Health Committee on Nov. 29th, 2012

[The Chair, Conservative, Joy Smith]

We'll get started. We have some very dynamic individuals here today, and we're pleased to have you join us.

On video, we have Dr. Julio Montaner....

I think we just lost Dr. Montaner, so we will get back to him.

We have, from the Canadian College of Health Leaders, Ray Racette, president and chief executive officer. From St. Boniface Hospital, we have Dr. Michael Tétreault, president and chief executive officer of St. Boniface Hospital. Some very innovative ideas are going to be forthcoming from both these individuals this morning.

From the University of Manitoba and the Concordia and Joint Replacement Group, we have Dr. Eric Bohm, associate professor. He has a PowerPoint presentation in English. We have had unanimous consent for that to happen.

We also have Dr. Christopher Fotti, a doctor from the Pritchard Farm Health Centre, a very innovative project that has happened in my riding. He will be presenting as well.

Can you hear me, Dr. Montaner?

[Dr. Julio Montaner, Director, British Columbia Centre for Excellence in HIV/AIDS]

Yes, I can hear you. Thank you.

[The Chair, Conservative, Joy Smith]

Dr. Montaner, I'm sorry that our video feed went in and out and we lost you for a couple of moments. If you have something you would like to say at some point, just let me know by raising your hand.

I don't know if you heard all the guests we have this morning. Did you hear that?

[Dr. Julio Montaner]

I can hear you all right.

[The Chair, Conservative, Joy Smith]

We are going to hear a presentation from each individual and then we'll have questions and answers.

Dr. Bohm, do you have your video all set up and ready to go?

[Dr. Eric Bohm, Associate Professor, Concordia Joint Replacement Group, University of Manitoba]

I do, yes.

[The Chair, Conservative, Joy Smith]

Would you begin, please?

[Dr. Eric Bohm]

Thank you very much. My apologies again for the English-only version. I'll leave it for translation.

I'd like to take the next few minutes to speak to you about innovative orthopedic health care delivery and device development.

I'm one of four surgeons who work at the Concordia Hip and Knee Institute. We specialize in primary and revision hip and knee replacements.

We have a multidisciplinary pre-hab and education team to help prepare patients for surgery. We have a digital radiology suite with RSA capabilities for research and follow-up. We have an implant retrieval and analysis laboratory and an implant ware and testing laboratory. We have quite an active clinical research group. We also participate in access and quality of care initiatives within the Winnipeg Regional Health Authority. We have also recently started into orthopedic device innovation. All of this happens under one roof at the Hip and Knee Institute.

I want to talk a little bit about health system performance and tie in some manufacturing theory and how we've improved that. I'll give some examples around physician assistance, wait times for joint replacement, and quality of joint replacement at the time of hip fracture surgery.

Health system performance can be considered as access to care, appropriateness with the correct intervention for the correct patient at the correct time, effectiveness, both cost and clinical, as well as safety.

This is a drawing of our wait list for hip and knee replacement surgery back in 2005. You can see that of patients who had undergone surgery, many of them fell past that benchmark of 26 weeks, which is represented by the yellow line in the middle of the graph. So we really needed to fix this.

The theory of constraints tells you to identify bottlenecks in the process and apply resources to relieve that bottleneck, so that's what we started to do. We looked to find where the bottlenecks were.

In a typical eight-hour day, one orthopedic surgeon could do three joint replacements. There are quite a few steps involved in doing a joint replacement. You need to bring the patient into the room, get the room set up, anesthetize the patient, and then there's positioning, prepping, draping, and so forth. Actually putting in the joint replacement only consumed about two and a half hours in total out of that eight-hour day.

It was quite obvious to us that the surgeon was the bottleneck, and we needed to do something to improve that productivity. We looked at increasing productivity by employing physician assistants. Among many of the things they can do, they're excellent assistants in the OR. They can help with positioning, prepping, draping, and closure during the procedure.

What we did is started running what we call double rooms. We would have one surgeon with two rooms, and each room would have a physician assistant, an anesthesiologist, and a nursing team. This would allow the surgeon to get started in the first room while in the second room the patient was being brought into the room, the equipment set up, and so forth. When the surgeon was finished in the first room, he or she could walk over to the second room and do the next case. This allowed us to significantly improve our surgical throughput. We went from three patients a day up to seven patients a day.

