Background:Increasing incidence rates of colorectal cancer (CRC) diagnosed before age 50 have been reported in Canada and other Western countries. Several organizations have lowered their recommended starting age for CRC screening. We aimed to analyze CRC rates in Canada and model the impacts of lowering the age to start faecal immunochemical test (FIT)-based screening in Canada. Methods:We evaluated the differences in absolute and relative incidence rates between age groups over time using the Canadian Cancer Registry data. Additionally, we used the OncoSim-Colorectal microsimulation model to examine starting FIT screening at 45 years of age over a lifetime time horizon. We estimated changes in CRC cases, deaths, potential years of life gained, and costs. Results:Absolute CRC incidence increased among groups below 50 years of age, with recent birth cohorts experiencing the greatest relative increases. Microsimulation results suggest that screening at 45 would result in fewer CRC cases (15 070) and CRC deaths (6100) in Canada between 2025 and 2071. For every additional 100 colonoscopies, 3.5 fewer CRC cases and 1.4 fewer CRC deaths are expected. Modelling suggests this may lead to an overall cost savings of $233 million CAD over the lifespan of eligible cohorts. Conclusion:Our results indicate that as CRC incidence in younger age groups has continued to increase, lowering the age to start FIT screening to 45 would result in overall population benefit through reduced CRC incidence and mortality. However, given resource considerations, provincial decision makers must evaluate changes in their programs to ensure proper implementation.

This study conducted a geospatial analysis of the distribution of the dental hygienist workforce relative to the distribution of the population in Ontario, Canada, aiming to address workforce imbalances and inform regional and international workforce planning. Geospatial analysis techniques were employed to examine the dental hygienist workforce distribution using anonymized datasets from the College of Dental Hygienists of Ontario (the professional regulatory body) and the Canadian census. The data were linked using the forward sortation area (FSA) component of Canadian postal codes, covering 520 FSAs across Ontario. Analyses were conducted at three levels, based on different aggregations of postal code data. The study found significant variations in the distribution of dental hygienists across Ontario. The analysis revealed pockets of high dental hygienist density, mostly in urban areas, and areas with low dental hygienist rates, especially in rural and remote locations. The overall provincial rate was 97 dental hygienists per 100,000 population, with variation across the 520 FSAs, from zero to 20,000 dental hygienists per 100,000 population (or zero to 739 dental hygienists per 100,000 population if five outlier FSAs were removed). The study underscores the complexity of dental hygienist workforce distribution in Ontario, revealing significant geographical disparities that suggest areas of both oversupply and undersupply. These insights provide actionable guidance for workforce policies and regulatory strategies, such as targeted incentives and public health initiatives, to address the mismatch between workforce supply and population needs. The findings highlight the importance of regular geospatial analyses to track changes in workforce distribution over time. The rigorous methodological approach and comprehensive evaluation of potential limitations offer valuable guidance for similar analyses in other jurisdictions. By providing a detailed framework and insights that extend beyond Ontario, this study contributes to the global understanding of dental hygienist workforce dynamics and supports the development of informed policies on a broader scale.

In northern Canada, medical travel - the movement of patients to a larger centre to access healthcare services outside their home community - is a dominant feature of the healthcare system. This qualitative study explored the medical travel experiences of Gwich'in living above the Arctic Circle in the Gwich'in Settlement Area in Northwest Territories (NT). Data collection in 2020 comprised storytelling sessions with 10 Gwich'in medical travellers (6 female, 4 male). Using inductive and deductive methods with continual critical reflexivity, and guided by Gwich'in values, concerns about access to healthcare were found to be at the heart of each story. A broad conceptualisation of access was applied to understand and interpret the results according to six dimensions: accessibility, availability, affordability, adequacy, acceptability, and awareness. Situated within a context of colonialism, structural inequities and other factors relevant across the Circumpolar North, the results suggest that the NT medical travel policy framework provides only partial access to care. This article illustrates a need for healthcare and other government systems to think about policy and programmes in a more wholistic, equitable and relationship-centred way, which would help not only to bridge distances across geography, but also between peoples.

The global demand for clinical genetic and genomic tests such as exome and genome sequencing continues to grow, with numerous genomic programs and initiatives being implemented nationally. This study aimed to describe the barriers and facilitators of genomic testing implementation, providing a comprehensive understanding of this landscape across diverse national contexts.

