Institute of Health Policy

Not a ‘miracle test’: 91�Թ� expert explains the true costs of genetic testing

ullahnor — Fri, 27 Apr 2018 16:40:19 +0000

Not a ‘miracle test’: 91�Թ� expert explains the true costs of genetic testing

ullahnor Fri, 04/27/2018 - 12:40

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(photo by iStock)

Rebecca Biason

Topic

Breaking Research

Dalla Lana School of Public Health

Institute of Health Policy

Research & Innovation

From 23 and Me and Ancestry DNA to research laboratories, genome sequencing has become widely available, but better understanding is needed on when it should be used and whether it should be covered by health plans, says a 91�Թ� health economics professor.

“On the one hand, it’s great to see the public becoming more aware of options for genetic testing, but one downside is that people start to think of sequencing as a ‘miracle test,’ and that we should screen for every possible future disease no matter what the cost,” says Wendy Ungar a professor of health economics at the Dalla Lana School of Public Health's Institute of Health Policy, Management and Evaluation.

While the technology has advanced rapidly in recent years, policy has yet to keep up, she says. Some of the questions that need to be explored include whether all genetic testing should be covered by provincial health plans or just a few. Health-care systems like Ontario’s have constrained budgets, so understanding what types or topics of genetic testing are cost-effective, is of major interest to the Ministry of Health and Long-term Care.

“We have to look at what makes sense in terms of value, and not simply whether a test costs $100 or even $1,000,” says Ungar, who is also director of technology assessment at Sick Kids. “Is the test supported by scientific and economic evidence and will it truly help patients and clinicians in terms of treating or preventing disease – these are the types of questions we need to consider, not just the dollar amount.”

Ungar is chair of Health Quality Ontario’s Ontario Genetics Advisory Committee, also known as OGAC, where she and her colleagues are working to help the province and the ministry gain a better understanding of the value of different genetic tests and how or if they should be funded.

“We prioritize different topics of testing, such as carrier screening and non-invasive prenatal testing among others, and look at where there is the most need or demand,” Ungar says. “Once these tests are prioritized, a health technology assessment and budget impact analysis are conducted, and the results are deliberated by the committee.”

One topic of testing currently under deliberation is non-invasive prenatal screening.

“A pregnant woman actually has fetal DNA circulating in her bloodstream, so a simple blood draw can be analyzed to look at whether certain conditions may be present in the fetus,” says Ungar.

This test can identify chromosomal abnormalities related to trisomies such as Down syndrome and is currently only funded for women who are pregnant and considered high risk, such as those over the age of 40 or those with a family history of trisomies and other chromosomal abnormalities. The test, however, is not publicly funded for everyone.

“Amniocentesis and chorionic villus sampling are other testing options available, but they pose a risk to the fetus and the pregnancy because they are much more invasive,” Ungar says.

The committee also needs to consider the care pathway for prenatal care and how it might change if the decision was made to make the test available to all pregnant women.

“At what stage of care should we offer the test – at the first ultrasound or as part of the first blood test? These are further questions we are taking into account as part of the review,” Ungar says.

A funding recommendation for the test is expected to be posted to the HQO website for public feedback in May.

As for whether we should be more cautious about newer generations of genetic testing such as genome sequencing, Ungar explains that patients can have several potentially pathogenic variants appear that are not related to the original reason for undergoing a genetic test.

These variants can show risks for breast cancer or colon cancer or even Huntington’s disease. Once disclosed to the patient, they can trigger further costs to the health system as patients seek care from specialists to reduce their risks for such diseases.

“It is not just a single test, a single result, or a single patient – there are a whole host of cascading effects that we need to consider, including effects on the patients themselves and their family members.”

Improving health outcomes in Canada’s North: A 91�Թ� graduate student's practicum experience

rasbachn — Tue, 12 Dec 2017 18:45:52 +0000

Improving health outcomes in Canada’s North: A 91�Թ� graduate student's practicum experience

rasbachn Tue, 12/12/2017 - 13:45

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A view of Yellowknife, where Allie Margaret May completed her practicum (photo courtesy of Allie Margaret May)

Rebecca Biason

Topic

Our Community

Graduate Students

Institute of Health Policy

School of Graduate Studies

Arriving in Yellowknife, with its rural landscape, slightly cooler temperatures and the summer sun shining an average 22 hours a day, Allie Margaret May expected to find a health-care system that was different from Southern Ontario’s urban centres. Instead, the Master of Health Informatics student found that the two regions are more similar than she first thought.

“As I delved into my project, I realized that many of the challenges my patients faced in Ontario were similar to those of the Northwest Territories. Access to the right medical care at the right time is an incredibly universal issue,” said May, who embarked on her practicum placement with the Northwest Territories government this past summer.

As part of the Master of Health Informatics degree at the 91�Թ�’s Institute of Health Policy, Management and Evaluation, students are expected to complete a four-month practicum placement with a health-care organization and report on their experience. May worked with N.W.T. chief medical information officer Dr. Ewan Affleck to analyze effective communication models such as eConsultation in order to improve health outcomes.

May (pictured right) participated in the team’s shift to an entirely different model of communication and health information exchange, which was aimed at developing better communication between clinicians and patients.

“It became clear to us that eConsultation was one piece of a much bigger puzzle,” said May. “We realized that we needed to first implement a system that would be able to function on a more robust level as the territory expanded its programs.”

The new system provided clinicians with the ability to access more patient-centred technology that would improve the patient experience.