That was really the only way for us to increase our primary joint replacement volumes, because we didn't have any more days in the week to operate. We were already busy Monday to Friday. So this is how we increased our volumes. We saw a 42% increase in our volumes, and our median wait times back then dropped from 44 weeks down to 30 weeks.

Another thing we looked at is hip fracture care. Back in 2005, Manitoba was not doing a very good job in getting hip fracture patients into surgery in a timely fashion. The national benchmark was 48 hours. Only 53% of our patients were making it into surgery within 48 hours. This compared rather poorly, I would say, to the national average of 65%, so we needed to do something.

We applied some Lean thinking to this problem. We determined what the customer values. The customer is the patient with the hip fracture, and I can tell you they valued getting into the surgery and having it done quickly. We identified the non-value-added things we were doing and aligned the activities to meet that goal of surgery within 48 hours.

First of all, we sought to understand the problem. We implemented some standardized tracking methods to determine where the delays were. We identified things such as Plavix, which is a blood thinner. We found patients were being delayed for surgery five to seven days for the Plavix to wear off.

On the issue of mandatory internal medicine consultation, it was the practice back then to have an internal medicine doctor see every single patient with a hip fracture when it really wasn't necessary. Fitness for surgery could be decided with the anesthesiologist and the orthopedic surgeon working together. Issues around OR time and surgeon availability were also apparent.

We sorted out the issue of Plavix with our anesthesia colleagues and their standards committee. We ran several grand rounds sessions to help convey the importance of the impact of delay on mortality and that reducing delay will improve mortality. We discussed the issue of Plavix and the mandatory medicine consultation. We modified some of the OR booking rules to allow these patients to get into surgery quickly. We had direct written communication of the sites and physicians, and we improved repatriation of patients to their home hospital.

This seemed to be quite effective. This is data showing the mean time to surgery, length of stay, and mortality before the intervention. You can see that patients waited an average three and a half days; length of stay was almost 30 days in hospital; and in-hospital mortality was 6.4%.

After we introduced those changes, we dropped our mean time to surgery to 1.8 days; the length of stay decreased to a little less than 25 days; and we dropped the in-hospital mortality to 5%. These were all statistically significant, so a good effect on length of time to surgery and on mortality.

I'm happy to report that we've improved significantly across Canada. In the last report, 87% of Manitoba patients received timely hip fracture surgery. This compares quite favourably to 80% for the rest of Canada.

We've also done some work with the regional joint replacement registry to improve the outcomes of hip and knee replacement surgery. We applied some principles of Lean Six Sigma, and it really depended upon the data and facts, collecting good data and reporting it back to the providers to improve care.

Our regional joint registry consists of preoperative data collected from patients, functional scores, and medical comorbidities. We collect data during the operation itself, on the procedure, details, the implant used, and so forth. One year after the operation we ask patients how they are doing, how their function is, had they any complications, what their satisfaction is, and whether they have had a revision. So we're asking patients about their outcome and interaction with the health care system.

This data is compiled into a yearly report that goes to the region, to the site, and to the surgeon, so they can each compare themselves to their peers as a whole.

I will draw your attention to one of the metrics we report on, and that is patient satisfaction. We have created a fictitious report for a surgeon to show that 83% of their knee patients were satisfied, yet 7% were unsatisfied. This data can be taken back to improve the quality of the care a surgeon delivers to patients—very useful information.

Another example of the results of this registry is a steady reduction in revision rates. You can see that we started the registry back in 2004. At the start of 2005 and up to 2009, we've seen a steady reduction in early revision rates of hip and knee replacements. This is a better outcome for patients and less cost to the health care system.

To innovate health care delivery, I truly think it is important to understand what the customer wants, what the patient needs—to measure it properly, report it clearly, and align care in order to deliver what is important. I also think it's important to hold health care providers accountable.

I'll talk briefly about the Orthopaedic Innovation Centre. In 2011, we received $2.5 million in a Western Economic Diversification grant. Our mandate is to create, commercialize, and license orthopedic medical technology in a multidisciplinary environment. We currently have 10 researchers utilizing grant-funded equipment.

