomatic individuals should do rapid antigen testing 3-5 times per week.

BACKGROUND:Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS:We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS:We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION:We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

About Us: The Ontario COVID-19 Science Advisory Table is a group of scientific experts and health system leaders who evaluate and report on emerging evidence relevant to the COVID-19 pandemic, to inform Ontario's response.Our mandate is to provide weekly summaries of relevant scientific evidence for the COVID-19 Health Coordination Table of the Province of Ontario, integrating information from existing scientific tables, Ontario's universities and agencies, and the best global evidence.The Science Table summarizes its findings for the Health Coordination Table and the public in Science Briefs.

KEY POINTS Health care organizations exist to provide care to patients. Yet recent public debates on hospital parking and access to health records show that, far too often, decisions about how health services are designed and delivered have been made by managers and clinicians alone. Health care

Importance The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date. Objective To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). Design, Setting, and Participants This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019. Exposures Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. Main Outcomes and Measures Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). Results Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively. Conclusions and Relevance Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.

Key Points Question Does providing a comprehensive set of essential medicines at no charge to primary care patients who have difficulty affording medicines improve treatment adherence? Findings In this randomized clinical trial of 786 primary care patients, free distribution of essential medicines vs usual access resulted in greater adherence to treatment with medicines (absolute risk difference, 11.6%). Control of type 1 and 2 diabetes was not significantly improved by free distribution of essential medicines (hemoglobin A1c, −0.38%), systolic blood pressure was reduced (−7.2 mm Hg), and low-density lipoprotein cholesterol levels were not affected (−2.3 mg/dL). Meaning Distributing essential medicines at no charge increased adherence to appropriately prescribed treatment with medicines and improved some disease-specific surrogate health outcomes.

OBJECTIVES:Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.METHODS:An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.RESULTS:Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.CONCLUSION:A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions.

Objective: This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital. Method: Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period. Results: In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population. Conclusions: A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.

Promoting the scale and spread of effective health innovations requires dedicated action from health system leaders. In order to maximise the effects of leadership strategies to promote the spread and scale of health innovations, conceptual clarity and well-defined strategies are essential. In this commentary, we propose definitions of the concepts of 'innovation', 'spread' and 'scale', and explain how these concepts can be used by health system leaders to generate interest, excitement and commitment for specific innovations from a broad community of stakeholders. We then outline two strategies from the community organising literature that leaders can use to promote spread and scale.

IMPORTANCE International nephrology societies advise against nonsteroidal anti-inflammatory drug (NSAID) use in patients with hypertension, heart failure, or chronic kidney disease (CKD); however, recent studies have not investigated the frequency or associations of use in these patients. OBJECTIVES To estimate the frequency of and variation in prescription NSAID use among high-risk patients, to identify characteristics associated with prescription NSAID use, and to investigate whether use is associated with short-term, safety-related outcomes. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, administrative claims databases were linked to create a cohort of primary care visits for a musculoskeletal disorder involving patients 65 years and older with a history of hypertension, heart failure, or CKD between April 1, 2012, and March 31, 2016, in Ontario, Canada. EXPOSURE Prescription NSAID use was defined as at least 1 patient-level Ontario Drug Benefit claim for a prescription NSAID dispensing within 7 days after a visit. MAIN OUTCOMES AND MEASURES Multiple cardiovascular and renal safety-related outcomes were observed between 8 and 37 days after each visit, including cardiac complications (any emergency department visit or hospitalization for cardiovascular disease), renal complications (any hospitalization for hyperkalemia, acute kidney injury, or dialysis), and death. RESULTS The study identified 2 415 291 musculoskeletal-related primary care visits by 814 049 older adults (mean [SD] age, 75.3 [4.0] years; 61.1% female) with hypertension, heart failure, or CKD, of which 224 825 (9.3%) were followed by prescription NSAID use. The median physician-level prescribing rate was 11.0% (interquartile range, 6.7%-16.7%) among 7365 primary care physicians. Within a sample of 35 552 matched patient pairs, each consisting of an exposed and nonexposed patient matched on the logit of their propensity score for prescription NSAID use (exposure), the study found similar rates of cardiac complications (288 [0.8%] vs 279 [0.8%]), renal complications (34 [0.1%] vs 33 [0.1%]), and death (27 [0.1%] vs 30 [0.1%]). For cardiovascular and renal-safety related outcomes, there was no difference between exposed patients (308 [0.9%]) and nonexposed patients (300 [0.8%]) (absolute risk reduction, 0.0003; 95% CI, -0.001 to 0.002; P =.74). CONCLUSIONS AND RELEVANCE While prescription NSAID use in primary care was frequent among high-risk patients, with widespread physician-level variation, use was not associated with increased risk of short-term, safety-related outcomes.

