Health Committee on Feb. 28th, 2008

[Dr. John Haggie]

Yes, essentially.

[The Chair, Conservative, Joy Smith]

Madame Lefebvre, you wanted to make a comment on this. Would you please go ahead.

[Fleur-Ange Lefebvre]

Thank you.

When my mother was discharged from the hospital in early January, she was discharged with a piece of paper that contained the names of over 25 medications. Some she was to continue, some she was to stop, and some she was to start. There was a mistake, which I picked up. The pharmacist didn't know; it was on the piece of paper. Once they had plugged all the information into the pharmacist's computer, a drug interaction showed up.

We have the tools to do this; we're just not communicating. My mother has more than one physician—she has five physicians. Connecting this information is going to be very key to what we can do from now on.

Concerning your comment on the seriousness of the adverse drug reaction, the example we proposed was for a mild to moderate drug reaction. If somebody at the other end, at Health Canada, is monitoring the reports coming in through the electronic medical record, they have predetermined a number: if the severity is this, one is enough to get some feedback; if it's not, 100 may be enough.

Somebody has to be doing this work at the receiving end of the reports. Then we'll have a system in place that will be useful, educational, and used. That's where the “mandatory” may not be so important.

[David Tilson, Conservative, Dufferin—Caledon, ON]

Dr. Haggie, you mentioned that Canada needs to provide a user-friendly reporting system. You talked somewhat about that. Can you add to your comments about what you mean by that?

[Dr. John Haggie]

The issue of reporting an adverse event has been very cumbersome until lately. It has improved with Health Canada's MedEffect. Having said that, I would suggest that probably 60% of my colleagues aren't actually aware of its existence, even though it's been up and running for a while.

The difficulty with it is that the vast majority of primary care physicians, who probably write the vast majority of prescriptions in this country, aren't clear on what it is they're supposed to be reporting.

The side effects profile of a drug is documented in a thing called the Compendium of Pharmaceuticals and Specialties, which is a huge book and which has an arcane indexing system based on both the trade name and generic name. It takes probably four or five minutes to find the right page simply because of that. When you do, the information there, which is in very small print—and as you get a little bit older, that becomes an issue—is in a very logical and ordered fashion, but it's not usable. It doesn't tell me anything more about how that patient is likely to behave with that drug than I could have had, probably, without reading it, if it were a drug with which I'm familiar. Really and honestly, when you look in there for side effects....

I had a patient a few months ago who had what I thought was a significant reaction to an antibiotic I'd prescribed. They were jaundiced and they got worse, and I wondered if it might be the medication. I went to the CPS, and after 20 minutes of rummaging through there found that jaundice was a side effect of this particular medication. I stopped the medication, and the patient got better—and I did know more about it.

It was a significant adverse reaction, and it lengthened the length of stay with the patient. But the reason I stopped was that it was well known, well documented, and there was a percentage figure there in the book. Was my report going to add anything to the body of knowledge, based on what I understood of the system? I said to myself, no.

If you were dotting the is and crossing the ts there, then perhaps I was in some way culpable for not doing a report, but this is just a reflection of the utter lack of clarity about the current system. I didn't know whether it was a valuable thing to do, whether I was going to have problems with doing it, and whether it was indeed going to add anything. If it wasn't, then quite honestly I wasn't even going to spend the five minutes that would be required to log in on the Internet and do it, because I had other things to do.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Haggie.

I'm sorry, Mr. Tilson, we're out of time.

Monsieur Thibault.

[Christiane Gagnon, Bloc, Québec, QC]

Madam Chair, I just want to make one clarification. I did not refer to two million deaths, but rather, two million serious hospitalizations due to adverse drug reactions. However, there were some 106,000 deaths.

Two million relates more to the situation in the U.S.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Gagnon.

Monsieur Thibault.

[Robert Thibault, Liberal, West Nova, NS]

Thank you, Madam Chair.

Welcome to all of you, and thank you for the most useful presentation. I particularly welcome Dr. Haggie, from the east coast, from Newfoundland. Being an east-coaster myself, it's wonderful to hear that beautiful Newfoundland accent here in Ottawa.

[Dr. John Haggie]

We all have Newfoundland accents.