It's been a very interesting journey for us. We found there is very good support of initial innovation and a little less so of product development and commercialization, which we're working on now. There is a smaller pool of venture capital in Canada compared to elsewhere. There are some intellectual property policies in academic centres that I think need to be updated. There are, of course, health care budgetary constraints, and always the risk of brain drain to the U.S., but we're certainly enjoying this new aspect of our work.

For future work, I think it's important that we strengthen the Canadian Joint Replacement Registry. I talked about a regional registry; there is a Canadian Joint Replacement Registry. We don't have mandatory data collection yet, but we're getting there. Once we move there with regular, clear, and concise reporting, we can improve the care for Canadians. I also think it's important to link with Health Canada for post-market surveillance of new implants, to see if they're failing.

Promoting integrated data-driven models of care is important. There are many good examples across Canada of this. In the orthopedic world, the Arthritis Alliance of Canada has developed a framework. The Bone and Joint Decade Canada has done a lot of good work around hip and knee replacements and hip fracture care.

I think that continued orthopedic device innovation, linking registry data with retrievable data, testing data to improve implants and implant design, and continuing to improve a climate for commercialization are important as well.

If I can leave you with one hopefully humorous thought, it's on the importance of data, because if you don't measure, you don't know what you're doing. Here I have a picture of me and one of our nurses in Nicaragua about a month ago. We were doing some medical relief work down there, and the Americans who joined us brought down some “greens” they thought they could leave for the Nicaraguans, but they weren't quite the right size. So if you don't measure, you don't know what you're doing.

I thank you for your attention, and I would be happy to entertain your questions.

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. Bohm. That was a very compelling presentation.

I would like to now go to Ray Racette, president and chief executive officer of the Canadian College of Health Leaders.

Go ahead please, Ray.

[Ray Racette, President and Chief Executive Officer, Canadian College of Health Leaders]

Madam Chair and members of the Standing Committee on Health, it is a real honour to appear before you as a witness. The remarks I will be sharing with you this morning are really my own personal insights from working as a leader for over 30 years in health care administration, and also from working with the Canadian College of Health Leaders on both a national and international basis. In my remarks, I'm using that as a lens to provide some insights.

As leaders, we certainly take great pride in many aspects of our health system. There are many things we do well. A lot of these things we don't talk about; we're just busy doing what we're doing. But we also recognize that our health system is under a lot of strain. The strain is coming because our population is aging quickly, and we're also facing a growing prevalence of chronic illness. Our system was not designed for that type of patient. We were designed primarily around acute care and physician care, and we haven't really evolved our system sufficiently to handle those patients.

You might wonder why that is a big deal. It's a big deal because we're still a young country. If we look at ourselves compared to Europe, we're much younger, but if we look at Canada in 30 years' time, we'll be older than Europe. So if we're struggling at being young, we have to make changes to prepare for what is also coming.

This challenge we face is occurring despite considerable effort on many fronts, including the work of organizations, regions, health providers, and staff to improve service. If we look at the leadership agenda in the country, it's all focused on improvement, change, and safety. There's no question that governments have committed funding levels to support improvement, so why are we in this situation where we're struggling? It's an important question. I think the more important question is, how do we get out of struggling? How do we move forward? That, to me, is the more important question looking forward.

Why are we here? There are lots of reasons, but I want to focus on three things that I think have created a bit of the dynamic we face. First off, by virtue of how governments insure health services, we have focused health delivery primarily on hospitals or acute care and physician services, and, consequently, that's where care is funnelled to. We have some things that are insured outside of that, but primarily our major insurance platform is geared to those two venues.

As a consequence, what do we see today? We see hospitals being congested, often patients in the wrong setting. I think Ontario has said that 25% of their hospital beds are occupied by patients who are in the wrong setting. We often hear this expressed in terms of emergency department waits. Those are consequences of hospitals being congested, and then the patients can't move where they need to move. Also, we have patients waiting to see a physician. We have physician shortages, so of course patients are queueing up to see physicians, either family doctors or specialists. These two venues are also the most expensive, and we have patients concentrated there. If we look at that, that's an important factor to consider as well.