The United States and Canada share high costs, poor health system performance, and challenges to the transformation of primary care, in part due to the limitations of their fee-for-service payment models. Rapidly advancing alternative payment models (APMs) in both countries promise better support for the essential tasks of primary care. These include interdisciplinary teams, care coordination, self-management support, and ongoing communication. This article reviews learnings from a 2017 binational symposium of 150 experts in policy and research that included a discussion of ongoing APM experiments in the United States and Canada. Discussions ranged from APM challenges and successes to their real and potential impact on primary care. The gathering yielded many lessons for policy makers, payors, researchers, and providers. Experts lauded recent APM experimentation on both sides of the border, while cautioning against the risk of "pilotitis," or developing, implementing, and evaluating new payment models without plan or ability scale them into broader practice. Discussants highlighted the power of "learning at scale," highlighting large-scale primary care payment innovations launched by the US Center for Medicare and Medicaid Innovation since 2011, and called for a similar national center to drive innovation across provincial health systems in Canada. There was general consensus that altering payment models alone, absent incentives for innovation and continuous learning as well as increased proportional spending on primary care overall, would not correct health system deficiencies. Participants lamented the absence of more robust evaluation of APM successes and shortcomings, as well as more rapid release of results to accelerate further innovation. They also highlighted the importance of APMs that include flexible and upfront payments for primary care innovations, and which reward measuring and achieving global rather than intermediate outcomes, to achieve utilization goals and patient and provider satisfaction.

BACKGROUND:Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians.METHODS:In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr. 1, 2010, and Mar. 31, 2015, were identified via administrative claims data. Patients with a recent history (last 3 years) of any of the following were excluded: cardiac or pulmonary disease, high-risk comorbidity (e.g., diabetes), consultations/visits or procedures involving cardiac or pulmonary specialists, cancer and severe chest trauma. The primary outcome, a routine chest x-ray, was defined as at least 1 chest x-ray claim within 7 days after a PHE.RESULTS:While a routine chest x-ray followed only 2.42% of 2 847 508 PHEs, one-quarter of family physicians (499/2031) ordered chest x-rays for more than 5.0% of their PHEs (interquartile range 1.5%-5.0%) and accounted for 62.9% of all tests observed. Routine chest x-ray use declined by 2.0% per quarter (adjusted rate ratio 0.98, 95% confidence interval [CI] 0.97-0.98). Older age (45-64 yr v. 18-44 yr, adjusted odds ratio [OR] 1.82, 95% CI 1.78-1.86; ≥ 65 yr v. 18-44 yr, adjusted OR 2.48, 95% CI 2.39-2.58) and male sex of the patient (OR 2.19, 95% CI 2.14-2.24) and male sex of the provider (OR 1.55, 95% CI 1.51-1.59) were significantly associated with increased odds of a routine chest x-ray being ordered.INTERPRETATION:It is relatively uncommon for a chest x-ray to be ordered as part of a PHE in Ontario; however, the substantial variation observed among physicians suggests potential for interventions targeted at the most frequent users.

IMPORTANCE Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. OBJECTIVES To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. EXPOSURES Physician sex, years since medical school graduation, and primary care model. MAIN OUTCOMES AND MEASURES This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, >= 2). RESULTS The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female). who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median. 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2%(118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio. 2.04: 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. CONCLUSIONS AND RELEVANCE This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.