BackgroundThe emergence of artificial intelligence (AI) in health care has impacted health care systems, including employment, training, education, and professional regulation. It is incumbent on health professional associations to assist their membership in defining and preparing for AI-related change. Health professional associations, or the national groups convened to represent the interests of the members of a profession, play a unique role in establishing the sociocultural, normative, and regulative elements of health care professions. ObjectiveThe aim of this paper is to present a protocol for a proposed study of how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. MethodsAn exploratory multi-case study approach will be used. This study will be informed by the normalization process theory (NPT), which suggests behavioral constructs required for complex change, providing a novel lens through which to consider the agency of macrolevel actors in practice change. A total of 4 health professional associations will be studied, each representing an instrumental case and related fields selected for their early consideration of AI technologies. Data collection will consist of key informant interviews, observation of relevant meetings, and document review. Individual and collective sensemaking activities and action toward change will be identified using stakeholder network mapping. A hybrid inductive and deductive model will be used for a concurrent thematic analysis, mapping emergent themes against the NPT framework to assess fit and identify areas of discordance. ResultsAs of January 2021, we have conducted 17 interviews, with representation across the 4 health professional associations. Of these 17 interviews, 15 (88%) have been transcribed. Document review is underway and complete for one health professional association and nearly complete for another. Observation opportunities have been challenged by competing priorities during COVID-19 and may require revisiting. A linear cross-case analytic approach will be taken to present the data, highlighting both guidance for the implementation of AI and implications for the application of NPT at the macro level. The ability to inform consideration of AI will depend on the degree to which the engaged health professional associations have considered this topic at the time of the study and, hence, what priority it has been assigned within the health professional association and what actions have been taken to consider or prepare for it. The fact that this may differ between health professional associations and practice environments will require consideration throughout the analysis. ConclusionsUltimately, this protocol outlines a case study approach to understand how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. International Registered Report Identifier (IRRID)DERR1-10.2196/27340

BACKGROUND:This study involved a scoping review to explore factors influencing dental hygienist demand and supply in high-income countries.METHODS:A six-stage scoping review was conducted with separate search strategies tailored to four databases (MEDLINE, CINAHL, Google Scholar, and Google) plus a targeted scan of dental hygienist organization websites. This yielded 2,117 unique citations, leading to 148 articles included in the review.RESULTS:Nearly half of the articles (47%) focused on the United States, with 11% on Canada. Most articles (91%) were in English, alongside 13 in Korean and one in French. Journal articles comprised 62% of the publications, followed by reports/working papers (11%) and websites (11%). Other types included conference abstracts, policy briefs, and presentation slides. Content-wise, 47% were original research, with analysis articles (14%), commentaries (11%), and reviews (8%) also present. The articles were coded into three main categories: workforce characteristics/projections, factor-specific analyses, and workforce opportunities. The articles on workforce characteristics covered demographic, geographic, and employment aspects of dental hygienists, along with projections for supply and demand using simulation modelling and geospatial analyses. Factor-specific articles investigated the (1) working environment, (2) policy/regulatory/training environment, (3) job/career satisfaction and related human resource issues, and (4) scope of practice. The third key category of articles highlighted opportunities for expanding the workforce through alternative models in different sectors/settings (e.g., public health, primary care, long-term care, hospitals, mobile outreach, and non-clinical roles including research, education and leadership) and for a range of vulnerable or underserved populations (e.g., geriatric and pediatric populations, persons with disabilities, those living in rural/remote areas, Indigenous peoples, and incarcerated people).CONCLUSIONS:This review provides a comprehensive documentation of the current state of the dental hygienist workforce, compiling factors affecting demand and supply, and highlighting opportunities for the dental hygienist workforce in Canada and other high-income countries. The findings offer a foundation for future research, highlighting the need for more focused and rigorous reviews and underscoring the necessity of high-quality studies to verify the effectiveness of various interventions and policies. This is crucial to address dental hygienist workforce challenges and ensure the sustainability and effectiveness of oral health care delivery.

