Health Committee on April 25th, 2013

[The Chair, Conservative, Joy Smith]

I want to explain that today we have Dr. Richard Birtwhistle, scientific director for Technology Evaluation in the Elderly Network.

Thank you, Doctor, for joining us today, and thank you for your patience as we went through our business meeting prior to your entering the room.

By teleconference we have Dr. Saul Quint. He's the chief executive officer of INTERxVENT Canada.

Dr. Quint, I'm Joy Smith, the chair of the committee. Can you hear me?

[Dr. Saul Quint, Chief Executive Officer, INTERxVENT Canada, Interxvent]

Yes, I can. I'm pleased to meet you.

[The Chair, Conservative, Joy Smith]

I'm pleased to meet you as well. It looks like God calling, or something. We don't see you, but we hear you. Thank you for joining us.

[Dr. Saul Quint]

It's the first time I've been called that. Thank you.

[The Chair, Conservative, Joy Smith]

And it may be the last time. Welcome, anyway.

From the Terry Fox cancer research institute we have Dr. Victor Ling, who is going to join us at five o'clock. I understand that Mr. Weston knows Dr. Ling. We'll give a formal introduction to you when he arrives.

You each have a 10-minute presentation.

We're quite looking forward to yours, Dr. Birtwhistle. Could you begin now, please?

[Dr. Richard Birtwhistle, Scientific Director, Technology Evaluation in the Elderly Network]

Good afternoon, Madam Chair and everyone. Thank you for giving me the opportunity to address the committee today about the use of technology in the management of people with chronic disease.

l am a family doctor and the interim scientific director of the Technology Evaluation in the Elderly Network—that's TVN. We're at Queen's University and the Kingston General Hospital. TVN is a national centre of excellence with $23.8 million of funding to be used over the next five years. Our mission is to improve the care of seriously ill elderly patients and their families through the development, rigorous evaluation, and ethical implementation of health care technologies, ultimately leading to better outcomes for patients and families as well as health care professionals and the health care system as a whole. With researchers from across Canada and partnerships with industry and community organizations, the network is committed to improving care for the seriously ill elderly in Canada through solution-driven research and partnerships.

We are working to foster research and dissemination of information to ensure appropriate use of life-saving technology at the end of life that fulfills patients' wishes. We will also train students in this area to continue the development of a better way to care for the elderly at the end of life. Specifically, we are looking for impact in four areas: improved care of the sick elderly; improved efficiency of the health care system; evidence-informed policy and practice; and reduced moral distress for patients, families, and caregivers.

Here are a couple of examples of the research projects that we have recently funded. One was done by Dr. Karen Burns, entitled “Practices in End of Life Care and in Discontinuing Mechanical Ventilation in Elderly Critically Ill Patients”. Another project was done by Dr. Francis Lau and Dr. Doris Barwich, entitled “A Knowledge Translation Project on Benchmarking End of Life Care Practices for the Elderly in Primary Care”. A final example is Dr. Sean Bagshaw and Dr. Ron Wald's “OPTIMAL Selection For and Timing to Start Renal Replacement in Critically Ill Older Patients with Acute Kidney Injury”.

The national networks of centres of excellence program is a federally funded program through the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council, and the Social Sciences and Humanities Research Council. The goal of the NCE is to mobilize Canada's research talent in the academic, private, public, and not-for-profit sectors and apply it to the task of developing the economy and improving the quality of life of Canadians. Its other goal is for the mobilization of research knowledge and commercialization of technology.

I'll focus my comments on the use of technology in the sick elderly today. TVN has defined technology in a very broad sense, from low-tech things like data collection tools to very high-tech, life-preserving machines, diagnostic tests, and treatment. As you have heard from others, there are many ways to use technology to improve the care of patients with chronic disease. As one example, I also lead a national primary care chronic disease surveillance network that collects patient health information from electronic medical records. We use this information for chronic disease surveillance, quality improvement, and research. EMRs have great promise in improving chronic disease management in primary care.

But what happens when those chronic diseases progress until the end of life is inevitable, despite all our efforts, and the patient becomes very sick? We know from previous studies that Canadians' values about their health are often at odds with how they experience their health care. The focus on technology in acute care often results in elderly people being treated in ways that are not consistent with their values, may prolong suffering without improving quality of life, and often puts health professionals in positions that are at odds with their own values.

The increase in the absolute numbers of older Canadians dying and the concomitant rise in the use of life-sustaining technologies have really created a paradox in modern medicine at the end of life.

