Comparing Priorities for Chronic Disease Management in Ontario and British Columbia

By Coralee Sonnenburg and Gordon Tse

As healthcare costs continue to rise across the country, local governments seek to target healthcare spending towards the highest priority needs in their respective regions. In comparing Ontario and British Columbia provincial governments have identified different priority determinants based on the prevalence of chronic diseases in the different provinces.

The province of British Columbia in partnership with the city of Vancouver has identified mental health and addictions as a health priority. This effort is in response to a surge people that require in mental service services in Vancouver, as highlighted by a 43% increase in inpatient mental health services and an 18% increase in apprehension by police for those with mental illness (City of Vancouver, 2014). In comparison, Ontario’s public health sector has not been as active in addressing mental illness as it has been in responding to chronic disease (Ratnasingham, Cairney, Rehm, Manson, & Kurdyak, 2012). This despite that fact that “burden of mental illness and addictions in Ontario is more than 1.5 times that of all cancers, and more than seven times that of all infectious diseases” (Ratnasingham et al, 2012, p. 7). In its report addressing chronic disease in Ontario, Public Health Ontario does not even address mental illness (Public Health Ontario, 2018). Instead mental illness is considered its own individual focus outside the field of chronic disease management and despite evidence outlining the devastating effects of mental illness in terms of health adjusted life years (HALY’s) mental illness in Ontario continues to be undertreated (Ratnasingham et al, 2012).

In Ontario the primary focus for health prevention in chronic disease management focuses the prevention of heart disease, cancer, chronic respiratory disease and stroke (Cancer Care Ontario & Ontario Agency for Health Protection and Promotion, 2012). In Ontario 79% of all deaths can be attributed to one or more of these diseases and as such Ontario targets key risk factors related to these diseases (Cancer Care Ontario & Ontario Agency for Health Protection and Promotion, 2012). This includes policy change and educational program targeted at smoking cessation, increased alcohol consumption, healthy eating and increasing physical activity levels (Cancer Care Ontario & Ontario Agency for Health Protection and Promotion, 2012). The continued need to identify and resolve health inequities in Ontario has also been identified as a key determinant of health and the need for Ontario to improve its methods of data collection on inequity (Cancer Care Ontario & Ontario Agency for Health Protection and Promotion, 2012) and increase the public's awareness of inequities (Kirst et al, 2017) are essential.

While Ontario chooses to focus public health efforts on prevention of specific chronic disease, the focus of public health in British Columbia is “to optimize health by increasing the adoption of healthy behaviours by British Columbians” (Kothari et al, 2013, p. 7). This involves focus on active lifestyle, smoking cessation and healthy living as the primary areas of focus (Kothari et al, 2013). British Columbia also specifically focuses interventions using an equity lens, ensuring creating socio-economic awareness in policy decision and program planning, whereas Ontario acknowledges the importance of social and economic awareness and applies equity measures at the individual program level (Kothari et al, 2013).

Although the governments of Ontario and British Columbia outline different priorities for chronic disease prevention and management based on the differences in regional prevalence, many of the risk factors they target are similar as multiple risk factors affect many chronic diseases. Programs targeted at smoking cessation, an active lifestyle and resolving health inequities and are common to both provinces with a focus on lifestyle modifications in order to prevent chronic disease development.

References

Cancer Care Ontario & Ontario Agency for Health Protection and Promotion

(2012). Taking action to prevent chronic disease: recommendations

for a healthier Ontario. Toronto: Queen’s Printer for Ontario. Retrieved from https://www.publichealthontario.ca/en/eRepository/5870%20CCO%20EXEC%20 SUM%20ENG%20MAR%2015_12.pdf

City of Vancouver. (2014). Caring For All: Priority Actions to Address Mental Health and Addictions. Retrieved from http://vancouver.ca/files/cov/mayors-task-force-mental- health- addictions-priority-actions.pdf

Kothari, A., Gore, A., MacDonald, M., Bursey, G., Allan, D., Scarr, J., & The Renewal of Public Health Systems Research Team. (2013). Chronic disease prevention policy in British Columbia and Ontario in light of public health renewal: a comparative policy analysis. BMC Public Health, 13(934). Retrieved from https://doi.org/10.1186/1471-2458-13-934