Secondly, I think it is fair to say that the consumer—and when I say “consumer”, I'm talking about patients, clients, or whatever terms we choose to use—is largely marginalized in our decision-making. We have quite a paternalistic system. Patients could assume more responsibility if they were enabled to do so and if we respected them in a way where they were actually engaged as a team member in health care. We have a lot of work to do on that. We do some things well, but there's a lot that we could do better.

Also, our health system is fragmented. There are many structural and professional divisions across the country. There is limited coordination of effort across the country, resulting in inefficiencies, duplication, and inconsistencies. Dr. Bohm's presentation...that's unique and is being developed for Manitoba, but it's probably being developed in different ways in other parts of the country—everybody trying to achieve the same thing. We lack a national health agenda for a $200 billion industry. We should be concerned with that.

How do we then look at improving efficiency and performance of our health system? We could start by talking about countries that have similar values—that's very important—that are serving an older population, that are achieving better outcomes at lower cost, because that's really the agenda we're trying to tackle.

Let's look at a country such as Sweden. Sweden is a country that we have visited many times for study tours. Let's see how they've tackled all three of those issues that I mentioned.

First off, the backbone of the Swedish health system is primary care and not acute care, and every citizen is connected to a primary care network. That primary care network links very closely with hospitals so that patients can move in and out quite easily. There's a lot of information sharing, a lot of knowledge transfer, so when the patient is admitted, their history of what happened in primary care moves in. When they get discharged, what happened in the hospital visit and the discharge orders move out. It's very smooth.

There's an electronic health record that connects primary care to acute care, so that information sharing is smooth. The primary care units are team-based and patients can have appointments with any member of the team quite readily.

The role of acute care, though, not to be undermined, is very important, but it's focused. The hospital care is very specialized. Hospital capacity is protected: it's used for hospital care. Patients who require care in other settings move along very smoothly, so the hospitals do not get backlogged caring for patients who are in the wrong setting.

The hospitals are very efficient. They utilize Lean tools, as was discussed earlier, to streamline their processes in the nursing units, emergency departments, and clinical and diagnostic areas.

There is a national focus on improving the quality and safety of care to the elderly. This is very important, because Sweden has the oldest population in Europe. The population is much older than in Canada. There's a major effort to care for the elderly in their homes rather than in institutions. The average length of stay in nursing homes in Sweden is one year, and that reflects the effort to keep people at home as long as they can. Also, palliative care is strongly supported in the home setting.

In terms of a national agenda, patient safety and quality of care are part of the national agenda. I'll give you one example where they have really done very well, and that's that whole issue of hospital-acquired pressure ulcers or bedsores. In Sweden, the incidence of patients who get them during hospital care is 5%. In Canada, it's between 20% and 25%. We perform very poorly on that front, relative to other countries.

There's also a very strong national focus in Sweden on medication safety for the elderly, because we know that many of our hospital admissions and emergency visits are due to medication issues with patients who end up having to be admitted because they're not taking their medications right and so forth.

Infection control is very strong in Sweden. We struggle with handwashing in Canada. The handwashing compliance level in Sweden is almost 100%. But it's not just that; in patient care settings, nothing below the elbow is allowed in the patient rooms: no sleeves, no jewellery, no gel nails. We have debates on that in Canada, but in Sweden you're absolutely forbidden to have gel nails and jewellery and anything below the elbow in patient rooms. Their infection rates are very low. Their standards are very high and their consistency rate is very high.

When you look at how their system works, it's clearly evident that it was designed with the patient in mind. We have a lot of difficulty with handing patients off from one sector to another. In Sweden it's very smooth, because patient movement is orchestrated between the sectors and the patient just moves.

When we talk to them about alternative level of care patients, hospital patients in the wrong setting, they do not have that issue, and they look at us as if to say, “Well, what are you talking about?”

There is a very strong commitment to efficiency in processes through the use of Lean thinking. They actively tender for services if they're struggling with an area that they want to improve. They can do projects where they'll tender for those services—to the private or public sector—and they use that as a way of getting improvement.

They view industry differently than we do. We tend to view industry as vendors; they sell us commodities. They view industry as knowledge brokers. These companies are global companies working in hundreds of systems. Their view is that they can get innovation from those companies because of their scope of exposure, so they view them as a knowledge partner. That's also very important.