Although most elderly patients prefer less aggressive treatments, they often have these life-sustaining technologies used in the final stages of illness and dying.

Currently in the western world, one in five elderly people who die in hospital, actually die in the intensive care unit. The proportion of patients 80 years or older who are admitted to the ICU in Canada has increased from 10%, in the mid-1990s, to nearly 20% today. Most older patients value quality of life and avoiding unnecessary prolongation of life through the use of technology. Yet aggressive life supports are often provided to patients during the final months of life, even when the patient or family prefer comfort care. An example of this is that rates of using cardiopulmonary resuscitation before death are increasing in hospitalized patients.

It's questions like these. Do I put a breathing tube into an elderly patient with emphysema who develops pneumonia and needs ventilation? Do I put a pacemaker in an elderly patient with dementia who has a heart rhythm irregularity? Do I start an elderly patient with multiple chronic diseases on kidney dialysis? These questions are faced daily by doctors, patients, and families. Often the right questions are not asked, the technology is started without discussion, and everyone ends up in a place they don't want to be.

Although technology can be extremely beneficial to support Canadians to live better and longer with chronic disease, there is a serious and immediate need to improve the care of seriously ill elderly patients and their families through the development of some sort of rigorous evaluation and ethical implementation of health care technologies. There is mounting evidence that the unwanted use of technology at the end of life is associated with worse ratings of quality of life for both patients and families, and result in increased family ratings of anxiety and depression. This is a fundamental issue for us with existing and future uses of technology. There is an urgent need to improve communication and decision-making about the use of these life-sustaining technologies. In particular, this includes communication among health care professionals, particularly at care transition points; communication of information about a patient's health and wishes; and communication among professionals and patients and family.

A couple of recommendations I'd like to suggest are that we need to spread the word about the very low-tech approaches, such as advanced care planning. What would it be like if all Canadians had an advanced care plan so that when they entered a hospital, family and health professionals would know their wishes? What if each of us had an advanced care plan as a smartphone app and could carry it around with us? The federal government can encourage this dialogue on advanced care planning at times of life transitions, and consider including such information in mail-outs for CPP applications.

We must develop an ethical framework about how technology should be used in the sick, elderly patient at the end of life so that they are getting the appropriate care at the right time. The federal government should make it a priority to engage provincial and territorial ministers of health in discussion of the best practices and the common metrics of care and standards.

Health care information must be available to whoever is providing the care. It needs to be timely and it needs to be easily accessible. While Canada has spent billions of dollars on the development of electronic health records, we need to continue to invest in this to get to where we want to go.

Finally, the federal government must continue to invest in national programs like the NCE to foster world-class research and the dissemination of knowledge and commercialization of technology.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Birtwhistle. Those were excellent comments.

Now we'll go to Dr. Saul Quint, please. You have 10 minutes, Dr. Quint.

[Dr. Saul Quint]

Thank you so much.

I'd like to introduce myself. I am a family physician as well as the CEO of INTERxVENT Canada. Ours is a for-profit organization. From listening to the previous speaker, I would say that the difference between their funding and research, and what we do, makes a point that needs to be taken. I want to emphasize that while I'd like to describe what we do at INTERxVENT Canada, as a background my entry into this world of preventative care was precisely to try to prevent the description of the seriously ill and chronic disease patient—not only the elderly but across Canada—and by my realization that the problems that result from chronic disease can so much better be managed if we prevent, rather than attempt to cure.

With that in mind, I'd like to start by providing a high-level overview of INTERxVENT's platform and product offerings, not as a pitch for INTERxVENT but for products like INTERxVENT's, and how important wellness and disease management programs are for population screening, early identification of risks, and the management of chronic disease at an earlier stage so that we can delay what is inevitable as much as possible and try to improve quality of life and health outcomes for as long as possible.

I believe that our product and many others like ours have the ability to achieve that population screening, early identification, and improved quality of life in a cost-effective and scalable fashion, as we have done in many countries.

I'd like also to very briefly introduce Dr. Neil Gordon, just to put what INTERxVENT is in context. Dr. Neil Gordon was formerly a classmate of mine in South Africa. He emigrated to the United States and has spent the last 25 years of his life totally devoted to preventative health.

He is a former professor of medicine at Emory University and a past chairman of the American Heart Association's committee of exercise, cardiac rehab, and prevention. He has been building the INTERxVENT platform and product suite over the last 16 years. He has published more than 100 scientific manuscripts and abstracts in all the major peer-reviewed medical journals and has written eight books on preventative care. The focus of Dr. Gordon's life is evidence-based care in a scalable fashion.