Kirst, M., Shankardass, K., Singhal, S., Lofters,A., Muntaner, C., & Quiñonez, C. (2017). Addressing health inequities in Ontario, Canada: what solutions do the public support? BMC Public Health, 17(7). doi 10.1186/s12889-016-3932-x

Public Health Ontario. (2018). Taking Action to Prevent Chronic Disease. Retrieved from https://www.publichealthontario.ca/en/BrowseByTopic/ChronicDiseasesAndInjuri es/Pages/Taking-Action-to-Prevent-Chronic-Disease-Recommendations-for-a- Healthier-Ontario.aspx

Ratnasingham, S., Cairney, J., Rehm, J., Manson, H., & Kurdyak, P. A. (2012). Opening Eyes, Opening Minds: The Ontario Burden of Mental Illness and Addictions Report. An ICES/PHO Report. Toronto: Institute for Clinical Evaluative Sciences and Public Health Ontario. Retrieved from https://www.publichealthontario.ca/en/eRepository/Opening_Eyes_Report_En_2012.pdf

Thinking FAST and Beyond

An ecological examination of stroke in Canada and Waterloo Region and best practice standards for care

Why Should We Care?

Working in the emergency department many of our patients come to us because of complications of chronic disease. In 2012, 1260 deaths were attributed to chronic disease in Waterloo Region (Region of Waterloo Public Health, 2017). The two most common chronic conditions were cardiovascular disease and cerebral vascular disease, with 154 deaths in the region related specifically contributed to stroke (Region of Waterloo Public Health, 2017) , stroke and cerebral vascular disease are the third leading cause of death in Canada (Public Health Agency of Canada, 2017).Our hospital is part of Waterloo Wellington’s Integrated stroke program with a focus on preventing strokes, treating acute strokes and providing rehabilitation. Waterloo Wellington is a provincial leader in stroke care including public education, acute stroke treatment and rehabilitation (Ontario Stroke Network, 2017). Working in the emergency department we not only treat acute strokes everyday, but also manage the complex medical needs of those patients living with the effects of stroke. Nationally in 2012 there were approximately 741,800 Canadians living with the effects of stroke (Government of Canada, 2016) and the cost of stroke is estimated to be approximately 2.8 billion dollars a year (Mittmann et al, 2012). The prevalence of, and cost associated with stroke care demonstrates the importance of understanding the primary determinants of stroke and in doing so develop an understanding of best practice for prevention and treatment of stroke.

Risk Factors and Stroke Prevention

There is a multitude of research available on the cause and risk factors associated with stroke. The Heart and Stroke Foundation of Canada states that key modifiable risk factors for stroke include, healthy diet, exercise, weight management, smoking cessation, lipid management and management of blood pressure (Wein & Gladstone, 2017). Hypertension is identified as being the single most controllable risk factor for stroke (Wein & Gladstone, 2017).

The Heart and Stroke Foundation of Canada uses a multisystem approach to address stroke prevention in Canada as demonstrated by the following model.

A multilayer framework identifying key elements of stroke prevention. From Heart and Stroke Foundation: Canadian Stroke Best Practices (Wein & Gladstone, 2017).

As many of the risk factors associated with stroke prevention target high risk groups, the use of social ecological theory in stroke prevention integrates individual behavioural changes with environmental enhancement in order to target the larges portions of the population at risk for stroke (Pearson, 2011). This “high-risk approach” is used by both the American Heart Association (Pearson, 2011), and the Hearth and Stroke Foundation of Canada to target those at risk for stroke (Wein & Gladstone, 2017). At the policy level risk for stroke is addressed through regulation of trans fats and sodium in foods, physical activity guidelines and national legislation and taxation of tobacco (Perason, 2011). An example of legislative action that has directly affected stroke is a decrease in hospital admission rates in Toronto for cardiovascular conditions (including stroke) after the banning of smoking in public places in 1999 (Naiman, Glazier, & Moineddin, 2010).

Institutional policy may dictate tobacco use in the workplace or encourage physical activity during the work day. These types of policies directly effect workplace environments; a key determinant of health according to the Government of Canada (Government of Canada, 2018). Interpersonal factors would include access to primary health care practitioners to test and treat for hypertension and hyperlipidemia, some of the most cost-effective methods for stroke prevention (Pearson, 2011). Access to health service is therefore an essential determinant in the prevention of stroke.