KEY POINTS Canadians are healthier than ever before,[1][1] and in many respects, the quality of health care provided to Canadians is also better than ever.[2][2]–[4][3] However, there are still large gaps between what we know to be high-quality health care and the care that many Canadians receive

Health professions regulation today faces a myriad of challenges, due to both the perceived performance of regulatory colleges, how health systems have evolved, and even larger political and economic shifts such as the renegotiation of NAFTA. In this issue of Healthcare Papers, Wilkie and Tzountzouris (2017) describe the work of the College of Medical Laboratory Technologists of Ontario (CMLTO) to redefine professionalism in the context of these challenges. Their paper, and the comments of the responding authors in this issue highlight that there, is an overarching perception that health regulatory structures - across a range of professions - are not working as effectively as they should. Across this issue of Healthcare Papers, attention is drawn to the fact that more can be done to improve both the function and perception of professional regulatory bodies. However, each paper presents a different approach to how improvements in function and perception are possible.

Promoting timely and continuous care for people experiencing homelessness has been a challenge in many jurisdictions, plagued by access barriers and service fragmentation. As part of a larger programme evaluation, this study used qualitative methods to examine the role of a brief interdisciplinary intervention in supporting continuity of care for this population in a large Canadian urban centre. The intervention provides time-limited case management, primary and psychiatric care, and peer accompaniment to homeless adults with unmet health needs discharged from hospital. Data were collected from 52 study participants between July 2013 and December 2014. Three focus groups were conducted with service providers and people with lived experience of homelessness, and 29 individual, semi-structured interviews were conducted with service users and other key informants. Transcripts were analysed using thematic analysis. Analysis was informed by existing frameworks for continuity of care, while remaining open to additional or unexpected findings. Findings suggest that brief interdisciplinary interventions can promote continuity of care by offering low-barrier access, timely and responsive service provision, including timely connection to long-term services and supports, appropriate individualised services and effective co-ordination of services. Although brief interdisciplinary interventions were perceived to promote access, timeliness and co-ordination of care for this population with complex health and social needs, gaps in the local service delivery context can present persisting barriers to care comprehensiveness and continuity.

IMPORTANCE Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown.OBJECTIVE To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE.DESIGN, SETTING, AND PARTICIPANTS A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE.EXPOSURES Receipt of an ECG within 30 days of an AHE.MAIN OUTCOMES AND MEASURES Primary outcomewas receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months.RESULTS A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P<.001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.CONCLUSIONS AND RELEVANCE Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.

The Coordinated Access to Care for Homeless People (CATCH) program is a brief multidisciplinary case management intervention for homeless adults discharged from hospital in Toronto, Canada. Here we describe the rationale for CATCH program development, details of the mixed methods evaluation underway, and the characteristics of 225 CATCH service users. Funded in 2010 by the local health authority, CATCH aimed to improve access, continuity of care, health and service use outcomes for homeless adults discharged from hospital. To assess the feasibility, acceptability and impact of the program, a mixed methods case study was undertaken in 2013. In total, 225 CATCH program users were enrolled in the study and completed quantitative survey measures at program entry to assess key health and social outcomes using a pre-post cohort study design. Follow-up assessments took place at 3- and 6-months. At study entry, most participants were male (79%), white (65%), Canadian-born (74%), single or never married (60%), and their average age was 39.9 ± 12.0 years. Nearly all participants (88%) had at least one emergency department visit in the past 6 months, more than half (53%) indicated at least three chronic health conditions, and 44% indicated at least three mental health diagnoses. In addition, qualitative data was collected to evaluate the experiences of continuity of care and challenges during care transitions for this population using in-depth interviews with a sample of CATCH service users ( n = 22) and managers of partnered organizations ( n = 7), as well as focus groups with CATCH staff ( n = 8), other service providers ( n = 7) and people with lived experience of homelessness ( n = 8). Improving health and health service use outcomes among homeless adults with chronic health conditions are key priorities in many jurisdictions. Future findings can inform service delivery to homeless adults discharged from hospital, by exposing factors associated with positive program outcomes, as well as barriers and facilitators to continuity of care for this disadvantaged population.

Mental illness is a substantial and rising contributor to the global burden of disease. Access to and utilization of mental health care, however, is limited by structural barriers such as specialist availability, time, out-of-pocket costs, and attitudinal barriers including stigma. Innovative solutions like virtual care are rapidly entering the health care domain. The advancement and adoption of virtual care for mental health, however, often occurs in the absence of rigorous evaluation and adequate planning for sustainability and spread.