Consumers are actively engaged in personal wellness, but they're actively engaged in selecting their care options. Patient choice reform in Sweden is a very strong movement, where the patient can choose providers. For many of the services where they choose to go, the money goes with that choice. That incents providers to offer high quality to attract a patient who then brings them funding.

The last issue I would say about Sweden is they spend a lot less than we do, but they have better outcomes, and it's quite remarkable, considering that it's an older population. Their insured basket of goods includes dental care for the young and the elderly, a national pharmacare program, a national primary care network, and home care, all insured and they're spending less money. They've achieved that with 97% public funding.

It's a publicly funded health system. They view health as a business and they're planning to the year 2025.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Racette.

Now you realize the committee is going to be lobbying to go on a field trip to Sweden, and this is not good, right?

Thank you so very much. It was a very insightful message.

I'll now go to Dr. Fotti, who is here as an individual.

[Dr. Christopher Fotti, Pritchard Farm Health Centre, As an Individual]

Thanks, everyone, for having me out today, and my thanks to my clinic doctors and staff.

I met Joy when I started to create a new clinic just outside of Winnipeg. We are a 10-physician clinic just outside the perimeter, only a couple of minutes from East St. Paul, Manitoba. Why did I want to make a clinic there? Well, I live in the neighbourhood, so it was a great idea for a short commute to work, plus I realized that there was little health care in the area. People had to go all the way to Winnipeg even to get blood work and see their doctors. We're on a main artery that comes into the city, so in the morning and evening there's constant traffic coming by our site, and people can stop there and receive their health care needs.

When we started, we wanted to have a very modern clinic. We wanted to make use of all the available technologies and be prepared to use newer technologies. We all understand that technological advances are very helpful for the patients—they improve patient care and efficiency, and they produce better outcomes for the patients. So when we designed our clinic, we had that in mind. When you come into our clinic, it's a reasonably nice-looking clinic. It's fully computerized, fully electronic. We interface with our labs and everything that way. It's very helpful for all of us. We wanted to do that because we wanted to be very progressive in this area.

We have nine family doctors. Actually, we have only eight right now, but the ninth is starting in February 2013. We have one specialist, whose training is in auto-immune and skin diseases. She is also trained in general internal medicine, and she does some private cosmetic stuff. The really nice thing is that in our family practice setting we also have specialist backup, people we can talk to in the hallway for hallway consultations, and formal consultations for our patients. That really improves the stream for the patients. For example, if I have a question, I can go ask our specialist. She might not be able to see the patient at that moment, but she can give me some information on starting a treatment or an investigation that will speed things up when she does see the patient.

One of the other things we wanted was not to, I want to say, be “just” a family practice clinic, but we wanted to work collaboratively at our clinic. If I have a question about something, I can ask one of the other family doctors down the hall. So if you are at the clinic, quite often you might see two or three of us going into a patient room to look at a case. Three brains are better than one. Sometimes that will speed things up and maybe reduce unnecessary consultations.

One of the other nice things about our clinic doctors is that many have specialized interests. We all do full-practice family care in the office, but we also have some people who do very specialized care. For example, I do respiratory medicine. I'm on the College of Family Physicians of Canada's Respiratory Medicine Program Committee. So in my clinic, when one of the other doctors has a respiratory patient who might benefit from some of the additional knowledge I have, then I'll see that patient for him. We have one doctor in our clinic right now, and another one starting in February, who does obstetric care. If you want to be at the clinic for the whole time for your obstetric care, then this doctor can take care of you and deliver your baby. And it'll be the same thing with the new doctor who's coming on. If I have obstetric patients of my own, usually we'll see those patients up to about 28 weeks before we pass them on. This reduces the burden on the obstetricians and gynecologists—they don't have to do all the regular prenatal care. But if I need advice or guidance, I can rely on this doctor in our clinic with her advanced knowledge.

Four of our doctors do hospital care as well. They admit patients. They admit unassigned patients to hospital. That also helps with transition. If our clinic patients are in hospital, it's very easy to transition over, which also keeps them in the loop as we try to make changes in the hospital system to improve the flow of patient care.