Stroke education is also a key determinant in the prevention and management of this devastating disease. Public policy targeted at education of stroke symptoms and media campaigns to identify the risk of stroke are used to ensure access for all to available stroke care programs in a timely manor due to improved outcomes for stroke patients based on the time in which they are seen by a healthcare professional (Government of Canada, 2016).

A public education flyer published by Health Canada 2016.

Stroke Practice Guidelines

Stroke prevention is not the only focus of managing this chronic disease. Once strokes occur treatment programs and risk factor modification are a key element in limiting the long-term disability associated with stroke. Every nine minutes in Canada a patient is treated in emergency departments for acute stroke or transient ischemic attack (or TIA) (Casaubon et al, 2015) and the Heart and Stroke Foundation of Canada Best Practice Advisory committee clearly outlines critical care guidelines for the treatment of stroke (Causbon et al, 2015). These guidelines include the management of TIA by primary care physicians, ambulance transportation of stroke patients to appropriate hospitals and emergency department rapid assessment and treatment of stroke (Causbon et al, 2015). The Ontario government also publishes best practice guidelines for stroke care in Ontario hospitals (Health Quality Ontario, 2016).

Our local regional centre is monitored by Ontario Stroke Network (OSN). OSN provides leadership to regional stroke centers, encouraging best practice standards are met and reporting on 20 key performance indicators for regional stroke care, from prevention, risk management, acute stroke care, rehabilitation, outcomes and mortality (Ontario Stroke Network, 2017). The emergency department in which I work is the local stroke center and we are one of the highest performs in Ontario in terms of acute stroke management (Ontario Stroke Network, 2017). Our regional stroke team adheres to best practice through a clearly mapped care plan for stroke patients at all stages of disease from prevention to rehabilitation (Waterloo Wellington Integrated Clinical Programs, n.d.).

My experience in my current practice involves primarily acute stroke care. Adhering to best practice guidelines we ensure exceptional acute stroke care through the assessment and identification of acute stroke, initiating a hospital directed “Code Stroke” procedure to initiate prompt lab testing, imaging and medication administration. These practices adhere to best practice guidelines for the acute treatment of stroke (Causbon et al, 2015; Health Quality Ontario 2016; Waterloo Wellington Rehabilitative Care System, n.d.). Management of acute hypertension in the emergency department is how we directly affect stroke risk, this is in line with the Registered Nurses of Ontario (RNAO) best practice guidelines for managing hypertension (RNAO, 2015).

Links for Stroke Care Best Practice

By following best practice guidelines for treatment of stroke we can help to improve quality of life outcomes for our patients, decrease the financial burden of stroke and work with patients to prevent future complications or subsequent stroke. Below are listed key resources for healthcare staff looking to improve their knowledge related to best practice stroke care standards in Ontario.

· Heart and Stroke Canada Best Practice (Federal)

· Ministry of Health and Long-Term Care Clinical Handbook for Stroke (Provincial)

· Waterloo Wellington Stroke Pathway Care Mapping (Regional)

References

Casaubon, L. K., Boulanger, J., Blacquiere, D., Boucher, S., Brown, K., Goddard, T., … on behalf of the Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee (2015). Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015. International Journal of Stroke. 10(6), 924-940. https://doi.org/10.1111/ijs.12551

Government of Canada. (2016). Stroke in Canada. Retrieved from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/stroke- in-canada.html

Government of Canada. (2018). Social determinants of health and health inequalities. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html?option

Health Quality Ontario. (2016). Ministry of Health and Long-Term Care. Quality-based procedures: clinical handbook for stroke (acute and postacute). Toronto: Health Quality Ontario. Retrieved from http://www.hqontario.ca/evidence/evidence-process/episodes-of- care#community-stroke

Mittmann., N., Seung, S.J., Hill, M.D., Phillips, S.J., Hachinski, V., Coté, R., … Sharma., M. (2012). Impact of disability status on ischemic stroke costs in Canada in the first year. The Canadian Journal of Neurological Sciences, 39(6). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23041400

Naiman, A., Glazier, R. H., & Moineddin, R. (2010). Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions. Canadian Medical Association Journal, 182(8). doi: https://doi.org/10.1503/cmaj.091130

Ontario Stroke Network. (2017). Ontario and LHIN 2015/16 Stroke Report Cards and Progress Reports. Retrieved from https://www.corhealthontario.ca/ICES-Stroke-Report-2017.pdf

Pearson, T. A. (2011). Public Policy Approaches to the Prevention of Heart Disease and Stroke. Circulation, 124(23). Retrieved from https://doi.org/10.1161/CIRCULATIONAHA.110.