I'll say one more thing about Dr. Gordon and what he's doing in the United States, just to again put it into context, and then I'll move totally on to Canada.

INTERxVENT International has just recently partnered with the American College of Cardiology to bring this suite of programs to patients through 40,000 cardiology offices as well as, under the American College of Cardiology brand, “workplace wellness programs”. We have followed in Canada a similar track, if you will, by partnering with C-CHANGE, the Canadian Cardiovascular Harmonized National Guidelines Endeavour, which is an endeavour by academic and scientific leaders in Canada of the eight guideline groups to come up with a harmonized group of guidelines.

We as family physicians—I'm sure Dr. Birtwhistle will agree with me—are pummelled with guidelines from different organizations that are similar but not exactly the same. These guideline groups got together and created a harmonized set of guidelines. At the Health Care Innovation Working Group, the premiers announced the implementation of C-CHANGE guidelines as one of the three main directives.

Working with C-CHANGE, Dr. Gordon and I have implemented the C-CHANGE set of guidelines into the INTERxVENT suite of programs, such that the guidelines are now able to be delivered on a participant-by-participant or patient-by-patient basis.

What is INTERxVENT? It's a platform that builds. It all starts with a very sophisticated, algorithmically driven health risk assessment. This is a self-reported instrument, but it's complemented by the integration of laboratory tests and biometric testing.

We are partnered in a large way with Gamma-Dynacare Medical Laboratories. They have been one of our primary funders to date. We have an integrated module whereby we can integrate labs, which are auto-populated into the health risk assessment and help us to stratify participants, whether they be employees or patients, into low, moderate, or high risk. Once participants are stratified into low, moderate, or high risk, they are offered online self-help interventions.

I will describe a little of what our health risk assessment consists of. They are online self-help interventions, which are sequenced educational kits or programs on nutrition, weight management, physical activity, stress management, tobacco cessation, medication management. Diabetes and depression are two disease management modules we've recently added.

Not only can participants take part in self-managed programs, they are also, depending on who is using the program, offered the use of a health coach. This is a health professional who has been trained on the back-end database of INTERxVENT. The participants are therefore delivered coached programs—either a comprehensive program or a program on nutrition, weight management, depression, diabetes, etc.—by the relevant experts, who are also trained on the back end of the database to ensure that guidelines are followed and that, while each offering is personalized, it is also standardized to clinical guidelines.

There is some very sophisticated reporting that comes out of the health risk assessment and the scorecards and the detailed reports that follow. In addition, we have some physician reports that I will mention in a moment.

In conjunction with Shoppers Drug Mart we have also added a medications module, whereby patients or employees—whoever the participants are—can fill in the medications they're taking by entering a drug identification number or the name of the drug or names of herbal remedies. It brings up drug-herb interactions. It alerts INTERxVENT coaches as to who has poor medication-taking behaviour. There is lots of evidence that shows that patients stop taking their medications without instructions from a health care provider. Our publications have shown that while one is on a coached program, compliance with and adherence to medication regimes are almost 100%.

As I mentioned earlier, we have partnered with Gamma-Dynacare labs, and a participant is able to download—right off the health risk assessment—a lab requisition with the required glucose, hemoglobin A1C, and lipid tests, and those for blood pressure and weight.

Those measurements—blood measurements and biometric measurements—are done at a Gamma-Dynacare Laboratory patient service centre anywhere across the country and are auto-populated into the health risk assessment, and they may dramatically change somebody's risk profile. Participants who thought they were low risk, because they hadn't had a glucose test in the last three years, might be found to be diabetic and be moved from a low into a high-risk stratification.

Obviously the intensity and duration of the programs that follow are based on the participant's willingness to change, first, and second, on the modifiable risk factor profile.

Really, INTERxVENT is in the business of behaviour change. While behaviour change is a very difficult thing to do, our coaches are trained in behaviour and in behaviour change, and we have very good results, as do many other wellness and disease management programs that follow evidence-based guidelines.

We also offer the health risk assessment, have numerous risk codes that are identified, and we refer participants to appropriate health care professionals. For instance, people with depression, anxiety, or substance abuse are referred to an EAP provider in some of our programs. Others who are identified as having diabetes are referred to a pharmacist for a diabetes meds check.

[The Chair, Conservative, Joy Smith]

Excuse me, Dr. Quint.

[Dr. Saul Quint]

Yes.

[The Chair, Conservative, Joy Smith]

Our time is up now. Can you wrap it up in the next couple of minutes for me, please, so that we can get to questions?

[Dr. Saul Quint]

Sure I can. I apologize for going over.