One of our doctors has an interest in sports medicine. That's also a very helpful thing. We have quite an array of physicians doing full-service family care, but we also have people who, though not specialists, have special interests and some additional training in other areas. Again, that really improves the flow of the clinic.

One of the other things we wanted to do was to make sure that our clinic was accessible. Definitely that's one of the most important things.

Actually, I do have a document here. The college told me they sent it to everybody on the health committee earlier, but if anybody would like this bilingual document called, “The Patient's Medical Home”, you can just let me know and I will have them send it to you. The basic idea behind “The Patient's Medical Home” is that everyone have access to a family doctor in a timely fashion and access to alternative care, for example, after-hours care and things like that.

When we set up our clinic—

[The Chair, Conservative, Joy Smith]

Excuse me, Dr. Fotti. Before I forget, can you be so kind as to send a copy to the clerk? We'll make sure they're distributed properly. We get so much information coming to our offices that the members may or may not have seen that, and it is important for them to see it.

[Dr. Christopher Fotti]

Yes, just let me know how many you need. They are more than happy to send it out, but they just don't want to send out a whole bunch if they don't know....

The whole idea with the “Patient's Home” is that everyone have access to a family doctor in a timely fashion and that the medical home also interact with other health care professionals—specialists' services, dieticians, social workers, and all those things, to try to streamline and improve patient care.

All our doctors have same-day slots, which means there is a very good chance that if you phone in the morning because you need to be seen, you will be seen by your doctor that day or the next day. In many clinics that's not the case. I'm sure many of you have experienced or have heard from friends and family that they call their doctor because they think they have a urinary tract infection and they get an appointment for a month or two later. That doesn't really do anybody any good, and then, of course, people end up in the emergency room and in other more inappropriate care settings for issues like that.

We've been maintaining that, and it's been working very well. Our patients are very satisfied that, for the most part, they can be seen rather quickly.

One of the other things we wanted to do was to provide alternative care, after-hours care, for our patients, and for patients in the community as well. We decided to have walk-in hours for any patient who wanted to come in—and obviously for our clinic patients. We do our walk-in hours in the evening. We do those from 5 to 9, and we'll be starting up the Saturday walk-in soon. So, for example, if you phoned in and you couldn't get in to see me because my schedule was too busy, you could come to the walk-in at night and still get care within the same day.

We've alerted all the urgent cares and hospitals and ERs that we are open during those hours, and sometimes they redirect patients who don't need emergency room care to come see us. Our hope is to improve care for our patients, to improve care for the patients in the community, and to reduce the impact on other health care services, so that, for example, patients who really do need to be in the emergency room aren't waiting with a bunch of patients who don't really need to be in an emergency room. That has been working very well for us.

Like many clinics, we have a pharmacy and a lab in-house. Our pharmacist collaborates with us. We're often running in and out of her office and her store to ask her questions. Even for patients that she's not even seeing to dispense medications, she'll give us guidance as to what to do.

We're expecting the X-ray clinic to open up next door in the next week or so. They are fully electronic, with X-ray, EKG, and spirometry, and we've set it up so that they actually data-link into our system. So if I order an X-ray, you can go next door and get your X-ray and it pops back into my computer before you come back. If I'm not sure about that X-ray, we have access to the radiologist 24/7, so I can just pick up the phone and hit the speed dial number and the radiologist, for the most part, will be able to look at the film with me, wherever it is they're looking at it on their system, and give us guidance on what the image may represent.

Again, we've expanded to have more services, but we've done so by using electronic and technological items as well as we can. Our clinic is fully electronic, so everything is often just shifting through data ports. Patients will be able to book online appointments soon and go from there.

We tried to follow the model in “The Patient's Medical Home”—and we'll definitely send that out to everybody—and so far, it seems we are working well for the community. Patients have a lot of access to us. Patients can get in quickly to see us. We're working well with lots of other services to streamline things, and that is definitely the way of the future.

Maybe the last thing I'll say is that my business partner and I both teach at the university as well, which is also an important component of this—to teach student learners, whether they be physicians, nurses, or anyone else, and to have them in our clinics. It's good for us. It's good to keep us up to date on things. Students keep you on your toes, for sure. It's also good to expose the students to various health care models.