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Public Health Agency of Canada. (2017). Stroke In Canada. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases- conditions/stroke-vasculaires/stroke-vasculaires-canada-eng.pdf

Registered Nurses Association of Ontario. (2005). Nursing Best Practice Guideline; Nursing Management of Hypertension. Retrieved from http://rnao.ca/sites/rnao- ca/files/Nursing_Management_of_Hypertension.pdf

Region of Waterloo Public Health (2017). Chronic Disease Mortality, Waterloo Region and Ontario, 2010, 2011 and 2012. Retrieved from https://www.regionofwaterloo.ca/en/regional-government/resources/Reports-Plans-- Data/Public-Health-and-Emergency- Services/QSCHRONIC_DISEASE_MORTALITY.pdf

Waterloo Wellington Rehabilitative Care System, (n.d.). Stroke. Retrieved from http://regionalhealthprogramsww.com/HealthCareProviders/CarePathways/Stroke?deptI D=2

Wein, T. & Gladstone, D. (2017). Canadian Stroke Best Practice Recommendation

Prevention of Stroke 6th Edition. Heart and Stroke Foundation of Canada. Retrieved from http://www.strokebestpractices.ca/wp-content/uploads/2018/03/CSBPR2017-SPoS- Module-Master-FINAL-ENGLISH-without-Appendix-Four.pdf

Seeing Beyond The Patient

Using an ecological model for health promotion to understand risk for suicidal behaviours in adolescents.

**Disclaimer – this post poses theoretical discussion surrounding suicide risk and may contain triggers**

I’ve chosen this week to examine and ecological model proposed by McLeroy, Bibeau, Steckler, & Glanz (1988) that uses ecological theory to examine health promotion programs. The emergency department in which I practice is both the regional pediatric centre, as well as being on a Form 1 mental health facility. As such, a daily occurrence that we encounter in our childhood and adolescent populations is suicidal behaviours and thoughts. I have chosen to outline why the complex nature of suicide risk can be appropriately examined using an ecological perspective on determinants of health.

Ecological theories of health take into consideration both the individual, their environments, and the effects of overlaying policy (Sallis & Owen, 2015). One of the earliest, modern multiple levels of health theory was proposed by Urie Bronfenbrenner in in 1977, his model described multiple levels of influence on the individual behaviour in the micro-, meso-, exo- and macrosystems and how all of these layers of influence interact with each other (Tannenbaum, 2018).

Tannenbaum, R. [Rachel Tannenbaum]. (2018, January 3). Bronfenbrenner’s ecological theory [Video File].

McLeroy, Bibeau, Steckler, & Glanz propose an ecological perspective of health promotion that uses the theory of Bronfenbrenner as a conceptual base (1988). Their theory examines determinants of health in terms of layers of social and environmental factors that can be targeted for health promotion (McLeroy et al, 1988). This model demonstrates how individual and community behaviour can be affected by and can affect the social environment (McLeroy et al, 1988). The theory proposes these five levels of analysis that affect health behaviours, each level having the potential for health promotion interventions.

· intrapersonal factors – personal characteristics, both physical and social including knowledge, beliefs and skills

· interpersonal process – individual social support and networks including family and friendships

· institutional factors – social institutions (both formal and informal as in schools, workplace or sports teams)

· community factors – relationships amongst institutions and organizations

· public policy – laws and policies existing both locally and nationally

Adapted from McLeroy et al (1988).

The use of an ecological model in examining adolescent suicide is relevant due to the complex nature and difficulty in identifying causal risk factors associated with adolescent suicide behaviours (Perkins & Hartless, 2002). The use of ecological theory allows adolescent suicidal behaviours to be viewed in a multifaceted lens and aid in understanding the complex relationship between risk factors as causal relationships between risk factors and suicidal acts have not been identified (Ayyah-Abdo, 2002).