One example involved the implementation of secure mobile devices. If patients needing assessment were cut off from treatment or access to a health-care provider because of extreme weather in a rural area, they would not need to be medically evacuated into the city in order to receive treatment. Instead, by utilizing portable technology, they would be able to speak with or have their symptoms assessed by a care provider remotely.

With this new framework in mind, May was given the task of spearheading a health information exchange strategy that would restructure the way clinicians communicate with each other. She surveyed people from all over the Northwest Territories and its surrounding jurisdictions, from nurses in remote rural regions to neurologists in Edmonton, making sure that patient advocacy groups and patients themselves were able to have their voices heard throughout the change process.

“They were very open in allowing me to participate in the decision-making process,” said May. “It was empowering for me as an emerging professional and made me even more passionate about universal access to care, as well as more cognizant of barriers that inhibit that, such as the social determinants of health, which are not always identified.”

May said she will build what she has learned into a business case to make recommendations for next steps in the development of an information network platform.

She called her experience “eye-opening.” Though it was challenging to move outside of her comfort zone, and beyond the familiarity of her surroundings, choosing to accept this practicum in Yellowknife was an exercise in personal development.

“Health Informatics is a dynamic field,” said May. “If you are willing to become an adaptive person with an ability to enter a new environment and succeed, your chances of performing successfully as a health informatician are that much greater.”

Fentanyl scare and why Toronto needs safe injection sites: 91�Թ� public health researchers explain

ullahnor — Wed, 11 Jan 2017 21:05:15 +0000

Fentanyl scare and why Toronto needs safe injection sites: 91�Թ� public health researchers explain

ullahnor Wed, 01/11/2017 - 16:05

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Syringe left on the street (photo by eric molina via Flickr)

Nicole Bodnar

Author legacy

Nicole Bodnar

Topic

City & Culture

Public Health

Drugs

Dalla Lana School of Public Health

Institute of Health Policy

Management and Evaluation

Across Canada and the United States, rates of overdose from opioid drugs including fentanyl have skyrocketed in recent years.

The situation in British Columbia led the province to declare a public health emergency after 200 overdose deaths in the first four months of 2016. And this past summer, Toronto's former medical officer of health, Dr. David McKeown spoke to Toronto City Council in favour of creating supervised injection services to help address overdose-related deaths in Toronto, which climbed to an all-time high of 252 in 2014.

This week, Ontario’s Minister of Health agreed to fund three sites in Toronto.

Carol Strike, a professor at the Dalla Lana School of Public Health, and Dr. Ahmed Bayoumi, a professor at 91�Թ�'s Institute of Health Policy, Management and Evaluation and a clinician-scientist at St. Michael’s Hospital, have studied this issue and underlined Toronto’s need for these services.

Five years after they first published research that Toronto would benefit from supervised injection facilities, recommendations are being implemented by policymakers, and safe-injection services will be available in Toronto within the next “several months.”

91�Թ�'s Nicole Bodnar spoke with Strike and Bayoumi about the need for supervised injection services.

What are supervised injection services?

Ahmed Bayoumi: Supervised injection services (SIS) are legally sanctioned spaces where people can inject illegal drugs, typically opiates or cocaine, under the supervision of trained health staff and without fear of arrest. These services allow for safer injection, and scientific evidence shows that they lead to a reduced number of overdoses, increased referrals to drug treatment and benefit public order.

There are more than 90 of these operating globally, most within nine European countries, one in Australia and two in Vancouver. There have also been reports of pop-up locations in Vancouver and Victoria.

Are supervised injection services effective?

Ahmed Bayoumi: Research has shown that supervised injection services reduce public drug use and drug-related littering, and decreases the number of overdoses and risky injection practices. They also provide an important way to refer people to drug treatment, and health and social services. They are a cost-effective way to improve the health of people who use drugs.

Where are the proposed locations of supervised injection services in Toronto?

Ahmed Bayoumi: The facilities will be located at Queen and Bathurst, near Yonge and Dundas and in Leslieville.

Toronto carefully selected the locations of these services to be in communities where rates of injected drug use are high, and more than 80 per cent of Torontonians who participated in recent surveys noted that supervised injection services would bring benefits to these communities.

This is an excellent example of fitting the service to the real, unmet needs of people who use drugs.

Will people living in these neighbourhoods notice a difference?

Carol Strike: Already, there are more than 50 places across the city – community health centres, public health, social service organizations etc. — that offer harm reduction service where people access needle and syringe distribution programs every day. For over 30 years, these facilities have integrated so well into their neighborhoods that they have gone largely unnoticed. Operating quietly but efficiently helps to address the stigma associated with drug use.

Because supervised injection is an extension of these services and will be opened in facilities with a wealth of experience in harm reduction, we expect they will not significantly change surrounding communities – except by decreasing public drug use, which benefits everyone.

Will people use them?

Carol Strike: When Vancouver’s first supervised injection site, Insite, opened, there were wait lines immediately. There is similar high demand for a recent pop-up site opened by community activists in Vancouver. In Toronto, people inject in places that are not always clean or safe, and where they may not be able to get help if they need it.

People who inject drugs in Toronto attended the consultations held over the past year to vocally offer their support of these lifesaving programs. Over 75 per cent of people in Toronto who inject drugs said that they would use one.

What happens if Toronto does not provide supervised injection services?

Carol Strike: If we do not provide a safe space, we are ignoring a problem that will only getting worse – more people will overdose, and we will fail to prevent infections such as hepatitis C and HIV.