[Robert Thibault, Liberal, West Nova, NS]

I appreciated the comments you made.

I've been struggling with some of the testimony we've had. We know that we don't want our family practitioners to be burdened with more paperwork that doesn't have value. We know that we ask them now, if we need CPP, if we need insurance claims, to do a lot of paperwork that doesn't necessarily contribute to our health and that wastes our time. And that's very difficult in a time when we know that we have a lack of medical professionals.

But you made a point, I think, that if we structure this properly, this could be a very useful tool on both ends. You could have an electronic system that helps you in prescribing, as it did the pharmacist in Madame Lefebvre's mother's case. It could help you in prescribing and also make it very easy for you to report incidents without having to worry about whether they're significant or not significant. In the case of the jaundice situation you were talking about, you could have reported that case. It would have been two keystrokes rather than you having to spend an hour typing out a report. I think that would be useful, with the proper analysis.

It seems to me that with the initiatives we're taking on the Canada Health Infoway and with those investments being made--we already have a digital data transmittal system for billing for family practitioners--those things could be achieved, and I hope they will be.

Before I come back to it, I had a couple of questions for clarification for Dr. McCallum. You're saying that in the case of Ontario, you had 20,000 deaths that involved the coroner and that 15,000 of them were seen as natural deaths but involved a coroner. And a number of those were drug related. Some of them, you said, had a death effect and others were involvement. What were the numbers in each of those two categories?

[Dr. Andrew McCallum]

You're correct. Just to give you a breakdown of that, of the 176 in which there was involvement—in other words, an adverse drug event occurred but it didn't cause the death—141 were natural. That is 141 out of 176. Twenty-eight were considered accidental. And I don't have the breakdown of what “accident” means. We consider an accident to be the death of someone due to an unforeseen occurrence, and that would include certain drug reactions. Of the small number, the 18 I referred to, 14 were natural and four were accidents.

[Robert Thibault, Liberal, West Nova, NS]

So it comes down to a very small number in our most populous province.

In those 176 cases, would you include drugs like morphine, in the case of palliative care, that could have an involvement but would not be an unexpected...?

[Dr. Andrew McCallum]

Yes, that's a possibility.

[Robert Thibault, Liberal, West Nova, NS]

So morphine in palliative care would be included.

[Dr. Andrew McCallum]

Not necessarily. It would only be included if it caused an adverse drug event. For example, if a patient who is being palliated were to suffer respiratory failure because of an inadvertent overdose of narcotic and then died of the cancer the palliation was required for, that would be a natural death with an adverse drug event included as an involvement.

[Robert Thibault, Liberal, West Nova, NS]

So it would be included in those 176.

[Dr. Andrew McCallum]

Yes.

[Robert Thibault, Liberal, West Nova, NS]

How many, within those 176, would you suggest are that type of thing--not necessarily morphine, but that type of palliative care or chronic care--that would be, I would say, unavoidable?

[Dr. Andrew McCallum]

I would say that the majority would be, and I think the key word used there is “unavoidable”, but not in the sense that the death was unavoidable.

[Robert Thibault, Liberal, West Nova, NS]

Right.

[Dr. Andrew McCallum]

The event could have been avoided, but it didn't cause the death.

[Robert Thibault, Liberal, West Nova, NS]

Yes, but in normal medical practice, when my turn comes and I'm dying and in excruciating pain from cancer, I hope you're not going to withhold morphine because it might have a negative health effect.

[Dr. Andrew McCallum]

Thank you for the question. And if I might just comment, it's very important that the committee understand that key fact. We do not want to have a chilling effect on physicians, particularly in end-of-life care, so they're afraid to prescribe appropriate palliative medication because of fear of death investigators coming along and saying, “Oh, you gave a lot of morphine there and we're concerned about your practice.” We certainly don't want that. So we're very careful about that.

[Robert Thibault, Liberal, West Nova, NS]

I have one last, broad question. We've heard here--and I don't want to go either way on this question, I'm trying to learn--that only 10% of serious adverse effects are currently reported. But we know that if we poll the Canadian population on political matters, we are content with polling 1,000 Canadians, and it gives us a significant picture. Is the 10% we're having reported now representative of the population and not the practice? Would that give us the picture of what's happening in the pharmaceutical/medical world?