Medical travel, where a patient travels to a larger centre for services not available in their home community, is a critical element of the Northwest Territories (NT) health care system. For residents with a valid NT health care card who do not have other coverage for medical travel, the territorial government administers some travel benefits through the NT Medical Travel Program as well as the federally funded non-insured health benefits program. The Gwich'in Tribal Council (GTC) recognizes that medical travel constitutes a major burden and presents extraordinary challenges for Gwich'in living in small remote communities in NT. In 2020, the GTC conducted research that suggests current policy and programs provide only partial access to care. Informed by Gwich'in medical travel stories and drawing from literature on the concepts of health care access, knowledge, power, and Indigenous rights, this article reframes prevailing understandings of the problems, politics, and policy associated with medical travel in NT. The authors contend that relevant and equitable medical travel in NT depends on policy-making that engages First Nations as equal partners with different levels of government and describe key considerations relevant to policymakers in NT and throughout Canada.

The purpose of this policy briefing is to examine our health care systems through the lens of the COVID-19 pandemic and identify how we can strengthen health care in Canada post-pandemic. The COVID-19 pandemic has provided compelling evidence that substantive changes to our health care systems are needed. Specifically, the pandemic has emphasized structural inequities on a broad scale within Canadian society. These include systemic racial and socioeconomic inequities that must be addressed broadly, including in the delivery of health care. We make recommendations about what we can do to emerge stronger from the pandemic. While these recommendations are not novel, how they are framed and contextualized differs because of the problems in our health care system that have been highlighted and exacerbated by the pandemic.The evidence is clear that socioeconomic circumstances, intergenerational trauma, adverse early life experiences, and educational opportunities are critical factors when it comes to health over the life course. Given the problems in the delivery of health care that the pandemic has revealed, we need a different approach. How health care was organized prior to the COVID-19 pandemic did not produce what people wanted and needed in terms of health care and outcomes. How do we emerge from COVID-19 with an effective, equitable, and resilient health care system for all Canadians? To address health inequities and emerge from the pandemic with strengthened health care in Canada, we must consider how Amartya Sen's capabilities framework on social well-being can be operationalized to achieve better health care and health outcomes. Specifically, we address the need to: strengthen primary care and improve access to primary care; utilize a community-embedded approach to care; and implement better integration across the care continuum, including integration between primary care and public health. Coherent governance and leadership that are charged with realizing benefits through collaboration will maximize outcomes and promote sustainability. Only when we provide access to high-quality culturally competent care that is centered around the individual and their needs will we be able to make true headway in addressing these long-standing health inequities.

CARO 2022 breast cancer 13 months after enrolment.In the group receiving further EBRT, one patient had metastatic disease from a second primary 1 month after enrolment.No radiation therapy toxicities Grades 3 or 4 were observed in either group.The most common post-operative complication were seroma and cellulitis, with no significant difference among groups. Conclusions:The use of TARGIT for patients undergoing BCT at a median follow-up of 3.9 years, shows no significant difference in LRR, incidence of radiation therapy toxicities or post-operative complications.We conclude that TARGIT is a clinically safe treatment for carefully selected early-stage breast cancer patients with no pathological high-risk features.Further assessment of longer follow-up data, and cost-effectiveness analyses comparing both modalities are needed.

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.

Governments deploy comprehensive strategies to address complex social problems with various New Public Governance and horizontal initiatives. Minimal attention, however, has focused on developing evidence-informed strategy design for such initiatives. Using a systematic literature review, five strategy design principles were identified: 1) proper selection of interventions; 2) system enablers; 3) a guiding purpose; 4) substantive political commitment; and 5) joined-up governance. Three case studies including document review and interviews tested strategy design principles. Empirical work supported, expanded, and further refined these principles. Application of these principles would likely contribute to improving the success of horizontal strategy initiatives. Real-world political pressures and public administration constraints can be somewhat alleviated through learnings from well-designed strategies and experiences.