Most of our new doctors were students we taught. Most of the doctors who started at our clinic had zero patients when they started. Within four or five weeks, all of those doctors were maxed out. They had taken all the patients they could take. For the last doctor we hired, when we advertised, it took just over two weeks for her to max out with over 1,000 patients. It just goes to show you that there's still a lot of work that needs to be done. There are a lot of people who still need doctors.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Fotti. I know that it's really an amazing place, and the feedback I've heard from so many people has just been amazing.

I just want to say that one of my staffers who went—she changed doctors and went to your clinic, actually—was diagnosed with something rather serious. She'd been going to some place forever and they hadn't caught it, because there wasn't that symmetry between all the specialists.

Thank you for sharing that with all of us today. We appreciate it very much.

Now we will go to Dr. Montaner. We're looking forward to hearing you.

[Dr. Julio Montaner]

Thank you, Madam Chair.

Let me first introduce my partner in this presentation, Dr. Thomas Kerr, from the B.C. Centre for Excellence. He's the director of the urban health program here at the centre at St. Paul's Hospital and the University of British Columbia.

The theme I would like to discuss for you relates to the efforts we have made over the last couple of decades to control HIV and AIDS in the province of British Columbia.

Here on the west coast, we have been affected by the worst HIV epidemic in the country. As Dr. Racette indicated, our health system is under significant stress, and sustainability of these efforts is a serious consideration. We agree wholeheartedly with Dr. Bohm's closing remarks that accurately monitoring our epidemic is essential for understanding what's happening. But at the end of the day, if we don't do something about it, monitoring is not going to cut it for us.

The B.C. Centre for Excellence is unique, in the sense that it's mandated not only to distribute antiretroviral therapies throughout the province to all eligible individuals, fully free of charge, but to also support laboratory monitoring. And we have a mandate to monitor health outcomes related to HIV.

Back in 1995, research conducted at the centre and elsewhere showed that by using three-drug combination therapy, we could arrest the course of the disease. What happens is that it shuts down the replication of the virus, and in a matter of weeks, the amount of virus circulating in blood goes to undetectable levels. As a result, immunity recovers, the patient doesn't get sick, and we restore the person's normal life. Today, a 20-year-old individual who starts on this regimen will expect five decades of normal life. We have really changed the outcome of HIV from a rapidly lethal disease to a disease that can be completely managed as a long-term, chronic management proposition.

As a result of that, morbidity and mortality in the province of British Columbia have decreased by greater than 90%, which goes a great deal to contributing to decreasing the burden on our hospitals and our health care system. Treatment has been deemed to be highly cost-effective for this reason, and as a result, the province continues to support free treatment for all in need.

During the years 1996 to 2000, we briskly rolled out antiretroviral therapy in the province. As a result of our monitoring efforts, we saw unexpectedly that the number of new HIV infections in the province decreased by approximately 40%. This was an unexpected event at the time, but it was a tip for us that the treatment not only prevents disease progression, but, in addition, and most importantly, it can stop HIV transmission.

We looked then at this phenomenon in the mother-to-child transmission setting. We found that by treating the mothers, we could stop transmission to the babies by nearly 100%. In more recent work we've done, in collaboration with others, we have shown that the same principle applies when you treat an injection drug user or when you treat a member of an HIV-discordant couple, in which one member of the couple is HIV-positive and the other is HIV-negative.

The province of British Columbia, therefore, has embarked, for a number of years now, on a new strategy, which we call seek and treat. We're seeking out individuals by facilitating and normalizing HIV testing, and we are screening the population for HIV so that we can chip away at the recurrent statistic that 25% of people infected with HIV are unaware of the infection. The Public Health Agency of Canada, year after year, reports the same number, yet we have not changed our guidelines regarding HIV testing.

We are advocating a national strategy on HIV testing such that the testing can be generalized so that we can identify those individuals and do the best for them, and in doing so, stop HIV transmission. By approaching the problem in this way, British Columbia, in addition to decreasing morbidity and mortality by greater than 90%, has now decreased new HIV infections by greater than 66%.

Let me emphasize that we are the only jurisdiction in the country that has seen a meaningful decrease in the number of new HIV diagnoses per year in the last two decades, at a time when Saskatchewan has seen a fivefold increase in the number of cases and Manitoba has a threefold increase in the number of cases. There is also a rising number of cases in Newfoundland and in your own great city of Ottawa. First nations individuals are five times overrepresented in this epidemic.