Using the ecological model proposed by McLeroy et al (1988), risk factors associated with suicide can be viewed through five layers ensuring strategies aimed at prevention to not focus solely on the victim, but on all environmental factors. The first and second layers of analysis include the intra-, and interpersonal interactions. The most significant intrapersonal factors associated with adolescent suicide are hopelessness, substance abuse and depression (Ayyah-Abdo, 2002). McLeroy et al (1988) emphasise the importance of tailoring health promotion not solely on the behaviour of the individual but on the interpersonal factors that affect these behaviours. These interpersonal relationships including family, friends and acquaintances provide social support (McLeroy et al, 1988) and are of vital importance to adolescent development. Family history of suicide, parental psychopathology, loss of important relationships are all risk factors identified in adolescent suicide and almost one third of suicide attempts by adolescents are reported after a perceived loss (Ayyah-Abdo, 2002). Ecological theory of health promotion would therefor suggest focusing interventions on determinants of health that directly affect the mental health of families with children in order to mitigate the risk associated with family dysfunction and a sense of isolation felt by adolescents without adequate support.

The institutional, community and policy levels of analysis associated with ecological theory on health promotion as described by McLeroy et al (1988) can be used to examine suicidal behaviour risk factors on a macro-systems level. Adolescents spend a large amount of time in the school setting and those who feel they are a failure in school are at an increased risk for suicide (Ayyah-Abdo, 2002). Thus, highlighting the importance of school systems being engaged and involved in program decisions around mitigating suicide risk. The community setting can refer not only the physical, but also the psychological sense of community (McLeroy et al, 1988) and to adolescents this would include traditional as well as social media. Although research into social media use and suicide risk has yet to draw many sound conclusions, cyberbullying increases the risk of suicide amongst adolescents at two times the rate of those who are not (Luxton, June, & Fairall, 2012). Creation of public policies related to reducing cyberbullying occurs at the policy level of ecological health promotion theory and could include education programs, national policies and the development of laws aimed at targeting cyberbullying (Luxton et al, 2012). Social media and the internet can be used to preventatively in order to address suicide prevention in health promotion activities aimed at targeting, individuals, schools and by creating larger public health outreach campaigns (Luxton et al, 2012).

Suicide is a complex problem that is becoming more and more prevalent in our society, it is the second leading cause of death from age 14-35 (Statistics Canada, 2017). By using ecological theory to address the complex risk factors associated with suicide healthcare professionals can develop a more complete understanding of this devastating issue. Creation of public policy and programming aimed at all levels of the environment can help to identify adolescents at risk and provide support to adolescents and their families in the hopes of mitigating the risks associated with suicidal behaviours.

References

Ayyash-Abdo, H. (2002). Adolescent Suicide: An ecological approach. Psychology in the Schools, 39(4). doi: 10.1002/pits.10042

Luxton, D., June, J. D., & Fairall, J. M. (2012). Social Media and Suicide: A Public Health Perspective. American Journal of Public Health, 102(2). doi:10.2105/AJPH.2011.300608

McLeory, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 15(4). Retrieved from https://www.cdc.gov/violenceprevention/overview/social- ecologicalmodel.htmlhttps://www.researchgate.net/profile/Kenneth_Mcleroy/publication/ 20088489_An_Ecology_Perspective_on_Health_Promotion_Programs/links/0d1c84f972 a1e3f12d000000/An-Ecology-Perspective-on-Health-Promotion-Programs.pdf

Perkins, D. F., & Hartless, G. (2002). An Ecological Risk-Factor Examination of Suicide Ideation and Behavior of Adolescents. Journal of Adolescent Research, 17(1).

Sallis, J. F., & Owen, N. (2015). Ecological Models of Health Behaviour. In K. Glanz, B. Rimer, & K. Viswanath (Eds.), Health Behaviour: Theory, Research, and Practice (pp. 43-64). Retrieved from https://books.google.ca/books?id=0j4LCgAAQBAJ&printsec=frontcover&source=gbs_g e_summary_r&cad=0#v=onepage&q&f=false

Statistics Canada. (2017). Suicide Rates: An overview. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm

Tannenbaum, R. [Rachel Tannenbaum]. (2018, January 3). Bronfenbrenner’s ecological theory [Video File]. Retrieved from https://www.youtube.com/watch?v=HV4E05BnoI8