Background: In their landmark report on the “Principles and Practice of Screening for Disease” (1968), Wilson and Jungner noted that the practice of screening is just as important for securing beneficial outcomes and avoiding harms as the formulation of principles. Many jurisdictions have since established various kinds of “screening governance organizations” to provide oversight of screening practice. Yet to date there has been relatively little reflection on the nature and organization of screening governance itself, or on how different governance arrangements affect the way screening is implemented and perceived and the balance of benefits and harms it delivers. Methods: An international expert policy workshop convened by Sturdy, Miller and Hogarth. Results: While effective governance is essential to promote beneficial screening practices and avoid attendant harms, screening governance organizations face enduring challenges. These challenges are social and ethical as much as technical. Evidence-based adjudication of the benefits and harms of population screening must take account of factors that inform the production and interpretation of evidence, including the divergent professional, financial and personal commitments of stakeholders. Similarly, when planning and overseeing organized screening programs, screening governance organizations must persuade or compel multiple stakeholders to work together to a common end. Screening governance organizations in different jurisdictions vary widely in how they are constituted, how they relate to other interested organizations and actors, and what powers and authority they wield. Yet we know little about how these differences affect the way screening is implemented, and with what consequences. Conclusions: Systematic research into how screening governance is organized in different jurisdictions would facilitate policy learning to address enduring challenges. Even without such research, informal exchange and sharing of experiences between screening governance organizations can deliver invaluable insights into the social as well as the technical aspects of governance.

RATIONALE, AIM, AND OBJECTIVESHeart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics.METHODSFollowing an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory.RESULTSA total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome).CONCLUSIONGiven the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

Reviewer #1: I read with interest the manuscript "Governance of health research funding agencies: an integrated conceptual framework and actionable functions of governance" and have some suggestions to give in order to improve it. Most of them relate to restructuring the current version of the manuscript. I would clarify since the beginning what funding agencies/organizations fall within the scope of this analysis. This should be made clear since the beginning and motivated exclusion and inclusion criteria should be listed in the methods section in order to understand who are exactly the institutions the framework we want to apply to. Answer: The clarification is now added to Section 2: About the governance of health research by funding institutions. The paragraph now starts with:

Background: In their landmark report on the “Principles and Practice Open Peer Review

Background: First Nations peoples in Ontario are facing increasing rates of cancer and have been found to have poorer survival. Cancer screening is an important strategy to improve cancer outcomes; yet, Indigenous people in Canada are less likely to participate in screening. Ontario has established organized breast, cervical and colorectal cancer screening programs; this paper examines the health policy context that informs these programs for First Nations peoples in the province. Method: This paper follows an embedded multiple-case study design, drawing upon a document review to outline the existing policy context and on key informant interviews to explore the aforementioned context from the perspective of stakeholders. Results: Policies created by agencies operating across federal, regional and provincial levels impact First Nations peoples' access to screening. Interviews identified issues of jurisdictional ambiguity, appropriateness of program design for First Nations persons and lack of cultural competency as barriers to participation in screening. Conclusion: Federal, provincial and regional policy makers must work in collaboration with First Nations peoples to overcome barriers to cancer screening created and sustained by existing policies.

Background: In their landmark report on the “Principles and Practice Open Peer Review

The COVID-19 pandemic has brought the long-standing vulnerability of the medical product supply chain into sharp focus. Global shortages of medical products accompanied the global spread of the disease, joined by high prices, the proliferation of suspect dealers and dramatic interventions by governments, philanthropy and industry in oftentimes-unsuccessful attempts to secure solutions. Much attention has focused on personal protective equipment (PPE). But reported shortages have extended much further—to testing supplies, dialysis materials, pharmaceuticals and a wide range of commodities essential for daily care delivery—both for patients with and without COVID-19.1 2 PPE shortages have received particular attention because they endanger the healthcare workforce.3 But all product shortages endanger patients due to delays in care, rationing or denial of care, the use of substandard products, or heightened risk of error when using replacement products—risks that extend to increased mortality.4 Medical product shortages threaten the goal to deliver the right care to the right person at the right time—and have done so for decades.5 The COVID-19 pandemic has highlighted more than ever that these systemic risks can no longer be ignored. It may also mean that new solutions have become more possible. ### Why care about medical supply chains? Unexpected shortages of medical products do not fit neatly into any single quality domain, but can affect all of them. We cannot provide effective, efficient or timely care when medicines and other supplies required for crucial elements of care become difficult or impossible to acquire. Many shortages seen during the COVID-19 crisis clearly affect safety, and they can exacerbate widespread problems with equity. Just as critical incidents afford the opportunity to identify not just obvious active errors but also latent safety problems,6 crises such as COVID-19 expose general supply chain weaknesses. In fact, product shortages often exhibit the combination of active and latent errors (or …