Madam Chair, we think we have a solution at the Canadian level. The United States has actually formally embraced this approach. We would like to recommend that HIV treatment and prevention be made a national priority for this country immediately.

I will let Dr. Kerr discuss how this should be enforced among injection drug users.

Thank you.

[The Chair, Conservative, Joy Smith]

Dr. Kerr, you have three minutes.

We look forward to hearing from you.

[Dr. Thomas Kerr, Director, Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS]

Three minutes? I was under the impression I had five minutes.

[The Chair, Conservative, Joy Smith]

You have four minutes.

[Dr. Thomas Kerr]

I would like to just take some time to discuss some issues of relevance on the information provided by Dr. Montaner. As he has pointed out, and as I'm sure many of you know, a significant majority of new infections occurring in Canada are among individuals who use illicit drugs. Currently the fastest-growing epidemic of HIV infection in Canada is occurring among drugs users in Saskatchewan.

It is very clear now that if we are going to succeed in controlling the HIV epidemic in Canada, we must address illicit drug use. This requires adhering to principles of evidence-based medicine, supporting innovation, and improving efficiency.

The federal government has certainly dedicated some attention to drug use through its national strategy and bills specific to criminal justice measures. I do not want to discuss the relative merits of this approach, but I will say that one consequence of the approach being taken is that, as a country, we appear to be falling behind other countries when it comes to implementing and expanding innovative preventive and treatment measures focused on drug use and the prevention of HIV infection among drug users.

There is now a substantial body of scientific literature that indicates very clearly that substance use programming should be based on a continuum of services that includes not only abstinence-based programs, but programs that engage people who are active in their drug use with so-called “harm reduction” programs.

The scientific evidence in support of harm reduction is so strong that the United Nations and the World Health Organization have issued technical guidance documents that state that these programs are essential. We know that these programs facilitate prevention by providing materials that reduce the likelihood of disease transmission, but they also prevent HIV infection by engaging HIV-positive individuals in treatment for HIV disease.

Accordingly, in Vancouver we followed this approach, and while roughly 19% of all injection drug users were infected in the downtown east side in 1997, that rate has dropped to less than 1%.

We also know that harm reduction programs facilitate entry into abstinence-based programs, including detoxification.

But despite these well-established facts, we are not adhering to international standards or optimizing our HIV prevention and treatment efforts. If we share the goals of preventing HIV infection, promoting the use of addiction treatment and abstinence from drugs, then it's clear we should be supporting the scale-up of harm reduction programs in Canada.

It is also clear that we are falling behind in terms of innovation and addiction treatment in the use of electronic systems to prevent harms with drug use. Recently the federal health minister elected not to stand in the way of production of generic copies of Oxycontin. I won't discuss the merits of this decision, but rather I'd like to focus on a systems-level gap that, if addressed, could offset much of the risk posed by Oxycontin misuse.

The Province of British Columbia has implemented a province-wide PharmaNet system that allows pharmacists and doctors to see exactly what medications an individual has been prescribed, including opiates. This is very helpful when assessing the risks posed by prescription opiate use in double-doctoring. However, this type of system is not available in many provinces where opiate misuse remains a major problem.

Another area where we could do more to promote innovation is by supporting the implementation and testing of new medications for addiction. For example, Vivitrol is an FDA-approved opiate receptor antagonist that has been shown to be very effective in the treatment of opiate addiction and recent alcohol addiction. Yet Vivitrol remains unavailable in Canada and we have faced substantial difficulty in obtaining access to the drug in order to test it in a randomized controlled trial—

[The Chair, Conservative, Joy Smith]

I'm sorry, Dr. Kerr, you're over time now.

[Dr. Thomas Kerr]

In summary—

[The Chair, Conservative, Joy Smith]

My apologies. Could you summarize very quickly?

[Dr. Thomas Kerr]

—despite the fact that addiction and HIV remain major challenges, we are falling behind. More can be done to support innovation in systems, policy, research, and program development.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to St. Boniface Hospital, to Dr. Tétreault, president and chief executive officer.