We have validated scales such as the workplace product impairment score. The workplace validated score is a screening test that identifies for participants whether they require a colonoscopy, a pap smear, etc.

Lastly, there's a physician summary report, which has C-CHANGE guidelines incorporated into it, which directs the physician, in a polite way, to relook at the treatment of their patient to ensure they're being treated according—

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. Quint.

[Dr. Saul Quint]

Sorry I went over my time.

[The Chair, Conservative, Joy Smith]

Thank you so much for your comments. It was very insightful.

I must say that, just to alert the committee and our witnesses, two things are going to happen.

Dr. Victor Ling will be here at five o'clock and he'll give his presentation. You'll only have five minutes to ask him questions, so whoever is on the agenda will have the opportunity to do that. He couldn't make it before that.

On the other side, bells will ring at 5:15, and as soon as the bells ring, we will have to be dismissed. So we will keep everything sharp today. We'll get through as much as we can, but we'll try to get as many people in as we can.

We'll go into the Q and A, the seven-minute round right now, and when Dr. Ling comes in, I will interrupt it so he can give his presentation.

We'll begin with Dr. Sellah, please.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you, Madam Chair.

I would like to thank our witnesses, Dr. Birtwhistle, who is here with us, and Dr. Quint, who is joining us by teleconference.

Since we have been speaking about innovation, and that includes studies we have already done on chronic illnesses, we are aware that Canadians are not all in good health as they age, and that is an enormous burden for the health care system.

Dr. Birtwhistle, I listened to your presentation carefully. You said that when people came to the end of their lives, new technologies decreased their quality of life. Could you tell us a little more about that?

[Dr. Richard Birtwhistle]

Thank you for the question.

I guess I need to understand a little bit more about new technologies that would improve quality of life. Certainly there are technologies that improve quality of life by allowing people to recover faster, if they're going to recover. In terms of the end of life, though, in fact, there are new technologies that probably decrease quality of life, rather than increase quality of life, because what happens is that people with a terminal illness or who may have a few weeks to live, have some technology applied to them that in fact results in prolongation of life in a very poor state.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

You spoke about communication between patients and health care professionals, especially doctors.

I'll give you an example from my own experience. I did my residency in Quebec City. When very ill patients came in, we had to ask the individuals themselves, if they were conscious, or their family if they weren't, if we should perform CPR if they had a heart attack or something like that. That was our approach. Since I don't practise anymore, I don't know if things are still done this way. During our residency, when we had an elderly person who was suffering, we always had to ask them this question first. It was a way of asking patients if we should prolong their life, as you said, or if our treatment should be aimed at palliative care.

With respect to best practices, I would like to know if that is done in certain areas, to your knowledge.

[The Chair, Conservative, Joy Smith]

Mr. Birtwhistle, do you want to answer that one? Then maybe we'll let Dr. Quint have a chance at doing it as well.

Dr. Birtwhistle.

[Dr. Richard Birtwhistle]

Thank you.

There are bold attempts by physicians and nurses and others to ask that question if they have the opportunity, but it is by no means routine. Of course the concern is that elderly persons may get into hospital but be in a state in which they can't answer. They may or may not have a power of attorney, so health professionals are left in a situation in which they actually have to make the decision on the spot. We've been trained to try to save people, so what happens is often whatever the technology, whether it's putting in a pacemaker or resuscitating a person and trying to treat heart failure, it actually ends up prolonging life when that may not have been the patient's wish.

[The Chair, Conservative, Joy Smith]

Dr. Quint, do you have a comment on this before our time runs out for Dr. Sellah?

[Dr. Saul Quint]

I'll make a very short comment. I'm not a heart specialist but it goes to our training that we always feel better if we do something for a patient, and sometimes what we do is not always improving their quality of life.

[The Chair, Conservative, Joy Smith]

You have a minute and a half, Dr. Sellah.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

I would like to continue along those same lines.

In fact, we did not just use that approach for patients who came to emergency and were suffering. I remember that, at the time, we even considered asking family doctors to discuss with their patients whether they would like us to try to resuscitate them using tools or medications, should a situation arise.

I think this new approach could be more widespread across Canada. As you said, when someone comes to the end of life stage, the best thing is to provide palliative care, rather than try to resuscitate the person.

[The Chair, Conservative, Joy Smith]

Okay. Thank you.

We are pretty well out of time, but these are very good questions, very profound questions.

We'll now go to Dr. Carrie and Ms. Block, who will be sharing their time. Who wants to begin?

Dr. Carrie.